Do guys on PrEP get more STIs?

By Emen8, updated 2 years ago in Health / Sexual health

man with hand on face looking pensive

It’s the end of a long day and you’ve earned an evening on the couch. It’s still early, so you fire up your favourite ‘dating’ app and get to checking the listings. He catches your eye straight away: great smile, sexy profile and not too far away… But then you see he’s on PrEP. And if he’s on PrEP, then you’d be playing Russian gono-roulette if you hooked up with him, right?

In the brave new world of PrEP and the utilisation of an undetectable viral load as an HIV prevention strategy, we’ve got a some very effective new tools to help prevent the spread of HIV. Offering a level of protection on par with condoms (or even better), antiretroviral medications have reduced the number of new HIV diagnoses in NSW to their lowest level since the start of the HIV epidemic. And some guys on PrEP are in fact making the choice to reduce their condom use for that reason (and because, unsurprisingly, they report that it makes sex more enjoyable for them).

But HIV isn’t the only potential microscopic stowaway you might be carrying around. PrEP doesn’t protect against chlamydia, gonorrhea or syphilis, for example, which have all been on the rise. And if guys on PrEP are using condoms less, doesn’t that make them more likely to acquire or pass on STIs? Are you right to be suspicious of your new online buddy?

The answer isn’t as simple as you might think. Read on for a few important facts around PrEP, condoms and STIs.

1. More testing = more diagnosis = more treatment.

A lot of the press about PrEP and STIs has come from a study in Washington State, which found that guys on PrEP were 20 times more likely to be diagnosed with an STI than HIV-negative guys who weren’t on PrEP.

But that doesn’t necessarily mean that guys on PrEP are actually getting more STIs.

The key word here is ‘diagnosed’. As the researchers point out, if you’re on PrEP, you’re seeing your doctor every three months to get a prescription. And to get a PrEP prescription, you have to get all your STI testing done as well. That’s a full STI test every three months, with or without symptoms. The researchers believe that this increased testing is diagnosing and treating a lot of STIs which would previously have gone under the radar for months, especially for guys who have no symptoms (which is a lot of us).

As a comparison, the HIV 2015 testing data in Australia, compiled by the Kirby Institute, shows that gay and bisexual guys are testing on average between once and twice a year, with just over half of us getting tested more than once a year.

2. STIs are on the rise. But PrEP isn’t responsible.

Given how recently PrEP has become available, its impact on STI rates – apart from HIV – can’t even be assessed yet.

Research by the Kirby Institute shows that STIs among gay and bi guys were on the rise in Australia long before PrEP was approved here or overseas. And don’t worry, your straight friends didn’t miss out — STI diagnoses have been rising for them as well. There are likely a number of factors involved (e.g. the influence of dating apps and better testing technology), but PrEP definitely didn’t start the fire.

3. Having more people on PrEP could actually cause STI rates to fall.

In a study conducted at Emory University in Atlanta, researchers ran a mathematical model to see what effect a wider uptake of PrEP would have on bacterial STIs like gonorrhea and chlamydia.

They found that over 40 per cent of chlamydia acquisitions and 42 per cent of gonorrhea acquisitions would be prevented over the next decade if 40 per cent of PrEP-eligible gay and bisexual men took PrEP and were tested at least twice a year for STIs. They suggest that this would hold true even with a 40 per cent reduction in condom use while on PrEP.

The short version from this study: more guys on PrEP could mean fewer guys with chlamydia and gonorrhea in the long term. Basically, more testing means earlier treatment, which means fewer opportunities for transmission.

4. Being ‘safe’ isn’t just about condoms or PrEP.

Protecting yourself from STIs starts long before you get to the bedroom/steam-room/playroom. Being informed about your sexual health is one of the best things you can do to maintain it. Nothing and nobody is 100 per cent safe even when you’re doing everything you possibly can, so if you’re having sex, talk to your doctor, get tested regularly and get treated if necessary.

The good news is that your online buddy with the sexy profile is already doing this, because he’s on PrEP. You should consider talking to him about it. Maybe in person.