High sexually transmitted infection rates spur condom debate
Sexually transmitted infections (STIs) have been on the upswing among gay and bisexual men over the past several years. Some have hypothesized that PrEP use among HIV-negative men, and treatment as prevention among HIV-positive men, have led gay and bi men to stop using condoms. This, in turn, has contributed to rising STI rates in recent years.
At the recent IDWeek 2016 conference in New Orleans, researchers debated these difficult-to-parse points. And, they presented data to try and answer the question—what’s causing the rising STI rates? And, do rising STI rates mean that we should be promoting condom use for everyone?
Rising STI Rates
Nationwide data included in the CDC’s latest Sexually Transmitted Diseases Surveillance report, released last month, shows that chlamydia, gonorrhea, and syphilis are at their highest levels ever. Young people, and gay men, are most heavily impacted. The syphilis rate among gay and bisexual men is 309 cases per 100,000, compared with just 2.9 per 100,000 among heterosexual men, according to new state-level data released at the recent STD Prevention Conference. The latest data from San Francisco show a steep climb in gonorrhea and syphilis among both HIV-positive and HIV-negative gay and bisexual men.
At IDWeek, Douglas Krakower, MD, presented findings from an analysis of trends in PrEP use and STI rates at Fenway Health, a clinic specializing in care for sexual and gender minorities in the Boston area (abstract 2379).
More than 19,000 men visited the clinic at least once between 2005 and 2015. About 15% of Fenway clients are HIV-positive. Almost all of them start ART within a year of HIV diagnosis and most (86%) achieve viral suppression.
Among HIV-negative clients there has been a rapid increase in PrEP use in the last five years. Truvada PrEP prescriptions climbed from just five in 2011 to 960 in 2015, and last year 14% of all men seen at the clinic for any reason decided to begin PrEP.
Between 2005 and 2015, 18% of men seen at the clinic were diagnosed with a bacterial STI: 7% with gonorrhea, 7% with syphilis, and 9% with chlamydia. By 2015, 14% of HIV-positive clinic patients and 25% of HIV-negative PrEP clients had at least one STI. Syphilis increased over the entire period, with an accelerated rise starting around 2011. Gonorrhea was relatively stable from 2003 through 2010, followed by a “near astronomical rise,” according to Krakower.
Being HIV-positive and using PrEP were both independently associated with a greater likelihood of being diagnosed with an STI in the Fenway study, but Krakower stressed that it is “hard to infer causality” from this type of data. The rise in STIs started before PrEP was widely used, and a substantial number of men who were neither HIV-positive nor on PrEP got STIs as well.
PrEP and STIs
A common concern about PrEP is that it will lead people to stop using condoms, putting them at risk for other STIs. This “risk compensation” was not seen in clinical trials that led to approval of Truvada PrEP, but it has been reported in real-world use, including at the San Francisco AIDS Foundation’s PrEP Health Program at Strut and at Kaiser Permanente San Francisco.
Participants in PrEP clinical trials, demonstration projects, and real-world PrEP programs generally do have high rates of STIs, both at the outset and while they are on PrEP. A recent meta-analysis by researchers at the University of California at Los Angeles found that gay men on PrEP were 25 times more likely to acquire gonorrhea and 45 times more likely to get syphilis than men not on PrEP.
This does show that the men seeking PrEP are the ones who likely need it most.
“Seeing a correlation between high rates of [STIs] and PrEP use is what we expect,” said Susan Philip, MD, from the San Francisco Department of Public Health. “Individuals with high rates of [STIs] are exactly the people we want to be considering and starting PrEP.”
While rising STI rates are a concern, the regular clinic visits recommended for HIV-negative people on PrEP offer more opportunities for frequent STI testing and prompt treatment.
The Centers for Disease Control and Prevention’s PrEP guidelines recommend STI testing at least every six months, but some people may benefit from more frequent tests. PrEP users should be seen every three months anyway for HIV testing and to monitor for kidney side effects, and some providers already do quarterly STI screenings as well.
Researchers with the PrEP Demo Project, which enrolled high-risk gay men and transgender women in San Francisco, Miami, and Washington, DC, recently reported that 40% of chlamydia, 34% of gonorrhea, and 20% of syphilis cases would have been missed if STI screening had been done only every six months instead of every three months.
Education about the risk and consequences of STIs, and the need for prompt treatment, is an important part of PrEP counseling.
“This work really emphasizes the need to educate people when they are receiving PrEP about the risk of acquiring sexually transmitted infections,” Pablo Tebas from the University of Pennsylvania said at an IDWeek press briefing.
What about STIs among people using treatment as prevention?
In the IDWeek debate, Roy Gulick, MD, from Weill Medical College of Cornell University and Lisa Winston, MD, from the University of California at San Francisco faced off over a question about whether men living with HIV should be advised by health practitioners to wear condoms—even if their viral loads are undetectable. Although the central question debated was about the potential for HIV transmission, the issue of rising STI rates was touched on as well.
Gulick took the position that condoms are not necessary in this situation, reviewing evidence that effective ART that maintains undetectable viral load dramatically reduces the risk of HIV transmission. He noted that a majority of gay and bi men are unwilling or unable to use condoms all the time, so it’s pointless to debate whether they “should.”
Winston discussed the potential for HIV transmission in situations when a person may believe they are undetectable, but focused her argument in favor of condoms on STI prevention.
She explained that drug-resistant gonorrhea is a growing threat, and that new evidence shows that emerging viruses such as Ebola virus and Zika virus can be sexually transmitted. Some STIs can have serious long-term consequences—including infertility, and syphilis affecting the eyes and brain.
“I think a lot of people would say that we’ve underestimated [STIs],” Winston said. “There’s been this feeling that — as long as you don’t get HIV — while it’s nice to avoid STIs, we can pretty much treat them and it’s not that important. But now I think we’re newly appreciating how scary some of these can be.”
Liz Highleyman is a freelance medical writer and editor of HIVandHepatitis.com.