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'Gay bowel syndrome': Relic or real (and returning) phenomenon?
Abstract
This article aims to review the term 'gay bowel syndrome', including the recent research looking at increased rates of bowel infections in men who have sex with men (MSM), particularly in light of the recent Shigella outbreaks in MSM in London and New York, and considers whether 'gay bowel syndrome' is a syndrome that really exists and is worthy of further research and specific treatment, or whether the term continues to be obsolete and not useful.
Little or no recent research exists around the concept of a specific syndrome affecting the bowels of MSM. Rather, there seems to be a clustering of diseases in certain high-risk groups, especially those in urban areas with multiple sexual partners, recreational drug use, and possible concomitant HIV infection.
All healthcare practitioners (including non-sexual health/HIV specialists) need to consider careful and thorough history taking (including sexual history) to identify those at risk.
... Interest in rectal and colonic pathogens in men who have sex with men (MSM) rose in the late 1970s (just prior to the start of the HIV epidemic in the USA), with the publication of a case series by Kazal et al. [1] describing a "gay bowel syndrome" in MSM presenting with anorectal complaints. The term, which is now outdated and considered pejorative [2], did not truly describe a syndrome, but rather a list of conditions, including anorectal ulcers and proctitis/colitis, which were observed with increased frequency in MSM as compared to men who have sex with women only (MSW) [3]. Further testing revealed that these conditions were primarily caused by sexually transmitted infections (STIs) (including rectal gonorrhea, chlamydia, syphilis, herpes simplex virus, and human papillomavirus) as well as enteric pathogens (e.g., Shigella, Entamoeba histolytica, Giardia, and Campylobacter), whose transmission was related to sexual activity in MSM [4,5]. ...
Recent studies have raised interest in the possibility that dysbiosis of the gut microbiome (i.e., the communities of bacteria residing in the intestine) in HIV-infected patients could contribute to chronic immune activation, and, thus, to elevated mortality and increased risk of inflammation-related clinical diseases (e.g., stroke, cardiovascular disease, cancer, long-bone fractures, and renal dysfunction) found even in those on effective antiretroviral therapy. Yet, to date, a consistent pattern of HIV-associated dysbiosis has not been identified. What is becoming clear, however, is that status as a man who has sex with men (MSM) may profoundly impact the structure of the gut microbiota, and that this factor likely confounded many HIV-related intestinal microbiome studies. However, what factor associated with MSM status drives these gut microbiota-related changes is unclear, and what impact, if any, these changes may have on the health of MSM is unknown. In this review, we outline available data on changes in the structure of the gut microbiome in HIV, based on studies that controlled for MSM status. We then examine what is known regarding the gut microbiota in MSM, and consider possible implications for research and the health of this population. Lastly, we discuss knowledge gaps and needed future studies.
... Enteric Infections "Gay bowel disease," an outdated term coined in the 1970s to describe a constellation of perianal and rectal diseases associated with MSM patients, has been replaced with an understanding of the separate etiologies of specific gastrointestinal syndromes. 67 Proctitis, a syndrome of rectal pain, discharge, or tenesmus may be secondary to gonorrhea, chlamydia, HSV, and syphilis. Proctocolitis syndromes may involve Campylobacter, Shigella, Salmonella, Entamoeba histolytica, and Giardia lamblia, as well as cytomegalovirus in the immunocompromised patient. ...
Background:
With repeal of "Don't Ask, Don't Tell" (DADT) in 2011 and the Supreme Court decision regarding Section 3 of the Defense of Marriage Act (DOMA) in 2013, military providers are now able to openly address unique health needs of lesbian, gay, and bisexual (LGB) service members and their same-sex spouse beneficiaries. These federal laws created health care barriers, either real or perceived, between providers and patients and often limited medical research involving LGB patients in the Military Health System (MHS). Men who have sex with men (MSM), the largest proportion of LGB service members, represent a segment of the population with the highest risks for disparities in primary care with regard to sexual health and mental health disorders. We provide a review of available research about this military population, in addition to a review of specific health care needs of the MSM patient in order to aid the primary care provider with screening, testing, and counseling.
Methods:
A structured literature search was conducted to identify recent literature pertaining to health needs of U.S. military MSM service members. In addition, a review of applicable clinical guidelines, Department of Defense policies, and expert opinion was used to identify areas of particular relevance.
Findings:
There is little published to characterize the MSM population and their health needs as beneficiaries of the MHS. Only recently have directed assessments of the active-duty MSM patient population been pursued in the post-DADT, DOMA era. Unique needs of the MSM patient identified center around both sexual and mental health, disparities that are paralleled within the nonmilitary MSM population. Population-specific epidemiology driving risk for sexually transmitted illnesses, substance abuse, and mental health disorders are identified and used to inform preventive medicine recommendations for the MSM patient. In addition, resources on MSM health for the health provider are included.
