Sexually Transmitted Diseases:
The 2010 Health Care Act and Barriers to Effective Health Promotion Among Men Who Have Sex With Men
Fessler, David A. MD, MPH*,†; Mitty, Jennifer MD, MPH*; Mayer, Kenneth H. MD*,‡; Makadon, Harvey J. MD‡
From the Divisions of *Infectious Diseases and †General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA; and ‡The Fenway Institute, Boston, MA
No authors have any financial disclosures. There are no sources of support that require acknowledgement.
Correspondence: David A. Fessler, MD, MPH, 330 Brookline Ave, Shapiro Building, 6th Floor, Boston, MA 02215. E-mail: email@example.com.
Received for publication September 18, 2011, and accepted January 24, 2012.
The 2010 Patient Protection and Affordable Care Act (PPACA) contains many provisions aimed at improving reimbursement for health promotion and disease prevention, which are not necessarily covered under many traditional health insurance plans. In particular, Title IV, Prevention of Chronic Diseases and Improving Public Health, provides for new funding and several prevention-based initiatives.1 The Act mandates that new private health plans and insurance policies beginning on or after September 23, 2010 cover an array of preventive services without expecting recipients to share costs. These covered services are to include those rated as “A” (strongly recommended) or “B” (recommended) by the US Preventive Services Task Force (USPSTF) and vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC). Similarly, since January 1, 2011, Medicare now covers an annual wellness visit with customized prevention plan, including coverage of many USPSTF recommended preventive services without cost-sharing. Starting in 2013, state Medicaid programs that eliminate cost-sharing for USPSTF-recommended preventive services may receive enhanced matching federal funds to support these services. Other ways in which the PPACA may well improve preventive health include increased access to health insurance without concern for lack of coverage for preexisting conditions, mental health, or substance abuse treatment. The focus on integrated care and support for community health centers will also likely benefit underserved populations substantially.
Nevertheless, as these welcome changes are phased in, it is important to be aware of the gaps, which may emerge or be exacerbated in specific subpopulations whose preventive care needs are not fully addressed by the USPSTF and ACIP recommendations. One such group is men who have sex with men (MSM). The Department of Health and Human Services identified MSM in their Healthy People 2010 document as an underserved population group experiencing significant health disparities.2 MSM have several unique health risks compared with demographically matched heterosexual men, including increased prevalence and incidence of HIV and other sexually transmitted diseases (STDs), including human papillomavirus (HPV)-related anal cancer.3 As highlighted in a recent report by the Institute of Medicine,4 the underserved and stigmatized nature of the MSM population can also make it difficult to conduct studies that provide the evidentiary criteria required for USPSTF grade A and B recommendations, which focus on broader representative primary care populations, generally with larger sample sizes. The recently updated STD treatment guidelines published by the CDC provide evidence-based screening recommendations specific to the MSM population, which vary significantly from those of the USPSTF and ACIP, generally in the direction of more proactive screening for MSM.5 The most striking differences between these organizations' recommended practices for MSM occur in routine screening for gonorrhea, chlamydia, and hepatitis C, although important differences exist as well in recommendations for screening for HIV, syphilis, and anal dysplasia. The included Table 1 summarizes differences in recommended screening practices between the USPSTF/ACIP and the CDC. Given the increased incidence of STDs in this population and overlapping transmission dynamics of many of these diseases among MSM, more proactive screening is warranted, but several appropriate and important screening measures will not have mandated coverage under the auspices of the PPACA.
According to recent data, MSM continue to be one of the few major at-risk groups in the United States in which the rate of new HIV infections continues to rise, particularly among younger MSM and those from racial or ethnic minority communities.6 In this analysis, 61% of all new cases of HIV in 2009 were among MSM, with a 20% increase in incidence compared with 2006. Data from 2008 estimated overall HIV prevalence in urban MSM at 19%.7 Forty-four percent of these individuals were unaware of their infection, and 55% of this group had not had HIV testing performed during the previous year. Both the CDC and USPSTF recommend screening sexually active MSM for HIV. However, the USPSTF maintains a “C” recommendation for HIV screening in individuals without recognized risk factors,8 whereas the CDC has recommended near-universal opt-out HIV testing, with annual screening recommended for high-risk individuals including sexually active MSM.5 The reliance on providers' accurate assessment of recognized risk factors in their MSM patients for determination of HIV screening is problematic due to frequent nondisclosure both of sexual orientation and of risky sexual practices,9 a pernicious example of “don't ask, don't tell.”
