https://orcid.org/0000-0002-1614-758X
Abstract
In this retrospective analysis of men who have sex with men with human immunodeficiency virus (HIV) in the South from 2014 through 2019, incident bacterial sexually transmitted infections (STIs) increased regardless of virologic control. Clinicians should prioritize STI screening and management in primary HIV care.
The human immunodeficiency virus (HIV) epidemic in the United States experienced slight declines in new diagnoses in recent years, yet >36 000 persons were diagnosed in 2019 [1]. Simultaneously, sexually transmitted infection (STI) incidence continues to markedly increase to all-time highs [2]. Men who have sex with men (MSM) experience disproportionately high rates of both HIV and STIs compared to other groups [1, 2]. HIV and STIs persist as a syndemic through complex interplays promoting transmission. Biologically, STIs increase the chances for HIV acquisition by multiple mechanisms, including compromised mucosal integrity via genital ulcer diseases such as syphilis or herpes simplex virus as well as increases in local inflammation and target cell recruitment, ultimately favoring attachment of the HIV virion [3]. STIs indirectly increase HIV transmission risk by raising the HIV viral load in genital and anorectal fluids [4].
Remarkable advances in our ability to diagnose, treat, and prevent HIV over the last the 2 decades have contributed to recent declines in new HIV diagnoses. Moreover, for a person with HIV, antiretroviral therapy leading to viral suppression essentially eliminates sexual transmission [5]. The clinical and research approaches to HIV and STIs have often been siloed and often considered separately, but to confront these intersecting STI and HIV epidemics, we need to better understand the interplay of the syndemic [6]. The Deep South of the United States (Alabama, Georgia, Louisiana, Mississippi, and South Carolina) experiences the highest rates of HIV and bacterial STIs, but limited data describe incident STIs among MSM with HIV in this region. This study evaluates STI incidence rates among MSM with HIV in the context of HIV virologic control in the treatment as prevention era.
METHODS
This retrospective cohort study analyzes bacterial STI incidence trends from 2014 to 2019 among a group of MSM at a clinic providing the majority of care to people with HIV in Birmingham, Alabama. To be included in this analysis, participants (1) identified as cisgender MSM; (2) were with HIV for at least 1 year and prescribed antiretroviral therapy for 6 months to allow for viral suppression; and (3) had at least 1 bacterial STI test for gonorrhea, chlamydia, or syphilis. We defined incident bacterial STI as any positive nucleic acid amplification test or culture for Chlamydia trachomatis or Neisseria gonorrhoeae from any site (genital, anal, or oropharynx swab), or incident syphilis as any of the following: (1) initial reactive rapid plasma reagin (RPR) titer of ≥1:16; (2) an RPR titer of ≥1:1 in a patient with no history of reactive RPR; (3) a nonreactive RPR followed by an RPR titer of ≥1:4 in a patient with a history of reactive RPR; or (4) a 4-fold increase in RPR titer from 1 follow-up period to the next [7]. We stratified MSM into 2 categories by viral load control at the time of incident STI diagnosis: suppressed (viral load <200 copies/mL) and not suppressed (≥200 copies/mL), as most studies evaluating HIV transmission used this level of 200 copies/mL [5]. The primary outcome was incident bacterial STI. We calculated bacterial STI incidence rates per 1000 person-years (PY) for each viral load category for each year in the study from 2014 through 2019. Each visit for STI test contributed 0.25 PY to the analysis, that is, limited follow-up time to every 3 months to reduce potential bias from more frequent testing [7]. This work was approved as exempt by the University of Alabama at Birmingham Institutional Review Board (IRB-300003953).
RESULTS
The number of tests performed, the number of positive results, and the incidence rate per 1000 PY increased from 2014 to 2019 (Figure 1). In 2014, Black/African American MSM accounted for 49.7% of the cohort, and this proportion increased to 60.5% in 2019. In each year, the majority of the cohort was virally suppressed (range, 84.4%–86.4%), and the proportion of MSM with viral suppression increased from 2014 (84.4%) to 2019 (86.4%) (Supplementary Table 1).