Discussion/impact/recommendation:
The MHS at large now openly serves the MSM population and is making progress toward addressing their unique health needs. Despite ongoing challenges to address remaining disparities, MSM patients, beneficiaries, and primary providers are now more able to have frank, open discussions about specific health needs of this minority segment of the U.S. military without fear of reprisal.
... 3,4 In this context, MSM are more frequently diagnosed with sexually transmitted infections (STIs) compared with the general population, 5 with a concomitant higher incidence of STIrelated diseases. 5 This is usually attributed to the high number of sexual partners among MSM and frequent penetrative or receptive sex, which exposes highly receptive tissues (the anorectal mucosa, the inner surface of the foreskin and the urethral meatus [6][7][8] to potential pathogen transmission. ...
Background:
Prevalence of and severity of lower urinary tract symptoms (LUTS) according to male sexual orientation have been scantly analysed. We aimed to assess the prevalence and severity of LUTS in a cohort of Caucasian-European men who have sex with men seeking medical help for uroandrologic reasons other than LUTS.
Methods:
Data from 949 consecutive individuals in an outpatient setting were analysed. Severity of LUTS was measured with the International Prostate Symptom Score (IPSS). Men with storage symptoms scored 1-3 and ⩾4 (of 15), and voiding symptoms scored 1-4 and ⩾5 (of 20) were considered as having mild and moderate-to-severe symptoms, respectively. For individual symptoms, patients with scores ⩾1 were deemed symptomatic (according to Apostolidis et al.(15)). Descriptive statistics and logistic regression models tested the association between LUTS and sexual orientation.
Results:
Complete data were available for 213 (22.4%) men who have sex with men (MSM) and 736 (77.6%) heterosexuals (mean age (s.d.): 41.0 (12.2) vs 39.9 (12.1) years). Compared with heterosexuals, MSM reported higher rates of total IPSS scores suggestive of moderate (21.6% vs 20%) and severe LUTS (3.8% vs 2.4%) (P=0.004). Similarly, MSM showed higher rates of mild (48.8% vs 45.2%) and moderate-to-severe (39.4% vs 30.4%) storage symptoms (all P<0.001), and of mild (45.1% vs 34.8%) and moderate-to-severe (20.2% vs 19.2%) voiding symptoms (all P<0.01). MSM status was an independent predictor of mild voiding symptoms (odds ratio (OR): 1.40; P=0.004), moderate-to-severe storage symptoms (OR: 1.40; P=0.04) and severe total IPSS (OR: 1.49; P=0.03), after adjusting for other variables.
Conclusions:
These findings suggest a higher prevalence and severity of LUTS in MSM compared with heterosexual men seeking medical help for uroandrologic reasons other than LUTS.Prostate Cancer and Prostatic Diseases advance online publication, 29 September 2015; doi:10.1038/pcan.2015.41.
In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.
This chapter discusses the descriptive epidemiology of HIV; explains the pathophysiology of HIV infection and its clinical manifestations; briefly discusses important events in the medical and public health response to the HIV epidemic; reviews the impact of minority stress and intersectional vulnerabilities on the epidemic; and describes in general terms the public health and clinical approaches to prevention and treatment of HIV/AIDS. Special risk factors and barriers to treatment of HIV/AIDS in LGBTQ people are also examined.
A Brief History of Shigella, Page 1 of 2
Abstract
The history of Shigella, the causative agent of bacillary dysentery, is a long and fascinating one. This brief historical account starts with descriptions of the disease and its impact on human health from ancient time to the present. Our story of the bacterium starts just before the identification of the dysentery bacillus by Kiyoshi Shiga in 1898 and follows the scientific discoveries and principal scientists who contributed to the elucidation of Shigella pathogenesis in the first 100 years. Over the past century, Shigella has proved to be an outstanding model of an invasive bacterial pathogen and has served as a paradigm for the study of other bacterial pathogens. In addition to invasion of epithelial cells, some of those shared virulence traits include toxin production, multiple-antibiotic resistance, virulence genes encoded on plasmids and bacteriophages, global regulation of virulence genes, pathogenicity islands, intracellular motility, remodeling of host cytoskeleton, inflammation/polymorphonuclear leukocyte signaling, apoptosis induction/inhibition, and “black holes” and antivirulence genes. While there is still much to learn from studying Shigella pathogenesis, what we have learned so far has also contributed greatly to our broader understanding of bacterial pathogenesis.
Purpose of review:
Sexual transmission of enteric pathogens in men who have sex with men (MSM) has been described since the 1970s. Recently, an increasing number of enteric infection outbreaks have been reported in MSM. This article summarizes recent outbreaks and discusses the key issues for prevention and control.
Recent findings:
Sexually transmissible enteric infections (STEIs) can spread rapidly and internationally within highly connected MSM populations and are often associated with antimicrobial resistance (AMR). The infections often cluster in high-risk groups of HIV-positive MSM who are more likely to engage in diverse sexual practices and chemsex, and to have multiple other sexually transmitted infections (STIs).
