In the European Union/Eurasian Economic Union (EU/EEU) in 2016, men who have sex with men (MSM) were over-represented in new STI diagnoses. Although they represent only 3-4% of the population they were responsible for 13% of Hep B, 13.5% of acute HCV, 42% of HIV, 51% of Gonorrhoea, 74% of Syphilis and 100% of Lympho granulosis venereum (LGV) cases. In France, a comparable upsurge in Chlamydia/LGV was seen. And in Boston USA a marked upsurge of 3-4 fold in all bacterial STIs has been observed since 2011.
So, how do we contain the STI epidemic?
The encouragement of the previous "ABC" used in HIV containment - "Abstain, Be faithful, use Condoms" - is again being proposed as a strategy. (This I would think has a limited chance of success in the current environment).
The number of casual partners seems to be a key driver of STI acquisition, rather than just condom use, and needs to be targeted (but again I question the likelihood of success).
Other proposals include:
- Antibiotic prophylaxis for gonorrhoea and chlamydia - but there are of course problems with antibiotic choices in the context of emerging gonorrhoea resistance
- Opportunistic vaccination for Hepatitis B, A, HPV
- Possible collateral benefit of meningococcus B mass vaccination (Bexsero), which shares 2 of 3 recombinant proteins with N. Gonorrhoea.
- Improve STI management with a focus on practices that promote more frequent testing and reduced time to commencement of treatment. Some other strategies proposed - Test and Treat, Point of Care Testing, Rapid tests, home-based testing, use of Apps to assist contact tracing and prompt treatment.
So, the bottom line is that STIs are all experiencing a huge upsurge in the MSM population using PrEP but new cases of HIV are much reduced.
There are a number of strategies to consider and to incorporate if possible in managing patients on PrEP to contain and reduce other STI infections.
I will certainly now be more mindful of utilizing reminder systems to improve the frequency of STI testing, and establishing hepatitis A, B and HPV vaccination currency in patients on PrEP. I would be most interested in a trial of Bexsero vaccination for reducing Gonorrhoea. And access to appropriate Apps for patients to anonymously link with contacts regarding STI results sounds like a fabulous strategy for achieving rapid treatment of STI’s and reduction of transmission.
Author bio:
Dr Jane Hunt is a GP working in high case-load HIV practice at Holdsworth House Medical Practice (HHMP) in Darlinghurst N.S.W.
