Working Hypothesis: PrEP And The STD Explosion

Can the HIV-prevention pill be tied to the rise in chlamydia, gonorrhea, and syphilis in the U.S.?

An estimated 79,000 people have started using pre-exposure prophylaxis (PrEP) since the once-daily HIV-prevention pill was approved by the FDA in 2012. In that time, rates of sexually transmitted infections in the United States have experienced dramatic increases, according to a recent report from the Centers for Disease Control.

Cases of chlamydia jumped by almost 6% between 2014 and 2015, gonorrhea skyrocketed for almost all populations (a 75.1% increase among whites, 71.3% among American Indians/Alaska Natives, 70% among Asians, 61% among Native Hawaiians/Other Pacific Islanders, and 53.8% among Hispanics, while falling 4% among African Americans who still have the highest rates overall).

And rates of primary and secondary syphilis increased for all populations, but remain highest among African-American men between the ages of 20–24 and 25–29.

The news has led to some understandable handwringing in public health circles: Antibiotic-resistant strains of chlamydia and gonorrhea exist, though they are still quite rare, and even the run-of-the-mill varieties of those STDs can facilitate HIV transmission and other serious health consequences if left untreated.

In fact it would be fair to classify this situation as a public health crisis, especially considering that, not long ago, gonorrhea was at an all-time low and syphilis was on the verge of extinction. Some have begun to question the role of PrEP in the rise of STDs, especially as it is prioritized over condoms as a prevention method in public health discussions.

So is widespread adoption of PrEP feeding the flames of an STD conflagration?

Not in any significant way, no.

First of all we have to consider the role of more and better testing when accounting for these numbers, especially when considering chlamydia, which is often asymptomatic. Expanded use of nucleic acid amplification tests (NAATs) and swabbing of multiple sites (rectum, throat, etc.) explains some of this increase.

We should also examine the populations hardest hit by these increases: Two-thirds of the upsurge in chlamydia is among cisgender women. Among men, the highest rates of STDs were among black and Native Americans, young queers, and Southerners—demographics that have seen the lowest incidences of PrEP adoption, and who are also those who could benefit most from its use.

Syphilis has actually been on the rise since 2001: Larry Kramer even devotes a portion of his 2004 polemic, The Tragedy of Today’s Gays, to waving his fist at the phenomenon.

Meanwhile, California, the state with the highest incidence of PrEP use, has 140 reported cases of gonorrhea per 100,000 people. That’s 54% lower than Louisiana, one of the states with the fewest people taking the anti-HIV medication.

But while PrEP is definitively not a major factor in the high rates of sexually transmitted disease seen in 2015, it is certainly having an impact on HIV: Evidence suggests “mail order” PrEP is having a major impact against HIV infections in the gay and bisexual community in London, where new infections have dropped 40% in just a year.

Given that half of the U.K.’s new HIV infections occur among gay and bisexual men that represents a massive decrease for the whole country.

And researchers at the CDC believe that PrEP is at least partially responsible for the impressive drop in new HIV infections—almost a 20% reduction in the past six years. (That’s following two decades of stagnation at about 45,000 to 50,000 new cases a year). Of course, increased testing and treatment enacted by public health officials nationwide has been a driving force behind the falling HIV infection rate.

Unfortunately, gay and bisexual men haven’t seen the same gains as our heterosexual counterparts, and for some subpopulations—gay and bisexual Latino men, and men who have sex with men between the ages of 25–34—infection rates are still spiraling up.

That’s deeply concerning but, if anything, it just underscores the need for more PrEP education and promotion, not less—especiall in our most underserved communities. Unfortunately Republican efforts to “repeal and replace” Obamacare could deprive millions of affordable STD testing, and make PrEP even more difficult to access.

Brenden Shucart live in Atlanta, where he is writer, actor and advocate for people living with HIV.
@Brenshu