Gonorrhea and chlamydia also remain highly prevalent among MSM and can be associated with epididymitis, prostatitis, male infertility, and increased risk of HIV transmission or acquisition.10 Estimates of prevalence vary significantly, but a retrospective review of STD prevalence with screening in an MSM population at a large Boston primary care clinic demonstrated a gonorrhea prevalence ranging from 1.9% to 13.4% depending on anatomical site sampled, and urethral chlamydia prevalence of 5.7%.11 Both rectal and pharyngeal gonorrhea and rectal chlamydia may serve as asymptomatic reservoirs facilitating the spread of infection, with >50% of all gonococcal and chlamydial infections found at nonurethral sites in one study.12 Screening at least annually is recommended by the CDC for urethral gonorrhea and chlamydia for all MSM engaging in insertive intercourse, rectal gonorrhea and chlamydia for all MSM engaging in receptive anal intercourse, and pharyngeal gonorrhea for all MSM engaging in receptive oral intercourse, by urine, rectal, and pharyngeal nucleic acid amplification testing, respectively. In contrast, the USPSTF does not recommend screening (“I” recommendation) for gonorrhea or chlamydia in high-risk male patients, including MSM.13,14
Syphilis incidence has been increasing since the early 2000s, with the majority of this rise attributable to increased rates of infection in the MSM population. In 2009, MSM accounted for 62% of all cases of syphilis in the United States.15 Approximately 50% to 60% of these men were also HIV-infected, raising concerns for increased risk of HIV spread, due to the increased transmissibility of HIV with syphilis coinfection.16 The CDC recommends syphilis screening in all MSM patients at least annually, whereas the USPSTF strongly recommends (“A” recommendation) screening for syphilis in all people at increased risk, including in this group only MSM who specifically engage in high-risk behavior, with no recommendations for an optimal screening interval.17
Although prevalence of hepatitis C in the nonintravenous drug user MSM population remains low, outbreaks of sexually transmitted acute hepatitis C have been widely reported in the United States, Europe, and Australia, mainly in HIV-infected MSM.18 CDC guidelines recommend screening for hepatitis C in MSM who are first diagnosed with HIV and in HIV-infected MSM who experience unexplained blood transaminase elevations and recommend considering screening in HIV-infected MSM who engage in traumatic sexual activities (e.g., multiple partners or other behaviors exposing the anal mucosa to increased friction) or with concomitant ulcerative STDs.5 In contrast, the USPSTF does not recommend screening for hepatitis C (“I” recommendation) even in individuals with high risk of infection, including MSM with or without HIV or a history of intravenous drug use.19 The ACIP does support routine vaccination for hepatitis A and B among MSM, noting increased incidence in this population.20,21
An emerging issue in preventive medicine for the MSM population is screening and immunization for HPV-related anal dysplasia. The risk of HPV-related anal carcinoma is significantly higher among MSM compared with the general population, with estimates of incidence ranging between 12.5 and 36.5 cases per 100,000 in the HIV-uninfected population, and up to 137 cases per 100,000 in the HIV-infected MSM population.22 The cost-effectiveness of screening with annual anal cytology with subsequent high-resolution anoscopy for positive results in HIV-infected MSM was estimated at $16,600 per quality-adjusted life-year saved,23 with a higher incremental cost for HIV-negative MSM. Current CDC guidelines state that screening for anal cytologic abnormalities can be considered, although the practice is not formally recommended due to limited evidence regarding the natural history of anal intraepithelial neoplasia, reliability of screening methods, safety and response to treatments, and necessary programmatic support.5
Ultimately, anal cytologic screening may become unnecessary, if wider use of HPV vaccination results in increased herd immunity. A cost-effectiveness analysis estimated the cost of HPV vaccination for MSM at $15,290 per quality-adjusted life-year gained if vaccinated at the age of 12 years and $19,470 if vaccinated at the age of 20 years.24 Following recent evidence demonstrating high vaccine efficacy for the prevention of HPV-associated anal intraepithelial neoplasia in MSM aged 16 to 26 years,25 the ACIP has now recommended routine quadrivalent HPV immunization in boys aged 11 to 12 years, with catch-up immunization up to age of 21 years and an option to immunize as early as age 9 or as late as age 26.26 Although the ACIP has now recommended routine HPV vaccination for young men, it is not known whether vaccination of older MSM is cost-effective. In the interim, further studies of the optimal intervals for anal cytologic screening of MSM are needed.
MSM have increased risks of HIV and other sexually transmitted infections. Clearly, better representative data are needed regarding preventive health interventions in this population to reach USPSTF level A and B evidentiary criteria. We agree with the conclusions of the 2011 Institute of Medicine report, which provides an initial framework to address these issues, recommending collecting data on sexual orientation and gender identity in health surveys administered by the Department of Health and Human Services, as well as advocating for the National Institutes of Health to support methodological research regarding sexual minorities, to establish a research training program to raise awareness of gender and sexual minority health issues, and to encourage researchers to include these populations in their studies.4
The complex, overlapping, and evolving transmission dynamics among sexually transmitted infections, many of which are increasing in incidence among MSM, should lead to an aggressive preventive approach in this population. The PPACA may well improve several aspects of care for MSM, including better access to healthcare coverage, which cannot be biased against preexisting conditions, mental health conditions, or substance abuse, as well as by encouraging integrated care and providing increased resources for community health centers. However, certain CDC-recommended preventive screenings will continue to lack mandated coverage under the PPACA, particularly for gonorrhea, chlamydia, and hepatitis C, which do not currently meet evidentiary criteria for USPSTF class A or B recommendations. Although broadening the range of covered preventive services would require new legislation, awareness of these limitations is important for providers caring for this population. Representative, population-based research in MSM, as outlined in the Institute of Medicine report, is also urgently needed to investigate efficacy and cost-effectiveness of these screening measures, both to improve the evidence-based care we provide for this population and to provide an evidentiary framework for future USPSTF recommendations.
1. The Patient Protection and Affordable Care Act, Pub.L. No. 111–148,124 Stat. 119 (March 23, 2010).
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