Summary:
The roles of asymptomatic and/or persistent infection and other contextual factors in STEI transmission are not well described. STEI-associated AMR is increasing and has potential to spread rapidly in MSM, warranting further public health attention. A better understanding of the factors associated with sexual transmission will enable the development of more effective control measures. A holistic approach that promotes health and wellbeing as well as infection prevention and management is needed.
The cause of Crohn’s disease (CD) has posed a conundrum for at least a century. A large body of work coupled with recent technological advances in genome research have at last started to provide some of the answers. Initially this review seeks to explain and to differentiate between bowel inflammation in the primary immunodeficiencies that generally lead to very early onset diffuse bowel inflammation in humans and in animal models, and the real syndrome of CD. In the latter, a trigger, almost certainly enteric infection by one of a multitude of organisms, allows the faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. Direct investigation of patients’ inflammatory response together with genome-wide association studies (GWAS) and DNA sequencing indicate that in CD the failure of acute inflammation and the clearance of bacteria from the tissues, and from within cells, is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. In this review I will examine the contemporary evidence that has led to this understanding, and look for explanations for the recent dramatic increase in the incidence of this disease.
The cause of Crohn's disease (CD) has posed a conundrum for at least a century. A large body of work coupled with recent technological advances in genome research have at last started to provide some of the answers. Initially this review seeks to explain and to differentiate between bowel inflammation in the primary immunodeficiencies that generally lead to very early onset diffuse bowel inflammation in humans and in animal models, and the real syndrome of CD. In the latter, a trigger, almost certainly enteric infection by one of a multitude of organisms, allows the faeces access to the tissues, at which stage the response of individuals predisposed to CD is abnormal. Direct investigation of patients' inflammatory response together with genome-wide association studies (GWAS) and DNA sequencing indicate that in CD the failure of acute inflammation and the clearance of bacteria from the tissues, and from within cells, is defective. The retained faecal products result in the characteristic chronic granulomatous inflammation and adaptive immune response. In this review I will examine the contemporary evidence that has led to this understanding, and look for explanations for the recent dramatic increase in the incidence of this disease.
Hepatitis C virus (HCV) is not considered to be efficiently transmitted sexually, but since the early 2000s, HCV infection of HIV-infected men who have sex with men has emerged as an epidemic worldwide. In this review, we discuss the epidemiology of sexually transmitted acute HCV, the growing body of literature regarding risk factors for acquisition, and possible mechanisms of transmission. We also discuss the progression of liver disease in these men and the advances in therapy of acute HCV with interferon-free regimens and put forth our current approach of evaluating and treating these men in New York City.
In South Korea, men who have sex with men (MSM) are rather understudied, but are known to be at high risk for human immunodeficiency virus infection (HIV)/acquired immunodeficiency syndrome (AIDS). This study was to access HIV/AIDS knowledge, attitudes, and risk behaviors, and to identify the factors of condom use in HIV prevention.
We recruited 1070 MSM in Korea, using the Internet to maximize the confidentiality of the MSM.
The prevalence of self-reported and sexually transmitted infections and HIV in the total sample was 10.7% and 2.7%, respectively. Factual knowledge and phobias regarding HIV/AIDS and self-efficacy were relatively high among the MSM. After controlling for age, education, marital status, and sexual identity, predictors of condom use at most recent anal sex included knowledge (OR = 1.25; p < 0.0001); self-efficacy (OR = 1.33; p = 0.02), additionally, having HIV testing (OR = 1.45; p = 0.02); and having a regular partner (OR = 0.53; p < 0.0001) were also positively associated with condom use.
The intervention programs for MSM in Korea may need to take the idiosyncratic societal and cultural pressures of the region into consideration in order to reduce infection risk.
Objectives To estimate life expectancy for people with HIV undergoing treatment compared with life expectancy in the general population and to assess the impact on life expectancy of late treatment, defined as CD4 count <200 cells/mm3 at start of antiretroviral therapy.
Design Cohort study.
Setting Outpatient HIV clinics throughout the United Kingdom.
Population Adult patients from the UK Collaborative HIV Cohort (UK CHIC) Study with CD4 count ≤350 cells/mm3 at start of antiretroviral therapy in 1996-2008.
Main outcome measures Life expectancy at the exact age of 20 (the average additional years that will be lived by a person after age 20), according to the cross sectional age specific mortality rates during the study period.
Results 1248 of 17 661 eligible patients died during 91 203 person years’ follow-up. Life expectancy (standard error) at exact age 20 increased from 30.0 (1.2) to 45.8 (1.7) years from 1996-9 to 2006-8. Life expectancy was 39.5 (0.45) for male patients and 50.2 (0.45) years for female patients compared with 57.8 and 61.6 years for men and women in the general population (1996-2006). Starting antiretroviral therapy later than guidelines suggest resulted in up to 15 years’ loss of life: at age 20, life expectancy was 37.9 (1.3), 41.0 (2.2), and 53.4 (1.2) years in those starting antiretroviral therapy with CD4 count <100, 100-199, and 200-350 cells/mm3, respectively.
