August 2012
Getting tested for sexually transmitted infections (STIs) every 6 months and receiving brief risk counseling from HIV providers lowered the rate of new STIs in gay and bisexual men with HIV.1 In this study in four U.S. cities, only 11% of detected STIs caused signs or symptoms noticed by the infected person: That finding underlines the importance of regular testing for STIs in sexually active people, because many STIs cause no signs or symptoms that indicate infection.
Most people who become infected with HIV get infected during sex. If an HIV-positive person has unprotected sex, that person runs a risk of picking up another STI, such as chlamydia, gonorrhea, or syphilis. Having an STI can raise an HIV-positive person's viral load and can make it easier for that person to infect someone else with their HIV.
Gay and bisexual men in the United States and other countries often run a high risk of infection with HIV and other STIs because many men have multiple sex partners, have sex without condoms, and do other things that make picking up an STI more likely (such as drink alcohol or use drugs before having sex).
The Centers for Disease Control and Prevention (CDC) advises HIV providers to talk to patients regularly about how to avoid STIs. The CDC also says sexually active people should get tested regularly for STIs, even if they have no signs or symptoms of infection. An STI may cause no visible sores or rashes and may not make a person feel sick. So regular testing is often the only way to detect STIs.
One brief STI counseling approach recommended by the CDC is called Partnership for Health.2,3 CDC researchers and other HIV experts conducted this study to see if Partnership for Health could lower the rate of new STIs in HIV-positive gay and bisexual men in the United States.
The study involved gay and bisexual men who were members of the SUN Study. The SUN Study is an ongoing study of HIV-positive men and women in Denver, Minneapolis, Providence, and St. Louis. SUN Study members come for check-ups every 6 months. At these visits everyone gets tested for STIs and everyone completes a computer-assisted interview about STI risk factors and habits like smoking and recreational drug use.
The new study focused on HIV-positive men who said they had had sex with another man before joining the SUN Study. All these men were tested for gonorrhea, chlamydia, and syphilis when they entered the SUN Study and every 6 months after that. The men also reported possible signs or symptoms of STIs whenever they got tested.
All these men and their HIV providers took part in the Partnership for Health program. A full description of this program can be read at the link following reference 2 below. Briefly, whenever people visit the HIV clinic they see messages about safer sex behavior in posters, brochures, and flyers. During each person's health check-up, their HIV provider reinforces these messages. HIV providers and all other clinic staff receive training in the Partnership for Health program.
SUN Study participants get tested for STIs every 6 months. The researchers who ran this STI study analyzed data from two SUN Study visits 12 months apart. The first study visit was the one at which the study participant was first exposed to the Partnership for Health program. The second study visit was the one that took place 12 months after the first study visit.
Finally, the researchers compared the number of new STIs at the first study visit with the number at the second study visit. They also compared sex behaviors at those two visits.
The study included 216 gay or bisexual HIV-positive men who had complete STI testing data and risk behavior data available from the first study visit and the second study visit (12 months after the first). At the first visit, these men had a median age of 44. Most men (77%) were white, 11% were black, and 11% were Hispanic.
Median CD4 count when the study began stood at 511. Of the 216 men studied, 179 (83%) were taking combination antiretroviral therapy and 182 (84%) had an undetectable viral load. When the study started, 163 men (75%) said they were sexually active. Among the 53 men not sexually active when the study began, 28 (53%) became sexually active during the 12-month study period. Only 3% of men who were sexually active when the study began were not sexually active 12 months later.
Seventy-eight men (36%) said they had unprotected anal or vaginal intercourse at some point. Eighty-two men (38%) had more than four alcoholic drinks in the past month, and 81 (38%) had used any drug (not counting marijuana), 67 (31%) used inhaled nitrites, 46 (21%) used an erection drug (such as Viagra), and 16 (7%) used methamphetamine.
Almost half of the men in this study -- 103 or 48% -- said they had depression. (For more on depression, see the article in this issue, "Depression and Wider Waist Linked to Sleeping Problem in People With HIV.")
