Clinical Education Initiative Support@ceitraining.org TITLE: UPDATE ON MSM SEXUAL HEALTH Speaker: Maureen Scahill, MS NP 1/25/2017 2/10/2017
Update on MSM Sexual Health [video transcript] 00:00:08 - [Maureen] Welcome to the University of Rochester Project Echo. This is the didactic presentation originally presented on January 25th, 2017. 00:00:25 Today's presentation is an update on MSM Health, or men who have sex with other men health. I'm Maureen Scahill, I'm a nurse practitioner with University of Rochester Medical Center, in the Department of Medicine, Infectious Diseases Division, with the STD HIV program collaboration with the county health department, Monroe County, and also a member of the STD Center of Excellence. 00:00:58 I have no relevant disclosures. 00:01:01 So let's get started. The objectives for today's brief presentation is to review current screening recommendation for so-called sexually active men who have sex with men, and to review new vaccine recommendations for these men. 00:01:19 So let's talk about the screening recommendations. 00:01:25 The references used for this presentation include the CDC's STD treatment guidelines released in 2015, and they are still the current version, and the CDC recommendations for laboratory-based detection of chlamydia and gonorrhea, which was released in 2014 and referenced in the STD treatment guidelines as the current set of guidelines. 00:01:58 And it's important to note that the New York State Department of Health also endorses these CDC guidelines. So HIV screening for MSM should be at least annually, but consider every three to six months depending on risk. The recommendations for laboratory tests for HIV screening, for those whose status is unknown and regardless of condom use is an HIV antibody test, typically ELISA or EIA technology, and strongly advised that fourth generation HIV antibody ELISA tests are preferred because the fourth generation not only detect the antibody, but also antigen. And these have been available since 2014. 00:02:48 If screening tests are positive, the lab will automatically or should automatically default to other HIV tests to confirm diagnosis. For example, or that is, Western Blot or RNA testing. More screening for MSM, at least annually, but should be done every three to six depending on risk and epidemiology, and 1
regardless of HIV status and condom use. Syphilis serology to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, are manifesting a slow serologic response to appropriate prior therapy, or are serofast. So let's go over the next slide. 00:03:41 If no known history of syphilis, order a treponemal antibody test ELISA or EIA and another type is CIA. Or you can order a RPR. If either of these screens are positive, the lab should automatically default to other syphilis antibody tests to confirm the diagnosis and the test that is recommended by the CDC is the TPPA. FDA can also be used by the TPPA is the first line recommendation. A titer will be needed if starting with a TP-specific test so if you start with the ELISA or CIA and you get a positive 00:04:30 result, you will need to reflex to some other test, so that's coming up in the next slide. If there is a known history of syphilis, order RPR to guide diagnosis, treatment, treatment response, and follow up. This will allow comparisons with prior RPR's and how you can determine what prior RPR records there are, is if you don't have them on site as we do at the health department, you can contact and I strongly recommend to do so, the local health department, for New York state that would be the New York State Department of Health, Syphilis Registry information. Contact your local state, city, or county health department if you're unsure. 00:05:25 CDC-recommended screening diagnostic tests for syphilis. Since there are a few different types of tests for syphilis as illustrated in the last couple slides, the screening has become more challenging. Nontreponemal antibody test, which would be traditionally VDRL but RPR usually is done at this time. These provide a titer which can guide as note if the diagnosis, treatment, and follow-up. Treponemal or TPspecific antibody tests as noted ELISA or CIA can provide likely evidence of disease but are not adequate as a stand-alone test as already noted. The CDC has an algorithm for interpreting TP-specific or TPnonspecific tests. And the link is here. It can sometimes be complicated even with a pretty clear algorithm and this will be a good example of a time when you could call the CEI line to get guidance or help in interpreting lab results. 00:06:39 Alright so about the syphilis registry, this is how you contact them. You can go to the New York State Department of Health website and search this or you can go directly to the NYSACHO which is the New York State County Health Officials organization and they provide current information and that is endorsed by the state health department. 00:07:06 So let's talk about some other screening recommendations. Again, regardless of HIV status and condom use. At least annually, but should be done every three to six months depending on risk and epi, is a test for gonorrhea and chlamydia urethral infections in men who have had insertive intercourse during the preceding year, meaning the man has inserted his penis somewhere. And urine NAAT is preferred, a 2
