The underpinnings of the global HIV and STI epidemics are inextricable. A new report looks at combined solutions. We offer highlights.
Syndemic: “Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.”
Current challenges in STI Treatment: Co-infections, Emerging STIs. Experts are debating whether PrEP causes risk compensation; but, STI co-infections are increasing and integrated care is necessary to treat STIs among people living with HIV. There are STIs emerging in people living with HIV: lymphogranuloma venereum, HCV.
Current Challenges in STI Treatment: Antibiotic Resistance. Nucleic acid amplification tests are non-invasive, offer fast turnaround, and are highly sensitive and specific but are costly. Antibiotic-resistant gonorrhea is a challenge; no new treatments for >30 years; there is a global shortage of benzathine penicillin G and risk of shortage of off patent first-line antibiotics for chlamydia, gonorrhoea and trichomonias.
Improving Care for STIs in Primary Care. STI care has shifted from STI specialty clinics to routine care settings. In primary care settings the focus should be on: Improved screening, providing HBV and HPV vaccines, expediting partner therapy for chlamydia/gonorrhea (where legal), extragenital testing for chlamydia/gonorrhea in clinics with high risk individuals (eg, men who have sex with men [MSM]).
Improving Care for STIs in Other Settings. There are opportunities for expanding services including offering STI screening in family planning clinics as well as expanding services to men; HIV prevention and care settings can offer regular STI screening, extragenital testing for STIs among people with HIV, those on PrEP; and other setting where STI might be offered include school-based clinics, EDs, correctional facilities.
Current Trends in Sexually transmitted HCV. Despite highly effective DAAs, sexually transmitted HCV may contribute to ongoing infection related to high-risk sex behavior: transmission from HIV-positive MSM and HIV-negative MSM eligible or on PrEP. International MSM transmission networks with possible overlap with people who inject drugs. Damage to rectal mucosum may increase susceptibility for sexual transmission. HCV risk increased with HIV, low CD4 count, high HIV RNA levels, coinfection with other STIs.
Prevention of Sexually-transmitted HCV. Early diagnosis is essential to prevent transmission; hampered by slow rate of HCV antibody seroconversion; antibodies may be negative in HIV infection; HCV core antigen test may improve early diagnosis, more studies needed. Targeted, combined prevention efforts also are needed to include behavioral interventions and scale-up of HCV testing and treatment, especially for high risk MSM.
 “Understanding and addressing the HIV and STI syndemics,” an August 2019 special issue of the Journal of the International AIDS Society, presents the results of a meeting of experts convened to discuss the epidemiologic, clinical, behavioral, and structural issues underpinning the HIV and STI syndemics. The short slide show below summarizes key articles on the global HIV and STI epidemics including calls for action at the local level and pertinent to primary care.Â
