The rising popularity of PrEP – thanks in large part to state government-sponsored trials in NSW and Victoria – may be leading to a rise in other STIs as condoms fall out of favour among gay men.
In recent years, the blue PrEP pill has gone from virtually unknown to having its own Grindr emoji.
But while PrEP medication is more than 99% effective in preventing HIV transmission, it does nothing to protect individuals from more common STIs such as Chlamydia, Gonorrhea and Syphilis.
“Indeed, the risk of catching other STIs is much higher than HIV, because the incidence is much higher in the general population,” says Dr Mitchell Tanner, a GP and founder of Sigma Health.
STD rates have been on the rise for at least a decade in Australia.
Sexual health organisations tell SBS that while it’s too early for definitive data, they won’t be surprised if there’s a further increase since the advent of PrEP – but that it could be accompanied by a quite dramatic fall in HIV infections.
“In the second half of last year we saw roughly a 23% decline in HIV infections compared to the same period last year,” says Dr Andrew Grulich, one of the researchers being the EPIC-NSW PrEP trial.
“We certainly anticipate we will continue to see major declines, but we want another couple of quarters of data to be certain that we’re seeing a true decline as a result of PrEP – that’s why we haven’t been crowing from the rooftops.”
Dr Grulich says that international experience suggests that there will also be a rise in other STIs.
“That’s why we really have to educate people about PrEP – if you want protection from STIs, then you need to be using condoms.”
While most STIs are relatively simple to treat, there are concerns about the rise of so-called ‘super-gonorrhoea’ – a drug-resistant form of the infection which broke out among straight couples in the UK in 2015.
Repetitive curing with antibiotics can lead to drug-resistance.
James Gray, Associate Director of Policy, Strategy and Research at LGBT+ health group ACON, says that public health organisations are keeping a close eye on the situation.
“We haven’t really seen the very resistant forms of gonorrhea in Australia yet, but what we are seeing is that gonorrhea is becoming more and more resistant to certain antibiotics,” he says.
While the risk isn’t imminent, he says it should be taken seriously.
“It is something that could come to Australia sooner rather than later.”
But for both Mr Gray and Dr Grulich, the trade-off is worth it.
“If you accept that PrEP is as effective as we know it is – which is 99%+ effective, close to completely effective – then why wouldn’t you want to roll this out at scale to prevent against the HIV epidemic?” Dr Grulich says.
The NSW government’s ambitious target of eliminating HIV transmission by 2020 wouldn’t be possible without the drug, he tells SBS.
“HIV is still a fatal disease if left untreated, and while the treatments generally do keep people healthy, you have to be on treatment every day for the rest of your life,” Dr Grulich says.
Bareback sex on the rise?
Anecdotally, gay men in Sydney appear to be seeing an increase in STIs as more and more men ditch condoms and rely solely on PrEP.
PrEP status is often listed in profiles on gay hook-up apps.
Daniel, a gay man on PrEP in Sydney, says he was concerned about people’s recklessness when the drug first became available - but since starting on the drug himself, he says he’s been far less stringent with using condoms.
“I’m not opposed to using condoms at all – but it’s just not something that is even in my mind, if I catch something I just know I can get cured.”
That’s happened several times, he says, and as a result he’s decided to limit his number of sexual partners – but he still enjoys sex without condoms.
Like many men, Daniel first became aware of the drug through Grindr. He says alarm bells went off when he saw how enthusiastic PrEP users had become about bareback sex, even in high-risk situations.
“They seemed very defensive on it because it protected them from HIV, but they weren’t willing to talk about the other risks it was opening them up to,” he says, before conceding: “But I’m now one of those people, so I’m a bit of a hypocrite here.”
Mr Gray says the sudden advent of the wonder-drug has caused a lot of people to re-define their barriers, but there may be a reality check as people realise the risk of contracting other STIs.
“We’re going through a period of disruption about what constitutes safe sex norms,” he says, “it’s going to take a little while for people’s practice to sort itself out.”
“But after 30 years of condoms being the primary method, it’s clear that it isn’t what works for everyone.”
Mr Gray says ACON and other organisations have adopted a strategy of promoting PrEP alongside condom use – as well as educating men that drug is not effective against other STDs.
“It wouldn’t be surprising if some of that messaging was lost in the initial enthusiasm around PrEP – but we’ll continue to be talking about it,” he says.
“In the end, the thinking is really around respecting the agency and the thinking of the populations we work with.”
Measuring the expected rise
Dr Grulich says it’s difficult to measure the impact of PrEP on STI rates for a number of reasons – partly because STI rates were on the rise before the pill became available in Australia.
“It’s not straightforward for us to measure if there is going to be an increase in STIs,” he says.
PrEP trial participants are tested every few months for STIs, and given that’s higher than the average population he says there’ll be higher rate of infection discovery anyway.
“Given the complexities of the analysis we’re doing, any specific results won’t be available till next year,” he says.
Dr Grulich says that while there are good reasons to be concerned about a rise in other STIs, the situation is not unprecedented.
“There is a really good historical comparison here, and that’s with the advent of oral contraception for women.”
‘The pill’ saw a dramatic spike in other STIs, he says, because people could suddenly have sex without condoms without risking pregnancy.
“There is precedence in this area, so it’s not just something limited to gay men; it’s something observable in all human sexuality.”