Prevention in Focus

Fall 2015 

Views from the front lines: Sexually transmitted infections and gay men

We spoke to three service providers to find their views and approaches to the issues related to the rising rates of sexually transmitted infections (STIs) in gay men:

Jody Jollimore

Within your organization, what are you doing to address the rising rates of STIs among gay men?

Health Initiative for Men (HIM) has a number of harm reduction initiatives focused on STIs. The most concrete example is our interagency collaboration on syphilis. This initiative was spearheaded by our local health authority, who brought together a number of agencies across Vancouver to discuss the rising rates of syphilis among gay men – which are at a 30-year high – and discuss what we can do about it. We recognized that while a lot of emphasis goes in to HIV testing, many people are not being routinely tested for STIs, including syphilis. In response, this group launched a campaign called What’s Trending in Vancouver. We have launched the campaign twice already.

A more recent STI campaign that we led is the human papillomavirus (HPV) #Get Guarded campaign, which promotes knowledge and uptake of the Gardasil vaccine, how to access it, and the risks associated with HPV.

HIM also leads extensive health promotion programming with gay and bisexual men in the city, which all integrate STIs in some way. We have our online risk calculator where people can read about STIs. We also provide five clinics across the city that have low-barrier access, where gay and bi guys can  get services in the communities where they live or hang out, provided by local volunteers and nurses who are often gay men as well. By engaging gay and gay-knowledgeable staff and volunteers, we are able to avoid some of the issues that were raised in the article The (re)emergence of STIs among MSM: Why does it matter and what can be done? about providers not knowing what questions to ask or where to swab for STIs – our people have a lot of knowledge of and comfort with gay lives. 

Current STI testing and screening efforts are often inadequate. Healthcare providers do not always offer STI testing to gay men, and among those who do, testing is often focused only on the penis, not areas such as the throat and rectum. What can we do to improve current STI testing and screening efforts among Canadian healthcare providers?

Providers – we have to start with the providers. While there are many healthcare providers who are extremely well trained in testing gay men for a number of STIs,  and who know how and where to swab, this isn’t the case for everyone. Many healthcare providers outside the usual gay testing venues admit to a lack of cultural competency, which provides a barrier to appropriate care. In B.C., all public health nurses have to go through an STI certification course, which brings nurses up to speed on the needs of gay men. However, there is not an equivalent physician education program. It is not that doctors who lack this cultural competency are unable to provide the care; it is that some are uncomfortable asking the right questions to find out what care is even required. We need to give physicians the right tools to be able to do this.

HIM is working with Vancouver Coastal Health to make this happen. Together, we are developing a physician continuing medical education (CME) course to develop competencies in the things that we are talking about right now. It will not only give these physicians knowledge about factors impacting gay men’s health like STIs and mental health,  but also the competency to ask the right questions and to understand gay men’s needs.

The lack of cultural competency is a structural issue and we need to focus our efforts on the medical training colleges and divisions of family practice. We need to make sure that STI training is up-to-date and that we design education to help doctors start to feel comfortable with asking questions about gay men.

Doctors need to get comfortable asking a pretty simple question: “Do you have sex with men, women, or both?”

As the new biomedical prevention technologies such as treatment as prevention and pre-exposure prophylaxis (PrEP) don’t rely on condoms exclusively, how do you think this will affect your prevention services and programs for gay men?

This is an opportunity! Guys who are on HIV treatment and guys taking PrEP have a link to the healthcare system every three months – this is an opportunity to test guys every three months and provide necessary supports and counselling. We need to consider the integration of STI testing into the HIV testing system in general and this is a good place to focus.  Yes, these biomedical interventions may increase condomless sex, but they also provide an opportunity for more testing and more conversations about STIs and health.

This leads me to another point: I think we as gay men need to start talking about the number of partners we have and how that can have an impact on STI rates. Some guys enjoy having lots of partners, and that’s great, but some other gay men may feel pressured or are socialized to have many partners. Some gay men seek out sex as a means of coping with isolation or depression. Vulnerable men should have access to supports other than sexual networking sites. Maybe we need to spend time looking at that. I am not the sex police! Sex pigs are great! But not all guys are like this and we don’t talk about  the fact that for some gay men, high partner turn-over is the result of something else going on, not simply the desire to fuck a lot. This is not about telling guys that they have to have fewer partners. It’s about the guys who want to have fewer partners and supporting them around that. Do some guys need more help around relationships? Or is it about mental health and trauma? We need to think about this and not lump all gay men into the same boat when it comes to motivations for sex and partners. This should be considered in our prevention services and programs for gay men.

