How to Have Sex in a New Epidemic of STIs

Howard A. Grossman, M.D.
Howard A. Grossman, M.D.

I am a gay doctor with large medical practice in New York who's been involved in caring for LGBT people and in fighting the HIV epidemic for over three decades. And I am beginning to get freaked out about the tidal wave of STIs I'm seeing in my practice.

Let me make one thing clear right up front. I am a proud, out, gay man, devoted to HIV treatment and a staunch advocate for sexual freedom and for PrEP. I've written elsewhere about my own decision to take Truvada (tenofovir/FTC). Nothing in this article should be construed as indicting PrEP use, as some misguided souls have done, or the new, less anxiety-ridden sexual freedoms we all are enjoying. It's about time that we are finally able to uncouple sex and death in the bedroom.

Sharp Rise in STIs

In November 2015, the U.S. Centers for Disease Control and Prevention (CDC) reported a sharp rise in the rate of sexually transmitted infections (STIs) among men who have sex with men (MSM), the first rapid rise since 2006.

I feel a need to raise an alarm regarding this spike in STI rates. Something is wrong when MSM account for 83% of reported cases of syphilis among men. And that CDC report is based on 2014 data, which is woefully out of date compared with what I'm seeing now. In 2014, I was seeing perhaps one new STI every week or two. In the last eight or nine months I have been seeing three or more infections in my patients nearly every single day!

Some people have theorized that the STI increase is a statistical artifact caused by the increased surveillance testing that we're doing in our patients on PrEP. But I have been prescribing PrEP since 2013, and I can tell you that something very different is happening.

It's Not PrEP

Others have blamed PrEP use for this, but this STI spike is not just happening in people on PrEP, who are actually leading the way in getting tested more frequently.

PrEP works incredibly well in prevention HIV infection. Yes, there is one person who has been documented to have been infected with a multi-drug resistant virus -- it is not surprising at all that Truvada (tenofovir-emtricitabine) would not work when confronted with a virus already resistant to it. But these resistant viruses are incredibly rare. And this is one case when a low estimate is that there are over 40,000 people on PrEP. This is an amazingly effective prevention method.

I am also seeing an STI surge in patients who are not on PrEP, and in both people who are HIV positive and HIV negative. Nor do I think it's just that some have stopped using condoms. I am seeing spikes in oral infections as well as in anal ones, and no reasonable person has suggested condoms for oral sex for years.

So what's behind this? It is clear that gay men are feeling more comfortable with sex than they have in 30 years. Treatment as Prevention (TasP), Pre-Exposure Prophylaxis (PrEP) and safer, more convenient and more effective treatments for HIV have finally lifted the cloud that many of us have lived under for years. For men in their 20s and 30s especially, this liberation comes at a time of increased use of social media apps that make it easy to "hook up" for sex -- the modern equivalent of the bathhouses and backrooms of the '70s.

Having More Sex Is Not the Problem

Make no mistake; I celebrate these changes. After watching the devastation left in the wake of HIV, after years of trying to help my patients navigate a sexual world that left many in perpetual fear, after years of having to navigate those issues myself, I am thrilled that we seem to be on the threshold of a new era of sexual freedom.

I also understand that the younger MSM population doesn't perceive risk in the same way that my generation does after living with the pandemic for so long. Thank goodness that they never experienced what we did. During those dark days, the math was straightforward: No Condom = Possible Death. That equation may now be moot with respect to HIV.

This is a good thing. Having more sex is not the problem. I find reprehensible the recent tendency of some to accuse gay men of being irresponsible and, once again, pathologize us as nothing but vectors for disease. And I can only stare slack-jawed at the disinformation campaigns against PrEP by some that can only create more fear, more confusion and perpetuate the epidemic -- and seem to be especially targeted at communities of color. But I also have to take serious issue with those who are so determined to protect their newfound sexual freedom that they deny any evidence of unintended consequences, such as this rise in STIs. This battle going on within parts of the gay community risks stopping us from addressing the STI epidemic.

We Need STI Screening, Treatment and Education

The real problem, in my view, is that adequate screening and treatment for STIs is often not available, and education about STIs in the United States sucks (to put it mildly).

For the last 30 years, the only message about sexual health that many young people received was either to practice abstinence-only or, in more liberal venues, to wear a condom every time to prevent HIV. The lack of knowledge about STI transmission, prevention and treatment is a damning indictment of our educational system.

In many places testing is not even available. But even when people have access to care, those who ask for STI testing and/or PrEP advice are often told "we don't do that here" or "we don't know how to do that." And when they can access testing, often it does not include testing for oral and anal infections.

Many people are not aware of how few options are available for successfully treating STIs. The outrageous cost of hepatitis C treatment is putting it out of reach of many patients. There is basically one drug for syphilis and one for gonorrhea, making the threat of drug resistance enormous. If we lose these two drugs then we will be thrown back to a situation not seen since the first part of the 20th century before antibiotics were widely available.

So I'm getting really nervous. I'm doing everything I can to educate my patients. This is a crisis that needs to be immediately addressed.

What You Can Do Right Now

Here things you can do right now that may help to protect you:

  1. Get tested more often and get treated right away.
    If you are sexually active, you should be tested for STIs on a regular basis. Those on PrEP are being tested every three months as part of many centers' protocol, but that may not be often enough. PreP or not, HIV positive or negative -- if you're having sex with multiple partners on a frequent basis, you may want to consider getting tested monthly or every six weeks. Early testing and treatment may be the way we get this STI epidemic under control, and if you are choosing not to use condoms, then increased awareness of STIs, more frequent testing and earlier treatment may be your best harm-reduction tools.
  2. Talk to your partners.
    When your sex partner tells you he has been recently tested, and he's "STI-free," your next question should be "how were you tested?" If he says blood and urine tests, you may want to put off sex, have non-penetrative sex or pull out that condom you weren't going to use.
  3. Keep condoms in your toolbox for risk reduction.
    The risk of transmission of STIs from oral sex will continue. Even if you feel comfortable forgoing condoms because you're on PrEP and feel protected from HIV, condoms need to remain in your toolbox of harm-reduction methods for use in anal sex to prevent STIs. It's your choice whether to use them or not, but I encourage those of you who have stopped using them completely to reconsider, depending on your sexual situation.
  4. Demand that all medical providers do appropriate testing.
    All providers must be educated to do appropriate testing that evaluates all sites of possible infection, and testing should be available in all primary care settings. If your provider is not testing for oral and anal infection, then they are not testing appropriately.
  5. Demand that the government step up it's commitment.
    STI testing must be more widely and economically available. We must demand that city and state health departments step up efforts to make testing available to all.
  6. Demand point-of-care testing.
    Point-of-care testing will allow faster identification of people in need and more rapid deployment of treatment. We could be testing people in venues associated with sex, in nontraditional settings and even at home.
  7. Demand new treatments for STIs.
    We need a concerted effort spearheaded by the National Institutes of Health and pharmaceutical companies to develop new, effective treatments for STIs before drug resistance becomes widespread.

This article is incomplete. I don't have the space to talk about all the other factors at play in this STI epidemic: stigma, both of STIs and of HIV; poverty; homelessness; selling sex for shelter or food; and lack of access to care for LGBT folk, especially transgender men and women. I leave it to others to do that. We need to start talking, though, as a community.

Once upon a time in the 1970s we thought that all infectious diseases were going to be easily controllable. HIV taught us the price of that arrogance. We ignore the rise in STIs and the looming threat of drug resistance at our own peril. WAKE UP!