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HIV and sexually transmitted infections: reconciling estranged bedfellows in the U = U and PrEP era

K. Mayer,H. D. de Vries

Published 2019 in Journal of the International AIDS Society

ABSTRACT

Since the earliest days of the AIDS epidemic, it was clear that HIV and other sexually transmitted infections (STI) had many features in common [1]. Their spread involved the same behaviours, and often affected the same socially marginalized people, including men who have sex with men (MSM), sex workers, substance users and migrants. As the aetiologic agent of AIDS, HIV, was elucidated, it became clearer that there were biological interactions between HIV and STI. Inflammatory and ulcerative STI facilitated HIV transmission and acquisition, and HIV infection led to increased infectiousness of several STI pathogens [2,3]. A more sophisticated understanding of their epidemiology also suggested that individuals who were engaging in behaviours that led to STI acquisition were more likely to be part of sexual networks where HIV transmission or acquisition were more likely. Prior to the advent of antiretrovirals for prevention, common strategies employed to decrease HIV/STI spread, mainly involved the promotion of “ABC”: Abstinence, or Behaviour change (decreasing the number of partners), and Condom use. However, over the past decade, the evidence proving that people living with HIV who had undetectable plasma HIV RNA do not transmit HIV (U = U) [4,5], and the demonstration that pre-exposure prophylaxis (PrEP) using tenofovir-based regimens protects individuals against the sexual acquisition of HIV [6-8] has altered the dynamics of HIV-STI epidemiologic synergy. In the current era, individuals who are adherent to antiretroviral medication, whether for treatment or prevention, can expect to engage in condomless intercourse without either acquiring HIV or transmitting the virus to others, but are still at high risk for acquiring and transmitting STI. Moreover, during this same time period, STI increases have been occurring globally, particularly in key populations. Historically, HIV researchers, STI specialists and frontline clinicians have had differing perspectives about the relationships between HIV and STI. In the earliest days of the epidemic, HIV research was focused on trying to identify an unknown, highly lethal pathogen, whereas most STI pathogens were well known and well described. HIV clinical care involved treating individuals who were at risk for recurrent opportunistic infections and neoplasms, whereas STI management was able to focus on the development of systems to diagnose and treat infections, with much attention was devoted to identifying people who were HIV-infected and treating their intimate contacts. Because of the dire illnesses that people living with HIV developed, and the rapid growth of the epidemic, a sense of urgency led to funding dedicated siloed programmes, such as the NIH clinical trials networks, the PEPFAR initiative and the Global Fund, with scant consideration of concomitant STI that were frequently co-prevalent. Yet at the same time, STI specialists who worked for decades with high disease burden populations found that support for their work was not expanding, and sometimes shrinking. The separation of HIV and STI support through categorical funding further impeded fruitful collaborations [9,10]. Over the past decade, the situation has been altered dramatically because of the recognition that, although there are now tools to control the HIV epidemic, without addressing STI, their spread will accelerate, leading to widespread morbidity, complicating HIV control efforts [9,10]. Increases in congenital syphilis, expanding antimicrobial resistance in gonococci, and sexually transmitted Hepatitis C are three of many examples of how the global public health community has come to recognize that without addressing STI, the successes in the AIDS epidemic will be compromised. It is with that intent in mind that the International AIDS Society sponsored the STI 2018 pre-conference in Amsterdam in July, 2018. The two-day meeting featured a variety of presentations that addressed the epidemiological, clinical, behavioural and structural issues that have driven the HIV and STI syndemics. Several key papers have been assembled for this special issue of the Journal of the International AIDS Society which summarize the key themes discussed at the conference, in order to inform readers about the current state of the science related to HIV and STI interactions and to discuss challenges ahead Mayer KH and de Vries HJC Journal of the International AIDS Society 2019, 22(S6):e25357 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25357/full | https://doi.org/10.1002/jia2.25357

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