The Centers for Disease Control and Prevention (CDC) just published a report on the rates of chlamydia, gonorrhea and syphilis in 2015, finding the highest number of case reports on these infections in 20 years and a steep increase over the last reported period in 2014. Is this a cause for concern? Absolutely. But, as will inevitably be the case, there are going to be questions about whether increasing use of pre-exposure prophylaxis (PrEP) is to blame and the answer is pretty conclusively “no” as far as one can tell from the available data and the CDC as much as says so.
Here are some of the numbers with some important considerations:
- Chlamydia cases in 2015 rose by 5.9% over 2014 in all, with over two thirds of cases in cisgender women.
- New cases in cisgender men increased between 2001 and 2015 by 20%. However, a coinciding increase in the availability of urine, pharyngeal (throat) and rectal testing, mostly among men who have sex with men (MSM), may have had a lot to do with it. A study presented last year looking at multisite testing (e.g. urine, throat and rectum) of a high-risk population of MSM revealed that single site testing missed half of all gonorrhea and chlamydia infections on average, especially from the throat. Thus, how much of the 20% increase is a result of more testing and better testing?
- Between 2014 and 2015 gonorrhea cases increased by 18.3% in cisgender men and 6.8% among cisgender women. In both cases, they reflect a very significant increase since hitting an all-time low in 2009. The CDC estimates that most of the cases among cisgender men where in MSM.
- Rates of gonorrhea overall were highest among Blacks and American Indian/Alaska Natives, but rates actually dropped somewhat (4.9%) among Black Americans while they increased among all other racial and ethnic groups.
- Syphilis cases have been rising in the United States since 2001, with massive increases among men who have sex with men, particularly HIV-positive MSM. This “epidemic” was first detected in the early 2000s and syphilis testing and elimination campaigns have been launched in many cities, though with variable effect.
- Like HIV, however, syphilis is not a gay disease: new cases increased among cisgender women by 27.3% between 2014 and 2015.
- Rates of syphilis increased in all racial and ethnic groups, but remained highest among Blacks.
Increase in antibiotic-resistant gonorrhea and chlamydia
Though the rates of diagnosis with strains of gonorrhea and chlamydia that are resistant to the preferred treatment regimens have increased, they currently remain low. This is still a very serious concern, however, as there are no high-potency back-up regimens and investment in new treatments has been very small due to a perceived lack of profit by the pharmaceutical industry. Thus, there is simply nothing great on the short term horizon.
PrEP and STD rates
It is almost certain that those who’ve been most critical of PrEP will use this new report as proof that their concerns about MSM abandoning condoms, whether on PrEP or not, have come true. The data simply don’t support that argument, however, at least not fully.
It is certainly possible that reducing condom use while taking PrEP might increase the spread of bacterial STDs within a person’s sexual networks, and overall condom use has been dropping in some surveys since the late 1990s. These new data, however, don’t allow micro-targeting of the geographic locations where PrEP roll-out has been most extensive. Where they do break diagnoses down by age and geography, the data would actually contradict the interpretation that PrEP is driving condomless sex and therefore leading to increased STDs.
Rates of diagnoses of most new STDs are among the highest in the South, among younger people, and among Black Americans – in each case, these are all places and people where PrEP uptake has been the lowest. California, a state that by itself accounted for more Truvada for PrEP prescriptions than most other states combined since 2012, actually had a rate of gonorrhea cases proportional to the overall population that was 36% to 54% lower than states where PrEP uptake has been lowest. Add to this the fact that along with PrEP services comes vastly increased odds of both more frequent testing and multi-site testing and it is hard to argue that PrEP is even a modest cause for the increases. See the map below:
Perhaps most importantly, PrEP use is still a less than one tenth of what the CDC estimates is needed in the United States. As the CDC’s Director of HIVAIDS, Viral Hepatitis, STD, and TB Prevention, Dr. Jonathan Mermin said, “It is doubtful that the STD increases reported in the 2015 STD surveillance report are attributable to the use of PrEP. While CDC estimates more than 1.2 million people who are at high risk for HIV infection would benefit from using PrEP, the magnitude of individuals currently on PrEP is not large enough to account for all of the STD increases in 2015.”
The bottom line
As an organization concerned with preventing new HIV infections and ensuring culturally competent health care for those at risk, Project Inform is immensely interested in expansion of effective models of combination HIV and STD prevention. New York City’s work in this area should be held up as a model. Leveraging the commitment from the state to “end the epidemic”, it is not solely HIV focused and does not minimize condoms or concerns about STDs. Rather, it assumes that STD clinics, community based organizations and public health can work in partnership to promote and deliver comprehensive sexual health care. San Francisco’s “Getting to Zero” model does the same. This includes HIV testing and rapid treatment, STD testing and treatment, and promotion of all methods that reduce HIV and other STDs including partner reduction, condoms and PrEP for those who would benefit most from it.
Indeed, the takeaway here, is that resources for culturally competent sexual health care – particularly STD testing and treatment – are in many parts of the country on the wane at a time when the demand is greatest. Federal and state budgets for STD surveillance, testing and treatment are under fire. Our energy should be spent not in debates over PrEP versus condoms, but money for PrEP and condoms, and vehicles for delivery that are meaningful and acceptable to those who need them.