Another Advance for HIV Prevention: STD Testing


Wednesday, December 1st, 2010 is World AIDS Day.

Another World AIDS Day.  A day I know many of us will look forward to committing to the ash heap of history in the not too distant future.  However, until then, we’ve got to figure out how we continually recast and reassess our basic messages around research, prevention, care, treatment and a cure lest we be cast further down the ever increasing priority list of needs and the ever shrinking pots of money tapped to bring this horrible disease to an end.

Last week brought great news about the success of preventing HIV infection by proactively delivering medications pre-exposure (PrEP).  It is a major advance in the HIV prevention toolbox, but at present, I am hard pressed to embrace the news with enthusiasm when, according to my friends at NASTAD, 4,157 people living in 9 states are on waiting lists to receive the same or similar drugs that will prolong and enrich their lives. 

The news of PrEP’s success however, as well as news earlier this year of a successful trial of a microbicide gel to prevent infection, should renew all our hopes that preventing HIV is possible when we continue to pursue the right research.

And so it was this year that during my preparations for a number of presentations at annual state-wide meetings of my organization’s members, I was hit over the head with a mallet of frustration that the connection between STD infection and HIV acquisition remains too far down the priority list of our prevention focus.

This frustration crystallized when I was perusing the 1997 Institute of Medicine report titled The Hidden Epidemic: Confronting Sexually Transmitted Diseases.  Nearly 15 years since this report was released, I was reading critical clarion calls for development of a national STD strategy – inclusive of HIV and that called for getting to the bottom of understanding and undoing the destructive role of other STDs in HIV acquisition and transmission.  To this day, it’s a call mostly unheeded.

Why has there been so little progress in focusing and prioritizing STD prevention as HIV prevention?

At about the same time of the dispelling of the myth that “poppers” were the cause of Gay-Related Immune Deficiency (GRID), the outwardly stigmatizing and despicable early name for AIDS, we have also known that being currently infected with another sexually transmitted disease (STD) raised the biological stakes of acquiring what would become known as HIV.  No one questions this fact.

If you go to the CDC’s website and look up the general consumer-focused information about HIV and STDs, you find supportive messages that encourage testing for other STDs in addition to HIV testing.  The CDC’s STD Division is even more explicit that STD screening and treatment IS HIV prevention.  They have a fact sheet underscoring the biological susceptibility to acquiring HIV if you have an existing underlying STD infection as well as describing how someone with HIV and another STD are more likely to infect a partner with HIV as a result of having the additional STD infection.

Still, it’s a bit like the chicken and the egg — we have not been able to nail down in any concrete way which came first?  Was a person infected with HIV and then another STD or was an underlying STD the culprit in exacerbating HIV acquisition.  It’s an interesting question to ponder, but in the real world, we know that the vast majority of the 19 million new STD infections in the US each year go unnoticed because their direct symptoms are minimal or non-existent.  Yet, the compromising connection of these undiagnosed and untreated STD infections to acquiring HIV is indisputable.

In part, this has been the case because screening for some of the most common STDs, like Chlamydia and Gonorrhea, have rightfully had the dubious distinction of not creating the most pleasurable experience for the patient.  Visions of giant sized Q-tips linger in the minds of too many.  But advances in technology – such as simple urine tests and self collected swabs – have made STD testing less intrusive and more easily carried out.   The issue is that the public relations push for how much easier STD testing can be is virtually non-existent.

I am not suggesting in any way that we take our eyes off the important task of continuously scaling up HIV testing.  Knowing one’s HIV status, getting on treatment when positive and driving down viral load is also HIV prevention.  But what I am suggesting is that the jettisoning of testing and screening for other STDs as a separate type of work – of lesser import perhaps – has done nothing but exacerbate the HIV – and other STD – epidemics in this country.

It’s a sobering and perhaps even a provocative statement, but it’s a factual one.  And sadly, it is a consistently neglected one. 

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  • cpolis

    Thank you for this article, and for your work on sexually transmitted infections.  I strongly believe that STIs are a critical public health issue and that their diagnosis and treatment is an essential part of healthcare (regardless of any connection with HIV).  I also remain open to the possibility that STI treatment/prevention may one day be found to be an effective HIV prevention strategy.  But it seems unfair to say the call to investigate the relationship between STIs and HIV acquisition has gone unheeded in the past 15 years, given that nine randomized trials (and numerous observational studies) have assessed this subject.

    In 1995, the first randomized controlled trial (the gold standard of evidence) was published assessing STI treatment as an HIV prevention strategy.  Findings suggested a 40% reduction in HIV due to improved STI services.  Along with available data from observational studies, STI prevention seemed a promising HIV prevention strategy at the time the IOM report you mention was published  (1997).  However, beginning in 1999, eight additional randomized controlled trials were successively published, NONE of which found treating STIs to be effective in reducing HIV acquisition.

    Do these randomized trials (significant undertakings which require a lot of time, energy, and money) really constitute an unheeded call to investigate this relationship?  Or, instead, is the problem just extremely complex, given that the data are difficult to interpret (biological mechanisms are plausible, observational evidence suggests a strong association between STI and HIV acquisition, but the vast majority of interventions tested in randomized trials do not show an effect)?  With limited resources, is it appropriate to channel money towards an unproven HIV prevention strategy (and to call it an HIV prevention strategy), before we have solid proof that it helps to substantially prevent HIV?

    It would be wonderful if newer, stronger interventions for STI treatment/prevention prove in the future to be effective HIV prevention strategies.  My fingers remain crossed!  Until that hopeful time, STI prevention, testing, and treatment can and should still be strongly championed on its own merit, given the substantial morbidity and mortality caused by various STIs.

  • william-smith

    Thank you so much for this thoughtful commentary.  I do indeed recognize that some effort has been expended in exploring the connections between STD and HIV and the studies you cite are such instances.  There are, however, also additional studies documenting positive impacts not included in your assessment — some of these can be found on the CDC site but I am happy to exchange research citations if you’d like to email me directly (wsmith@ncsddc.org).  I would also refer you to an article I co-authored with Judy Auerbach published in the San Francisco AIDS Foundation’s journal Beta [http://www.sfaf.org/hiv-info/hot-topics/beta/beta_2008_sum_evidence.pdf] where there is a thoughtful treatment of going beyond the randomized control trial (RCT) framework on the very complex issue of HIV prevention.  RCT are not the only measure by which we need to define evidence of what works.  To this extent, I would argue from the experience of NCSD’s members in health departments across the country, on a daily basis and in interaction with patients and clients, the reality that siloed STD and HIV screening is counterproductive, particularly for those populations MOST at risk.

     

    You are absolutely correct that this is indeed complex, but it is also ever evolving.  For example, we know that the ONLY population in which new HIV infections are increasing in this country is among gay men — and more particularly — young gay black men and middle aged white men.  So while I am not not in anyway suggesting we scale up universal STD screening tomorrow…when we know where the disease is on the rise or prevalence so high, we ought to be scaling up targeted STD screening among those populations and in those communities.  No sexually active gay men in these populations, for example, should go unscreened annually for non-genital STD infections yet, it is quite rare that such screening takes place…And currently we are in the very midst of a rather severe syphilis and HIV co-infection epidemic that demands more integrated screening and treatment efforts.

    So yes, this is quite complex but there are kernels of clarity where some robust work can and must occur and with some immediacy.