The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia

Abstract

Data reporting sexually transmitted infection (STI) incidence rates among HIV-negative U.S. men who have sex with men (MSM) are lacking. In addition, it is difficult to analyze the effect of STI on HIV acquisition given that sexual risk behaviors confound the relationship between bacterial STIs and incident HIV. The InvolveMENt study was a longitudinal cohort of black and white HIV-negative, sexually active MSM in Atlanta who underwent routine screening for STI and HIV and completed behavioral questionnaires. Age-adjusted incidence rates were calculated for urethral and rectal Chlamydia (CT), gonorrhea (GC), and syphilis, stratified by race. Propensity-score-weighted Cox proportional hazards models were used to estimate the effect of STI on HIV incidence and calculate the population attributable fraction (PAF) for STI. We included 562 HIV-negative MSM with 843 person-years of follow-up in this analysis. High incidence rates were documented for all STIs, particularly among black MSM. Having a rectal STI was significantly associated with subsequent HIV incidence in adjusted analyses (aHR 2.7; 95% CI 1.2, 6.4) that controlled for behavioral risk factors associated with STI and HIV using propensity score weights. The PAF for rectal STI was 14.6 (95% CI 6.8, 31.4). The high incidence of STIs among Atlanta MSM and the association of rectal STI with HIV acquisition after controlling for behavioral risk underscore the importance of routine screening and treatment for STIs among sexually active MSM. Our data support targeting intensive HIV prevention interventions, such as preexposure chemoprophylaxis (PrEP), for Atlanta MSM diagnosed with rectal STIs.

HIV Incidence Among Men Who Have Sex With Men After Diagnosis With Sexually Transmitted Infections

“…This population-based study supports conclusions from previous studies in clinical and research settings that MSM with rectal infections and early syphilis are at extremely high risk of subsequently acquiring HIV, though our absolute risk estimates are lower than those previously reported 19–22 . Similar to a study in New York City STD clinics 19 , we observed higher HIV incidence following rectal gonorrhea than rectal chlamydia diagnosis, but HIV incidence in both groups was greater in New York City than in Washington State (7.1 vs. 4.1 per 100 person-years for rectal gonorrhea; 5.9 vs. 1.6 for rectal chlamydial infection).…”

“…PrEP is efficacious 13 but expensive, and cost-effectiveness analyses have consistently found that it is only cost-effective when targeted to the highest risk men 14–18 . Previous studies suggest that HIV-negative MSM diagnosed with early syphilis, rectal gonorrhea, and rectal chlamydial infection may be at particularly high risk of subsequent HIV infection 19–22 . However, these studies did not estimate HIV incidence for all bacterial STIs by anatomic site or stage of infection, were limited to STD clinics or study populations, did not estimate the proportion of all HIV infections among MSM occurring in men with a recent STI diagnosis, and measured only the incidence of HIV diagnosis rather than HIV infection.…”

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

“…25,59,60 Asymptomatic bacterial sexually transmissible infections may also play a role in potentiating HIV acquisition and transmission among MSM through genital tract inflammation involving increased local density of immune cells that are at risk for acquiring HIV, ulcerations and abrasions. [61][62][63] However, beyond individual behaviours, there are other forces driving the disproportionate HIV burden among MSM (Fig. 2), including biologically mediated factors.…”

Rectal Infection WithNeisseria gonorrhoeaeandChlamydia trachomatisin Men in the United States

“…The number of patients with rectal specimens tested in this study serves as an indicator of the large numbers of men who might have engaged in unprotected anal sex, a risk behavior for acquisition of HIV infection. Several previous studies have found that men who had had rectal GC or CT infections were more likely to have newly acquired HIV infection or to be subsequently diagnosed with HIV than men who had no rectal GC or CT [3,4,15,16]. Another study also found that GC and CT infections were common in men with newly diagnosed HIV infection [17].…”