Are STI Rates Rising Because of Our Successes in HIV Prevention and Treatment?


HI Damon,

I was at a talk recently where there was a 'debate' that PrEP and U=U have led to higher rates of STIs. Is this true?


Hi there, thank you for reading!

There has been much debate and confusion about whether PrEP, a pill that prevents HIV has led to higher STI rates. There is further confusion about how U=U, i.e, the science that proves that someone who is HIV+ and undetectable is also sexually untransmittable, contributes to these statistics. Both of these medical advancements allow sexual partners to connect without condoms without fear of HIV transmissions. These two regimens combined have already contributed to record low HIV rates in areas where both have been widely adopted. But do lower HIV rates result in higher STI rates?

Not necessarily.

It may be accurate to say that higher STI rates are correlated with uptake of PrEP and U=U. Of course some studies show that higher STI rates are correlated with shaving pubic hair as well. The point being, one can point to anything that has increased in the past 12 years and examine a positive relationship between higher incidence of one thing, and STIs to the other. It doesn't mean that one CAUSED the other.

We know that STI rates in the U.S. have been exponentially increasing since 2007, long before we had any science or evidence of PrEP's efficacy. And although some scientists understood U=U back then, it was not known by the general public, and still isn't in many areas. So PrEP and U=U certainly can't account for significant increases from 12 years ago.

So what does explain the increase? The New York State Department of Health recently provided an excellent explanation of several variables that help us understand why higher rates of STIs have been diagnosed in the past decade. They include:

  • Invention of the Smart Phone in 2007
  • Grindr and Scruff both launch in 2009
  • The Affordable Care Act became available for the first time in the U.S. in January, 2014, giving millions of adults access to medical services for the first time in their lives.
  • CDC released first PrEP Guidelines in May, 2014, and were the first established protocols to include rectal swabs as integral part of regular care.
  • 160% increase in rectal swabs reported by LabCorp in New York State between 2013-2015, demonstrating that more rectal swabs were being offered than before
  • STI rates higher in geographic regions where PrEP uptake is lowest
  • No significant differences in STIs in comparable non-PrEP populations
  • In short, Correlation ≠ Causation

What we know and have seen is that offering PrEP to groups of sexually active gay and bisexual men are resulting in recording and documenting of higher rates of STIs on paper. Is that because there are really higher rates of STIs or just better documentation? That answer is not 100% clear on either side but we do know is that we anticipate STI rates are likely to come down once sexually active communities are connected to healthcare, using PrEP or U=U, as has already happened in London.

So next time you're at one of these so-called 'debates', feel free to pull out your smart phone and ask people to think about how much their sexual activities have changed since we've had the technology and convenience to seek out sexual partners from the comfort of our living rooms.

You may consider an exercise I've used as well when I teach about PrEP and U=U around the world. I ask the audience to raise their hands if they have been offered a rectal swab by a healthcare professional in the last 12 months. At my talks, most people in the audience raise their hands, or at least more than 50%.

Then I ask, "Now raise your hand if you had been offered a rectal swab buy a healthcare professional before ten years ago at this time." Inevitably, one or two raise their hands, but most of the room is silent. It vividly demonstrates that sexually active communities have been fundamentally neglected by most medical services in the past. But now, largely thanks to PrEP and U=U, more and more people have formed trusting relationships with their local medical communities, and are now being swabbed 3-4x a year. So if you go from swabbing butts zero times a year, to 3-4x a year, you can bet you will see a more STIs on paper than you used to.

I hope this information allows you to make the sexual health decisions that bring you and your partner the most satisfaction, connection, and pleasure. Yes, STIs are a reality, but so is crossing the street. We all mitigate risk every day (and night) of our lives, and hopefully are doing so armed with facts, education, and confidence.