Gay Men's Health - Vaccinations

"With respect to gay men who are sexually active (assume not monogamous), are there specific kinds of vaccinations we should get apart from what adults normally ought to have?"

Dr. Vy Chu, reponds:

This is a great, straightforward question that we're very proud to answer.

As a primary care clinic, we deal with vaccinations daily. Here's a rundown of the vaccinations that we routinely discuss with our patients:

1. Hepatitis A: Hep A is a virus that attack the liver causing several weeks of abdominal pain, malaise, and jaundice and is spread via fecal-oral route. Outbreaks typically occur due to poor hygiene on the part of food handlers, but it's thought that given our sexual patterns and practices (think: oral sex, rimming) the GLBT population is at particular risk and is thus recommended for us in particular by the CDC. Immunity is essentially lifetime, and conferred by getting two shots separated by six months.
2. Hepatitis B: Hep B is a virus that attacks the liver as well, but the danger with HepB is that it can cause chronic lifetime infection and while there is treatment, there is no cure. In the GLBT population it is primarily sexually transmitted. Immunity is essentially lifetime, and conferred by a three-shot series (first visit, one month later, and six months later).
3. Tetanus: Yup, you still have to get tetanus boosters every ten years. Tetanus is a disease of the nervous system that is caused by a bacteria that is found in the soil, and can be life-threatening. You're at risk for it every time you have an injury that breaks the skin.
4. Influenza: We recommend that you get the flu shot every season, this season in particular. This season so far, the most commonly encountered flu strains are luckily related to one of the strains contained in the vaccine.

Finally, in addition to the above, our HIV patients and patients with chronic medical conditions such as diabetes and hepatitis must receive pneumonia vaccination (HIV patients every five years).

I hope that answers the question! Really, Hep A vaccination is the only "routine" vaccination that is recommended in particular for the GLBT population.

In contrary to memories from childhood, all these vaccines are given with a pretty small needle (smaller than that used for blood draws). You CANNOT, I repeat, CANNOT develop any of the above diseases from these vaccines. Tetanus may make your shoulder feel mildly sore the day after, but that's about the worst of it.

Please make an appointment to see one of us if you feel you need to renew or review your vaccinations!

--Vy Chu, MD


Rob Killian responds:

There is also a vaccine for shingles.This is designed for our older patients who do not have HIV. There is still some controversy about this vaccine but if you want to talk about it at your visit feel free to do so. It is live viral vaccine...so those who have HIV cannot get this vaccine at this point....although we have under close observation done so in some HIV positive men who had normalized their immune system.

Oral Sex and HIV: What are the risks?

One of the most common questions gay or gay-friendly physicians are asked is this one from one of our readers:

"I am a little unclear regarding the specific risks involved with oral sex between two males. Can you outline them for me? Also, how likely is HIV to be transmitted between oral sex?"

Rob Killian, MD responds:

Even among our three providers there is some debate on how best to handle this question. Let me tackle it this way:

From public health studies we know that men who have sex with men can get HIV from oral sex. It is the third most common way to get HIV in this community according to a well-respected public health community study out of San Francisco: (Google San Francisco Public Health and HIV statistics).

There is some risk of contracting HIV through oral sex. But attempting to quantify that risk is both frustrating and difficult. We know that anal sex, either as a top or a bottom (without a condom) is significantly more risky than receptive oral sex. There have been attempts to quantify the risk, but these have all proven to be inconclusive or to have mixed or inconclusive results... and transferring public health data to ones sexual encounter is very very difficult. This is science at its worst and at its best. The question is, honestly, impossible to answer in a black and white fashion.

Having treated HIV positive patients for over twelve years now I can, without a doubt, tell you that people can get HIV from oral receptive sexual encounters. Any of the HIV specialist providers I know will tell you that we all have some patients whose only risk for getting HIV was by giving blow jobs. But it is certainly a minority of our HIV positive patients.

So, none of us want anyone reading this to think that oral sex is without its risks. The other thing we all want to pass along is that HIV is not the only sexually transmitted disease to be worried about. With oral sex there is risk for Gonorrhea, Chlamydia, Syphilis, Herpes, HPV (warts) and Hepatitis--especially Hepatitis A. So, while oral sex is common, fun, and part of our sexual lives, it is not without some risk for STDs to consider.

Here is how I handle this personally. I try to get to know my partners first. I ask questions and try to be open and honest with them. I get to know them before even considering allowing them to come inside my mouth. And I get tested regularly.

This question alone is a good reason to have a physician or medical provider you can trust, to be honest with and to be able to openly discuss your questions, worries and risk. And one you feel comfortable going back to for repeated testing and repeated questions. Building a relationship with a medical provider is important. Being open and honest and expecting the same in return will add value to your life and your medical relationships.

Not one of us at Capitol Hill Medical want to prevent you from exploring your full sexual experiences and life. But, please, get tested, talk to your partners, talk to your healthcare provider and know the risks as best you can.

Dr. Chu or Dr. Dave do you have anything to add?


Dr. Vy Chu responds:

Hi Rob - thanks for taking a stab at this difficult and VERY common question.

Here's what we KNOW:

• People can and do become HIV positive from receptive oral sex (it has been documented in medical literature)

• Getting HIV from performing receptive oral sex is much less risky than than either receptive or insertive unprotected anal intercourse - let's call it a distant third

• As far as I know, there have not been any documented instances of HIV transmission from receiving oral sex (though certainly there is a theoretical risk)

Here's what we DON'T KNOW:

• We don't know exactly HOW much less risky oral sex is compared to receptive anal, or insertive anal sex; but for those demanding our best guesses, here is some data* listed by the CDC's January 21, 2005 guidelines on post-exposure prophylaxis for HIV ("post-exposure prophylaxis" means - you were exposed to HIV and we are going to give you meds to try to prevent you from actually getting infected):

*Note that I list this table under "What we don't know" because, despite the very certain-looking numbers in the table, these are still guesses and estimates (seriously, the authors of the study on which these numbers are based fully admit to making best estimates).

