Gonorrhea, chlamydia, and syphilis, they are known as the bacterial STIs. If you haven’t heard, the Centers for Disease Control and Prevention (CDC) says the US is experiencing the highest levels reported for the past 20 years. Although the rise started before HIV pre-exposure prophylaxis (HIV PrEP) was approved in 2012 for use in the US, the rate of increase since 2013 has been rising sharply each year and has done so for 4 years in a row.
So, is PrEP fueling the STI epidemic? Ask this question in a room full of sexual health experts and be prepared for a heated debate. What follows is my best effort to frame all sides of this debate, trying my best to avoid “picking a side” because the deeper you go down this rabbit hole you may realize what you think is the problem may be part of the solution.
The concern is that of unintended consequences. Nobody wants to contract HIV or bacterial STIs. Because PrEP can be up to 99% effective against HIV, it has become a new “safe sex” option for people who never liked using condoms in the first place. But is PrEP creating “new converts” to engage in condomless sex? The answer is uncertain, and the question may be off base. PrEP programs are intended to reach people who prefer condomless sex. That doesn’t mean that PrEP programs are promoting condomless sex.
For the person who enjoys sex and prefers using a condom, they are likely to view PrEP as overkill. Think about it, PrEP means quarterly doctor visits, medical bills, remembering to take a daily pill, and although rare, the possibility of side effects.
Although the bareback aficionado doesn’t want syphilis, let’s be clear, the bacterial STIs can be cured and HIV cannot. Pleasure is an important goal of sex. When doctors dictate the levels of risk that are “acceptable” for the pleasures one stands to gain from sex, they risk alienating the people we need to reach the most. Condoms still matter, but if that method worked for everyone enjoying sex, we would have ending this HIV epidemic decades ago.
PrEP is a Program
It has become my mantra for the past several years, “PrEP is part of a program not just a pill.” At every annual scientific meeting, researchers argue back and forth whether the latest data proves beyond a shadow of a doubt that PrEP programs are worsening the STI epidemic.
I argue that this whole question is flawed because what is considered the “standard” for PrEP services is changing all the time. There are programs on the cutting edge of STI prevention & treatment, and those that are offering the bare minimum. Yet both are still lumped together as “PrEP programs.”
Take the Dean St. Express Clinic in the United Kingdom where PrEP patients have walk-in STI testing using a private e-check-in process, a private booth to collect their own samples for testing, and text notifications within 5 minutes regarding results and treatment.
On the other end there are PrEP offices where patients are referred out to a State office because they don’t have adequate STI services in house. It takes time for innovative and effective services to become the “standard.” Instead of investing time and research dollars on answering whether PrEP programs are making things worse, shouldn’t we be researching what makes some PrEP programs better?
It’s Not All Bad News
Similar to our rankings for HIV, Louisiana ranks in the top 5 for rates of chlamydia, gonorrhea, and syphilis. And just like the national trend of rising STI rates, ours are on the rise too.
The numbers, however, are not all bad news. We know part of the increase is due to increased use of new testing methods that detect infections that previously went undiagnosed. This is because for infections in certain parts of the body, a majority of people have no symptoms. Ten years ago, clinics did not routinely test for rectal or throat STIs but today they do. Adding more complexity to the picture, for a patient to receive PrEP they must agree to bacterial STI testing every 3-6 months. If PrEP is done right, these programs have the capacity to uncover and treat many more STIs than they might “promote.” How programs can step up to the challenge, now that’s worthy of research.
Want to learn more or start on HIV PrEP? Visit Ochsner.org/PrEP. Rapid PrEP starts are available with Dr. Garnett Friday afternoons at the Tchoupitoulas Health Center. Visit our site or call our PrEP Hotline for an appointment 855-241-9347.
I welcome questions, feedback, and requests for future topics at DrG.HIVWarrior@gmail.com. Christopher Garnett, MD/MPH is a native of Lima, Peru and is a fluent Spanish speaker. He is board certified by the American Board of Internal Medicine and American Academy of HIV Medicine.