Sexually transmitted infections among homosexual and bisexual men who have sex with men: A 9-year retrospective cross-sectional comparative study

Abstract

Context:

The number of men who have sex with men (MSM) seeking health care has increased in recent years, but the research comparing sexually transmitted infections (STI) prevalence and risk behaviors between homosexual and bisexual MSM is limited, particularly postpandemic.

Aims:

To compare the profile of STIs and risk behaviors between homosexual and bisexual MSM attending our STI clinic.

Methodology:

In this comparative cross-sectional study, we analyzed the records of all male STI patients who reported at least one male partner who attended our STI clinic from January 2015 to December 2023 for demographic details, sexual history, clinical examination, and laboratory findings.

Statistical Analysis:

Chi-square test and logistic regression were utilized.

Results:

The number of MSM attending STI clinics showed a rising trend, with a sharp decline during the pandemic followed by a significant rebound. Bisexuals outnumbered homosexuals until the lockdown, after which the trend reversed. About 42.6% of homosexuals and 26.7% of bisexuals reported first sexual exposure before the age of 16 (odds ratio (OR) = 2.04, 95% confidence interval (CI): 1.17–3.55, P = 0.01). Syphilis was the most prevalent STI (70.6%), followed by HIV (29.8%) and condyloma acuminata (16.6%). Homosexuals had a significantly higher prevalence of syphilis (adjusted OR 4.82, 95% CI 1.94–11.93, P < 0.01) than bisexuals. 51.4% of HIV cases were newly diagnosed on evaluation after attending the STI clinic.

Conclusions:

There was a sharp rise in the number of MSM attending the STI clinic, especially homosexuals. Syphilis was the most prevalent STI, particularly among homosexuals, which frequently coexisted with HIV.

Introduction

The WHO regards men who have sex with men (MSM) as a key population at risk of HIV and sexually transmitted infections (STI), with approximately 3.5 lakh MSM in India.[1,2] While MSMs are 26 times more likely to acquire HIV compared to the general population, 29.3% avoid seeking health care due to stigma and discrimination.[2] High-risk sexual practices and bisexual behavior among MSMs contribute significantly to the spread of STIs and HIV in the community.[3,4]

We have noticed an increase in the number of MSM seeking testing and treatment at our STI clinic in recent years. The rising social acceptance of homosexuality and the social environment created by the pandemic may have contributed to an increase in homosexual behavior in recent years.

There is limited research comparing the prevalence of STIs and risk behaviors among homosexual and bisexual MSM in India. Understanding the different risk factors among them could help create targeted interventions and preventative strategies to effectively reduce STI transmission among MSM in India.[5]

Methodology

This was a retrospective, record-based study. Ethical clearance was obtained from the institutional review board. Records of all male patients with STIs who reported at least one male partner and attended our STI clinic between January 2015 and December 2023 were reviewed. The study excluded patients with congenital syphilis and records with incomplete data. Patients reporting any female partners were classified as bisexual, while those reporting exclusively male partners were classified as homosexual.

Demographic data, marital and sexual history, including the total number of partners, type of partner (regular and casual), sexual practices (oral, anal, or both), clinical examination, and laboratory findings, were collected from STI clinic records and entered into Microsoft Excel.

The data were analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, New York, USA). Numerical variables were expressed as mean and standard deviation. Categorical variables were reported using frequencies and percentages. The Chi-square test was used to compare STI prevalence between the two groups, and logistic regression was used to calculate odds ratios (ORs) and their 95% confidence intervals (CIs) for each group. P < 0.05 was taken as significant.

Results

Over the 9-year period, 228 of the 804 males who attended the STI clinic (28.4%) reported having at least one male partner. Among them, 108 (47.4%) were exclusively homosexuals, and 120 (52.6%) were bisexuals. The number of MSM who visited our clinic showed a rising trend, with a sharp decline during the COVID-19 pandemic, followed by a rebound increase. Bisexuals were proportionally more until 2019, after which homosexuals predominated [Figure 1].

Figure 1.

Distribution of homosexual and bisexual men who have sex with men from 2015 to 2023

The mean age was 26.3 ± 5.0 years for homosexuals and 34.7 ± 9.1 years for bisexuals. Most homosexuals (72.2%) were younger (21–30 years), while bisexuals (35%) were older (31–40 years) (P < 0.01) [Figure 2].

Figure 2.

Age distribution among homosexual and bisexual men who have sex with men

Majority in both groups had a graduate level of education (46.3% of homosexuals and 30.8% of bisexuals) and were semi-professionals (57.4% of homosexuals and 77.5% of bisexuals). Three homosexuals and one bisexual reported sex work as their primary source of income. Smoking and alcoholism were more common among bisexuals (34.2%, 54.2%) than homosexuals (17.6%, 41.7%) (smoking: OR = 2.43, 95% CI = 1.30–4.53, P < 0.01; alcoholism: OR = 1.65, 95% CI = 0.979–2.79, P < 0.05). Four bisexuals (3.3%) and 2 homosexuals (1.9%) reported the use of intravenous drugs (OR = 1.56, 95% CI = 0.26–9.21, P = 0.62).

