PrEP Use Doesn't Increase STIs Among Black MSM, New Study Shows

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The HIV Prevention Trials Network 073 (HPTN 073) study continues to provide glimpses into how black men who have sex with men (BMSM) are engaging with pre-exposure prophylaxis (PrEP) and other sexual health interventions. One of the most striking takeaways from the study is that greater PrEP uptake among BMSM does not correlate to greater sexually transmitted infections (STI) rates.

According to the researchers' latest article, titled "Incidence and Correlates of STIs among Black Men who have Sex with Men Participating in the HPTN 073 PrEP Study," PrEP use did not cause a spike in STI rates. Higher rates of STIs were observed in younger BMSM; however, the overall rates of STIs in study participants were lower than in previous PrEP trials. At the study baseline, STI prevalence was observed at 14.2%. Halfway through, at 26 weeks, the STI incidence crept to 16.2%, and it reached 18.2% at 52 weeks, which was not a significant boost. Chlamydia was ranked the most common infection at 10.2%, followed by gonorrhea and syphilis, at 5.3% and 1.3%, respectively.

Age served as the distinguishing factor in baseline STI prevalence within HPTN 073's 226-person cohort. A high baseline of STIs was observed in participants younger than 25 years (25.3%), whereas participants aged 25 years and older had a baseline 6.7% prevalence rate.

"We have to be consistent with our messaging," said Sheldon D. Fields, Ph.D., RN, FAAN, an HPTN network scientist and CEO of The S.D.F. Group, LLC. "And clearly, those who are anally receptive and younger than 25 still appear to be at significant risk for contracting STIs, but I think it's also consistent with the general population."

Fields is one of the two protocol chairs of HPTN 073. He spoke with TheBodyPRO about HPTN 073 and the importance of centering black same-gender-loving men within sexual health research -- both as a focus of research and also with research led by black MSM about their own communities. BMSM accounted for 26% of the 38,739 newly diagnosed HIV cases in 2017, and with these disproportionate numbers, more research is necessary, Fields said.

But with more research, there can be the perception that the hyperfocus on BMSM in HIV research creates stigma in and of itself, even while trying to find solutions to the epidemic. Daniel D. Driffin, M.P.H., director of external affairs at THRIVE SS in Atlanta, shared his thoughts on the hyper-sexualization of black men: "The only aspect of living for black men is sex, and we are reduced only to HIV," he said. "Using these words often times outright erases black men's humanity and personhood."

But the issue of whether PrEP would increase not just stigma but also STIs has been around since it was approved in 2012. Many public health practitioners express nervousness around risk compensation. The often-used anecdote is condom use frequency could plummet with more people using PrEP in lieu of condoms, though PrEP is only effective at preventing HIV. Meanwhile, gonorrhea, chlamydia, and syphilis rates remain high, in a new social climate welcoming of PrEP but adverse to condoms.

"In our PrEP study, we were not anti-condom, as some people would like to think," Fields said. "When we counseled folks in this study, we talked about all of their options. We talked about the need to also use condoms to prevent other STIs," Fields said.

HPTN 073 focused its efforts on BMSM in three U.S. cities: Washington, D.C., Los Angeles, and Chapel Hill, North Carolina. All participants were offered oral PrEP to be taken daily, combined with client-centered care coordination. This intervention included a theory-based counseling approach to promote and support PrEP use along with service referral, linkage, and follow-up strategies to assist participants in addressing unmet psychosocial needs.

Fields, a nurse practitioner, offered recommendations to fellow colleagues: "[When you] notice someone is at risk, you don't withhold a prescription for PrEP because it's your fear they will contract a sexually transmitted infection. Not only continue to prescribe PrEP, but you need to counsel your patients accordingly about that continued risk of contracting other STIs, particularly those that may be drug-resistant."

"Screening of STIs has to be comprehensive," Fields added. "A lot of providers will only do blood draws for sexually transmitted infections and not ask questions about what their clients actually do sexually, because in order to do the comprehensive testing, you need to do pharyngeal swabs and rectal swabs, and that often gets missed. There are a lot of STIs that go undetected for too long."

For gay and bisexual men, more than 70% of gonorrhea and more than 85% of chlamydia go undetected if three-site testing isn't used.

For some black men, speaking with their providers can be difficult.

"I still think the vast majority of black gay men do not disclose to their provider," Fields said. "Sometimes for good reason. I think providers have to own a part of this problem."

Providers need to be aware of their biases, Fields added. "A large proportion of providers are still not comfortable with taking a comprehensive sex history. When you do that, you place your own personal biases ahead of the welfare of the patient. ... It's more about sexual health on a spectrum than just whether or not you have an STI."