Rising STIs, Trump's Deal w/Gilead, U=U, & HIV Drugs w/out Prescription!

Update on HIV/STI Prevention Interventions and Treatment in 2019

2019 marks significant developments in the ways of addressing the HIV and STI syndemics, as new technologies for prophylactic treatment, like Truvada and, as of this month, Descovy, are rolled out; while interventional concepts like U=U were validated on New Year’s Day and accepted in the community as part of a combined strategy to end AIDS. These changes signal tectonic shifts at the intersections of culture, health, and sexuality that should inspire a renewed inquisition of the institutions guiding these interventions and their implications for advancing sexual minority health and the political economy of HIV.

Released this week: According to the annual Sexually Transmitted Disease Surveillance Report, STDs increased for the fifth consecutive year – with nearly 2.5 million combined cases of chlamydia, gonorrhea, and syphilis. Cases of congenital syphilis – syphilis passed from a mother to her baby during pregnancy– increased 40 percent from 2017-2018. Congenital syphilis can result in miscarriage, stillbirth, newborn death, and severe lifelong physical and neurological problems.And as expected, the burden of disease is highest among gay, bisexual, and other men who have sex with men (MSM). 

At home: Coastal cities in the Mid-Atlantic report record-breaking incidences of STI and HIV infections, with one community organization describing the crises as “urgent and alarming.” Stacie Walls of LGBT Life Center, the area’s oldest and largest AIDS service organization, alerted media about the 34 positive HIV tests collected by the Center in the last five months, compared to 28 throughout all of 2018 (>120%); and there are still several months for data collection. 
The steady rise in newly-reported HIV cases in the region is part of an overall increase in laboratory tests for STIs that came back positive for HIV/STI infection in clinics across the nation. These numbers are surpassing previous records made in the 1990s and highlights the need for vulnerable communities to prepare for this syndemic. Reports from LGBT Life Center are being echoed in communities throughout the country; and these shocking community-level accounts are being matched by public sector surveillance data from Virginia Department of Health. 

Released this week, 2018 STD statistics indicate the steady rise in sexually-acquired infectious disease rates for sexual minorities in the Tidewater area, and regions throughout the state, is expected to continue; as part of a syndemic health crisis developing in the United States. Newly released (10/8) data from CDC report the burden of U.S. infections from three sexually transmitted infectious disease have risen for the fifth consecutive year; with 1.7 million new cases of chlamydia, about 580,000 incidences of gonorrhea, and record 15% rise in syphilis rates, 35,000 cases of which represent the most contagious forms of the disease, the highest numbers since 1991. The increases coincide with public health funding cuts and clinic closures, according to CDC officials; and Stacie Walls of LGBT Life Center agrees, calling attention to the massive budget cuts under the Trump administration and barriers to treatment and prevention access, pharmaceutical drug costs, and stigma associated with having an STI or being LGBTQ.  

National response: Damning reports on HIV/STI epidemiology across the U.S. have raised questions about the effectiveness of public health prevention programs and interventional strategies for addressing multiple HIV and STI syndemics; shedding light on the power relations between funding and program implementation, individuals and governments,  and the biopolitics of community health disparities. In California, the alarm was heard loud and clear; as Democratic Governor Gavin Newsom signed a new bill into law making the state the first in the nation to allow pharmacist to dispense HIV treatment drugs to HIV negative individuals without a prescription. Senate Bill 159, authorizing the use of antiretroviral (ARV) drug treatments for pre-exposure prophylaxis, PrEP, and post-exposure prophylaxis, PEP, is a landmark development in the fight against AIDS; which will have widespread social, biological, and political impacts on the epidemiology of HIV and STIs in California, the U.S., and countries across the globe. Like the drastic rise in STIs, the radical scaling up of PrEP and PEP use for HIV treatment is part of a larger movement towards using biomedical strategies to “treat our way of this epidemic”; and in the same manner of questioning our assumptions about the growing numbers of sexually transmitted disease in our communities, we must investigate implications of extensive PrEP (and PEP) uptake on the ecology of sexual health, and HIV politics; and critically examine how pharmacologically mediated prevention is reframing cultural ideas about biology, identity, pleasure, and rights.

What are the implications of rising STIs, scaling up PrEP, U=U and backdoor deals with global pharmaceutical giants? And, how will this effect the most vulnerable?

I have some questions:

Overall	• Is the high incidence of STI likely to undermine the success of TasP or PrEP in the long term, in certain populations, or with new PrEP agents? • Can approaches focused on broader spectrum prevention (i.e., agents that inhibit HIV and other viruses) be effective for both HIV and STI PrEP? • What are the broad implications, including funding and trial design, for clinical research in STIs and HIV?
Biology and HIV–STI synergy	• When mucosal injury occurs, does the immune environment influence healing time? • What does hormonal contraception do to the interaction of STI and HIV and to the vaginal microbiome? • Are these processes different in the adolescent genital tract? • How does asymptomatic rectal STI and its treatment perturb the rectal mucosal environment and its receptivity to HIV infection? • For non-TDF-FTC PrEP regimens, can inflammation facilitate breakthrough replication that could overcome the effect of PrEP or promote the risk of HIV/STI transmission? • Could HIV cure strategies that involve interventions to “shock” the virus from latent reservoirs release transmissible virus in the genital tract?
Epidemiology of STIs and sexual behavior in the PrEP era	• To what degree is the increased detection of STI in persons on PrEP due to increase screening (ascertainment bias) versus a true increase in acquisition? • How will prolonged PrEP use impact sexual behavior and sexual networks? • How is PrEP utilized in the context of multiple sexual partnerships? • What is the relative contribution of enhanced detection through routine screening among PrEP users and HIV-infected MSM in care versus absolute increases in STI acquisition due to increases in unprotected sex?
Implementation science	• What innovative testing strategies improve STI diagnosis among individuals on PrEP? • What will be the economic and workforce implications of the increase in STI screening we will continue to see with expanding use of PrEP? • Can STI clinics integrate the provision of PrEP as part of their menu of services? • Can primary care settings seeing patients at risk for HIV improve the quality of STI screening and service provision? • What interventions decrease racial/ethnic disparities in PrEP uptake and STIs?
Study design	• How can we leverage HIV prevention studies using the factorial design strategy to “layer on” STI prevention interventions? • What STI prevention strategies are amenable to more efficient studies focused on operational endpoints (i.e., coverage) instead of effectiveness? • Can the stepped wedge cluster randomized trial approach be used more widely to study clinic-based and population-based STI prevention strategies?