Eight (7.4%) homosexuals and 78 (65%) bisexuals were married. The mean age of first sexual contact was slightly younger (17.5 + 6.1 years) for homosexuals compared to bisexuals (21.2 + 6.6 years). Before the age of 16, 42.6% of homosexuals and 26.7% of bisexuals reported their first sexual exposure, all involving a known adult (OR = 2.04, 95% CI: 1.17–3.55, P = 0.01). A higher proportion of bisexuals (59.4%) reported having more than four partners in their lifetime compared to homosexuals (48.5%) (P < 0.01). 23.1% of homosexuals were monogamous. 37.0% of homosexuals and 45% of bisexuals had casual partners, with almost half (49% in both groups) meeting online. 9.3% of homosexuals and 15% of bisexuals had sexual contact with sex workers.

Homosexuals reported higher rates of peno-anal contact (90.6% vs. 75.3%; OR = 3.15, 95% CI: 1.27–7.76, P < 0.01) and lower rates of peno-oral sex (67.1% vs. 83.5%; OR = 2.48, 95% CI: 1.22–5.04, P < 0.01) compared to bisexuals.

Table 1 shows information on condom use, history of past STIs, and reasons for attending OPD.

Table 1.

Frequency of condom use, history of sexually transmitted infections, and reasons for attending outdoor patient department among men who have sex with men

	Homosexual	Bisexual	Total	Percentage	P
Inconsistent condom use	54	51	105	46.0	0.387
Previous history of STIs	19	25	44	19.3	0.095
Reason for attending OPD
Symptomatic	57	53	110	48.2	0.112
Detected on routine blood screening	46	55	101	44.3
As part of surveillance programme	1	1	2	0.88
Detected on partner screening	3	10	13	5.7
Due to fear/doubt	1	1	2	0.88

STIs=Sexually transmitted infections; OPD=Outdoor patient department

Syphilis was the most prevalent STI among MSM (70.6%), followed by HIV (29.8%) and condyloma acuminata (16.6%).

Homosexuals had a significantly higher frequency of syphilis (adjusted OR = 4.82, 95% CI = 1.94–11.93, P < 0.01) and a lower frequency of herpes genitalis (adjusted OR = 0.257, 95% CI = 0.09–0.73, P = 0.011) compared to bisexuals.

Primary and secondary syphilis were more prevalent among homosexuals, while latent syphilis was the same and neurosyphilis was lesser.

Although not statistically significant, bisexual males had slightly higher rates of HIV, hepatitis B, gonococcal urethritis, and nongonococcal urethritis than homosexuals [Table 2].

Table 2.

Comparison of distribution of different sexually transmitted infections among homosexual and bisexual men who have sex with men

	Homosexuals, frequency (%)	Bisexuals, frequency (%)	Total, frequency (%)	P	COR	AOR	95% CI
Herpes genitalis	12 (11.1)	21 (17.5)	33 (14.4)	0.011	0.71	0.25	0.09–0.73
Condyloma acuminata	20 (18.5)	18 (15)	38 (16.6)	0.347	1.55	1.55	0.62–3.81
Molluscum contagiosum	2 (1.8)	1 (0.8)	3 (1.3)	0.531	1.81	2.56	0.17–29.99
HIV
Total	31 (28.7)	37 (30.8)	68 (29.8)	0.732	0.94	0.89	0.49–1.63
Newly diagnosed	19 (17.5)	16 (13.3)	35
Already diagnosed	12 (11.1)	18 (15)	30
Hepatitis B	2 (1.8)	4 (3.3)	6 (2.6)	0.682	0.55	0.67	0.10–4.47
Syphilis	86 (79.6)	75 (62.5)	161 (70.6)	0.001	2.34	4.82	1.94–11.93
Primary syphilis	14 (12.9)	6 (5)	20 (8.7)
Secondary syphilis	18 (16.6)	14 (11.6)	32 (14.0)
Early latent syphilis	6 (5.5)	7 (5.8)	13 (5.7)
Late latent syphilis	45 (41.6)	53 (44.1)	98 (42.9)
Neuro syphilis	3 (2.7)	6 (5)	9 (3.9)
Gonococcal urethritis	1 (0.9)	5 (4.1)	6 (2.6)	0.605	0.89	1.58	0.27–9.15
Nongonococcal urethritis	6 (5.5)	8 (6.6)	14 (6.1)	0.530	0.82	0.64	0.18–2.25

COR=Crude odds ratio; AOR=Adjusted odds ratio; CI=Confidence interval

Multiple coexisting STIs were present in 41.6% of MSM, slightly more among bisexuals (42.5%) than homosexuals (40.7%) (P = 0.78). HIV-syphilis coinfection was the most common among both bisexuals (n = 28; 23.3%) and homosexuals (n = 24; 22.2%).

