PDPH Advisory – LGBTQ Health Recommendations

The Philadelphia Department of Public Health has released a Health Advisory regarding health and disease prevention recommendations during Pride in Philadelphia for the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community members. It is available from https://hip.phila.gov.

Health Advisory
LGBTQ Health and Disease Prevention Recommendations
During Pride in Philadelphia
June 15, 2017

Summary Points

  • Syphilis increases continue in Philadelphia among all populations and MSM
  • Screen sexually active patients for syphilis, gonorrhea and Chlamydia from multiple anatomic sites
  • Provide routine opt-out HIV testing to all patients between the ages of 13-64 who present to a healthcare setting
  • Offer PrEP when indicated, a once daily medication that is over 90% effective when taken consistently in preventing HIV
  • Vaccinate MSM and TSM with hepatitis A, hepatitis B, Meningococcal and HPV vaccines

Each June, Philadelphia celebrates Pride and the rich diversity of its Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community members. The Philadelphia Department of Public Health (PDPH) is highlighting the importance of providing our LGBTQ Philadelphians with high quality, comprehensive, and affirming sexual health care. Men who have sex with men (MSM) and transgender persons who have sex with men (TSM) experience high rates of HIV and sexually transmitted infections (STIs) in Philadelphia. Communities of color specifically, Black and Latino MSM and TSM, are disproportionately affected by HIV and STIs. Incidence of early syphilis (Primary, Secondary and Early Latent) has continued to increase among MSM in Philadelphia over the past 10 years (Figure), and has continued to increase in 2017 by 30% compared to the same time period in 2016.  Condoms prevent many STIs when used correctly and consistently.

Taking a comprehensive, non-judgmental sexual history of patients creates open dialogue between patients and their medical providers about sexual desire and pleasure which leads to optimal risk reduction opportunities.  Sexual histories should be taken at initial visits, routine preventive exams, and visits addressing sexual health issues. Utilize the five “P”s of sexual health when taking a sexual history.  These include:

  • Partners
  • Practices
  • Protection from STIs
  • Past history of STIs
  • Prevention of Pregnancy

Screening and treatment should be routinely offered to sexually active MSM and TSM every 3-6 months.  Complete STI screening of MSM, TSM, and others who engage in anal sex includes:

  • Screen for gonorrhea and Chlamydia using nucleic acid amplification test (NAAT) at oral, anal, and urine/urethral sites. Screening urogenital sites alone may miss up to 70% of gonorrhea and Chlamydia infections in MSM and TSM.
  • Screen and treat for syphilis and report all cases to PDPH Division of Disease Control at 215-685-6737.
  • Provide routine opt-out HIV testing. PDPH and the Centers for Disease Control and Prevention (CDC) recommend this for all patients between the ages of 13-64 in a healthcare setting including hospital EDs, urgent-care clinics, inpatient services, sexually transmitted disease (STD) clinics, substance abuse treatment clinics, other public health and community clinics, correctional healthcare facilities, and primary care settings.
  • Screen persons at high risk of continued HIV exposure for HIV at least annually but more frequently dependent on risk. Persons likely to be at high risk for continued HIV exposure include people who inject drugs and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and MSM or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

Clinicians should use blood-based HIV-1/2 antigen/antibody combination immunoassay (4th generation) to screen for HIV infection. If antibody or antigen positive, clinicians should refer patients for immediate initiation of antiretroviral therapy (ART). For additional information or support, contact the PDPH AIDS Activities Coordinating Office (AACO) Client Services Unit at 215-985-2437. In addition to consistent and correct condom use, which protects against HIV and STIs, HIV pre-exposure prophylaxis (PrEP) is a bio-behavioral once daily medication that is highly effective, over 90% when taken consistently, in preventing HIV acquisition. PrEP is available through City STD Clinics (Health Center 1 and Health Center 5). Post-exposure prophylaxis (PEP) can prevent HIV acquisition after exposure if initiated within 72 hours. HIV negative persons with early (i.e., primary or secondary) syphilis or a rectal STI are at increased risk of acquiring HIV in the future.  These individuals should be offered PrEP to prevent HIV.

Vaccinations also play an important part in preventive health and wellness. CDC routinely recommends several vaccines to the MSM and TSM population:

    • Hepatitis A outbreaks have been reported in Europe and New York City among unvaccinated MSM.  MSM and TSM are also at risk for hepatitis B.  Vaccinate MSM and TSM who are non-immune or who have not previously received a documented complete series of both hepatitis A and B vaccines.
    • Adults who seek protection from hepatitis B virus infection may receive a 3-dose series of single-antigen hepatitis B vaccine (HepB) (Engerix-B, Recombivax HB) at 0, 1, and 6 months. Adults may also receive a combined hepatitis A and hepatitis B vaccine (HepA-HepB) (Twinrix) at 0, 1, and 6 months. Acknowledgment of a specific risk factor by those who seek protection is not needed.
    • Quadrivalent meningococcal conjugate vaccine (MCV4) is now recommended by national guidelines for all people living with HIV. PDPH also recommends vaccinating MSM, regardless of HIV status, who regularly have close or intimate contact with men met through an online website, digital application (“app”), or at a bar or party.
    • MSM and TSM through age 26 years who have not received any HPV vaccine should receive a 3-dose series of HPV vaccine at 0, 1-2, and 6 months.

Resources:
Routinized Opt-Out HIV Testing: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
PrEP Clinical Care Guidelines: https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf
STI Treatment Guidelines: https://www.cdc.gov/std/tg2015/tg-2015-print.pdf
Vaccination for special populations: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html

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