HIV Providers and Advocates Continue to Debate STI Rates in the Era of PrEP and U=U

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From Aug. 27 to 30, the Centers for Disease Control and Prevention (CDC)'s Division of Sexually Transmitted Disease (STD) Prevention will host the STD Prevention Conference in Washington, D.C. This biennial conference could not be timelier as the U.S. is facing a resurgence in sexually transmitted infections (STIs). The growing STI epidemic has reached record levels nationwide. The most recently available national data from the CDC identified 1.6 million diagnoses of chlamydia, 470,000 of gonorrhea, and nearly 28,000 of primary and secondary syphilis in 2016.

At this year's International AIDS Conference's STI Pre-Conference held in Amsterdam, the Netherlands, Kenneth Mayer, M.D., medical research director with the Fenway Institute in Boston, presented data detailing that most syphilis cases are found among men who have sex with men (MSM). Furthermore, nearly half of these diagnosed MSM are living with HIV. As with any public health crisis, it is important to decipher the cause and/or source of the rise.

Simultaneously, there has been a concerted effort to reduce the number of HIV infections by expanding awareness and access to emtricitabine/tenofovir disoproxil fumarate (Truvada) as pre-exposure prophylaxis (PrEP). PrEP has been shown to effectively avert sexually acquired HIV infections when taken as prescribed. In the six years since PrEP has available to the U.S. public, there have been reports of declining utilization of condoms by PrEP users. As PrEP does not prevent STIs, increased condom-free sex can put individuals at higher risk of STI infection or re-infection when exposed.

There has been a growing fear among some public health professionals that increasing PrEP use may inadvertently fuel a nationwide STI epidemic -- or even a global pandemic. At last year's CROI conference, a presentation detailed how complicated the association between STIs and PrEP may be. The gay male participants in this Seattle-based study had an STI acquisition rate three times higher than average prior to beginning PrEP, which suggests that gay men who use condoms less and acquire STIs may be more likely to seek out and decide to use PrEP. After beginning PrEP, the participants experienced an increase in chlamydia cases; however, they experienced a decrease in syphilis infections.

"When it comes to STIs, what we actually need is more screening and prompt treatment," said Mayer. "We never want to demonize people taking care of their health. We must be focused on bringing people into care. STIs are increasing throughout whether or not the patients are using PrEP. Public health [officials] cannot afford to be in the same arena as alternative facts."

Individuals who use PrEP to prevent HIV infection are typically screened for HIV and STIs semi-annually or quarterly as a standard best practice, which means they are more likely to be screened and treated quickly for STIs than are people not on PrEP.

Related: HIV Undetectable = Untransmittable (U=U): Information for Providers

"We should be more concerned with the rates of STIs for people not on PrEP," said Asa Radix, M.D., M.P.H., FACP, senior director of research and evaluation with Callen Lorde Community Health Center in New York City. "We're already optimizing STI screening and treatment options for people on PrEP. If I had to choose other quality indicators, they would include evaluating unintended gaps in PrEP care, ongoing adherence and persistence, and assessing behavioral health needs."

Radix's more holistic approach to care and its ultimate impact on HIV/STI acquisition and progression reverberates with other providers, especially those focused on serving the most impacted key populations.

"For decades, the HIV/STI field has used fear-based messaging to shame and stigmatize same-gender loving men, especially those from the African Diaspora," said David Malebranche, M.D., M.P.H., associate professor of medicine at the Morehouse School of Medicine. "That must end. Sex should be pleasurable. We need to make sure that we focus on helping people have the sex that they want. That it feels good. And that they can have that kind of pleasure in a healthy way."

It has been stressed that a culturally tailored and effective approach is needed before the epidemic becomes uncontrollable. Linda-Gail Bekker, M.B.Ch.B., FCP(SA), Ph.D., former president of the International AIDS Society and deputy director of Desmond Tutu HIV Centre, cautioned, "[W]e must do all that we can to stop STIs before drug-resistant forms develop which we cannot stop."

In an era of HIV biomedical prevention and undetectable equals untransmittable (U=U), the primacy of condom use has changed, but the need to consider approaches to decrease STIs has not. In an article published earlier this year, health policy leaders and providers, including Mayer, advocated for a "reassessment of the alignment and prioritization of HIV research funding, public health policy, and community engagement."