All HIV patients (n = 68) had coexisting STIs, with more than half (51.4%) being newly diagnosed on evaluation after visiting the STI clinic.

Discussion

Our study found an increased number of MSM attending STI clinics over time, with an abrupt drop during the COVID-19 lockdown period and a subsequent substantial rise, particularly among homosexuals. Similar findings were noted in Amsterdam, showing a decreased incidence of chlamydia, gonorrhea, and syphilis during initial COVID-19 restrictions, followed by an increase during the next two COVID-19 restrictions.[6] This could probably be due to increased homosexual behavior and limited STI testing and treatment services during lockdowns.[7] Similar studies from Kerala also found an increase in the number of MSM from 2015 to 2020.[8,9]

Our finding of 47.4% homosexuals is consistent with previous studies reporting the prevalence of homosexuals ranging from 33% to 51%, with an increasing trend in recent years.[5,10,11,12] The decriminalization of homosexuality in India in 2018 and the increasing social acceptance of homosexuality in recent years may have encouraged more MSMs, particularly homosexuals, to seek medical attention.

Our findings align with Pravitha et al.[8] and Aggarwal et al.[10] who reported majority of MSM between the ages of 21 and 30, and Santhakumar et al.[11] who reported differences in median age between homosexuals (25 years) and bisexuals (30 years). We found higher proportions of bisexuals in older age groups, which corresponds with previous research showing a possible association between older age and bisexual behavior and subjective evidence of older MSM changing sexual identities to bisexuality.[13] Reports also suggest that older men undergo less testing and diagnosis, increasing their infection risk.[14]

In our study, only 1.8% of MSM self-identified as sex workers, whereas Santhakumar et al.[11] and Prakash Narayan et al.[15] reported sex work among 4.4% and 19% of MSM, respectively. Both our study and Santhakumar et al.[11] found homosexuals twice as common as bisexuals among MSM who performed sex work. This disparity in proportions could be attributed to patients concealing their history of sex work to avoid judgment or rejection.

We found that bisexuals had significantly higher rates of smoking, alcoholism, and multiple partners, consistent with previous research reporting higher levels of psychosocial issues and high-risk behaviors such as substance abuse, unsafe sexual behaviors, and multiple sexual partners among bisexuals.[13]

Similar to our study, Santhakumar et al.[11] found 63.9% of bisexuals and 9.9% of homosexuals to be married. This is concerning, as most married or bisexual MSM may be perceived as heterosexuals and become less likely to benefit from targeted interventions.[16]

In addition, bisexual MSM serve as a bridge population, spreading the infection to their female partners.[11] The majority of MSMs are found to conceal their homosexuality and are more likely to marry heterosexuals to conform to Indian sociocultural norms and avoid stigma and rejection.[17]

Santhakumar et al.[11] reported that 69.6% of homosexuals and 51.6% of bisexuals had their first homosexual encounter before the age of 18, with over 25% reporting forced homosexuality, similar to our findings. A multi-site Indian study defining child sexual abuse (CSA) as unwanted sexual touching or intercourse before the age of 16 reported CSA was highly prevalent among MSM (22.4%), with affected individuals exhibiting a two-fold increase in lifetime HIV-related behaviors compared to those without CSA.[18] Although data on perpetrators were not available in all cases in our study, the available data indicate that many were older males in positions of authority (e.g., teachers and older relatives) trusted by children, consistent with previous research on CSA in India.[9,19] Given that CSA among boys in India is rarely discussed, interventions addressing CSA are critical for HIV prevention.[20]

We observed lower proportions of casual partners and sexual contact with sex workers among MSM compared to previous studies, reporting 82% having casual partners and 60% having sexual contact with sex workers.[11,21] Furthermore, we found 23.1% of homosexuals in monogamous relationships. These differences may be attributed to changing behavioral trends after the decriminalization of homosexuality in India, allowing homosexuals to disclose their sexuality and maintain monogamous relationships instead of seeking casual partners or sex workers.

