Sexual risk behaviour and sexually transmitted infections in men who have sex with men

INTRODUCTION

“Men who have sex with men” and the corresponding acronym “MSM” refers to all men who engage in sexual and/or romantic relations with other men or who experience sexual attraction towards the same sex.¹ The term “MSM” is inclusive of both variety of patterns of sexual behaviour by males with members of the same sex, and of diverse self-determined sexual identities and forms of sexual and social associations (“communities”).

MSM can include men who identify as gay or bisexual, transgender men who have sex with men, and men who identify as heterosexual. Some men who have sex with men also form relationships with, or are married to, women. Some men sell sex to other men, regardless of their sexual identity. Some men who have sex with men do not associate themselves with any particular identity, community or terminology.

Sexual roles may vary without regard to one’s sexual identity or primary orientation. MSM have been broadly categorised into various subgroups such as; kothis (effeminate men, predominantly the receptors in anal/oral sex with men); panthis (masculine, predominantly take insertive role in anal/oral sex with men); double-deckers (both receptor and penetrator in sexual relations with males); bisexual men and hijras (male to female transgenders).^2-4

Despite of the diversity in their identities and experiences, many MSM do share common experiences of social exclusion, marginalization, stigma, discrimination or violence - are associated with increased sexual risk behaviour. They may also have common experiences of support, affinity, friendship, love and community.

Sexually transmitted infections (STIs) among MSM are relatively higher than among heterosexual men and women. STIs can often be asymptomatic; they should be routinely screened for STIs, even in the absence of any physical complaints or symptoms.

In India the estimated MSM population is around 352, 000, among that 4.3% are living with human immunodeficiency virus (HIV), of whom around 65% are aware of their status. HIV prevalence among MSM varies between areas, high in Maharashtra (4.9%) and Andhra Pradesh and Telangana (10%) and in newer emerging pockets in Gujarat and Goa (6.8%), West Bengal, Jharkhand and Orissa (6.7%).⁵ Condom use remains moderate by MSM, at last sex with casual or male or hijra partner was 85.7%, but consistent condom use was 54.3%. Nearly 50% of MSM indicated they currently have a female partner and less than half of them used condom with female partner at last sex. Meanwhile, 78.1% of MSM have ever tested for HIV.⁶

In September 2018, India’s Supreme Court decriminalised homosexuality between consenting adults. The ruling overturned Section 377, a British pre-colonial era law that banned ‘carnal intercourse against the order of nature’ and carried a maximum jail sentence of 10 years. To date this law meant that HIV services were out of reach for men who have sex with men. The decision overturned a ruling made by the Supreme Court in 2013 that reinstated section 377, having previously suspended it in 2009.

Aims and objectives

The aims and objectives of the study was to determine the trends of sexual behaviour and the pattern of STIs in men who have sex with men.

METHODS

A retrospective chart review of the data collected from the clinical records of all male patients with homosexual or bisexual behaviour who had attended the STI clinic of Kilpauk Medical College, Chennai, Tamil Nadu, during the three year study period, from July 2016 to June 2019. Demographic data, STIs diagnosed based on the clinical finding and available lab tests like Gram stain, Tzanck smear, wet mount, potassium hydroxide (KOH) examination, dark field microscopic examination and serology was computed and analyzed. STIs were categorized in different syndromes as depicted by the National AIDS Control Organization in the syndromic management of STIs. Sexual behaviour of the clients like age of onset of sexual activity, type of sex, condom usage and sex after alcohol of the MSM patients were analyzed. All male patients who had attended the STI clinic, including direct walk-in clients and clients referred by NGOs, with homosexual or bisexual behaviour during the three-year study period were included. All male patients who denied history of homosexual behaviour and all female patients were excluded from the study. The data collected were computed and analyzed statistically. This study was approved by our institutional ethical committee.

RESULTS

A total of 489 MSM had attended the STI clinic during the study period of 3 years from July 2016 to June 2019. The socio-demographic characteristics are shown in Table 1. The common age group was 21 to 30 years; around 85.5% clients are between 21 to 40 years. 94% were literate and more than half of them 62.8% had at least secondary-level school education. Majority (89.6%) were employed in an occupation but most of them were (58.7%) were working as unskilled labourers. 60.7% of the MSM were unmarried and 35.6% were married and currently living with their female partners.

