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Why demonizing PrEP users for the increase of STI rates is the wrong approach #HIV #AIDS #PrEP

Why demonizing PrEP users for the increase of STI rates is the wrong approach #HIV #AIDS #PrEP

(This is my rant for the week. If you’re not in the mood for my going off, then this isn’t the post for you. Just the same though, if you’re considering PrEP then you might want to knuckle under and read this just the same.  I apologize for the length of this, but there are a lot of facts I need to share to back up my claims)


In order to keep myself up on current events and bring things to my site that catch my attention, I read the news daily.  I have a reader program that scours all the topics I have of interest and puts things all in one place for me.  Take a look at my site and you’ll see some common threads:

1. HIV/AIDS: the gay community all but abandoned HIV/AIDS for two reasons. Gay marriage became the all consuming topic. HIV meds became radically advanced, and HIV transitioned from something scary that would lead to AIDS related issues to something manageable, so everybody except advocates decided they weren’t going to spend any capital on it anymore.  In the mainstream, the press essentially took their cues from us and HIV/AIDS reporting dropped by 70% in a decade.  Nobody was talking about it. (NOTE: yes, I know that information is more than a decade old. I’m still in the process of looking for an updated report. I know it’s out there somewhere. Nothing much has changed in the years since.)

2. Tech News: I’m a tech geek, sue me. I love the stuff, and when there’s a significant advancement I tend to be all over it.

3. The odd and the weird: Hey, somebody has to cover the story about a Tickle Me Elmo being set aflame by a jet engine.

4. PrEP: PrEP is the biggest game changer in all the decades since C. Everett Koop told us all back in the 80’s if we didn’t want a risk of HIV exposure we had to use condoms. I was fortunate enough to get in on the first trials before FDA approval and I’ve been on it ever since. Truvada, when taken daily, reduces your risk of HIV exposure to damn near zero. The margin of error is near zero, and there’s study after study that supports that. It. Just. Plain. Works.

It’s a challenge to the fully engrained condom mentality and that rubs people the wrong way.  The common dispensing practice when you get on PrEP is that you’re told to keep it up with the condoms and that makes sense.  It’s not to give you an added barrier against HIV. It’s to protect you against STI’s.  Some guys toss the condoms in the wind and spin the wheel, some guys stay on condoms along with the PrEP.  Me? I’m a challenge to the status quo: I am an HIV advocate and have been for longer than some of you have been alive. I don’t always use condoms and my sexual partners are carefully chosen. I take extraordinary measures to protect myself against transmissions and they’ve paid off. Just the same, I get slapped around for being a Truvada whore and that’s fine. At the end of the day I manage my sexual health better than most people on the planet and I damn sure do it better than the ones pointing a finger at me.

This past week, the CDC released an alarming report showing that STI rates are on the rise and MSM (the catch all term for men who have sex with men) are the most predominately affected group in the data.  With that, we get to my rant of the week. Mark Joseph Sterm over at Slate wonders aloud of PrEP users are the cause of the increase:

What’s going on here? One obvious explanation could be the rise of PrEP (or Truvada), a daily pill, which, all available data indicatefully protects against HIV infection. Early studies of PrEP showed no evidence that those who took the drug would stop using condoms. But recent surveys suggest that at least some PrEP users do indeed use condoms less regularly once they’re on the pill. Most notably, a fairly small-scale study in San Francisco found a 30 percent instance in STIs among PrEP users after six months—which rose to a 50 percent after one year.* Just as troublingly, 41 percent of subjects admitted to using condoms less frequently while on PrEP.

The San Francisco study was too small to prove that PrEP is closely correlated to decreased condom use. But combined with the new CDC report, its findings should set off alarm bells. San Francisco is probably the first city in the world where PrEP usage has become normalized within the LGBTQ community. The apparent result: a decline in protected sex and a surge in STIs among the PrEP users. In early studies, when PrEP was novel and scarce, condom use stayed consistent. In newer studies, where PrEP has become widespread, condom use appears to be falling.

