PrEP protects against HIV — which alone, is fantastic and an incredible medical breakthrough — but it doesn’t protect against other sexually transmitted infections. According to the Centers for Disease Control and Prevention (CDC), there’s been a significant rise in STIs in the United States over the last few years. In 2014 there were 19,999 reported cases of syphilis (primary and secondary), up 15.1 percent since 2013. Men who have sex with men account for 74 percent of these cases. In addition, there were 350,062 reported cases of gonorrhea, up 5.1 percent, and 1,441,789 reported cases of chlamydia, up 2.8 percent.
Some critics have suggested that unprotected sex between men who have sex with men has been on the rise because of PrEP. Can this rise of STIs be put squarely on PrEP’s shoulders?
“People on PrEP are not more likely to have STIs, they’re just more likely to be treated for STIs,” suggests Damon Jacobs, a PrEP educator and marriage and family therapist from New York City. He’s been working in HIV prevention education since 1991 and his “PrEParing for PLEASURE” presentation has been seen throughout the state of New York, as well as at the 2015 Conference on Retroviruses and Opportunistic Infections. He also founded the popular PrEP Facts: Rethinking HIV Prevention and Sex Facebook page, which has 14,140 active users worldwide. “Most people who are on PrEP are being screened for STIs and if necessary, treated, about three to four times per year,” he says.
Since many STIs can be asymptomatic, many non-PrEP users who are infected may not know that they are, and thus may not go in for testing. The CDC suggests that PrEP users, on the other hand, get checked for STIs at least once every six months, so it could seem as though their infection rates are higher.
“When we look at our CDC numbers for syphilis, gonorrhea and chlamydia, these numbers have been going up exponentially since 2007,” Jacobs says.
According to the CDC, there were 5,979 cases of syphilis in the US in 2000, which increased to 8,724 cases in 2005 and 13,774 cases in 2010 — STIs have been on the rise way before PrEP came onto the scene.
“The only numbers we have about this right now go up to 2014,” adds Jacobs. “Now, in the US by the end of 2014 there were only about 17,000 people using PrEP in the United States, but you have 350,000 new gonorrhea rates during the same year, so it doesn’t make mathematical sense that PrEP could be a factor in all this.”
Syphilis is contracted by coming in direct contact with a sore during vaginal, anal or oral sex. You can also contract the virus by coming in contact with sores in areas not covered by a condom. Gonorrhea is also spread through unprotected vaginal, anal and oral sex. Anecdotally, most of the gay men I’ve spoken to don’t use condoms for oral sex, so there’s always a risk of contracting an STI if you’re having unprotected oral sex, but still wearing a condom for penetrative sex. It is important to note that wearing a condom during anal sex will certainly lower your chances of contracting any of these STIs — it’s definitely another layer of protection — but it can’t guarantee that you won’t become infected.
Even though it’s not clear whether the current rise of STIs can be linked to PrEP, there might one day be a rise of STIs in PrEP users.
“Some people will use [PrEP], and probably are using this as a pure substitute for previously consistent condom use,” says Dr Darrell Tan, whose research focuses on clinical trials in HIV prevention.
“I don’t think it’s the majority but I think it’s a reality that that’s going to happen. That’s kind of human nature. Without wanting to put a moral judgment on that, it does pose a public health challenge.”
“We have to recognize that if people are going to make a choice to decrease their condom use in the pursuit of pleasure and use PrEP instead it’s simply fact that you would expect to see more STIs as a result. So we can’t just blindly go and say, ‘Let’s celebrate PrEP,’ without acknowledging this fact — it is a fact — we have a huge problem with STIs that we don’t talk about enough,” Tan says. “The challenge is for all of us is to figure out how to combine that thread of thought with the very real, very important public health priorities that we have.”
This is not to say that people shouldn’t use PrEP — it’s a highly effective preventative tool in combatting HIV transmission. Tan acknowledges that bareback sex on PrEP is a major motivation for people using the drug, and so he’s suggesting ways to work with this fact. “We can’t lecture people and say that you absolutely must use condoms every single time even though you’re also on PrEP. You gotta be realistic and understand that this is part of people’s human nature.”
So what can be done to decrease the rates the transmission of STIs if you’re using PrEP? Having open and honest conversations about STIs is a great start. And the good news is, people on PrEP are at a bit of an advantage:
“A lot of people are proud and excited about the fact that they’re on PrEP. They’re excited to tell people about it,” Tan says. “Many people choose to disclose their PrEP status — that’s a gateway to talking about what people are doing about their sexual health . . . it’s a way to open a conversation with other people about STIs.”
Whether you’re on PrEP or not, your risk of contracting syphilis, gonorrhea and chlamydia will increase with unprotected oral sex. By having both unprotected oral and anal sex that risk increases even more. These are facts. But if I can credit PrEP with one social change, it’s that it has created a culture of communication when it comes to sexual health. Normalizing these conversations is a huge step in mitigating risk regardless of our other sexual health choices. Perhaps by doing this, we can expect a world without new HIV infections and decreased STI transmission rates for non-PrEP and PrEP users alike.