Risk factors and provider awareness of sexually transmitted enteric pathogens among men who have sex with men

ABSTRACT Sexual transmission of enteric pathogens among men who have sex with men (MSM) is well documented, although whether providers are cognizant of this risk when MSM patients present with gastrointestinal symptoms has not been studied. Over 34 months at a major tertiary metropolitan medical system, this study retrospectively analyzed 436 BioFire FilmArray Gastrointestinal results from 361 patients documented as MSM. An extensive chart review was performed, including specific sexual behaviors, socioeconomic risk factors, and whether providers charted a sexual history when a patient presented for care. Overall BioFire positivity rate was 62% with no significant difference in positivity between persons living with HIV and those without. Patients charted as sexually active had a significantly increased odds ratio (OR) of a positive result compared to those who were not. Anilingus had the highest OR. Providers charted any type of sexual history in 40.6% of cases, and HIV/infectious disease providers were significantly more likely to do this compared to other subspecialties. Sexual transmission of enteric pathogens within MSM is ongoing, and patients are at risk regardless of living with HIV. Not all sexual behaviors have the same associated risk, highlighting opportunities to decrease transmission. Increased provider vigilance and better patient education on sexual transmission of enteric pathogens are needed to reduce the disease burden. IMPORTANCE Our work adds several key findings to the growing body of literature describing the epidemiology of enteric pathogens as sexually transmitted infections among men who have sex with men (MSM). We analyzed clinical test results, housing status, provider awareness, sexual behaviors, and symptoms for 361 patients. We found that any sexual activity was associated with an increased risk of diarrheal pathogen detection, whereas being unhoused was not a risk factor. These findings suggest separate transmission networks between unhoused persons, who are also at risk of infectious diarrhea, and MSM. Moreover, our study suggested low awareness among patient-facing clinicians that diarrheal pathogens can be sexually transmitted. Together, our findings indicate an important opportunity to disrupt transmission cycles by educating clinicians on how to assess and counsel MSM patients.

1st Editorial Decision Re: Spectrum03577-23 (Risk Factors and Provider Awareness of Sexually Transmitted Enteric Pathogens among Men Who Have Sex with Men) Dear Dr. Timothy Isaac Miller: Thank you for the privilege of reviewing your work.Below you will find my comments, instructions from the Spectrum editorial office, and the reviewer comments.
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Sincerely, Vera Tesic Editor Microbiology Spectrum
Reviewer #1 (Comments for the Author): This is a very interesting study looking at factors associated with GI BioFire positivity among MSM at a large academic hospital.

General Comment
Please revise manuscript to incorporate person first language throughout.We should no longer identify patients or participants as HIV-positive or HIV-infected.They are people with HIV (PWH) or people living with HIV (PLWH).Similarly, would change HIVnegative to people without HIV.

Methods
How did you define PrEP use?Do you mean active PrEP prescription at time of testing on chart review?These are two different things Please include how sexual behaviors were collected on chart abstraction.For example, for oral-anal contact, if nothing was documented, was the patient considered to have no oral-anal contact?How did statistical analysis account for this?

Results
To follow results better, consider documenting % and absolute numbers Line 173 -HIV specific findings, 194 positive out of 300 PWH tested; however earlier its states that there were 238 PWH in the cohort.Similar discrepancy for people without HIV, please clarify Line 174-177 -Would just say that the small absolute increases in both groups were not statistically significant.Line 177-179 -Remove this sentence and discuss statistically significant organisms (Shigella and Giardia) Line 184 -Why is >40 c/mL used to define unsuppressed VL?This number is not clinically meaningful; would consider >200 c/mL Line 209 -What is the clinical significance of 3 years for an STI to be consider "recent"?Most guidelines and data, specifically in MSM, define recent as 12 months Discussion Line 218 -While I agree with this statement, I am not sure your data fully supports this.You present retrospective data of MSM with positive enteric pathogen screening.Sexual history data is somewhat incomplete or remote, of what is documented there is a correlation of higher sexual activity and oral-anal contact with positivity of tests.Line 242 -Serosorting practices have changed dramatically over the past 10 years with expansion of PrEP and U=U messaging, not sure this argument holds water currently Reviewer #2 (Comments for the Author): The discussion is very long and can be truncated.In the methods section, details on how samples for the Biofire test are collected can be added.It will also be important to add some background information on Biofire, e.g., what is the test?What is sensitivity specificity, etc?