Prevention in Focus

Spring 2019 

Views from the front lines: PrEP and sexually transmitted infections among gbMSM

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV but it does not protect against sexually transmitted infections (STIs). There is concern that there may be an increase in condomless sex among PrEP users which could lead to in an increase in STIs. This has fuelled a debate about whether PrEP use might propel the STI epidemic in gay, bisexual and other men who have sex with men (gbMSM).

We asked four service providers to give us their thoughts on whether or not PrEP might increase the risk for STIs among gbMSM using PrEP in Canada.

  • Dr. Mark Hull (St. Paul’s Hospital), Vancouver, B.C.
  • Mark McAllister (Chair, Edmonton Men’s Health Collective) & Thomas Trombetta (Board Member, Edmonton Men’s Health Collective & gbMSM Community Educator, HIV Edmonton), Edmonton, Alberta
  • Dr. Michael Fanous (Pharmacist, medsEXPERT Pharmacy), Toronto, Ontario

Dr. Mark Hull

When PrEP was first introduced as an HIV prevention tool, there was a lot of stigma due to its association with condomless sex and “irresponsible” behaviour, particularly among gbMSM. Do you think gbMSM still experience stigma around PrEP use? Please explain. Do you sense that this is changing as PrEP becomes more widely used?

First off, I am not sure I agree with the premise you are starting from in your background statement. We have to acknowledge that large numbers of gbMSM were not using condoms before PrEP became available (as shown in data from Canadian research such as the Engage and Momentum cohort studies), and we need to celebrate the rise of PrEP use. Expanded PrEP is going to prevent HIV infection in gbMSM, who have the highest rate of new diagnoses of HIV in the country. We need to continue to support significant expansion of PrEP programs across Canada, and I do not believe that concerns about rise of condomless sex should hold us back from this goal.

To answer your question, yes, I think stigma was definitely a concern for early adopters of PrEP, and they faced a lot of pre-conceived notions that somehow PrEP users were different from other gbMSM in terms of sexual behaviour – having more partners, or just wanting to not use condoms etc. I am hopeful now that as PrEP use becomes normalized as something every sexually active gbMSM would consider, the stigma associated with using it diminishes and people realize it is just another option for HIV prevention. People should support each other in having the kind of sex they want to have without judgement.

In your experience, how concerned are gbMSM who take PrEP about STIs? Do you think gbMSM who take PrEP consider the risk for STIs when they have sex, and understand the importance of routine STI testing? 

I believe gbMSM are well aware of STIs – rates of STIs were high even prior to PrEP. If we look at American data, rates of STIs are at their highest ever in the general population, and this is not PrEP-related. I would also point out that some of the increase in rates may in fact be related to improved testing for STIs as gbMSM begin PrEP programs that incorporate regular screening.

I am not sure that a lot of people — gay or straight — consciously formulate thoughts about STIs at the time that they have sex. Sex is supposed to be fun and enjoyable, and not just about worrying about infections! I think that afterwards there are of course concerns, and people often come in to our clinic for immediate testing or to talk about infections, so counselling about STIs in general is important. I think that most gbMSM are aware that PrEP doesn’t protect them from STIs, and in most clinics that focus on PrEP, education about the need for routine STI screening is highlighted at their first visit (whereas it may not be emphasized in settings where people are less familiar with PrEP guidelines).

American studies have shown that some doctors are not doing all of the recommended STI tests for PrEP users. In your experience, are doctors in Canada knowledgeable about providing appropriate STI testing for their gbMSM patients on PrEP?

I would say this likely related to experience of physicians in providing PrEP. For clinics that focus on PrEP prescribing, I would believe the majority of indviduals are offered STI testing every three months. We believe that STI testing is a critical component to PrEP programs, and our Canadian guidelines have very clear recommendations for routine testing of STIs from multiple body sites at each quarterly visit, even in asymptomatic individuals. There is strong data from American studies that show this enhances diagnosis of STIs in PrEP clients.

