Expert: it is dangerous to hush up the problem of STI growth against the background of a decrease in HIV cases

Antiretroviral therapy (ART) provides a stable virological response, and, in essence, eliminates the risk of sexual transmission of HIV. This gives hope that the “treatment as prevention” approach will play a key role in combating the epidemic. At the same time, a few years ago, people at risk of infection, also had the opportunity to significantly affect the reduction of new HIV cases. In order to do this, they only needed to start properly taking pre-contact prophylaxis (PrEP).

Nevertheless, experts note, as the use of new medical and prophylactic drugs increases, the sexual behavior of both HIV-positive and HIV-negative people who are at risk of infection has changed dramatically.

As ART has improved the quality of life, naturally affecting sexual health, an increase in the frequency of sexually transmitted infections (STIs) has been observed among people living with HIV, especially among men who have sex with men (MSM). particular syphilis.

This surge was called the “first wave” of STIs in the era after the advent of ART.

Similarly, as PrEP began to gain momentum, the specialists recorded a “second wave” of STIs with record MSM gonorrhea and syphilis.

The high efficacy and demand for PrEP, especially among MSM, suggests that in this group it is possible to avoid HIV infection even in the absence of barrier methods of contraception. This was the main reason for the surge in STIs.

Nevertheless, experts emphasize, MSM in this matter is not the only risk group. In countries of tropical Africa, PrEP is being introduced in conditions where syndromic treatment remains the standard approach to the treatment of STIs, which is certainly a non-optimal situation.

The consequences of the increase in the incidence of genital infections require a reassessment of the consistency and priorities of funding for HIV research, health policy, community participation and public awareness.

Are STIs an inevitable side effect of therapeutic HIV control, and is it necessary to change the perception of sexual health? Do we need to treat STI treatment differently among people at risk (screening, diagnosis, treatment, prevention)?

Can a high incidence of STIs undermine PrEP's long-term success? And should new approaches focus on the prevention of a wider range of STIs?

According to Jeanne Marrazzo from the University of Alabama, who spoke at the CROI plenary meeting on Tuesday to increase the number of bacterial infections in the era of effective HIV treatment and prevention, the number of diagnoses of chlamydia, gonorrhea and syphilis increased by 5 in the US only for 2 years from 2015 to 2017 %, 18% and 17%, respectively, despite the fact that the level of detection of syphilis in the years of a sharp decline in new HIV cases (before 2000) has steadily decreased. 46% of new cases of STIs were reported among MSM.

As the specialist stressed, in the USA and in other countries of the world, along with the increase in the number of genital infections, there are also concerns about the spread of resistant strains of gonorrhea and chlamydia. According to a recently published report, only in 7 countries the prevalence of resistant gonorrhea exceeds 5%. The development of an effective vaccine for this disease is an extremely topical issue.

The problem of the situation is added by the fact that the use of antibiotics to prevent gonorrhea also has its disadvantages. Despite its ease of use and effectiveness, scientists still know little about the duration of action of a substance and its side effects. So it is known that the drug doxycycline can cause dysbiosis, and its prolonged use is associated with weight gain and changes in the intestinal microflora.

On the other hand, in many countries around the world, patients can often get an antibiotic without even having a prescription. This certainly increases the risk of developing resistance of the strains.

The problem of STIs is extremely important in the context of the general fight against HIV infection, Ms. Marrazzo believes, but if we believe that the prevention of genital infections can affect HIV elimination, then we should pay more attention to this issue.

“... calls such as“ Reaching Zero ”... will never be implemented without addressing the problem of tolerance to STIs in the global HIV pandemic, in addition to responding to other factors of the spread of the virus, including economic, gender inequality and other human rights issues ", - quoted Marrazzo article from JIAS.

The thesis “Н = Н” (undetectable = not transmitting) has already achieved a lot in this connection. People’s confidence in the impossibility of HIV transmission during an undetectable viral load markedly affected stigma and discrimination. This is a significant step forward. However, with the spread of the conviction that there are no risks of infection, the level of unprotected relationships and STIs is also growing.

Of course, this problem, like a surge in genital infections against the background of PrEP proliferation in developed countries, should not be silent.

Comprehensive STI responses are required, primarily in key groups.

In addition, it is necessary to carry out activities in areas with limited resources, taking into account the specifics of the regions. It is extremely important to solve the issue with the availability of tests for STIs.