The new figures from Public Health England on STI rates make for quite grim reading.
Although overall the number of STI diagnoses in England remains level, there have been steep increases in the rates of gonorrhea (22%) and syphilis (20%).
Once again gay and bisexual men recorded particularly high rates of STIs, accounting for 43% of the gonorrhea cases, despite only accounting for about 3% of the population.
Some were quick to point the blame at the increasing use of PrEP as HIV prevention.
They argue that PrEP is driving people from condom use to non-barrier methods of HIV prevention which, unlike condoms, do not also protect against other STIs.
The truth is a bit more complex than that. For many men who have adopted PrEP it is not an alternative to condom use, but rather PrEP has allowed these men to shift from no condom use, and no protection from either HIV or other STIs, to PrEP use, protecting them from HIV but making no difference to their vulnerability to other infections.
For many of these men their STI risk remains the same but their HIV risk is reduced.
However, there is a growing body of evidence that suggests that STI incidence is increasing among PrEP users, according to some sources by as much as 25%.
The data seem to show increases in the number of partners and the number of occasions in which condoms are not used. However the proportion of men who don’t use condoms remains unchanged.
In other words, PrEP does not seem to be associated with a sudden abandonment of condoms but men who are already inconsistent in their condom use seem to be increasingly willing to take a chance on not using them.
Other factors contribute to men abandoning condoms
It is hard to untangle this data from other trends relating to gay men’s sexual behaviour. Although PrEP use may have prompted some more men to move away from condoms as a safer sex strategy, that trend was observed long before PrEP was an option.
Rising rates of condomless sex go back more than a decade, not just in the UK but in pretty much all Western countries.
It is likely that increases in chemsex, changing social attitudes to sex and sexuality, the effectiveness of HIV treatment, the rise of dating apps and other factors have all played a role in changing the way that gay men navigate sex.
Despite these changes, gay men’s condom use still outstrips that of heterosexual men.
Recent data from Australia, where PrEP use has increased particularly rapidly, found a decrease in condom use among men who previously did use them. Although overall, the number of men having sex with any risk of HIV transmission remained the same, the number of men having sex with a risk of STI transmission increased.
It is not true to suggest that increased use of PrEP inevitably leads to more STIs. Diagnosis of STIs is dependent on both the number of cases and the number of tests taken. When more people test, we expect to see more people being diagnosed.
More testing leads to prompt diagnosis and treatment
Considering many STIs will have no symptoms initially, reducing the levels of undiagnosed STI infection is crucial.
One of the benefits of PrEP being freely available through state-funded programs is that people are hooked into sexual health services. When people test more regularly they will be treated faster and, as a result, there will be less time when they are able to pass that infection on to sexual partners.
Between 2015 and 2016, Europe’s busiest sexual health clinic, 56 Dean Street, an early supporter of PrEP users, saw a 24% decline in gonorrhea cases among gay men, largely due to increased testing and earlier treatment.
Such success was only possible because they were able to test and treat people promptly, a success that is threatened by cuts that limit the number of appointments they can offer.
The greatest benefit of having PrEP as part of our HIV prevention armory is that it is so effective. A combination approach to prevention has led to dramatic drops in HIV diagnoses in London, Sydney, New York, San Francisco and other cities.
Don’t attack PrEP: Attack stigma
HIV remains a virus with an almost mythological level of stigma attached. I still believe we should be throwing our energies into fighting that, into preventing new infections and improving the lives and emotional health of those who are living with the virus.
As someone who is living with HIV, I believe that it’s vitally important that we use all of the tools available to us to end this epidemic.
I also believe that there is an important and distinct conversation to be had about gay men and other STIs. We need to recognise that good sexual health is more than HIV prevention.
I want there to be more discussion about STIs. I would like us to take the opportunity to talk about how much we, as gay men, value our sexual health. And how we can take care of each other within our communities.
Let’s talk about STIs and condom use and vaccinations. Let’s talk about regular sexual health check-ups, prompt diagnosis and treatment.
Just as with HIV, let’s talk about all the tools we have to prevent STIs – and let’s use them. An increase in STIs is not a call to withdraw successful HIV prevention methods. It is a call to begin a wider discussion of how we tackle STIs.
Matthew Hodson is Executive Director of NAM aidsmap and the recent winner of Social CEO of the year. Follow him on Twitter at @Matthew_Hodson. NAM aidsmap provides HIV news and treatment information to support people living with HIV, throughout the UK and internationally, to live longer and healthier lives. If you would like to make a donation to support NAM’s vital work, please visit: www.aidsmap.com/donate.