Issue:  Vol. 48 / No. 8 / 22 February 2018

Men at high risk of STIs seek PrEP


DPH's Dr. Susan Philip. Photo: Rick Gerharter
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Gay and bi men who use PrEP often do not use condoms and are at risk for sexually transmitted infections as well as HIV, suggesting that those men who seek PrEP are the ones who need it most, recent data show.

"Seeing a correlation between high rates of [sexually transmitted diseases] and PrEP use is what we expect – individuals with high rates of STDs are exactly the people we want to be considering and starting PrEP," Dr. Susan Philip, director of disease prevention and control at the San Francisco Department of Public Health, told the Bay Area Reporter.

The latest SFDPH HIV epidemiology annual report, released September 1, showed that new cases of HIV continue to steadily decline. The 255 newly diagnosed HIV infections in 2015 represent the lowest number since the start of the epidemic.

But at the same time sexually transmitted infections have continued an upward trajectory, especially among gay and bi men, according to reporting by laboratories and health providers throughout the city.

In 2006 there were around 200 cases of rectal gonorrhea among HIV-positive gay men and about 230 cases among HIV-negative men. After dipping slightly or remaining stable for a few years, rates began to rise sharply in 2010. By 2015 the numbers had increased to around 350 cases among HIV-positive and 650 among HIV-negative gay men. Early syphilis cases in both groups have increased nearly every year since 2006.

The U.S. Food and Drug Administration approved Gilead Sciences' Truvada (tenofovir/emtricitabine) for HIV prevention in July 2012 and its use has grown rapidly in recent years. A recent informal survey by the B.A.R. found that more than 6,000 people in San Francisco have been prescribed PrEP, most of them gay men.

"In San Francisco rates of STDs among gay men and other men who have sex with men were rising several years before Truvada became the first drug the FDA approved as PrEP in 2012," Philip said. "We cannot say that PrEP is causing the high rates of STDs, only that these things are correlated."


Role of PrEP

Dr. Jeffrey Klausner from UCLA, formerly director of the DPH's STD prevention section in San Francisco, recently published in the journal AIDS a study of the association between PrEP use and STIs among gay and bi men.

Klausner's team conducted a meta-analysis of studies that reported STI rates among men who have sex with men. They included five cohort studies in which participants received PrEP and 13 done in the pre-PrEP era. However, the populations were not well matched. By design, PrEP studies recruited gay and bi men who reported high-risk sexual behavior, while the non-PrEP studies had various different entry criteria.

Overall, the researchers found that men on PrEP were 11 times more likely to be diagnosed with chlamydia, 25 times more likely to be diagnosed with gonorrhea, and 45 times more likely to be diagnosed with syphilis compared to gay men not using PrEP.

"[M]ore research is needed to understand if PrEP causes a higher incidence of STIs among MSM," the study authors wrote. "We must ensure that our efforts fighting one public health crisis do not lead to another."

The Los Angeles-based AIDS Healthcare Foundation, which has a history of criticizing Truvada PrEP, issued a news release September 8 calling attention to what it called the "damning new report" linking PrEP use with an "astronomical" increase in STIs.

"This latest analysis should be a wake-up call for MSMs and other sexually active people that PrEP is not the magical panacea it's often promoted to be," said AHF President Michael Weinstein. "Despite some people's desire to simply wish them away, these common STDs remain health risks that must be taken seriously and are best avoided by using condoms."

But both formal studies and ample anecdotal evidence indicate that a substantial proportion of gay men cannot or do not want to use condoms every time they have sex.

"In reality a particular subset of gay men seem to be coming forward for PrEP who are, indeed, at very high HIV and STI risk – the right people are coming forward," said Gus Cairns, who spearheaded community engagement in the U.K. PROUD PrEP trial. "No one is denying [STIs] are a big health problem, but in my opinion they will still be if we stop giving out PrEP. I think we need a mature discussion about what our messaging and norms should be about condoms in the era of treatment-as-prevention and PrEP, rather than retreating to a message of 100 percent condom use."


Faster STI detection

The higher rate of STIs among PrEP users could be due to a variety of factors, including increased regular STI screening while on PrEP – thus detecting more of the cases that were already out there – or PrEP users having more sex partners or using condoms less.

Controlled clinical trials of PrEP for gay men generally did not see a rise in condomless sex. But some studies of PrEP in real-world use – including at Kaiser Permanente San Francisco and the San Francisco AIDS Foundation's Magnet program at Strut – have seen condom use drop off over time.

STI rates in these studies were typically around 20 percent at enrollment and did not change much over time. What did change is faster STI detection and treatment thanks to regular screening of PrEP users.

"PrEP is an opportunity for people to be tested and treated for sexually transmitted infections," PrEP researcher Dr. Robert Grant from the UCSF Gladstone Institutes told the B.A.R.

The Centers for Disease Control and Prevention recommends that gay men should get tested for STIs at least every six months. But PrEP users should be seen every three months for HIV testing and to monitor for kidney side effects, and some providers – including Strut – already do quarterly STI screening as well.

In the PrEP Demo Project, which enrolled 557 mostly gay men in San Francisco, Miami, and Washington, DC, SFDPH researchers found that 40 percent of chlamydia, 34 percent of gonorrhea, and 20 percent of syphilis cases detected during quarterly screening would have been missed – and treatment therefore delayed – if screening had been done only every six months. They calculated that screening every three, instead of every six, months prevented an average of eight sex partners from being exposed for each STI diagnosis.

Most experts and advocates concur that PrEP's protection against HIV – reducing the risk of infection by more than 90 percent if used consistently – is worth its drawbacks.

"PrEP is an extremely effective and important tool for decreasing HIV infection in persons at highest risk – we must continue to expand access to PrEP as part of our efforts to get to zero in San Francisco," Philip told the B.A.R. "At the same time, we must consider holistic sexual health and work on better ways to assist San Franciscans to prevent, identify, and be treated for other STDs as well."

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