Almost half of the MSM (51.9%) were bisexuals, reported to ever have had sex with a female partner and 48.1% were homosexuals. Sexual debut was most commonly seen in age group of 16 to 20 years in 41.5%. Oral sex alone was practised by 30.5%, anal sex alone by 22.9% and both by 46.6%. Exclusive active sex (insertive partner –panthis) was seen in 50.7%, exclusive passive sex (receptive partner –kothis) was seen in 15.8% and both were seen in 33.5%. Condom less sex was seen in majority, more than half of the MSM (53%). Consistent condom usage was seen in only 18.2% and 28.8% had inconsistent condom usage. Sex after alcohol was seen in 36.6% of the MSM (Table 2).

STIs were seen in 20.9% of the MSM and 1.4% of them were found to be HIV positive. Syphilis was the most commonly seen STI in10.8% of the MSM. Primary chancre in 2.0%, secondary syphilis in 2.5% and latent syphilis in 6.3% of MSM were seen. Other STIs commonly seen were genital wart in 3.5%, genital herpes in 3.1% and urethral discharge in 2.0% (Table 3).

The clinically diagnosed STIs were confirmed with appropriate laboratory investigations. All the patients with secondary and latent syphilis had reactive RPR (rapid plasma reagin) test, the titers ranging from 1:8 to 1:64 and in primary syphilis, the diagnosis was established by dark field microscopic examination of the smears taken from the ulcers. Multinucleate giant cells were demonstrated in the Tzanck smear done in all the 15 patients with genital herpes. Urethral discharge, seen in 10 patients, was confirmed by the presence of more than 5 polymorphonuclear leukocytes (PMNLs) per high power field microscopy and/or Gram-negative intracellular diplococcic in the Gram stained urethral secretions.

DISCUSSION

The incidence of many STIs in MSM including primary and secondary syphilis and antimicrobial-resistant gonorrhea is greater than that reported in women and men who have sex with women only.⁷ In addition to the negative effects of untreated STIs, elevated STI burden is of concern because it may indicate high risk for subsequent HIV infection. Annual increases in reported sexually transmitted diseases cases could reflect increased frequency of behaviours that transmit both STIs and HIV (e.g., condomless anal sex), and having an STI increases the risk of acquisition or transmission of HIV.

According to the Centers for Disease Control and Prevention estimates, HIV and early syphilis rates among homosexual men are more than 40 times higher than those among heterosexuals.^7-9 The relatively high incidence of STIs among MSM may be related to multiple factors, including individual behaviours and sexual network characteristics. The number of lifetime or recent sex partners, rate of partner exchange, and frequency of condomless sex each influence an individual’s probability of exposure to STIs. However, MSM network characteristics such as high prevalence of STIs, interconnectedness and concurrency of sex partners, and possibly limited access to healthcare also affect the risk of acquiring an STI.

This study shows that socio-demographic characteristics and sexual behaviour of MSM correlate well with the other studies from India, done by Silan et al, Setia et al, Brahmam et al and Garg et al.^10-13 The maximum number of MSM belonged to the age group 21 to 30 years; majority of them were unmarried, finished secondary level of school education and were employed as unskilled labourers.

It was noted that a little more than half of the MSM were bisexuals (51.9%) and the rest were homosexuals (48.1%). In our study, it was found that under the age of 20 years of age, 61.3% of MSM had coital debut. Oral sex was practiced by more than two-third (77.1%) of MSM, anal sex by 69.5% and both oral and anal sex by 46.6%.

In the present study exclusive active sex (panthis- 50.7%) was found to be more than the exclusive receptive sex (kothis-15.8%) and both (double decker) were 33.5%.

Majority of the MSM, more than half (53.0%) never used condom during the sexual act, consistent condom use was present only in 18.2%, less than one-fifth of MSM and inconsistent condom use was present in 28.8%, the findings were similar to the previous studies by Setia et al and Brahmam et al.^11,12 Condom usage found to be less with oral sex as they believed, unprotected oral sex was safe. In our study, the common reason for not using condom, were non-availability of condom, partner objection and reduced sexual pleasure. The other reasons were that they did not consider condom was necessary, the place was inappropriate, lack of awareness about condom and sex after alcohol.

