Keeping Gay Men Healthy
Richard S. Ferri, ANP, PhD, ACRN, FAAN

Health promotion for gay men is an important and growing clinical component of primary healthcare. Simply put, gay health is not just about AIDS anymore. Gay male health issues need to be addressed by all primary care providers, with an emphasis on primary prevention.

Self-identified gay men and men who have sex with men (MSM) have certain healthcare issues of special concern to them, such as infection with the human immunodeficiency virus (HIV), hepatitis, and anal carcinoma. They also face a variety of health problems common to all men, such as prostate and testicular cancers.

HIV Infection

Infection with the human immunodeficiency virus (HIV) remains a major health issue for all Americans. The Centers for Disease Control and Prevention has announced that the number of AIDS cases was up by 8% in 2001. This increase in newly infected people may signal that some people are not taking the threat of HIV disease seriously.¹ Gay men and MSM are nine times more likely to become infected with HIV than their heterosexual counterparts. In black and Latino communities, MSM are twice as likely to acquire HIV infection than whites.²

In addition to HIV disease, the rates of certain sexually transmitted diseases (STDs) are also on the rise. Approximately five million new cases of Trichomonas vaginalis occur in the US annually. Researchers believe that infection with T. vaginalis is an emerging factor in amplifying HIV transmission in both HIV positive and negative individuals. HIV shedding increases in HIV positive people coinfected with T. vaginalis. In HIV negative people, the potential portal of entry for HIV increases twofold when they’re infected with T. vaginalis. Additionally, since most individuals infected with T. vaginalis have little or no clinical symptoms, they may remain sexually active while infected.³

Finally the increased use of recreational or “party drugs,” such as Ecstasy, amal nitrate (poppers), and methamphetamines (crystal meth), influence unsafe sexual behaviors in HIV-positive gay men and MSM.⁴

The CDC is now recommending that all gay men and MSM be screened annually for a variety of STDs, including infection with HIV. Vaccination against hepatitis A and B is also recommended.⁵

Anal Cancer

One of the more pressing issues for gay men and MSM is anal carcinoma. Several recent studies have indicated that the rate of anal dysplasiais is on the increase in both HIV-positive and HIV-negative men. Ninety percent of HIV-positive men carry the human papilloma virus (HPV), while 65% of HIV-negative men have HPV. A significant portion of gay men have HPV type 16, the most troublesome for developing precursors to cancer.

Gay men and MSM should have an anal Pap smear each year to screen for disease. More frequent screening may be required if anal dysplasia is present or HIV disease is advanced.

Tobacco Abuse

Smoking continues to plague the gay community. Several research studies indicate that nearly 50 of gay men smoke whereas this rate is around 20% of the general public. There are few interventions that are designed to help gay men with tobacco abuse.⁷ The hazards of cigarette smoking have been well documented in the literature. However, for those who are HIV positive and develop significant cardiovascular disease from AIDS-treating medications, the need to curtail smoking in this cohort is paramount.

Hepatitis

All forms of hepatitis remain a major health concern for gay men. However, the rate of hepatitis C (HCV) is skyrocketing in the US. Nearly four million Americans — or 1.8% of the US population — are infected with HCV, and it kills an estimated 8,000 to 10,000 people per year.⁸ HCV infection rates are high in HIV-positive persons, and annual HCV screening for the disease is now recommended.

Domestic Violence

Domestic violence is dramatically underreported in the gay community. Most providers assume that in same-sex relationships violence is not issue, since anything that would occur would be a “fair fight among equals.”⁹ This is a myth that needs to be dispelled. Domestic violence is about power and control, and it does not have to be initiated by the physically stronger partner. While the true epidemiology of same-sex domestic violence is hard to quantify, several studies have indicated it may be as high as 50% in certain segments of the gay male population.¹⁰

Providing comprehensive care and health promotion for gay men requires specialized knowledge and the ability to talk about issues in a nonjudgmental manner. It is important to make all patients — especially those of a sexual minority — feel welcome and included in a clinical practice setting. Incorporating health promotion for gay men into routine clinical practice is essential for the delivery of comprehensive healthcare.

Richard S. Ferri, ANP, PhD, ACRN, FAAN, is managing editor of NUMEDX.com and a HIV/hepatitis nurse practitioner in private practice in Provincetown, MA. For more information please visit www.RichardFerri.com.

References

1. Linley L, Withum D, Weinstock H, Mei J, Bell K, Royalty J, Miller M. Using STARHS to Estimate HIV-1 Incidence Among Patients Attending STD Clinics in Selected U.S. Cities, 1997-1999. The XIV International AIDS Conference website. Available at: www.aids2002.com/Program/ViewAbstract.asp? id=/T-CMS_Content/Abstract/200206290750461580.xml. Accessed August 14, 2003.

2. Borenstein S. Early figures show AIDS on rise again. Detroit Free Press website. Available at: www.freep.com/ news/health/aids4_20020104.htm. Accessed August 13, 2002.

3 Sorvillo F, Smith L, Kerndt P, Ash L.Trichomonas vaginalis, HIV, and African-Americans. Emerg Infect Dis. 2001;7(6):927-932

4. Ekstrand ML, Crosby GM, Paul J, Martin J, Bangsberg D, Stall RD. HIV+ gay men taking ART are more likely to have unprotected sex with discordant partners when using “party drugs” AIDS Research Institute website. Available at: http://ari.ucsf.edu/posters.htm. Accessed August 14, 2003.

5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(no RR-6):1-79

6.Palefsky JM, Holly EA, Rolston MI, Arthur SP, Jay N, Berry JM, et al. Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men: prevalence and risk factors. J AIDS Human Retrovirus. 1998;177: 320-26.

7. Stall RD, Greenwood GL, Acree M, Paul J, Coates TJ. Cigarette smoking among gay and bisexual men. Am J Public Health. 1999; 89(12):1875-1878

8. Staples CT, Rimland D, Dudas D. Hepatitis C in the HIV (human immunodeficiency virus) Atlanta V.A. (Veterans Affairs Medical Center) cohort study (HAVACS): the effect of coinfection on survival. Clin Infect Dis. 1999;29:150-154.

9. Lynch MA, Ferri RS. Health needs of lesbian women and gay men. Clinician Rev. 1997;7:85-117

10. Ferri RS. Domestic violence in same-sex couples: Epidemiology, assessment, and intervention. Top Emerg Med. 1998; 20(4), 30-39.