Conclusions Life expectancy in people treated for HIV infection has increased by over 15 years during 1996-2008, but is still about 13 years less than that of the UK population. The higher life expectancy in women is magnified in those with HIV. Earlier diagnosis and subsequent timely treatment with antiretroviral therapy might increase life expectancy.
At the beginning of a new millennium, syphilis incidence has been increasing worldwide, occurring primarily among men who have sex with men (MSM). The clinical features of primary syphilis among MSM is described, a case-note review of the primary syphilis (PS) patients who attended the Institute of Skin and Venereal Diseases. The diagnosis was assessed based upon the clinical features and positive syphilis serology tests. Among 25 patients with early syphilis referred during 2010, PS was diagnosed in a total of 13 cases. In all patients, unprotected oral sex was the only possible route of transmission, and two out of 13 patients had HIV co-infection. Overall, 77% of men presented with atypical penile manifestation. The VDRL test was positive with low titers. The numerous atypical clinical presentations of PS emphasize the importance of continuing education of non-experienced physicians, especially in countries with lower reported incidence of syphilis.
HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA.
We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA.
We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is present.
HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden sexual risk behaviors in a region where quality behavioral data are limited.
Recognition of sexual behaviours and needs is essential for all doctors in diagnosis, care after major illness, and humane management of social needs. The majority of adults are heterosexually active from adolescence into old age, while a minority of individuals have homosexual relationships throughout their lives, or during shorter periods. Among adults aged 16-44 years, a third of men and a fifth of women report a new partnership in the past year, and this proportion is higher among younger adults and men who have sex with men (MSM). Anal intercourse is practised by a significant minority of heterosexuals, as well as among MSM for whom it is a major route of HIV transmission. A small minority of individuals have large numbers of partners (a 'core group'), and contribute disproportionately to the transmission of STIs and HIV. Behavioural interventions to reduce sexual risk among MSM can be effective, as in other groups, but attention to wider social determinants is also important in controlling STI and HIV transmission.
The pattern of gastroenterological manifestations of HIV infection has changed greatly since the advent of combination antiretroviral therapy (cART). The previous almost inevitable viral, protozoal and fungal opportunist infections now occur only in those presenting with very low CD4 counts. The prompt institution of cART is probably the most effective treatment for such individuals and with immune restoration most such infections are eradicated, although they may need specific treatment in the first few months of cART. Improvements in understanding the pathogenesis of HIV disease intimately involve the gastrointestinal tract. It is now recognized that shortly after first acquiring the virus there is a profound and possibly irreversible loss of CD4 memory cells in the lamina propria of the gut. Translocation of bacterial antigens across the gut appears to be common in HIV infection, and is perhaps related to the loss of CD4 memory cells or a depletion in the CD17 subset of cells. Such translocation is associated with immune activation, which may result in more rapid CD4 cell loss and reduced function of the immune system.
Background:
Effective treatment of gonorrhoea is fundamental to public health control; however, the ability of Neisseria gonorrhoeae to successively develop resistance to different treatments has hampered control efforts. The extended-spectrum cephalosporins--cefixime and ceftriaxone--have been recommended in the UK for treatment of gonorrhoea since 2005. We looked at surveillance data from England and Wales to ascertain the current usefulness of these drugs and to inform changes to national treatment guidelines.
Methods:
We obtained data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) for patients attending 26 genitourinary medicine clinics in England and Wales between 2007 and 2011. We did analyses with univariate and multivariable logistic regression methods to identify trends in susceptibility to cephalosporins and risk factors associated with infection with isolates with decreased susceptibility to cefixime, and we assessed changes in prescribing practices. We did molecular typing to investigate genetic relatedness of non-susceptible isolates.
Findings:
The prevalence of decreased susceptibility to both cefixime and ceftriaxone rose between 2007 and 2010 but was more noticeable for cefixime (an increase from 1·5% in 2007 to 17·1% in 2010), with a bimodal distribution of minimum inhibitory concentration recorded between 2009 and 2010. By multivariable analysis, isolates with decreased susceptibility to cefixime were associated with infection in men who have sex with men (odds ratio 5·47, 95% CI 3·99-7·48; p<0·0001) and year of isolation (in 2010, 13·08, 7·49-22·8; p<0·0001). Such isolates had a largely clonal population, with most belonging to genogroup G1407 and harbouring the penA mosaic gene. Data from 2011 showed a significant decline in prevalence of isolates with decreased cefixime susceptibility, falling from 17·1% in 2010 to 10·8% in 2011 (p<0·0001), concomitant with the change in prescribing practice in 2010 from cefixime to ceftriaxone plus azithromycin.
Interpretation:
Guidance for treatment of gonorrhoea in England and Wales was changed in 2010 to prolong the use of cephalosporins. The decline in prevalence of isolates with decreased cefixime susceptibility cannot be attributed unequivocally to this change in prescribing practice; however, the association is striking.