STIs were seen in 20.9% of the MSM and syphilis was the most common STI present in 10.8%, which is comparable with the study done by Garg et al.¹³ Of a total of 53 patients with syphilis, 10 had primary syphilis, 12 had secondary syphilis and 31 were identified as latent syphilis during routine rapid plasma reagin screening. Genital wart was the next common STI seen in 3.5% of patients. 3.1% patients presented with genital herpes and urethral discharge in 2.0%. HIV serology was positive in 7 (1.4%) of patients.

CONCLUSION

Our study elucidated the high prevalence of STIs among MSM and increasing trends of sexual risk behaviour. Health service providers must take necessary steps to improve the provision of biological and medical measures to screen, treat and prevent infections.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people:Recommendations for a public health approach. World Health Organization, United Nations Joint Programme on HIV/AIDS, German Federal Ministry for Economic Cooperation and Development, The Global Forum on MSM & HIV, United Nations Development Programme; 2011. Availble at: http://whqlibdoc.who.int/publications/2011/9789241501750_eng.pdf. Accessed on 3 November 2019.
2. 2. Setia MS, Brassard P, Jerajani HR, B harat S, Gogate A, Kumta S, et al. Men who have sex with men in India: A systematic review of the literature. JLGBT Health Res 2008;4:51-70.
3. 3. Phillips AE, Boily MC, Lowndes CM, Garnett GP, Gurav K, Ramesh BM, et al. Sexual identity and its contribution to MSM risk behaviour in Bengaluru (Bangalore), India: The results of a two-stage cluster sampling survey. J LGBT Health Res. 2008;4:111-26.
4. 4. Patel VV, Maver KH, Makondon HJ. Men who have sex with men in India: A diverse population in need of medical attention. Indian J Med Res. 2012;136(4):563-70.
5. 5. Strategic Technical Alignment for Results (Star) Process, PEPFAR India. Country Operational Plan, COP 2017. Strategic Direction Summary; 2017.
6. 6. Mid-Term Appraisal of National AIDS Control Programme, Phase IV. National AIDS Control Organization. Ministry of Health & Family Welfare. Government of India. 2016.
7. 7. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2017. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Division of STD Prevention, September 2018. Atlanta: U.S. Department of Health and Human Services. Available at: http://www.cdc.gov/std/stats09/default.htm. Accessed on 3 November 2019.
8. 8. Purcell DW, Johnson C, Lansay A, Prejean J, Stein R, Denning P, et al. Calculating disease rates for risk groups: Estimating the national population size of men who have sex with men (abstract) paper presented at: National STD Prevention Conference. Atlanta, Georgia; 2010.
9. 9. Bjekic MD, Sipetic-Grujicic SB, Vlajinac HD, Nikolic AM. Oral sex related knowledge and oral sex behavior among homosexual and heterosexual men in Belgrade: A cross-sectional study. Indian J Dermatol Venereol Leprol. 2018;84:563-8.
10. 10. Silan V, Kant S, Haldar P, Goswami K, Rai SK, Misra P. HIV risk behavior among men who have sex with men. North Am J Med Sci 2013;5:515-22.
11. 11. Setia MS, Lindan C, Jerajani HR, Kumta S, Ekstrand M, Mathur M, et al. Men who have sex with men and transgenders in Mumbai, India: an emerging risk group for STIs and HIV. Indian J Dermatol Venereol Leprol. 2006;72(6):425-31.
12. 12. Brahmam GN, Kodavalla V, Rajkumar H, Rachakulla HK, Kallam S, Myakala SP, et al. Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India. AIDS 2008;22(Suppl 5):S45-57.
13. 13. Garg T, Chander R, Jain A, Barara M. Sexually transmitted diseases among men who have sex with men: A retrospective analysis from Suraksha clinic in a tertiary care hospital. Indian J Sex Transm Dis. 2012;33:16-9.