How to Address the HIV-STI Syndemics

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.