{"id":2175,"date":"2019-07-17T11:30:34","date_gmt":"2019-07-17T10:30:34","guid":{"rendered":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/?p=2175"},"modified":"2019-07-26T13:29:58","modified_gmt":"2019-07-26T12:29:58","slug":"stop-blaming-prep-for-the-rise-in-stis-the-picture-is-more-complex-than-that","status":"publish","type":"post","link":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/2019\/07\/17\/stop-blaming-prep-for-the-rise-in-stis-the-picture-is-more-complex-than-that\/","title":{"rendered":"Stop blaming PrEP for the rise in STIs \u2013 the picture is more complex than that"},"content":{"rendered":"

\"\"
\nRising rates of STIs has fuelled a debate about whether growing PrEP\u00a0use might be propelling the\u00a0STI\u00a0epidemic. Oli Stevens and\u00a0Charles Witzel<\/span>\u00a0argue why this narrative is misleading and damaging.\u00a0<\/strong><\/p>\n

\n

The UK recently celebrated two landmark achievements in the ongoing fight against HIV. It is now the seventh country to reach the United Nations target of 90-90-90: that 90% of people living with HIV know their status, of whom 90% are on antiretroviral treatment, and of whom 90% are\u00a0unable to transmit the virus to others<\/a>.<\/p>\n

Also, London became the first city in the world to achieve 95-95-95. These are remarkable achievements and are a testament to the tireless, collective work of doctors, activists, policymakers and civil society organisations.<\/p>\n

Zeroing in on the progress made in reducing new HIV infections between men who have sex with men (MSM), particularly the\u00a0nearly one-third decrease between 2015-2017<\/a>, two likely contributors stand out: a scale-up in HIV testing, rapid progress to treatment and pre-exposure prophylaxis (PrEP).<\/p>\n

PrEP, sometimes discussed in hushed terms as a potential means of ending HIV transmissions, is a pill taken once daily or around higher-risk sex that\u00a0markedly reduces the risk of contracting HIV<\/a>.<\/p>\n

This recent success also invites us to take stock and reflect on our failures, the perhaps unexpected costs of progress and the emerging roadblocks on the horizon.<\/p>\n

The decrease in HIV transmissions has not been matched with a decrease in sexually transmitted infections (STIs). Instead, new diagnoses have risen year-on-year. The causal factors fuelling this increase are complex, driven by social and political changes.<\/p>\n

Damaging narrative<\/h2>\n

A\u00a0recent article<\/a>\u00a0in The Conversation attempted to simplify this phenomenon and, in doing so, blamed the resurgence of syphilis on PrEP users, particularly those engaging in chemsex (the use of illicit drugs to enhance sexual pleasure, often in group settings).<\/p>\n

The logic goes that PrEP decreases HIV risk and because of that encourages sex without a condom, allowing for the spread of STIs. Though we do not dispute that\u00a0increasing PrEP use can lead to decreased condom use<\/a>, nor that the overwhelming majority of syphilis cases are within the MSM community, this narrative is misleading and damaging.<\/p>\n

The STI picture in the UK is undeniably dire \u2013 a crisis that has spread far beyond chemsex, PrEP or the MSM community. Austerity has led to cuts in service funding, with local authority sexual health budgets shrinking by as much as 40%.<\/p>\n

In London, where most new syphilis cases are found,\u00a0six major clinics have been shut in the last 18 months<\/a>, meaning that getting an appointment can be very difficult. Also, as HIV has shifted to being\u00a0a chronic, manageable condition<\/a>, social perceptions of sexual risk have understandably evolved. Drops in condom use have spread beyond MSM. Nearly half of all 16 to 25-year-olds do not use a condom with a new sexual partner. And\u00a0one in ten<\/a>\u00a0have never used a condom at all. The results are unsurprising: rises in rates of chlamydia, gonorrhoea and syphilis.<\/p>\n

\n

\"One
One in ten 16 to 25-year-olds have never used a condom.\u00a0Purple Anvi\/Shutterstock<\/a>.<\/figcaption><\/figure><\/figure>\n

While more widely available in Scotland, Wales and Northern Ireland, in England PrEP is provided on a limited basis through clinical trials. PrEP is also available online and, due to the efforts of activists in the face of a reluctant health service<\/a>, uptake in England has been substantial.<\/p>\n

NHS England\u2019s refusal to fund a proper PrEP service for all represents an enormous missed opportunity. A visit to a clinic for a PrEP prescription would include the recommended quarterly STI test, helping with timely diagnosis and treatment.<\/p>\n

By driving patients to access drugs online, a vital link to health clinics is never forged, increasing the scope for undiagnosed STIs to persist far longer than necessary.<\/p>\n

PrEP is not the villain<\/h2>\n

PrEP, then, must not be cast as the lone villain in the syphilis crisis, nor MSM engaging in chemsex cast as debauched vectors of transmission. Public health has no place to mandate what people can or cannot do. It must respect people\u2019s choices and, as best it can, provide a supportive environment.<\/p>\n

Healthcare should be designed around people\u2019s needs rather than forcing a narrow view of sexual health that doesn\u2019t account for what good sex means to those having it. MSM engaging in chemsex are often invisible. They don\u2019t use drug services or visit their GP as their needs can be poorly understood and their decisions judged. Sexual health services, however, are a window into the world of chemsex where PrEP can be used as a powerful conversation starter around how to have a happy, fulfilling and safer sex life.<\/p>\n

When MSM seek out PrEP, it is a decision that should be supported. To castigate them is to increase stigma and discourage their engagement with health services, a major issue for the\u00a0most vulnerable to HIV transmission, such as black MSM<\/a>\u00a0and to risk undoing the progress we have made against HIV.<\/p>\n

We must encourage PrEP use, accept that condom use may fall as a result, design supportive care and be happy knowing that every averted HIV infection is a life-altering moment.<\/p>\n

Oli Stevens (@OStevens_<\/a>) is a research manager for the UNAIDS Reference Group for Estimates, Models, and Projections<\/a> at Imperial’s School of Public Health.<\/span><\/strong><\/p>\n

This piece was co-authored by T Charles Witzel (@TC_Witzel<\/b><\/a>) r<\/span>esearch fellow at the London School of Hygiene & Tropical Medicine.<\/strong><\/p>\n

\n

This article is republished from\u00a0The Conversation<\/a>\u00a0under a Creative Commons license (CC BY-ND 4.0). Read the\u00a0original article<\/a>.<\/em><\/p>\n

Lead image credit: Bowonpat Sakaew\/Shutterstock<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Rising rates of STIs has fuelled a debate about whether growing PrEP\u00a0use might be propelling the\u00a0STI\u00a0epidemic. Oli Stevens and\u00a0Charles Witzel\u00a0argue why this narrative is misleading and damaging.\u00a0 The UK recently celebrated two landmark achievements in the ongoing fight against HIV. It is now the seventh country to reach the United Nations target of 90-90-90: that […]<\/p>\n","protected":false},"author":1386,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[226],"tags":[11193,302381,218213],"class_list":["post-2175","post","type-post","status-publish","format-standard","hentry","category-school-of-public-health","tag-hiv","tag-prep","tag-sexual-health"],"_links":{"self":[{"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/posts\/2175","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/users\/1386"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/comments?post=2175"}],"version-history":[{"count":3,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/posts\/2175\/revisions"}],"predecessor-version":[{"id":2183,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/posts\/2175\/revisions\/2183"}],"wp:attachment":[{"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/media?parent=2175"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/categories?post=2175"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs-staging.imperial.ac.uk\/imperial-medicine\/wp-json\/wp\/v2\/tags?post=2175"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}