IDWeek 2016 was held in New Orleans from October 26th through 31st. This is a joint meeting of groups like the Infectious Disease Society of America and the HIV Medicine Association which is an association of the HIV doctors.
Another study presented at IDWeek from the Fenway Health Clinic in Boston confirmed significantly rising rates of gonorrhea, syphilis, and chlamydia since 2011. The bad news is that using preexposure prophylaxis (PrEP) to prevent HIV was associated with higher risk of acquiring sexually transmitted infections (STIs). But the good news is that more frequent STI testing and treatment has the potential to reduce increased cases of STIs.
Recent studies in gay and bisexual men have shown that if Truvada for PrEP is used consistently, it reduces the likelihood of HIV infection by more than 90%. Although there has been concern that using PrEP would lead to decreased condom use, resulting in higher STI transmission, this “risk compensation” was not seen in clinical trials. Nevertheless higher rates of STIs have been consistently reported in some PrEP demonstration projects and other realworld use.
Electronic health records were used by Douglas Krakower from Beth Israel Deaconess Medical Center and his team to analyze trends in PrEP use and STI rates at Fenway Health, a wellknown and highly respected HIV clinic that specializes in care for the LGBTQ community.
Data was reviewed from a total of 19,238 men who received care at the clinic at least one time from 2005 to 2015. Approximately, 75% of the cases reviewed were of white men, 6% were black, and 10% were Latino. Forty-three percent identified as gay and 3% as bisexual. But half did not report any sexual orientation.
According to Krakower, the rise in PrEP use in over the past 5 years among HIVnegative clients, has been “very rapid and steep”, the number of Fenway clients receiving prescriptions for Truvada for PrEP rose from just five in 2011 to 960 in 2015. Fourteen percent of all men seen at the clinic for any reason received a PrEP prescription last year.
Eighteen percent of men seen at the clinic were diagnosed with at least one STI between 2005 and 2015. STIs included 7% with gonorrhea, 7% with syphilis, and 9% with chlamydia. Almost all of these STI cases occurred in men who have sex with men. By 2015, 14% of HIVpositive people and 25% of HIVnegative PrEP clients had at least one STI. Krakower emphasized that even though this data looks definitive, it is nevertheless “hard to infer causality” from this type of data without more information because a substantial number of men who were HIVnegative and not using PrEP also got STIs.
All three STIs rose over time. Between 2000 and 2015, syphilis increased with an accelerated rise starting around 2011. Rates of gonorrhea were relatively stable from 2003 through 2010, but increased dramatically in 2011 a “near astronomical rise,” according to Krakower. Even though the number of clinic patients doubled during this period, gonorrhea cases nearly quadrupled. The clinic has noted chlamydia cases since 2011 which have increased significantly and consistently since 2011. Unfortunately, the combined number of STIs at Fenway rose from 162 in 2005 to 1329 in 2015.
Being HIVpositive and using PrEP were both independently associated with a greater likelihood of being diagnosed with STIs in a statistical analysis. Being African-American or of mixed race, and being on Medicaid, uninsured, or without stable health insurance were also associated with a higher STI risk.
At an IDWeek press conference previewing meeting highlights, Pablo Tebas of the University of Pennsylvania noted, “This work really emphasizes the need to educate people when they are receiving PrEP about the risk of acquiring sexually transmitted infections.”
Because regular clinic visits are recommended for HIVnegative people on PrEP, there are more opportunities for frequent STD testing and prompt treatment. The Centers for Disease Control and Prevention’s PrEP guidelines recommend STI tests at least every six months, but state that some people may benefit from more frequent testing. But results from the PrEP Demo Project, which enrolled atrisk gay men and transgender women in San Francisco, Miami, and Washington, D.C., recently reported that 40% of chlamydia, 34% of gonorrhea, and 20% of syphilis cases would have been undiagnosed if STI screening had been done every six instead of every three months. The message here is clear. If you are HIV and/or if you are using PrEP, you should be tested for STIs.
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