Top panel: Tests performed, number of incident sexually transmitted infections (STIs), and person-years (PY) by year and viral load control category. Bottom panel: Incident STI rates per 1000 PY by viral load category.
The proportion of men in this cohort with incident STI increased each year from 2014 (11.7%) to 2019 (18.8%). Among the group with HIV viral load <200 copies/mL (suppressed group), the STI incidence rates increased from 438.0 per 1000 PY in 2014 to 692.4 per 1000 PY in 2019 (Figure 1). The STI incidence rate increased from 598.8 per 1000 PY in 2014 to 887.2 per 1000 PY in 2019 among persons with uncontrolled viremia (Supplementary Appendix 1). Of positive tests, the majority of persons had a single STI at each visit, yet approximately 47% of suppressed and 40% of unsuppressed participants had multiple STIs during this analysis.
DISCUSSION
In this cohort of MSM at a large, urban HIV clinic in the Deep South, STI incidence increased from 2014 to 2019. The majority of the cohort were Black/African American, reflecting the epidemiology in surveillance data reported to the Centers for Disease Control and Prevention for known and new HIV diagnoses in the South [1, 2]. The increased incidence occurred despite high and increasing proportions of MSM with HIV virologic control.
STI incidence rates per 1000 PY were higher among persons with unsuppressed viral loads, yet the proportion of MSM with incident STIs was higher among those with suppressed viral loads. The difference in total number of MSM in these viral load categories and frequency of visits do not solely explain this difference in STI incidence, as each visit where testing occurred contributed only 0.25 PY. Additionally, the high rates observed in both suppressed and unsuppressed cohorts may be influenced by repeat positivity from some MSM, but nearly half (49%) of the cohort had only 1 STI to contribute. While treatment as prevention remains a pillar of ending the HIV epidemic, it fails to address the critical role that STIs have in the HIV epidemic. Despite substantial strides in improving the care of people living with HIV and reductions in new diagnoses, the large number of incident STIs remains a major public health burden that negatively impacts MSM sexual health.
Current HIV care guidelines recommend STI testing more frequently for persons with higher risk, but even this approach may not sufficiently stem the rising tide of STIs and its detrimental consequences [8]. These data indicate that frequent screening for STIs (ie, at every clinic visit) should be considered for all sexually active MSM, regardless of viral suppression status, and STI screening should continue to be a priority for all persons with HIV. As “serosorting” becomes less common, sexual networks expand and integrate, increasing the possibilities for STI transmission among MSM regardless of HIV status [9, 10]. HIV-negative MSM engaged in routine preexposure prophylaxis care receive STI screening at each quarterly visit, yet MSM with HIV engaged in routine HIV care, especially those with suppressed viral load, may receive STI screening only annually, if that. In addition to more frequent screening and treatment, new prevention modalities are on the horizon with clinical trials ongoing in STI preexposure prophylaxis and novel preventive vaccines, but these do not yet inform routine clinical practice [11, 12]. Until then, vigilance is critical to ensure that no opportunities are missed to screen and treat MSM for STIs.
This analysis is limited in that these data do not differentiate between routine STI screening and symptomatic or exposed STI testing. While this would not alter the number of positive results or the proportion of MSM with incident STI, it may influence the overall incidence rate. Furthermore, MSM with viral suppression who are more engaged in HIV care may be more likely to return for interval STI screening as opposed to MSM who are less engaged in care.
While HIV outcomes are improving, STIs continue to increase despite current control measures. Providers should prioritize sexual health services, including STI screening, STI treatment, and behavioral counseling to all MSM regardless of HIV status or HIV virologic control.
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.
Notes
Financial support. This work was supported by the University of Alabama at Birmingham Center for AIDS Research (grant number P30 AI027767) and the National Institute of Mental Health, National Institutes of Health (NIMH/NIH) (award number K23MH126794 to R. M. G.).
REFERENCES
Author notes
Potential conflicts of interest. E. T. O. reports consulting fees from ViiV and Merck. R. M. G. has received research funding to his institution from MSD. All other authors report no potential conflict.
All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