• We also don't know just how important some factors are in relation to each other in terms of oral transmission of HIV, such as: viral load of insertive partner, cuts in mouth/recent dental work/inflamed gums of receptive partner, whether the insertive partner ejaculated, etc. (though all these are theoretical contributors to risk of transmission)

In the end, as difficult as this question is to answer, it provides a great example of how best to navigate your risk. You need to talk to your sex partners, inquire about their HIV and STD status, and communicate openly about your concerns. So the more you know, the safer you can be. The less you ask, the higher your risk will be.

Rob, Dave, and I will always be here to help you navigate these risks...

- Vy Chu, MD

HPV infection and/ or Gardisil vaccine for Gay Men

There are several questions still pending, but this came in yesterday and I think it should be discussed:

"Can males get the HPV vaccine (also known as Gardasil)? It seems discriminatory to make a life-saving vaccine available only to females."

Rob Killian, MD responds:


The answer is yes to every implication in this question. HPV indeed affects both males and females. And the decision by the FDA to only authorize it for females was a disappointing decision by members in the previous administration. Because of that decision, the HPV vaccine for males has to be given 'off label' which means that most insurance companies do not pay for it.

If you are a male, you should consider this vaccine even if you are already sexually active and even if you already have genital warts, and here is why: There are dozens of serotypes of HPV. The vast majority cause warts, but some can cause cancer (anal, cervical, oropharyngeal). Just because you have genital warts DOESN'T mean you are also infected with the strains that cause cancer.

Some doctors are waiting to see the new studies involving the HPV vaccine that are currently underway on males. But it may be a few years before the results are available and another few years before the FDA makes any recommendation changes to include males. So, if you are able to pay for your vaccine you should ask your provider for this vaccine series. There is no reason to wait other than the cost.

We are offering this vaccine for our patients at Capitol Hill Medical.

Let me know if that opens up any other questions.

As an aside, when I confronted the female drug rep representing the company that makes the vaccine, she informed me that she had all of her four sons vaccinated ....she understood the disappointing decisions that led to the current situation. Merck appears to be trying to correct this as quickly as they can with the FDA, but if you can afford the vaccine then do not wait for politics to catch up with politics.

If you can't afford the vaccine now, there is hope around the corner in a few years. With luck, we'll get to a day where genital warts is a thing of the past.

And finally - the cost, if your insurance does not cover the vaccine for men is about $360 total. It is a series of three shots given over six months.

Rob

How often should one test for STDs?

Here is one of our first questions:

How often should I be tested for STDs/HIV if I engage in sexual activities with multiple partners on a regular basis? I do use condoms, so I figure I am low risk, but there is always something in the back of my head making me feel a little anxious... I've traditionally done once a year. Thanks!

Rob Killian responds:

This is a great question. There are at least ten common STDs. HIV, Hepatitis A and B, Gonorrhea, Chamydia, Syphilis, Herpes One and Two and then there are genital warts caused by Human Papiloma Virus and Crabs or Scabies.

The common tests that patients request include the HIV and Syphilis test. But each of us should know our exposure history to Herpes. We should be vaccinated to both Hepatitis A and B. I would hope that one who has multiple sexual partners would regularly be tested, report any sores or lesions or other physical symptoms.

Since one can be exposed to syphilis with not only skin to skin contact and saliva one should be tested regularly for this if one is sexually active.

If you have not been exposed to Herpes or do not know your status please ask for this screening test at your next medical visit. One can be contagious for herpes after exposure even if there is no sore or obvious lesion. Knowing your Herpes status is now more important than ever.

If one is fully safe with exposure to semen and blood then once every six to twelve months for HIV testing is fine.

If you have any penile discharge, burning with Urination, or mucousy rectal discharge then you should be tested for Gonorrhea and Chlamydia.

If there is less than safe exposure than a more frequent testing regimen should be included. All of us here at Capitol Hill Medical believe that is best to know your status and to learn how to play safely or to feel safe enough to discuss this important part of our lives.

Capitol Hill Medical also now offers the male Anal Pap smear to see if you have any changes to your rectal cells that could lead to Rectal cancer caused by the HPV or wart virus. There is a vaccine now against the four most aggressive strains of HPV and every gay man or male who practices ANAL sex should consider whether they should have this vaccine. It is called Gardisil. It is still not FDA approved for males, but many Gay men have chosen to get this vaccine anyway. The company that makes Gardisil is studying the efficacy in men and these studies should be available soon. But, we at Capitol Hill Medical are already willing to make it available to any patient that requests it. But, if you have any history of warts or not you should ask for the ANAL pap smear as part of your annual physical.

If you have never tested your immunity to the common Hepatitis Viruses we can offer these tests at your next visit. If you have not been vaccinated yet, you absolutely need to be vaccinated against these common viral ilnesses.

Let us know if you have any further questions.

First Post!

WELCOME to Capitol Hill Medical's Blog!

In the coming weeks we will be gathering some of the most common and most interesting questions asked of our providers by patients, friends, family and colleagues regarding GLBT healthcare and posting our answers and discussion here, once per week.

Expect topics to include anything from STD screening to preventative medicine in our GLBT elderly; from navigating HIV risks to navigating HIV medications; from hormone therapy for those between gender to substance use and abuse.

No question is silly, no topic is off-limits. We will base our answers on our practice experience as well as on the best available literature we can find on the topic, and we welcome your comments as well as the comments of our colleagues.

Please feel free to click on the link on the right side of this page to submit your own question!

Vy Chu, MD