STDs Among Gay Men in a New Era of PrEP
In tandem with (and prior to) the approval and uptake of PrEP, rates of sexually transmitted infections (STIs) have been increasing among men who have sex with men in San Francisco. What’s going on—and what can we do about the rising rates of STIs?
These are questions capturing the attention of infectious disease physicians, public health experts and the community at large—and a topic discussed by the medical director of City Clinic in San Francisco at a recent San Francisco General Hospital HIV Grand Rounds presentation. Here’s what we learned from Stephanie Cohen, MD, MPH about the relationship between STIs and PrEP.
Sharp increases in STI cases in San Francisco
In what Cohen described as a “pretty fascinating epidemiological divide,” beginning in 2008, the number of HIV cases in San Francisco began to decline while the number of syphilis and gonorrhea cases started to increase sharply.
“Historically, HIV and bacterial STDs have always really tracked pretty closely together,” said Cohen. Although there’s been a divergence in trends between STIs and HIV, the populations that are most severely affected are the same, with gay men and other men who have sex with men, African American people under the age of 25 and transgender people bearing the brunt of new infections.
Early syphilis cases have gone up sharply since the late 1990s, during which time the number of infections was close to zero. (In 2014, there were over 400 diagnosed cases of early syphilis among men who have with men in San Francisco.) The number of gonorrhea cases has also risen sharply among men who have sex with men, with close to 800 cases in 2014 compared to half that number in 2005.
Are the rise in STI cases caused by PrEP?
“This field is still early in its infancy, so I think we have more to learn,” said Cohen. The question is largely about risk compensation—in other words, is the protection afforded by PrEP cancelled out by an increase in risky behaviors by people who take PrEP?
There’s not a complete absence of risk compensation throughout the PrEP literature, said Cohen. An analysis of data collected during the US PrEP Demonstration Project found that people did change their serosorting intentions when on PrEP: People were less likely to report that they would serosort as an HIV prevention strategy, and more likely to say they would be willing to have sex without a condom with an HIV-positive partner. (The study did not find any significant change in serosorting practices, though.) People in the PROUD study were more likely to report having 10 or more sex partners if they were on PrEP, and people in the IPERGAY study reported more receptive condomless anal sex during the open-label portion of the study compared to the blinded study phase.
In the real world, men in San Francisco included in the National HIV Behavioral Surveillance System were less likely to report consistent condom use with anal sex in 2014 (when PrEP was more widely used) than in 2004, 2008 and 2011 (before PrEP was approved and available).
Since STIs were on the rise before PrEP was approved, it’s difficult to conclude that PrEP is solely responsible for the rise in STI rates, although it may play a role going forward. “It seems like regardless of what’s happening to folks who are choosing to use PrEP as their own HIV-prevention strategy, there are some shifts in HIV prevention behaviors that are occurring in the community at large,” said Cohen.
Do we need to change how we talk about STI prevention?
“We’ve always promoted condoms and encouraged condom use as a strategy to prevent HIV—and now we have other arguably more effective strategies to prevent HIV. But we really don’t have more effective strategies to prevent bacterial STDs,” said Cohen.
In a series of focus groups conducted with men who have with men in San Francisco by the San Francisco Department of Public Health, some people who participated shared a perspective that STIs “are part of sex.” And that, “it’s a concern, but I know [they will] happen. I know the way to treat [them], and you move on from there.” Another participant shared that “If you have something, they’ll treat it right away and then it’s gone and then nothing happened…there’s like, no change whatsoever. So why worry about it?”
The take-away, emphasized Cohen, is that practitioners should begin to engage clients in a conversation about sexual health goals—with the understanding that people need comprehensive sexual health information, resources and support for issues beyond HIV.
“PrEP offers opportunities to engage people in sexual health services, which is very, very important. We’ve seen that individuals on PrEP feel increased agency in their relationships and often feel more empowered to talk about other sexual health concerns.”
What can we do about it?
Increased screening for STIs—and treatment if needed—will be critical to decreasing rates of STIs in the community, emphasized Cohen. And regular STI screening is recommended as part of regular primary care for people living with HIV. One study found that HIV clinics have increased their regular syphilis, gonorrhea and chlamydia screening among men who have sex with men between 2004 and 2010—but that the gonorrhea and chlamydia screenings “really lags far behind” lipid screening and syphilis screening. “The GC/CT [gonorrhea/chlamydia screening] requires just a little more effort to collect the sample,” explained Cohen. “So there’s still work to do here.”
Innovative STI prevention strategies might also be part of the solution.
“There was a thought-provoking article published last year in STD [the journal Sexually Transmitted Diseases]. They did a small feasibility study looking at doxycycline PrEP for syphilis prevention. Although this was not an efficacy study, they did find an overall decrease in risk for an STD. This was largely determined by syphilis and chlamydia. So there’s a lot of discussion around whether a larger trial of this strategy should be funded. There’s of course a lot of questions and potential concerns about it, but I think we need to think outside the box for STD prevention,” said Cohen.
Get free HIV and STI testing at Strut, the new health and wellness center for gay, bi and transgender men in San Francisco, or at locations around San Francisco with the San Francisco AIDS Foundation Mobile Testing Unit.