Multiple research studies and real-world reports show increased sexually transmitted infections (STIs) among those who use pre-exposure prophylaxis (PrEP) for human immunodeficiency virus infection [1,2]. That is not surprising because PrEP is indicated for persons at high risk for HIV infection. Those individuals are also at high risk for other STIs.
Currently, guidelines from the Centers for Disease Control and Prevention (CDC) recommend Chlamydia trachomatis, Neisseria gonorrhoeae, and syphilis testing for PrEP users at least once every 6 months . The CDC's guidelines for STI management state that expedited partner therapy (EPT) is not recommended for chlamydial and gonococcal infections among MSM, the most frequent PrEP users, due to the risk of missing coexisting infections . The World Health Organization's guidelines state frequent HIV testing during PrEP use should ideally become an opportunity for STI screening and management; however, a clear recommendation on the frequency and type of testing is not provided .
Among PrEP users, quarterly STI screening with extragenital testing significantly increased detection of STIs, compared with current CDC guidelines that recommend screening every 6 months . In addition, a modeling study predicted that STI rates could even decrease with routine, frequent STI screening and treatment, addressing STIs that often remain undiagnosed among key populations . The study's authors reported that quarterly versus biannual screenings and treatment could reduce combined STI incidence by over 50% in PrEP users. Finally, by increasing PrEP coverage to 40% of everyone eligible for PrEP with biannual STI screenings, roughly half of all incident chlamydial and gonococcal infections could be averted among MSM in the United States over 10 years.
Many clinicians provide inadequate care for MSM. During healthcare visits, many providers fail to ask MSM about their sexual health often due to discomfort associated with that discussion, leading to suboptimal STI screening and treatment . In addition, CDC guidelines do not provide clinicians clear indications for testing of extragenital sites, which are commonly infected . Finally, antimicrobial resistant N. gonorrhoeae is often present in extragenital sites, which perpetuates the spread of antimicrobial resistant infection [4,9].
PrEP users commonly have extragenital STIs [10,11]. However, even at a large HIV primary care center, screening for extragenital STIs is often inadequate . PrEP providers must take sexual histories, perform focused physical examinations, have thorough discussions about sexual behavior, and screen extragenital sites for STI to administer comprehensive medical care (Fig. 1a). Providers must ensure that they do not miss anorectal and oropharyngeal STIs. Finally, as a sign of cultural competency for target communities, condoms and lubrication should continue to be recommended and made available at clinics, in addition to images of same-sex couples, educational and referral materials for local LGBTQ resources and/or Human Rights Campaign promotional items. Demographic data collection forms and electronic health records should contain multiple gender options including transgender.
Among PrEP users who test positive for C. trachomatis or N. gonorrhoeae, repeat screening is important to exclude reinfection, because a prior STI is a strong predictor of a new STI. Among those patients, an STI testing strategy should be implemented: screen the patient, treat the patient, treat the recent partner(s), and repeat at 3 months (Fig. 1b).
Partner services play an important role in STI treatment and prevention. Partner services must be expanded to maximize their public health benefit . Among PrEP users, CDC's guidelines should be updated to recommend EPT for chlamydial and gonococcal infection. A study among heterosexual persons found that EPT, when compared with standard partner referral services, reduced the persistence or recurrence of STIs . Benefits include increased treatment of STIs and reduction of contact with untreated partners. Disadvantages of EPT include possible adverse medication reactions and a potentially missed opportunity for clinical evaluation and patient counseling. But the benefits of EPT outweigh the risks, therefore EPT should be incorporated into routine STI management along with partner notification.
Innovative methods in prevention of bacterial STI could benefit PrEP users. Studies found doxycycline prophylaxis for bacterial STIs among HIV-infected and HIV-uninfected MSM reduced incidence of bacterial STIs [15,16].
Quarterly testing, extragenital testing, provider training, culturally competent care, repeat C. trachomatis and N. gonorrhoeae screening, and EPT should become the standard of quality care in the clinical management of those who use PrEP. With increasing antimicrobial resistance in Neisseria gonorrhoeae, the current inability to control gonorrhea could lead to another major public health crisis. Timely implementation of those recommendations needs to occur among providers with support and monitoring from local public health agencies. Future research is needed to investigate innovative approaches to prevent STIs among users of PrEP. PrEP, with implementation of a comprehensive STI screening and treatment program, is not only an opportunity to accelerate the reduction of HIV transmission, but also an effective means to control STIs.
N.K. is supported by the Fogarty International Center of the National Institutes of Health (NIH) under award number D43TW009343 and the University of California Global Health Institute (UCGHI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or UCGHI.
Time for literature review and article preparation was supported in part by NIH/FIC D43TW009343 (Fogarty International Center of the NIH and the University of California Global Health Institute Training Program), NIH P30MH058107 (The Center for HIV Identification, Prevention, and Treatment Services), and NIH/NIAID AI028697 (UCLA Center for AIDS Research). No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the article.
Conflicts of interest
There are no conflicts of interest.
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