little more on that in a minute. A test for gonorrhea and chlamydia rectal infection in men who have had receptive anal intercourse during the preceding year, meaning the man's rectum has been the receiver of penal sex. A test for gonorrhea pharyngeal infection in men who have had receptive oral intercourse during the preceding year and again that would mean who has had his mouth as the receiver for penal sex. And a test for chlamydial pharyngeal infection however is not recommended. Some guidelines suggest that but the CDC does not because there is no clinical significance. 00:08:22 So a little bit about the NAATs so nucleic acid amplification tests or NAATs have been available for a long time for urethral infections and cervical vaginal infections, but for extra genital sites, including the conjunctiva, the pharynx and the rectum, these have not been approved by the FDA. This is undergoing review on that level but the CD, sorry, the FDA has said that some laboratories can establish through CLIA-defined performance specifications when evaluating rectal or oropharyngeal swab specimens. Note that conjunctiva is not on that list. So there's a reference to a CDC MMWR at the bottom of the slide where you can check on that. That's in the STD treatment guidelines and if you need help with that, that is something you could call the CEI line and we could help guide you with that. And stay tuned because this may change soon. 00:09:44 Okay so those were CDC recommendations and these are not contrary to them, but they're another way to look at screening. So testing based on population statistics is recommended by many authorities, citations at the bottom of the slide. For screening MSM in all three sites, meaning the pharynx, the urethra, and the rectum, even without specific history of those sites being exposed. So that would include pharyngeal gonococcal testing, urethral gonococcal and chlamydial testing, and as noted the urine NAAT is absolutely recommended or you can do a urethral swab but to use the NAAT. And rectal gonococcal and chlamydial testing. Population statistics in case histories have shown inoculation of these sites can occur without even fully insertive or receptive activities. So for instance in our STD clinic we test all three sites on men who have sex with men even when they tell us that they for example don't perform oral sex and so the rationale is that based on epidemiology and case histories has noted there may be a need to test all three sites. 00:11:13 So let's go to vaccine updates. Vaccine recommendations by the CDC for MSM. The recommendation for viral Hepatitis A and B vaccinations have not changed. Since 1996 ACIP has recommended Hepatitis A vaccination of MSM, outbreaks among MSM have been reported frequently. And that's practically a direct quote from the CDC and then Hepatitis B vaccine has been recommended for MSM since 1982. And there are some citations on the slide for you. 00:11:51 Now as noted, this is being recorded subsequent to the original Echo Session date and as of February 7 th as a matter of fact, 2017, there were vaccine updates from CDC ACIP. These are just some images of a couple pages from a so called, sometimes they call it a pocket guide but it's a six-page reference guide 3
that shows the updates including highlighting those that have changed. So what I told you has not changed for Hepatitis A and B there were some changes for Hepatitis B but not specifically related to MSM. This is the website link to get this tool and to read the documentation of the rationale for changes. 00:12:48 So just a little bit more on Hepatitis B and MSM. A study of almost 2500 HIV positive and negative MSM in four cities across the U.S. was done and they had a follow-up of over nine years, that was the mean. At baseline only 31% of those men reported having at least one dose of Hepatitis B vaccine which at the time that this study started, the Hepatitis B vaccine had been available for over 20 years and had been a recommendation for MSM for nearly that long. So here are the summary of some of the outcome data. 151 of nearly 1800 men became HIV infected during that time obviously those are the men that entered, so that was 8.5% of the men in the study over that follow-up period of nine plus years. However, 244 of 2300 men became Hepatitis B infected and that was nearly 20% so there was much more seroconversion for Hepatitis B than there was for HIV, even though the denominators are a little different there. The point being that these were missed prevention opportunity because Hepatitis B is 95% effective and the reference is at the bottom of the slide. 00:14:29 So what about HPV, updates for MSM? HPV vaccine is recommended for all MSM regardless of HIV status and that part is new, up to the age of 26 for those who were not previously vaccinated. Young men who have sex with men whether identifying as gay or bisexual, or even if they haven't had sex with men, if they intend to have sex with men, they really need to be vaccinated. Young adults who are transgender either male to female or female to male and young adults with certain immunocompromising conditions including HIV through the age of 26 and again the reference is there. 