The overall rate of newly detected STIs fell from 8.8% at the first study visit to 4.2% at the second study months -- 12 months after men started participating in the Partnership for Health program (Figure 1). In other words, the new STI rate fell by half over the course of the study, as providers engaged HIV-positive men in discussing safer sex, and as men continued regular STI testing.
The rate of newly detected STIs in the anus and rectum fell from 6.9% at the first study visit to 2.8% at the second study visit 12 months later. In other words, the rate of this kind of STI fell by more than half during the study.
Of the 28 new STIs detected during the study, only 3 (11%) had noticeable signs or symptoms. So 25 of these new STIs would not have been detected without regular STI testing of all these men, and those undetected STIs could have been transmitted to other people.
Despite these improvements in STI rates, rates of anal or vaginal sex without a condom remained about the same -- 36% at the first study visit and 38% at the second study visit 12 months later. The rate of condom-free receptive or insertive anal intercourse rose from 19% to 25% with HIV-positive partners. But that rate did not change with HIV-negative partners or with partners whose HIV status was not known.
Self-reported rates of alcohol use or drug use did not change from the first to the second study visit.
This study found that the rate of new sexually transmitted infections (STIs) fell by half in the year after HIV-positive gay and bisexual men began getting tested for STIs every 6 months and started a program aimed to help them reduce risky sexual behavior. The rate of new anal or rectal STIs fell by almost 60%.
Nearly 90% of the new STIs detected during this study caused no signs or symptoms and did not make these men feel sick. If these men had not been tested for STIs every 6 months, these STIs would not have been detected. Treatment of STIs like gonorrhea, chlamydia, and syphilis is usually very simple. But if these infections are not treated, they can cause serious health problems. In addition, the bacteria that can gonorrhea, chlamydia, or syphilis can be passed on to a sex partner.
The Centers for Disease Control and Prevention (CDC) recommends regular STI testing for sexually active people.4 How often you get tested depends on how much sex you have and what risks you take when having sex. Gay and bisexual men who have several sex partners, who don't know their sex partners personally, or who have sex while drinking alcohol or taking drugs should probably get tested for STIs every 3 to 6 months.
Regular STI testing can help lower the rate of new infections by reminding people about avoiding STI risks. Because having an STI raises the risk of picking up other STIs, detecting hidden STIs and treating them could lower the STI rate. Regular testing also reminds HIV providers to counsel their patients about avoiding STIs. Table 1 lists other advice on avoiding STIs.
Because of the way this study was designed, the researchers could not figure whether regular STI testing or STI risk counseling -- or both -- explain the falling STI rate in the men studied. They suggest that both twice-yearly STI testing and risk-reduction counseling contributed to the falling STI rate and that these two strategies should be combined.
A previous study of the Partnership for Health program in 585 HIV-positive Californians found that it lowered the rate of condom-free anal or vaginal sex by 38% in people with two or more sex partners.3 Another 13-center study found that brief prevention counseling by HIV providers lowers rates of unprotected vaginal or anal sex with HIV-negative partners or partners with an unknown HIV status.5
It is also hard to explain why the study did not find a drop in risky sex behavior even though the new STI rate fell. The overall rate of sex without a condom remained the same from the first study visit to the second study visit 12 months later. It could be that some men did start practicing less risky sex recently, but that the survey they completed did not pick up that change.
Although the rate of anal sex without condoms with HIV-positive partners rose slightly during the 12-month study period, the rate of this kind of sex with HIV-negative partners did not change. Those findings suggest that some men may have adopted the strategy called serosorting -- having sex only with partners of the same HIV status (positives only with positives and negatives only with negatives). Although serosorting may lower the risk of picking up HIV infection, it does not cut the risk of picking up a new STI.
Wearing condoms during anal sex lowers the risk of getting infected with HIV and with other sexually transmitted infections. Consistent condom use is the surest and easiest way to prevent the spread of HIV and other STIs during sex.
