HIV experts and professionals agree that pre-exposure
prophylaxis (PrEP) is a valuable addition to HIV prevention, but have varied
views of the relationship between PrEP, reduced condom
use and sexually transmitted infections (STIs), according to a study published
last month in the Sociology of Health
& Illness.
Professor Martin Holt of the University of New South Wales
and colleagues closely examined the ways in which reduced condom use and STIs
“were constructed as policy problems”. They identified a concerned and alarmed
perspective, a neutral and normalising stance, and an optimistic and critical
position.
“All three stances were selective in the way they performed
evidence, emphasising some elements and ignoring or downplaying others,” the
authors say.
Twenty one Australian professionals were interviewed in
2017. Nine of the participants worked in policy or policy/advocacy roles, five
in clinical roles, five in research and two in health promotion.
Concerned and alarmed
views were most often expressed by clinicians or by government policymakers - a
professional group who are encouraged to anticipate risks in order to minimise
them. These interviewees tended to see the link between PrEP and STIs as
self-evident:
“The evidence is there
and our clinicians are telling us we need to be prepared that we’re going to
get an increase in STIs. We’re very concerned we’ve got a, we, you’re aware of
the syphilis outbreak? We’re very concerned about antibiotic-resistant
gonorrhoea. We have the highest rate of antibiotic resistance for gonorrhoea in
the country. Yeah. So these are, yeah, these are quite, you know, we’re aware
of this, as a consequence or by-product of introducing PrEP, so we need to be
mindful of responding to that.”
The fear of uncontrolled or untreatable STI epidemics and the potential threat to public health underpinned this viewpoint. As well as resistant gonorrhoea, interviewees talked
about serious complications of undiagnosed syphilis and other unusual cases.
Holt and colleagues point out that while we do know that
PrEP users use condoms infrequently and are diagnosed with STIs at high rates,
antibiotic resistance is rare in Australia and among PrEP users.
The ways in which these relationships are understood have implications for the future rollout of PrEP.
In contrast, many participants expressed more tempered
views, often questioning the self-evident linking of PrEP, reduced condom use
and increased STIs. These neutral and
normalising accounts engaged with much of the same evidence, but positioned
these effects as predictable and manageable. Interviewees often described
longer-term trends:
“We’ve also seen a
decade-long, trend increase in STIs prior to PrEP’s arrival as well as probably
a decade-long trend down around condom use. So PrEP is acting maybe as an
accelerant at this moment in time… I don’t have concerns. It’s another tool
that’s arrived and it’s about how we effectively incorporate it within our
prevention response.”
These interviewees said the benefits of PrEP outweighed any
risks. They emphasised that PrEP’s main purpose was to prevent HIV, but sometimed
added that it has other benefits:
“Of course, one of the
primary concerns was that there’d be this massive spike in other STIs because
people would stop using condoms where certainly we’re, you know, in some areas
there seems to be a slight, a slight decrease in condom use but that’s, that
was always gonna happen. And there are people that will sometimes, you know,
decide not to or choose not to use condoms anyway. And the reality is that they’re
more engaged with a health service that they trust and so any STIs that might
be transmitted are getting picked up earlier anyway.”
However, Holt comments that it is debatable whether changes
in condom use are ‘slight’. His
own research has identified large-scale shifts in sexual practices among
gay and bisexual men in Australia.
The third and final stance is described as optimistic and critical. People
expressing these ideas tended to be both optimistic about PrEP’s benefits for
STIs and critical of the ‘sex negative’ and ‘reactionary’ views of the first
group of interviewees. These respondents most often worked in community
organisations or in academic research. Their optimism was based on
beliefs that PrEP would facilitate regular screening for STIs:
“I think a lot of
people will understand that actually having large numbers of HIV-negative, gay
men who can be regularly tested is actually a really good thing that’s actually
quite difficult to achieve in other ways. So PrEP has that positive effect… There’s
some interesting modelling out of the CDC on this, it might be the case that
the effect of secondary prevention is enough that it will drive down incidence
of STIs.”
However the authors comment that these optimistic scenarios
and mathematical modelling studies are an unproven future. Just as the ‘worst
case’ scenarios described earlier have not actually
happened, these ‘best case’ scenarios have not been observed among PrEP users
or in communities that have embraced PrEP. At the same time, PrEP has been
transformed from being an HIV prevention technology into being both that and a
technology to increase STI testing.
The same respondents tended to be critical of what one
described as a “frenzied fear about increased STIs”. They noted that such
concerns tend to focus on gay men rather than any other group, noting parallels
with the ways in which the sexual behaviour of gay men has been scrutinised
since the beginning of the HIV epidemic.
Interviewees said that sex between men has been
‘pathologised’. While PrEP has the potential to relieve gay men of a persistent
fear of HIV, this has inspired a push back:
“I think that’s partly
why you also hear these arguments about, you know, ‘What about STIs?’ or
‘Everyone’s gonna be a ‘slut’’. It’s sort of the lingering effects of that, of
those decades of pathologisation, which I really don’t think can be
underestimated.”