Mark Randall

Within your organization, what are you doing to address the rising rates of STIs among gay men?

HIV Community Link has an MSM-specific program called HEAT (HIV Education and Awareness Today). This program speaks directly to gay, bi and other men who have sex with men and is starting to identify the needs for trans men. All of HIV Community Link’s work comes from a full blood-borne pathogen and sexually-transmitted infection strategy and HEAT fully integrates STI prevention and education into our work. We work a lot online – via mobile and online hook-up apps and sites. Guys are just hooking up so much more online. While we still do bar and bathhouse outreach, guys just aren’t attending bars and baths in the same frequency as they used to.

Many of our programs are delivered to community in partnership with other organizations from the city. One of our in-person programs that is really effective in addressing STIs among gay men is a partnership with Safeworks, the harm reduction team in Calgary. Together, we go to the bathhouse to provide health services to gay, bi and other MSM. Safeworks does full STI testing, including throat and rectal swabs, rapid point-of-care testing for HIV, and hepatitis C testing in the bathhouse, along with flu shots and hepatitis A and B vaccinations. My role is to provide education, counselling and support to guys who access the health services. I often find that guys want to talk to me about things including but beyond HIV and STIs. People want to talk about intersecting men’s health concerns around mental health, addictions, poverty, homelessness, cheating and relationships, culture and religion. These conversations are connected with HIV and STI prevention, but address other aspects of people’s lives.

Current STI testing and screening efforts are often inadequate. Healthcare providers do not always offer STI testing to gay men, and among those who do, testing is often focused only on the penis, not areas such as the throat and rectum. What can we do to improve current STI testing and screening efforts among Canadian healthcare providers?

I think that a great example of how to improve current STI testing and screening efforts is Health Initiative for Men (HIM) in Vancouver. Not only does HIM address the whole person, not just the sex that gay guys have, they also have gay volunteers and healthcare providers in gay centres. In these centres, guys can come to learn more about HIV and STIs, but also build community with other gay guys. They connect with clinical services through a community

My wish is that every city would have a clinic focused on gay men’s health – or at least have something that is culturally competent and asks men the right questions when they come in to a health centre. I mean, most men don’t talk to their family doctors. What a huge missed opportunity to connect with gay, bi and other MSM and address rising rates of STIs! Having service providers ask everyone “are you having sex with men, women or both?” and “how do you identify?” could change things enormously. The Canadian Medical Association needs to create focused educational tools to help healthcare providers engage with men around their health broadly.

As the new biomedical prevention technologies such as treatment as prevention and pre-exposure prophylaxis (PrEP) don’t rely on condoms exclusively, how do you think this will affect your prevention services and programs for gay men?

This is complex. The work has become more complex with these advances. First, to be clear about our position: HIV Community Link has posted a community position statement in favour of PrEP.  We know that given PrEP and other prevention strategies, guys are not always using condoms. Recognizing that people often have very good, considered, personal reasons for not using condoms is really important for our prevention work.  I recognize that condom use is important, but I come from an “every tool in the tool box has value” approach. All forms of HIV risk reduction and prevention are important.

As a gay man living with HIV and as the HEAT worker, I won’t totally step back from condoms. They are still most effective in reducing risk of HIV and STIs. However, I acknowledge that condom use is not always an option for all men who have sex with men, for whatever reason. So with that, I have to round out my messaging and information to include all tools in the toolbox. For my work, I always recommend guys to have conversations with people they are hooking up with, think about what you are doing and the risks. And if you are taking risks, just at least get tested every three months!

Patrick O’Byrne

Within your organization, what are you doing to address the rising rates of STIs among gay men?

