January 11, 2002

This is the first of a new series of articles I hope will be of interest and use to Seattle and King County men who have sex with men, regardless of their sexual identity. I first wrote a series of articles in the Seattle Gay News in 1987-89 that provided my perspective as an openly gay physician as I was assuming the directorship of the HIV/AIDS Program for Public Health - Seattle & King County. Those articles discussed what we knew at that time about HIV. A second series of articles appeared during 1997-98 that provided an update on the impressive and hopeful new developments in the treatment of HIV and an update on new knowledge around HIV prevention. This current series of articles will provide a third set of updates on the health of homosexually active men.

Many gay men today are unaware they are at risk for serious stomach cramps and diarrhea caused by a microscopic bug called Shigella. When this bug is present, disease can easily be spread from one person to another through rimming (oral-anal contact) and from oral contact with contaminated skin including skin in the groin area, the testicles and the penis. Increases in people infected with Shigella are being seen locally and in San Francisco among homosexually active men. People with HIV are more likely to have serious complications from infections with Shigella.

Shigella is often spread through fecally contaminated food and water, but can also be spread person-to-person through sexual activity. Many cities with sizeable gay/bi populations world-wide have experienced outbreaks of shigellosis within their homosexually active communities. Sexual practices more common in gay and bi men facilitate fecal-oral spread of the infection. For example, 50% of the sexually active men with Shigella questioned in San Francisco answered "yes" to the question: "in the week before your illness did you put your tongue in a partner's anus?"

Ingestion of Shigella bacteria indirectly, through touching or licking contaminated skin can transmit infection; that is, it is not necessary for one's tongue or mouth to touch an infected anus. An infected partner's penis or testicles that are less than perfectly clean can easily transmit infection. A very small amount of Shigella can cause infection resulting in serious stomach cramps, diarrhea, fever, and sometimes nausea and vomiting. Symptoms can occur 4-7 days after contact and may last up to a week. In San Francisco about 3 out of 4 infected men surveyed had performed fellatio (oral-genital contact) the week before they became ill.

Locally, many gay and bisexual men with shigellosis have expressed surprise that sexual behaviors can put them at risk of contracting diarrheal illnesses such as Shigella. But this is not earth breaking news, nor is Shigella the only gastrointestinal infection which homosexually active men are more likely to get. Other bugs commonly acquired through sex that can case stomach pain and diarrhea are Giardia, Amebiasis, and Cryptosporidium, three kinds of parasites. Also, about a year ago, public health investigators reported the first case of sexually transmitted typhoid fever between men. Finally, hepatitis A, caused by a virus, has long been known to be spread sexually between gay and bi men, through the fecal-oral route.

Prevention of shigellosis and other diarrhea-causing agents spread from the gut to the mouth requires homosexually active men to be aware of the increased risk of transmission of these bugs from oral-genital (fellatio) and oral-anal (anilingus) contact. The use of gloves for hand-anal contact, and the use of latex and other barriers like condoms, dental dams, and plastic wrap may help to reduce risks for anal intercourse, blow-jobs, and rimming (also called anilingus). However, the avoidance of oral contact with fecally contaminated body parts or objects, and the importance of very thorough genital and hand washing before and after sex, is also stressed.

Homosexually active men with active shigellosis or any diarrhea that may have an infectious origin should abstain from sex while symptoms are present, and not resume sex until at least 3 days after beginning an appropriate course of antibiotics. Preferably they should wait until a repeat stool culture shows them to be free of infection since antibiotic resistance is common. Doctors should routinely request antibiotic sensitivity testing, and based on test results might have to change antibiotics. Homosexually active men especially need to use careful and basic hand washing and food hygiene to prevent disease transmission by non-sexual routes.

The present Shigella epidemic reminds us that there are diseases out there that are more common in homosexually active men than in the general population. It is also a reminder that sexual risk taking by homosexually active men has been increasing.

I hope in future articles to address the problems of increasing sexually transmitted diseases and a rise in new cases of HIV. I will present evidence of these increases and my ideas about why this is happening, the potential impacts on the health of gay/bi men, options for action, and actual steps being taken by public health and community groups. My opinion is that this cluster of problems--increasing risk behaviors, rising STD and HIV rates, and now Shigella--are extremely serious threats to the health of the gay and bisexual community. Many of these diseases are easily and effectively treatable. HIV is another story. Yes, HIV is treatable these days, but as someone with the infection on treatment knows, treatment is often not easy, it is often unkind in creating occasionally bad side effects, and most likely lifelong treatment will be needed.

To protect and value our health and the health of our community, we must increase the emphasis on safer sex until our rates of disease can be brought back to healthier levels. Safety cannot solely be based on concern about one disease or another like HIV or Shigella but must reflect our caring and deep commitment to our community's health now and into the future.

For more information on Shigella, HIV, or other STDs, call the HIV/STD Hotline at (206) 205-7837, 8:00 AM - 5:00 PM Monday through Friday.