00:15:16 And another, a newer recommendation as of 2016 is to vaccinate MSM in the United States against meningococcal disease. As you know meningococcal disease can cause severe invasive infection which can be fatal 10 to 20% of the time and for about 20% of those who do survive, there can be significant sequelae including, for example, loss of hearing. loss of limbs, neurological deficits and others. And previously there was only quadrivalent meningococcal vaccine and the serogroups were A, C, Y, and W. However, now there are two recombinant protein vaccines for serogroup two and that's part of the reason for the changes in the vaccine recommendations. And the serogroup two is the most common cause of invasive meningococcal disease outbreaks in the U.S. currently, so it was very important to develop this vaccine. As you may know that vaccine has been typically recommended for infants and men in the pre-teen vaccinations and then during outbreaks. However, over the past several years there have been reports of meningococcal outbreaks among the MSM serogroup C including New York and Chicago in 2010 through '13 and Chicago '15 and most recently in Southern California just this past year. And now there is a recognition that serogroup B has become a problem as well. Ongoing clusters or outbreaks have increased awareness of meningococcal disease cases occurring among MSM. So understanding the risk for that disease is challenging and still not clearly understood. Nevertheless, it is 4
now recommended that meningococcal vaccine be given to MSM. And there may be associations with HIV, positive status or higher-risk behaviors, sexual behaviors, but all of this is still undergoing investigation and there are references on the bottom of the slide. 00:17:46 So how is the CDC responding to these outbreaks? As already said, the ACIP recommendations support vaccination in response to these outbreaks in areas where they occur. As they do for any area that has an outbreak. So college campuses and specifically among MSM and MSM populations which cannot always be that simple to define, but for healthcare providers that have a practice that may include more MSM than some other healthcare practices. So that recommendation is in response to outbreaks for gay, bisexual, and other MSM. So gay, bisexual is an identity, other MSM maybe non-gay or bisexual identified but it's still having sex with men. Vaccination recommended in response to these clusters in New York City, Los Angeles County, and Chicago targeting MSM recommendations remain in place in these jurisdictions at this time. Current outbreak vaccine recommendations are in place for Los Angeles County and also Los Angeles, some of the other areas of Los Angeles, Orange County and San Diego. Again in response to current outbreaks. References to this information are on the bottom of the slide. 00:19:22 So a summary of the work group discussions in ACIP about meningococcal disease in men who have sex with men. This was from last year 2014, outbreaks of meningococcal disease continue to occur among MSM population. They have had higher incidence rates than non-msm in both outbreak and nonoutbreak settings, so that's a really important piece of epidemiology. In non-outbreak settings, HIV infection appears to be the main driver of increased risk but again not clear. And although reasons for outbreaks among MSM are unclear as noted, they likely include the issues of close social networks or slash sexual networks and increased number of contacts and or higher risk behaviors. Continue to vaccinate with the quadrivalent vaccine as mentioned earlier. If additional outbreaks occur and enhanced surveillance for cases of meningococcal disease in MSM and HIV infected persons is ongoing and there is a particular report form that the CDC would like you to send. The link is at the bottom of the page, there is a very small image of what the report looks like. It's basically one and a half pages and mostly check boxes and can be completed online. And the meningococcal serogroup B vaccine is also now recommended. 00:21:05 So vaccine updates for MSM, meningococcal vaccine specifically are these. For serogroups C to the age of 26 for those who were not previously vaccinated, young adults who are transgender, young adults with certain immunocompromising conditions including HIV through the age of 26. I know I've already said that, but the point here is that New York State endorses the CDC's recommendations. 00:21:32 This is a page out of the New York State Department of Health recommendations in a health alert that was sent in 2015. Excuse me 2016. Meningococcal vaccines are recommended for HIV infected and prep eligible individuals. So this is one difference from the CDC guidelines. New York State is saying not only 5
for those who are HIV infected which the CDC has said, but also for those who are PrEP eligible, even if they're not yet on PrEP. So here is a list of specifics related to children and adults who are HIV positive but then I've highlighted this one area that says MSM and transgender individuals who are candidates for prep should receive one dose of the quadrivalent vaccine and if these individuals remain at high risk for HIV infection for a prolonged period of time, then a booster should be given every five years as long as that risk continues. Booster recommendations are not new, that continues to be in place for anybody that should receive meningococcal vaccine, but specifically this is what New York State is saying about MSM and trans individuals who are candidates for prep even if they're not yet taking it. 00:23:13 Here are some additional references. This is a reminder for contacting the CEI line, the number is here and you can contact as a clinician for any kind of questions regarding HIV, Hepatitis C, STD, post exposure, and pre exposure, HIV prophylaxes and in all cases you will be connected with a STD or HIV or viral Hepatitis clinical specialist who will answer your question often in real time and can then help you with follow-up so please don't hesitate to use that line. 00:23:59 And that is the end of the didactic portion for the January 25th, 2017 Echo, thank you. [End Video] 6