The entire crux of Sterm’s assertion is one small, localized study involving less than 700 men. In San Francisco no less.  In that study one third of the group acquired STI’s and that later went up to one half.  That’s why I’m pissed: it’s not bad enough that Stern published this accusation with a statistically invalid study, but his piece has gotten pickup.  Towleroad is a fairly large gay related website, and unfortunately these days they’ve gotten pretty big.  They’ve added a raft of writers who picked up on Slate’s piece; one of which also included his statement that most STI’s are becoming drug resistant. (They’re not. Instances of drug resistant gonorrhea have shown up, but that’s a FAR cry from saying that the whole panacea of STI’s out there are becoming drug resistant)  That’s the downfall of blogging journalism. Things get run without a lot of fact checking, they get picked up and reblogged by other sites, and then all of a sudden you have things in the wind that just aren’t true.  Like Stern’s piece

To be real clear: I’ve never met Mr. Stern, worked with him or read any of this other work. He could be an actual journalist who has press credentials, or he might be a freelancer who writes everything while sitting on his couch. I have no clue. In his piece on PrEP though, he missed a lot of facts that are on the CDC report plain as day, so he only read the top sheet of the CDC report, never bothered to tear through the data that’s included in the report, or didn’t understand what he read.  He just makes the blind assumption based on that one localized study that’s it’s ok to assume that PrEP users take STI’s for granted.  And I’m going to show you why he’s flat out wrong:

Let’s throw out the study he cites right off the bat, shall we?: Stern cites a three year study of 657 men that was focused solely in San Francisco.  No where else in the country to give a balanced view of the information, just SF.  Taking the study at it’s face and looking at the high end of their data, over the course of the three years one half of the guys acquired an STI. That’s 329 guys.  Now, given that there are at least 25,000 guys who are now on PrEP , 329 guys out of 25,000 is 0.01316%.  That just doesn’t pan out as being a significant increase of STI’s amongst the users.  Look at it from another angle: assuming that 1/2 of the guys on PrEP have acquired a STI while they’re on it. That’d be 12,500 men, and that just doesn’t pan out either. Do you think for an instant that if 12,500 guys acquired a sexually transmitted infection and they’re all on PrEP that nobody would notice at the CDC? The Centers for Disease Control has a battalion of statisticians and I can tell you from talking to just one of them: they would have noticed. The dispensing of PrEP would come to a screeching halt if almost 13,000 guys were getting STI’s because they’re on it.

Also of particular note: a major study was released the day before Stern’s piece. In it they looked at 600 men across three different cities to examine the results of PrEP amongst high risk users. What they discovered was pretty simple: PrEP works when you use it, no questions about it. One of the qualifiers of the study was that the participant had to have at least one diagnosis of syphillis, rectal gonorrhea or chlamydia. Across the study, their amount of sexual risk taking completely flatlined. They weren’t taking any more risk in a three city study and that runs totally counter to the San Francisco study:

The participants’ level of sexual risk-taking did not change as a result of receiving a Truvada prescription. This finding is in line with all of those seen in major studies of PrEP among MSM, but runs contrary to the findings in arecent study of MSM in a large PrEP program in San Francisco. At the outset of this new study, 365 participants (65.5 percent) reported having had condomless receptive anal intercourse during the previous three months. This rate remained stable through the study. A total of 147 participants (26.4 percent) had early syphilis, rectal gonorrhea or chlamydia at the beginning of the study. The STI infection rate was stable across the subsequent study visits. Half of all participants were diagnosed with at least one STI during the follow-up period.

To me, that’s a huge piece of information to process in considering why Stern’s assertion that PrEP uses might be to blame is just wrong.