Funding:
Department of Health (England), Public Health England.
Antiretroviral drugs that inhibit viral replication were expected to reduce transmission of HIV by lowering the concentration of HIV in the genital tract. In 11 of 13 observational studies, antiretroviral therapy (ART) provided to an HIV-infected index case led to greatly reduced transmission of HIV to a sexual partner. In the HPTN 052 randomised controlled trial, ART used in combination with condoms and counselling reduced HIV transmission by 96·4%. Evidence is growing that wider, earlier initiation of ART could reduce population-level incidence of HIV. However, the full benefits of this strategy will probably need universal access to very early ART and excellent adherence to treatment. Challenges to this approach are substantial. First, not all HIV-infected individuals can be located, especially people with acute and early infection who are most contagious. Second, the ability of ART to prevent HIV transmission in men who have sex with men (MSM) and people who use intravenous drugs has not been shown. Indeed, the stable or increased incidence of HIV in MSM in some communities where widespread use of ART has been established emphasises the concern that not enough is known about treatment as prevention for this crucial population. Third, although US guidelines call for immediate use of ART, such guidelines have not been embraced worldwide. Some experts do not believe that immediate or early ART is justified by present evidence, or that health-care infrastructure for this approach is sufficient. These concerns are very difficult to resolve. Ongoing community-based prospective trials of early ART are likely to help to establish the population-level benefit of ART, and-if successful-to galvanise treatment as prevention.
Background
Multiple studies have been done on adult men who have sex with men (MSM), but no studies have shown the rates of extragenital site sexually transmitted infections (STIs) among HIV positive young men who have sex with men (YMSM). The objective of this study was to document the rates of extragenital Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infection among HIV positive YMSM while conducting a validity study for the use of nucleic acid amplified tests (NAATs), to detect extragenital GC and CT.Methods
Behaviorally infected HIV positive YMSM were enrolled in this study from one urban adolescent HIV clinic, and were screened for urine and extragenital site GC and CT over a 2 year period. Samples from these sites (pharyngeal and rectal) were tested for GC and CT using both traditional culture media and NAAT technology. Urine was tested using only NAAT.ResultsOf 67 screenings, 36% (n = 24) yielded at least one positive, and 69% of participants (18/26) had at least one positive GC or CT test result during the study period. Of those with at least one positive result, 89% (16/18) had at least one extragenital site infection. Urine testing was positive in 11% (2/18) of those with a corresponding extragenital site infection. None of the extragenital CT infections detected by NAATs were detected by culture, and only 38% (5/13) of the extragenital GC infections detected by NAATs were detected by culture.Conclusions
Use of NAATs for extragenital STI screening yielded more confirmed positive results than did traditional cultures. By use of NAATs, the majority of routinely screened HIV positive YMSM in this sample was found to have an STI at an extragenital site.
‘Coming out’ is a key stage in the identity formation process for the homosexual male when the individual discloses his homosexual status to himself and others. Although previous research has indicated that homosexual men often use the Internet and computer-mediated communication (CMC) during the identity formation process to discover and develop their sexual and self-identities, studies to date have focused on their use of text-based CMC with scant attention paid to experiences within virtual worlds. This study explored whether homosexual males use virtual worlds in the sexual identity formation process and, specifically, the applicability of technoromanticism within this context. Qualitative retrospective biographical interviews were undertaken with 12 self-selected individuals who had engaged with virtual worlds before or during their sexual identity development. The CASE model (Community, Anonymity, Sexual experimentation, and Escape) was developed to characterise the key themes emerging from the data and illustrate the enactment of technoromanticism by homosexual males within virtual worlds. It is concluded that technoromanticism in virtual worlds can only have a profound impact on individuals if the individual’s personal development online is transferred offline as there is a potential to become toxically immersed and thus stall or halt the identity development process altogether.
There is increasing evidence that shigellosis is a predominantly sexually transmitted disease among men who have sex with men (MSM) and that infection with the human immunodeficiency virus (HIV) is a risk factor for shigellosis.
Retrospective analysis of antibiotic resistance profiles of Shigella species isolated from stool specimens of patients presenting with diarrhea from January 2010 to July 2012 in three German outpatient clinics specialized in HIV care.
Among 79 cases of Shigella sonnei, 56 occurred in HIV-infected MSM, while 23 were observed in HIV-negative MSM. High resistance rates (>90 %) were found for doxycycline, tetracycline, aminoglycosides, all cephalosporins of first and second generations tested, and trimethoprim/sulfamethoxazole. In total, 54 % of cases were resistant to ciprofloxacin. Compared to negative subjects, HIV-infected MSM had a significantly higher rate of quinolone resistance. For ciprofloxacin, the resistance rates were 66 versus 24 %, respectively (p = 0.0016). Individual resistance patterns did not indicate that this was due to a limited outbreak. Rates of resistance to other antibiotics than quinolones showed no differences between HIV-infected and HIV-negative cases. No resistance was found for carbapenems or newer cephalosporins such as ceftriaxone.