Approximately half of the casual partners in our study were met online, which is noteworthy because MSMs using apps to find sexual partners are more likely to have STIs than nonusers.[22] Interestingly, the online sex-seeking patterns among MSM in India are similar to those in other Asian countries and the West, suggesting that interventions used in the West can be tried for Indian MSM.[23]

In our study, nearly half (48.2%) of MSM presented with symptoms, while 44.3% were referred for STIs incidentally detected during blood screening, probably because of shame or guilt in seeking treatment. Previous research found that 70.3% of MSM were willing to seek medical help for sexual health issues, but 79.4% were unwilling to disclose their sexual behavior when seeking medical attention.[24]

While Pravitha et al.[8] also reported a high proportion of syphilis (64.9%) similar to us; other studies have found a lower prevalence of syphilis in India (6.4%) and other Asian countries.[25] This difference could probably be due to sociodemographic differences leading to increased detection of latent syphilis cases through routine blood screening (e.g., immigration or medical check-ups) in these studies. Recent studies also show an increase in primary and secondary syphilis cases over the last decade, with a higher proportion in MSM, emphasizing the need for targeted testing and education, as the relatively untroubling nature of infectious early syphilis may probably cause a delay in seeking medical attention, promoting community spread.[8,9,26]

Previous Indian studies on the prevalence of STIs among MSMs are given in Table 3. HIV was the second-most common STI (29.8%), which, although not statistically significant, was more prevalent among bisexuals than homosexuals, contrasting with global studies.[28,29] This difference in our study may be due to the high rate of HIV screening done for international occupational travel. The high prevalence of syphilis-HIV coinfection is concerning, given the mutual enhancement of transmission between these infections.[25] More than half (51.4%) of HIV cases were newly diagnosed at our STI clinic, consistent with previous research indicating that 70% of HIV-positive MSM in India are unaware of their status and have low awareness of the risk of HIV infection.[20,23]

Table 3.

Previous Indian studies on prevalence of sexually transmitted infections among men who have sex with men

Author	Study period	Place of study	Herpes genitalis	Syphilis	HIV	Nongonococcal urethritis	Gonococcal urethritis	Molluscum contagiosum	Condyloma acuminata	Genital scabies	Candidal balanoposthitis	Chancroid	Hepatitis B	Combination of STIs
Our study	2015–2023	Trivandrum, Kerala	14.4	70.6	29.8	6.1	2.6	1.3	16.6				2.6	41.2
Setia et al.[21]	2006	Mumbai	40	17	17		1.7	2.5		1.7		10
Brahmam et al.[27]	2006–2007	Andhra Pradesh	61.5	13.0	20.9	1.6	0.6
		Maharashtra	43.8	8.4	11.3	4.0	0.3
		Tamil Nadu	32.2	7.5	7.5	0.6	0.1
		Karnataka	36.7	17.3	17.3	1.6	0.6
Garg et al.[5]	2004–2010	Delhi	18.6	26.6	4	6.6	12		26	4	4	2.7		11
Aggarwal et al.[10]	2013–14	Delhi	11.5	21.1	23.1		5.7	9.6	23.1	1.9	7.7
Pravitha et al.[8]	2015–2020	Thrissur, Kerala	8.1	64.9	14.9		4.1		36.5				0
Krishnaprasanth et al.[12]	2018–2020	Chennai	10.6	22	0.5	16	10		2	0.3	0.3

STIs=Sexually transmitted infections

Factors such as social stigma, discrimination, unsafe sexual practices, long-term exposure, and reluctance to seek HIV services have been linked to increased infection risk in bisexuals or married MSM, particularly those with a longer history of MSM activity.[16,23] Although targeted interventions have reduced overall HIV prevalence among MSMs, studies show rising incidence in low-prevalence states, highlighting the need for more targeted testing, particularly among bisexual MSMs and partners.[30]

Our study has several limitations. Since the study was record-based and retrospective, variables not recorded in the case records could not be analyzed. It was a hospital-based study and does not fully reflect the data about MSM in the community. There is a possibility of misclassification between homosexuals and bisexuals because the distinction was based on reported female partners rather than self-identified sexual orientation. The data may be affected by recall bias and social desirability bias, particularly about private information such as sexual behavior.

Conclusions

There has been a steady increase in the number of MSM visiting STI clinics following the COVID-19 pandemic, particularly homosexuals, which can be attributed to changes in sexual behaviors during and after the lockdown period. Syphilis is the most common STI among MSM, particularly among homosexuals, followed by HIV, which frequently coexists with syphilis, increasing the risk of transmission for both infections. Over half of HIV patients were unaware of their disease, highlighting the urgent need for early detection and testing strategies. The high prevalence of CSA among MSM necessitates improved CSA awareness, reporting, and support services, particularly for boys in India.

It is crucial to address the specific challenges faced by MSM in India, including fear of disclosure, potential reprisals from families and communities, and barriers to accessing prevention services. Culturally sensitive education and counseling by healthcare providers can promote safer sexual practices and improve access to prevention services, ultimately reducing the STI burden.

Further studies with larger sample sizes and community-based research are needed to understand the different behavioral determinants of MSM in evolving social contexts postpandemic.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.