Mark McAllister & Thomas Trombetta

When PrEP was first introduced as an HIV prevention tool, there was a lot of stigma due to its association with condomless sex and “irresponsible” behaviour, particularly among gbMSM. Do you think gbMSM still experience stigma around PrEP use? Please explain. Do you sense that this is changing as PrEP becomes more widely used?

We do think that there is still a stigma that surrounds PrEP use in gbMSM. Although as a community we’ve come a long way since the days of labelling people “slutty” based solely on their decision to use PrEP, there are still a lot of judgments made by people when they see or hear that someone is on PrEP. Most often we hear about baseless assumptions regarding promiscuity or a lack of regard for public health – essentially blaming PrEP users for fuelling the current STI epidemic. However, we think these antiquated viewpoints and misplaced accusations are becoming less common as PrEP uptake continues to increase. More and more people are becoming educated on the issue, and a lot of this stigma is beginning to fade as the positive impacts of PrEP are witnessed. Being at the forefront of PrEP advocacy here in Edmonton we’ve witnessed literacy regarding PrEP skyrocket in the past couple of years, which is due largely in part to the education provided by community organizations. But it is also important to highlight that PrEP users themselves have become individual health advocates and educators working to dispel negative viewpoints on PrEP.

This isn’t to say that stigma surrounding PrEP use is being completely eradicated, because there are other forms of stigma that are faced by PrEP users. What we hear most about is stigma being enacted by different health care providers. LGBTQ2S+ people wanting to access PrEP have been reporting negative experiences speaking to their doctors about their sexual health. Many report gross misinformation from providers, while some encounter slut shaming and an unwillingness to discuss sexual health from evidence-based and affirming perspectives.

In your experience, how concerned are gbMSM who take PrEP about STIs? Do you think gbMSM who take PrEP consider the risk for STIs when they have sex, and understand the importance of routine STI testing? 

We would say that most gbMSM who take PrEP have a high level of awareness about STIs and are cognizant of the inherent risks associated with sexual activity. We don’t think concerns about STIs have been completely abandoned but have transitioned from a situation that is a cause for serious alarm to something that can be managed as soon as possible when detected. This is largely due to frequent exposure to ongoing testing and monitoring, as well as information learned through personal research carried out by many individuals who seek PrEP. While some gbMSM may engage in risk compensation after starting PrEP, through our education efforts we have seen this population being largely very receptive of sexual health related information and using that information to negotiate sex and prevention in new ways. This has manifested in a variety of forms from reinventing how we negotiate condom usage, to having more evidence-based conversations about prevention as opposed to simply repeating more traditional messages, which may be outdated. So, even though some guys may be engaging in more condomless sex since starting PrEP, it is not the result of ignorance or a disregard for public health. Rather, they are doing so with a wealth of knowledge and independence to determine their own sexual health, which is a refreshing change.

American studies have shown that some doctors are not doing all of the recommended STI tests for PrEP users. In your experience, are doctors in Canada knowledgeable about providing appropriate STI testing for their gbMSM patients on PrEP?

Prior to the introduction of publicly funded PrEP in Alberta most physicians were overall quite knowledgeable about required STI testing for gbMSM patients on PrEP, and reliably administered these tests at proper intervals. In most cases, PrEP competency in these physicians was facilitated by prior familiarity and work in the area of HIV and STI prevention, so there was a vested interest in ensuring that they were knowledgeable about the specific requirements of prescribing PrEP. However, there were certainly cases of prescribers misinforming clients and skipping baseline and follow-up testing. We heard one account of a prescriber not even running an HIV baseline test before a patient got their prescription. Had that patient been unknowingly HIV positive, this could have resulted in a much more severe outcome. However, now that prescribers must go through some form of training to prescribe free PrEP in Alberta, cases like these will hopefully be prevented from occurring in the future.