The high rates of S. sonnei isolates resistant to quinolones and other traditional antibiotics are of concern. Innovative prevention efforts are urgently needed. The empirical use of quinolones in HIV-infected patients presenting with S. sonnei infection is no longer recommended.
Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by the L-serovars of Chlamydia trachomatis. Like most bacterial STIs it remains prevalent worldwide, especially in tropical and resource-poor regions. In recent years it has also become recognized in populations of men who have sex with men (MSM) in the developed world, in whom it is now an important cause of proctitis in Europe and the USA. In contrast to tropical LGV that typically causes ulcer-adenopathy syndrome, MSM usually present with severe proctitis and a strong association with HIV infection exists. Conflicting data exist regarding the prevalence of asymptomatic MSM infection and our understanding of the exact modes of transmission remains incomplete. LGV proctitis can be confused clinically with other rectal STIs, as well as non-infectious enteropathies, leading to diagnostic delay and persistent morbidity. Modern nucleic acid tests have enabled more accurate diagnosis of LGV and allow it to be distinguished from the more common but less pathogenic non-LGV-serovar infections. Prompt antibiotic treatment with a 3-week course of oral doxycycline is effective and curative, yet broader awareness among clinicians is needed to enable appropriate investigation and management, and the interruption of onward spread.
Proctitis caused by Chlamydia trachomatis L2b can manifest with very mild, nonspecific symptoms, and appropriate diagnostic evaluation is crucial. The case report demonstrates that rapid screening test, detection of specific antibodies in serum, and direct pathogen identification by PCR performed on tissue sample or rectal swab allow successful diagnosis of the still emerging sexually transmitted disease among homosexual patients.
Overwhelming evidence indicates that distinct pathological phenomenon occurs within the gastrointestinal (GI) tract of progressively simian immunodeficiency virus (SIV)-infected Asian macaques and HIV-infected humans compared with other anatomical sites. Massive loss of GI tract lamina propria CD4 T cells, alteration in the profile of lymphocytic cytokine production, changes in the landscape of GI tract antigen-presenting cells, and variations to the structural barrier of the GI tract are hallmarks of progressive HIV/SIV infections. The pathology within the GI tract results in translocation of microbial products from the lumen of the intestine into peripheral circulation. These translocated microbial products directly stimulate the immune system and exacerbate immune activation and, thus, disease progression. Initiation of combination antiretroviral therapy (cART) does not restore completely the immunological abnormalities within the GI tract. This incomplete restoration within the GI tract may contribute to the increased mortality observed within HIV-infected individuals treated for decades with cART. Novel therapeutic interventions aimed at enhancing GI tract anatomy and physiology may improve the prognosis of HIV-infected individuals.Mucosal Immunology advance online publication, 3 April 2013; doi:10.1038/mi.2013.15.
Objective:
The objective was to assess factors associated with previous exposure to hepatitis C virus (HCV) infection among Brazilian adults in mental health centers.
Method:
A cross-sectional national multicenter study of 2087 psychiatric patients randomly selected from 26 public mental health services was conducted between 2005 and 2007 in Brazil. An interview was conducted for obtaining sociodemographic, clinical and behavioral data. Psychiatric diagnoses were obtained from medical charts. Serology testing was conducted using anti-HCV. The magnitude of the associations was estimated by the prevalence rate ratio under Poisson distribution. Multivariate analysis for previous HCV exposure was carried out by weighted Poisson regression.
Results:
The weighted prevalence of previous HCV exposure was 2.53% (95% confidence interval: 2.22-2.83). Factors associated with previous exposure to HCV infection included male gender; age ≥ 40 years; history of sexually transmitted infections; current tobacco use; lifetime injecting drug use; exchange of money/drugs for sex; and main psychiatric diagnoses of psychoses and bipolar disorders, substance use disorders or dementia.
Conclusions:
Our results indicate a high prevalence of previous exposure to HCV in this population of Brazilian psychiatric patients. Most factors statistically associated with HCV were demographic or behavioral related, indicating a potential high-vulnerability profile. Screening for HCV in high-risk patients should be routine practices in these mental health services in Brazil.