Where is the increase coming from?  Well, let’s look at that, shall we?  Poz Magazine does a great job of pushing aside a lot of the useless information and breaking this down. I’m going to include all their data so it’s not out of context. Read this, and I’ll be back in a second:

The 2014 incidence, rate of infection, and the infection rate’s rate of increase between 2013 and 2014 for each STI were as follows:

•    Chlamydia: 1.44 million cases, for a rate of 456 per 100,000 people, representing a 2.8 percent increase. This is the largest-ever number of reported cases for any STI in the United States. 
•    Gonorrhea: 350,000 cases, for a rate of 110 per 100,000 people, a 5.1 percent increase.
•    Syphilis: 20,000 cases, for a rate of 6.3 per 100,000 people, a 15.1 percent increase.

The actual number of syphilis cases, while low, is still a major concern for the CDC because the infection rate is following a steady and apparently accelerating rate of increase, driven by MSM. (Syphilis is the only STI for which information about the sex of the partner is reported.) Rates among MSM, who account for 83 percent of cases in which the sex of the partner is known, have been increasing since at least 2000.  

In December 2014, the CDC reported that MSM drove a 10 percent increase in the syphilis rate between 2012 and 2013. A January 2014 report showed an 11.1 percent increase, also driven by MSM, between 2011 and 2012.

Fifty-one percent of MSM diagnosed with syphilis in 2014 were HIV positive. Syphilis infection can facilitate HIV transmission by causing sores on the genitals.

Among MSM visiting clinics in the CDC’s STD Surveillance Network, STI rates were higher among those living with HIV. The respective prevalence rates of the various STIs among HIV-positive and HIV-negative MSM were: syphilis, 10.4 and 3.5 percent; urethral gonorrhea, 11.4 and 8.6 percent; pharyngeal gonorrhea, 6.7 and 7.4 percent; rectal gonorrhea, 12.4 and 5.5 percent.

Young people between the ages of 15 and 24, despite representing a smaller slice of the overall population, accounted for almost two-thirds of all reported STIs in 2014. Previous CDC estimates have suggested that half of the estimated 20 million new STIs diagnosed each year occur in this age bracket.

Do you know what stands out for me there? The majority of STI infections is occurring within the HIV positive category and the 15-24 year olds. HIV positive guys aren’t on PrEP, and I don’t know you but I don’t know many 15 year olds that have a PrEP prescription sitting  on their dresser in the bedroom.  Even if we split the difference, I doubt there’s a doctor out there who’s going to dispense to a 21 year old.  You don’t simply go to a doctor, ask for it and walk out the door again. You’re questioned as to why you need to be on it.  The US has not adopted the World Health Organization’s standard that every gay men should be on it regardless of risk factor.

Are PrEP users perfect? Always wearing a condom and never throwing caution to the wind? No, and it would be a ridiculous assertion from me if I had said they were.  My conclusion is pretty simple: the gay community stopped talking about HIV/AIDS and STI’s years ago.  Gay marriage became the hill for us all to die on, and HIV was just one of those manageable things that wasn’t so scary anymore. The generation behind me isn’t having the same conversations around sex and HIV that I did. And they sure as hell aren’t getting any guidance from us, now are they?  Do you think an ultra lame and largely forgotten It Gets Better video is all we need to do for the next generation? The generation behind us should be pissed off as hell that’s all we’re offering them.

I can’t give too much of a guess as to why the majority of new infections are in the HIV positive community. I’m not positive, and I don’t think it would be fair of me to toss a guess in the wind to see if it sticks without backing it up too much.

So, Mr. Stern, you’re wrong, and you need to backtrack on your hazarding a guess that it’s the PrEP users who are to blame. You back up your claim with nothing: a minor study and a statistical anomaly that gives nothing in terms of a snapshot into the PrEP community.  You didn’t bother to do your homework on this one and you sure as hell should have. PrEP has enough of a PR problem thanks to Michael Weinstein’s spouting from the AHF.  We don’t need more people NOT getting the right information because you couldn’t take the time to back up your claim properly. Your piece would have fallen into little bits if you had.

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