GayZone, an outreach clinic of the Ottawa Sexual Health Centre, is an intervention that was designed specifically for this purpose. This clinic brings together a series of service providers – clinical, social and community – to provide services to gay men that go beyond sexual health and look at other factors that influence sexual health. Yes, a huge part of GayZone is testing for STIs, which is a critical part of addressing the rising rates among gay men, but the other part is broader health. Programs that influence these other factors, such as yoga, book clubs and community fairs, which give guys a space to meet and make friends in a non-sexualized space, are also really important. GayZone moves past compartmentalizing sexual health and focuses on how varying aspects of life are interrelated. The GayZone clinic where I work is striving to increase the number of guys who access testing by streamlining services so we see as many people as possible, which is one piece of the puzzle.

Current STI testing and screening efforts are often inadequate. Healthcare providers do not always offer STI testing to gay men, and among those who do, testing is often focused only on the penis, not areas such as the throat and rectum. What can we do to improve current STI testing and screening efforts among Canadian healthcare providers?

Enhancing testing among primary care providers, such as family doctors and nurse practitioners, is really important. We need to move beyond silos in health care and support primary care providers to address multiple health factors including and beyond sexual health. To support this, we need better training for primary care providers. Yes, many providers in Ottawa refer guys to GayZone, but the rest of the providers need to be trained to provide this care, to see it as their role and to be comfortable providing it. We have to work together to address this issue. 

As for the issues around infections beyond the penis – or extra-genital infection as it is called – it’s a great point. Rectal and throat swabs can diagnose a lot of STIs and should be used. However, providers have to understand that they have terrible sensitivity, meaning that the percentage of guys who have STIs who are correctly identified as having an STI with a swab is relatively low. For example, rapid HIV testing has a sensitivity of 99%. The sensitivity of throat or rectal swabs is only 50%, meaning that you miss about half of the guys who have STIs! There is no question in my mind that we need throat and rectal swabbing and primary care providers need to be trained for this. However, providers need to understand the limitations.

One solution to address this issue is the use of nucleic acid amplification testing (NAAT) for extra-genital STIs. Swabbing is a lot of work (and all for a test that we know is not that good). We need to push for Health Canada to approve NAAT and local public health labs need to establish lab protocols. Community-based service providers can help by raising awareness and keeping it on the agenda among the laboratory service specialists. Collectively, we can lobby to try move this forward.

In the meantime, providers should consider the low sensitivity of swabbing when deciding on treatment for STIs. If they suspect that the person has chlamydia (if their partner has chlamydia, for example) but the swab is negative, think about the sensitivity of the test. Think about treating empirically even in the absence of the positive swab.   

As the new biomedical prevention technologies such as treatment as prevention and pre-exposure prophylaxis (PrEP) don’t rely on condoms exclusively, how do you think this will affect your prevention services and programs for gay men?

Providers need to be aware of PrEP and PEP and be prepared to talk to their patients about it. Some STI clinics should consider making PrEP and PEP available and their own role in biomedical prevention strategies. PrEP requires a lot more follow up than most STI sexual health clinics can provide. STI clinics need to consider expanding to provide these services or establish partnerships with providers who already do. These changes will make us work together more. Putting prevention and testing services in one place and care and treatment in another may be a thing of the past.

For providers who offer or counsel on PrEP, PEP and sexual health, we need to consider that these technologies work very well when the patient does not have a secondary STI. We therefore need to ensure that gay men can routinely obtain STI services that are fast and convenient. Providers need to talk to patients about the role that STIs can have in HIV transmission and try to make STI screening very simple. Many guys just need to get in and get out and carry on.

The Ottawa Sexual Health Centre, which is open to everyone, piloted an initiative to provide “express testing” for this reason. Having demonstrated its feasibility, we started to implement it at GayZone. For guys who are visiting our clinic for routine screening, we have removed many of the extraneous services that they may not actually need. They fill out the risk profile in the waiting room, the provider reviews it, takes the blood and swab and the patient can be on his way. This is not for everyone, but for those seeking routine screening, we think that this works really well. The patients seem happy, we are finding infections (for example, we have a 4.5% positivity rate for chlamydia) and we have benefited by reducing the time that the clinician spends with these patients. On average, express testing reduces clinician time by 15 minutes per patient, meaning that without hiring more staff, without expanding anything, this has expanded the clinical hours we have by 300 – meaning that we can see, screen, counsel and treat more people.

Related article

For more detailed information on STIs and gay men, see The (re)emergence of STIs among MSM: Why does it matter and what can be done?