This chapter addresses the natural history of anogenital human papillomavirus (HPV) infection. Cervical infections are the best understood HPV infection. Cervical HPV persistence is the known necessary event for the development of cervical cancer. New infections appearing at any age are benign unless they persist. Several long-term natural history studies have now shed light on the very low risk of cervical intraepithelial neoplasia (CIN) 3+ in women past the peak of HPV acquisition (e.g., 30 or older) who are HPV-negative or clear their HPV. Although data on transmission of HPV are finally emerging, rates of transmission between heterosexual couples vary widely among studies. Factors that affect the calculations of these rates include a) intervals between testing points, b) rates of concordance or discordance at baseline, and c) difficulty in defining established infections versus contamination. Both cervix to anus and anus to cervix autoinoculation in the same woman appears to be quite common. Whether either site serves as a long-term reservoir is unknown. Studies show that anal infections in women and in men who have sex with men are quite common with cumulative rates up to 70-90%. Similarly, clearance of anal HPV is also common, with few individuals showing persistence unless they are human immunodeficiency virus (HIV)-infected. HIV strongly influences the development of anal intraepithelial neoplasia (AIN). The few studies on the natural history of AIN in HIV-infected men suggest that high-grade AIN is a precursor to invasive anal cancer. Although no natural history studies of AIN are available in women, women with other HPV-associated lesions, including CIN3+ and vulvar cancer, have higher rates of anal cancer. Data on the natural history of HPV of the male genitalia are also emerging, although penile intraepithelial neoplasia is poorly understood. Cumulative rates of HPV are extremely high in men and risks are associated with sexual behavior. Unlike women, prevalence rates are steady across all ages, suggesting that men do not develop protection against reinfection. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide. Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. Our review of HIV prevention strategies for MSM identified several important themes. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission. Biomedical prevention strategies reduce the incidence of HIV infection. Delivery of barrier and biomedical interventions with coordinated behavioural and structural strategies could optimise the effectiveness of prevention. Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries. Scale-up of HIV prevention programmes for MSM is difficult because of homophobia and bias, suboptimum access to HIV testing and care, and financial constraints.
Men who have sex with men (MSM) have unique health-care needs, not only because of biological factors such as an increased susceptibility to infection with HIV and sexually transmitted infections associated with their sexual behaviour, but also because of internalisation of societal stigma related to homosexuality and gender non-conformity, resulting in depression, anxiety, substance use, and other adverse outcomes. Successful responses to the global HIV/AIDS epidemic will require the development of culturally sensitive clinical care programmes for MSM that address these health disparities and root causes of maladaptive behaviour (eg, societal homophobia). Health-care providers need to become familiar with local outreach agencies, hotlines, and media that can connect MSM with positive role models and social opportunities. Research is needed to understand how many MSM lead resilient and productive lives in the face of discrimination to develop assets-based interventions that build on community support. Optimum clinical care for sexual and gender minorities is a fundamental human right. MSM deserve to be treated with respect, and health-care providers need to interact with them in ways that promote disclosure of actionable health information.
Human herpes simplex virus infections are very common and represent significant morbidity in the immunocompromised host. Patients with acyclovir resistant strains of HSV based on viral thymidine kinase gene mutations need alternative therapeutic approaches. Leflunomide has been shown to possess antiviral activity against several viruses. Herein we describe a case of acyclovir resistant HSV-2 proctitis in an HIV patient successfully treated with leflunomide without significant side effects. Published by Elsevier B.V.
About 62 million cases of gonorrhoea are diagnosed each year worldwide. In the UK, the incidence decreased from the late 1970s, but has risen since 1993. Gonorrhoea is always sexually transmitted in adults. Vertical transmission also occurs, typically presenting in the first week after birth. The symptoms and signs of gonorrhoea depend on the site of infection. The sites at which positive cultures are found depend on the sexual lifestyle of the patient. In men, the most common finding is urethral discharge. In women, the most common signs are mucopurulent cervicitis and vaginal discharge. Complications of gonorrhoea are usually seen when untreated infection has been present for a prolonged period, and are more common in settings where access to medical care is difficult. In the UK, complications occur in about 3% of cases in females and less than 1% in males. Both local and desseminated complications may occur. Culture of the gonococcus remains the standard investigation, and provides information on antibiotic sensitivities. Newer diagnostic tests based on nucleic acid amplification are available with high specificity and sensitivity, and enable non-invasive sampling. They are more expensive than culture and lack the advantage of enabling antibiotic sensitivity testing, and there are some false-positive results. Gonococcal antibiotic resistance has become an increasing problem. A marked increase in quinolone-resistant gonorrhoea was seen in the UK between 2001 and 2002, with rates increasing from 5% to 14%. This has resulted in the current UK first-line treatment recommendation of a third-generation cephalosporin.
Over half (58.4%) of 77 recently diagnosed Chinese HIV infected men having sex with men (MSM) had networked sex partners through Internet in the year prior to their infections. Internet using MSM were younger (29.6y vs 38.7y; t = -4.77, P < 0.01), better educated, more likely to have a regular sex partner, and have undergone regular HIV testing (Chi square = 5.57, P < 0.05). These characteristics could be used for planning public health interventions.
