HPV infection and anal cancer. A prominent health issue in the MSM community is HPV, which can cause anal papilloma and/or anal cancer. Studies have found HPV infection of the anal canal in up to 60% of MSM, compared with 15% in heterosexual men.32-34 Notably, prevalence of HPV anal infection has been found in almost 100% of HIV-seropositive MSM.35,36 HIV-infected MSM also have an increased risk of anal cancer, compared with men without HIV.37 Oncogenic, high-risk HPV infection (eg, HPV types 16 and 18) causes most cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers.38

HPV infection causes genital warts, also called condyloma acuminata. These are small or large papular lesions, raised or flat, or shaped like a cauliflower. Signs and symptoms of HPV-related anal cancer include rectal bleeding, mass at the anal opening, pain or feeling of fullness in the anal area, changes in bowel movements, abnormal anal discharge, and swollen lymph nodes of the anal and perineal region.39


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Screening for HPV requires a digital rectal examination and anal Papanicolau (Pap) test. Anal condyloma can be cosmetically removed using podofilox or imiquimod. Alternatively, trichloroacetic acid or bichloroacetic acid, intralesional interferon, or fluorouracil can be used. Condyloma can also be removed via cautery or laser treatment. Condyloma can be treated; however, HPV infection often recurs and spreads easily between sexual partners. Preventive measures for MSM should include HPV vaccine.30


Condyloma acuminata caused by the human papillomavirus on the anus.

Viral hepatitis. MSM are at high risk for contracting hepatitis A, B, and C. Hepatitis A virus (HAV) is spread primarily through the fecal-oral route, either from person to person or through exposure to contaminated food or water. Most acute infections (85%) are asymptomatic.40 In all types of hepatitis, the patient may present with low-grade fever, anorexia, gastrointestinal symptoms, abdominal pain in the upper right quadrant, fatigue, pale stools, dark urine, and jaundice. HAV causes a self-limited infection of less than 2 months duration and confers immunity when resolved. A vaccine is available for HAV and should be recommended to MSM.41

Hepatitis B virus (HBV) is transmitted via blood or mucosal exposure to body fluids of an infected person. In the United States, the most common mode of transmission is by sexual contact and injection drug use.8,42 HBV can lead to chronic hepatitis, hepatitis fibrosis, cirrhosis, or liver cancer. According to the CDC, an estimated 20% of new HBV infections occur in MSM. Immunization against HBV is recommended for all MSM.41,43 Hepatitis B immunoglobulin (HBIg) can also be administered to impart temporary immunity to those exposed to HBV. Primary care clinicians should educate patients regarding safe sex, the necessity of three doses of HBV vaccine, and the availability of postexposure HBIg that can reduce the risk in close contacts.30

Hepatitis C virus (HCV) is transmitted by exposure to infected blood, most commonly through injection drug use. Sexual transmission occurs in rare cases; however, in both MSM and heterosexuals, the likelihood of sexual transmission rises with increase in number of sex partners and when sex partners are infected with HIV.44

Acute HCV infection progresses to chronic liver disease in 75% to 85% of cases.45 Infection commonly causes no symptoms, and the incubation period lasts several months to years. Mild to moderate liver disease may produce vague symptoms, such as chronic fatigue, for years. Due to an immune complex component of HCV infection, extrahepatic manifestations are possible. These include arthralgias, purpura, glomerular dysfunction, peripheral neuropathy, central nervous system vasculitis, and reduced complement levels.46

Chronic HCV infection is the leading cause of liver-related death and hepatocellular carcinoma in the Western world.47,48 It is estimated that only 50% of those chronically infected persons have been diagnosed. Also, fewer than 38% of those with an HCV diagnosis are referred to care and fewer than 11% who are referred for care are treated.49 Because this infection is often asymptomatic until advanced liver disease occurs, the primary care clinician should maintain a high level of suspicion. Spontaneous resolution of HCV infection can occur in some patients; it is unknown why some have natural clearance of the virus. Treatment of HCV consists of a combination of antiviral agents that are successful in greater than 95% of cases.50