Dr. Michael Fanous

When PrEP was first introduced as an HIV prevention tool, there was a lot of stigma due to its association with condomless sex and “irresponsible” behaviour, particularly among gbMSM. Do you think gbMSM still experience stigma around PrEP use? Please explain. Do you sense that this is changing as PrEP becomes more widely used?

When PrEP was first approved in the US in 2012 there was a mixed reaction from the LGBTQ+ community, including the gbMSM who would benefit most from the reduced risk of HIV. Many individuals understood the greater significance of reducing new HIV infections in the community but were still unaware of their own personal risk. The experiences of early adopters as well as the resistance to PrEP within the gbMSM community made it clear that we would have an uphill battle in spreading awareness of HIV risk and prevention, reducing stigma around condomless sex, and convincing providers, public health authorities and governments of the benefits of PrEP. A great example of the stigmatization of PrEP users is the term “Truvada Whore”, which was initially used by some members of the community to describe people taking PrEP; some of these critiques came from longtime HIV activists who were resistant to new forms of prevention that undermined the “condom code”. The term was later reclaimed by PrEP advocates, and sparked conversations around the world about the scale up of this new powerful prevention strategy.

My own work in advocacy and educating the community was negatively impacted by unsubstantiated accusations that PrEP would cause an increase in condomless sex and therefore other STIs. This reflects wider patterns of stigma and judgment in the community, which gbMSM most definitely experience when accessing PrEP at every step of the way. This ranges from hearing less educated opinions among their peers, sexual partners, or friends, to encountering stigma from healthcare professionals. Sadly, many gbMSM do not seek the care they need or use effective prevention methods because of this. However, things have changed in the last couple of years: following Health Canada’s approval of PrEP in 2016, the national guidelines for providers published in the Canadian Medical Association Journal in 2017, and my work at medsEXPERT in Toronto’s Gay Village, support for PrEP within the Canadian healthcare system has grown.

In your experience, how concerned are gbMSM who take PrEP about STIs? Do you think gbMSM who take PrEP consider the risk for STIs when they have sex, and understand the importance of routine STI testing? 

Clients interested in PrEP book a private consultation with me at medsEXPERT where we review HIV risk, efficacy of PrEP, potential adverse effects, and the routine monitoring for HIV and STIs that they will experience while on the medication. When assessing HIV risk, clients are informed about STIs and how that affects their own risk of acquiring HIV using the HIV risk calculator. By the end of the consultation, clients are able to visually see how their risk of HIV is greatly increased when co-infected with STIs. However, they are reassured that STIs are a normal risk of any sexual activity and that PrEP can lower their risk of HIV far greater than condoms alone. With comprehensive sexual health counselling, clients gain valuable knowledge of their risks and are comfortable with making informed decisions about their sexual health and where to access HIV and STI testing. All clients taking PrEP are monitored for HIV, STIs, and adverse effects affecting the liver and kidney every three months, which is a great comfort to them in knowing they are routinely followed by a provider familiar with gbMSM health.

American studies have shown that some doctors are not doing all of the recommended STI tests for PrEP users. In your experience, are doctors in Canada knowledgeable about providing appropriate STI testing for their gbMSM patients on PrEP?

In my opinion, too many providers are not familiar with the proper protocols for screening, prescribing and monitoring of PrEP clients. For that reason, I created educational learning opportunities for physicians and pharmacists interested in prescribing PrEP to review, understand and discuss HIV prevention strategies. Unfortunately, many providers have expressed that they do not feel comfortable with prescribing PrEP despite the fact that it has been approved by Health Canada and that there is plenty of literature demonstrating its efficacy among gbMSM. In my opinion, lack of understanding on the developing science of HIV prevention strategies should never be a reason why someone does not receive the care they need and expect from doctors. PrEP gives providers a great opportunity to discuss STIs with their patients, which we ultimately hope will only increase in the coming months and years.

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