A total of 599 Neisseria gonorrhoeae strains collected in Italy in 2 periods, 2003 to 2005 and 2007 to 2008, were screened for ciprofloxacin susceptibility by Etest. Ciprofloxacin-resistant strains (49.7%) were characterized by i) serovar determination, patterns of mutation in gyrA, and parC genes (38%, randomly selected) and ii) N. gonorrhoeae multiantigen sequence typing (56% of the strains isolated from patients who declared their sexual orientation). The percentage of ciprofloxacin-resistant strains increased from 42 (2003-2005) to 58 (2007-2008); in the second period, strains with MIC value >32 microg/mL have been observed. Mutations in gyrA and parC genes were identified in the majority of strains (88%). Ciprofloxacin-resistant isolates among men who have sex with men (MSM) increased from 24% in 2003 to 2005 to 47% in 2007 to 2008. However, sequence types exclusively found among MSM were mostly due to a single strain. This is the first study in Italy combining N. gonorrhoeae ciprofloxacin susceptibility testing with molecular analyses and comparing the results over time.
There are many kinds of clinical trials. The regulatory framework within which most drug development takes place appears to be the one that is to be applied to the development of novel stem cell-based clinical trials. In the standard drug development model, appropriate pre-clinical research is conducted (largely based upon non-human animal models), and investigators or research sponsors (typically a company) submit an investigational new drug (IND) application to the Food and Drug Administration (FDA).
If approved, typical clinical trials start with Phase I, which is usually a trial (with a small number of participants) to determine the maximum tolerable dose of a drug. Phase I trials are often referred to as “safety studies” because the primary goal of Phase I research is to determine if an intervention is safe (not whether it works).
Although the first human embryonic stem cells (hESCs) were produced in 1998, the direction of U.S. policy on stem cell research was set nearly 20 years earlier when the recommendations of a congressionally established Ethics Advisory Board were ignored by the Reagan administration. Thus began an unprecedented and unparalleled 30-year-long history of political intrusions in an area of scientific and biomedical research that has measurable impacts on the health of Americans. Driving these intrusions were religiously informed public policy positions that have usually escaped critical ethical analysis. Here I record my own encounters with this history of intrusions and the thinking behind them.
My most abrupt encounter with the politics of stem cell research occurred on September 6, 2006, at a hearing of the Senate Subcommittee on Labor, Health and Human Services and Related Agencies, chaired by Senator Arlen Specter. Just a week before, scientists at Advanced Cell Technology (ACT), a small Massachusetts biotech company, had published a paper in the journal Nature in which they described a method for extracting stem cells from early human embryos while leaving the embryos intact and viable. As head of ACT’s Ethics Advisory Board, I had supported this research.
The subacute spongiform encephalopathies include scrapie of sheep, transmissible mink encephalopathy, and kuru and Creutzfeldt-Jakob disease of man. These diseases are caused by filterable infectious agents with unique physical properties. The usual sources of infection in nature are not completely known. Epidemiological evidence suggests that the agents may enter the body through breaks in the skin and mucous membranes. Experimental studies of scrapie after subcutaneous inoculation demonstrated early replication of the agent in lymphoid tissues and later appearance in other organs; as the amount of agent in the central nervous system (CNS) increased, it decreased in or disappeared from lymphoid tissues. In preliminary studies of kuru and Creutzfeldt-Jakob disease, the infectious agents were regularly recovered from the brains of clinically-ill patients and experimental animals but only occasionally from organs outside the CNS. It remains to be seen if early events in the pathogenesis of the two human diseases, before the appearance of clinical signs, are similar to those in scrapie.
The clinical and pathological findings in a group of 260 homosexual men comprising 10% of a private proctologic practice are reviewed. A clinical pattern of anorectal and colon diseases encountered with unusual frequency in these homosexual patients is termed the gay bowel syndrome. The clinical diagnoses in decreasing order of frequency include condyloma acuminata, hemorrhoids, nonspecific proctitis, anal fistula, perirectal abscess, anal fissure, amebiasis, benign polyps, viral hepatitis, gonorrhea, syphilis, anorectal trauma and foreign bodies, shigellosis, rectal ulcers and lymphogranuloma venereum. 60 anorectal and sigmoid biopsies from 51 patients failed to disclose evidence of specific infection other than condyloma acuminata. Of 21 patients with biopsy diagnosis of nonspecific proctitis, 8 had a specific infection which was detected by other means,--5 cases of shigellosis and one case each of gonorrheal proctitis, amebiasis and lymphogranuloma venereum. In evaluating proctologic problems in the gay male, all of the known sexually transmitted diseases should be considered. Shigellosis, amebiasis and viral hepatitis should be included. Microbiological evaluation is essential. Concurrent infections with 2 or more pathogens should be anticipated. Chlamydia trachomatis, an important cause of nonspecific urethritis in the general population, is high on the list of possible causes of the nonspecific proctitis present in 31 of the 260 patients.
In 1976, a group of physicians in private proctologic practice in New York City coined the illness "Gay Bowel Syndrome" in reference to a constellation of gay male anorectal disorders. Through analysis of biomedical discourse and popular media, it is apparent that Gay Bowel Syndrome is an essentialized category of difference that is neither gay-specific, confined to the bowel, nor a syndrome. The use and diagnosis of Gay Bowel Syndrome must be abandoned before it further lends itself to the formation of social policies and governing practices that seek to force gay male bodies into positions of social, cultural, and political subordination.
- Sherrard