Sexually Transmitted Infections Adopting a Sexual Health Paradigm (2021) / Chapter Skim
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5 Intersection of HIV and STIs
5 Intersection of HIV and STIs
Pages 247-282
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From page 247... ...
5 Intersection of HIV and STIs Chapter Contents Introduction History • Treatment of STIs to Prevent HIV: Before Antiretroviral Treatment • Management of HIV, Antiretroviral Treatment, and STIs • Antiretroviral Agents as Pre-Exposure Prophylaxis (PrEP) for HIV • Substance Use, Alcohol Use, and STI/HIV Risk Consequences of STIs in People Living with HIV Important Lessons from the HIV Pandemic Conclusions 247
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From page 248... ...
The chapter also examines how prevention and care programs to control the distinct, yet intertwined HIV and "classical" STI epidemics diverged, with profound adverse effects on the spread of STIs. Considering this history emphasizes opportunities to develop more efficient programs going forward that recognize the "syndemic" relationship between HIV, STIs, and viral hepatitis that can and should be addressed in an integrated fashion.
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From page 249... ...
. As a consequence of transient very high viral loads, before the host immune system can respond, acutely infected persons have far higher transmission probabilities (Pilcher et al., 2004b; Pinkerton et al., 2011)
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. While HIV spread is driven by the prevalence of unrecognized and untreated HIV infections (Cohen, 2006)
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4 With intercurrent infections that increase HIV VL 3 2 FIGURE 5-1 Intercurrent infections and HIV viral load: A conceptual example of someone who might be more infectious at different times in the course of their HIV infection, depending on coinfections, notably sexually transmitted infections. NOTE: HSV-2 = herpes simplex virus type 2; TB = tuberculosis.
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In an effort to stem the global HIV pandemic, therapeutic studies of treatment of STIs to reduce HIV transmission efficiency were conducted. Treatment of STIs to Prevent HIV: Before Antiretroviral Treatment In the early days of the HIV epidemic, the principal tools to prevent sexual transmission were the "ABCs" -- abstain from sex, be faithful in sexual partnerships, and use latex condoms consistently and correctly (AIDS Epidemic Sparks Campaign to Encourage Condom Use, 1985)
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From page 253... ...
. Acyclovir, however, was not able to prevent HIV transmission; the authors and others have postulated that this inability to reduce HIV infections may have been due to inadequate dosing and/ or to persistent inflammation that treating HSV-2 did not eliminate (Zhu et al., 2009)
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Similarly, antiretroviral drugs prevented HIV transmission in pregnancy by reducing viral loads, particularly in parts of sub-Saharan Africa where young, reproductive-age women bore a disproportionate burden of disease (Guay et al., 1999; Stringer et al., 2003)
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. HIV is frequently detected in STI clinic patients, so STI clinics are important venues at which to screen and identify people with highly infectious acute, early, and/or untreated HIV infection (Fiscus et al., 2007; Kojima et al., 2009; Pilcher et al., 2004a; Powers et al., 2007; Rutstein et al., 2016; Wolpaw et al., 2011)
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(2021) found that previously diagnosed HIV infection was common among persons diagnosed with early syphilis, latent syphilis, and gonorrhea, yet that over a quarter of these patients were out of care and/or had unsuppressed HIV viral loads at the time of STI diagnosis.
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. The rising incidence of STIs in persons living with HIV or AIDS after the availability of ART launched a discussion of "risk compensation" or "behavioral disinhibition." This public health paradox theorizes that reduced fear of transmitting or acquiring HIV due to ART may have led to reduced use of condoms, more partners, and higher STI rates (DiClemente et al., 2002; Eaton and Kalichman, 2007; Moskowitz and Roloff, 2010; Pinkerton, 2001)
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demonstrated that cabotegravir was safe and superior to daily oral FTC/TDF for HIV prevention among cisgender women in sub-Saharan Africa (DelanyMoretlwe et al., 2020)
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. Despite what is clearly a complex relationship of STI rates in the setting of PrEP, one thing should not be ignored: in the context of a population with a more generalized HIV epidemic, presenting with a new STI should prompt a provider to discuss PrEP.
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: • Diagnose all individuals with HIV as early as possible after infection; • Treat HIV infection rapidly and effectively to achieve sustained viral suppression; • Prevent at-risk individuals from acquiring HIV, including the use of PrEP and syringe exchange programs; and • Rapidly detect and respond to emerging clusters of HIV infection to reduce new transmissions. While treatment of HIV/AIDS is a key pillar, STI control is not explicitly included in this strategy, which may represent a missed opportunity for better integration of management of HIV, STIs, and viral hepatitis.
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Scaling Up HIV Prevention Services in Specialty STI Clinics In 2019, each of the three jurisdictions was awarded $1.3 million to strengthen the infrastructure of STI clinics serving a high proportion of racial/ethnic and sexual minorities as part of the implementation phase of EHE. In just a few months, the jurisdictions implemented innovative, evidence-based approaches to scale up clinic capacity and HIV care services with self-registration kiosks, express visits, virtual visits for PrEP follow-up, and a citywide health resource directory to connect STI clinic patients with key resources.
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In 2003, President Bush developed the President's Emergency Plan for AIDS Relief with broad bipartisan support, providing resources to address global HIV prevention and treatment. These substantial funding commitments, nationally and globally, resulted in advances in diagnostics and therapies that fundamentally shifted outcomes, notably in Africa.
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The STI epidemic's growth reflects many social, biological, and behavioral forces; limited resources for public awareness and risk reduction education, and limited investments in surveillance, screening, and treatment, also contribute to STI spread. CONCLUSIONS This chapter has sought to provide historical information about HIV and emphasize the inextricable linkage between HIV, classical STIs, and viral hepatitis.
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Con versely, it is equally important to assess HIV status among those diagnosed with a bacterial STI; and for those with HIV infection, screening for other STIs should be elevated as a priority within routine clinical management of HIV. Conclusion 5-4: Ending the HIV Epidemic (EHE)
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2020. Opioid use fueling HIV transmission in an urban setting: An outbreak of HIV infection among people who inject drugs -- Massachusetts, 2015-2018.
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2011. Sexual behavior and HIV transmission risk of Ugandan adults taking antiretroviral therapy: 3 year follow-up.
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1998. Sexually transmitted diseases enhance HIV transmission: No longer a hypothesis.
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2019. Sexually transmitted infections and HIV in the era of antiretroviral treatment and prevention: The biologic basis for epidemiologic synergy.
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1999. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
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1995. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: Randomised controlled trial.
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2010. Treatment of sexually transmitted infections for HIV prevention: End of the road or new begin ning?
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2010. Sexually transmitted infections and infec tiousness beliefs among people living with HIV/AIDS: Implications for HIV treatment as prevention.
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Sexually Transmitted Infections 89(6)
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2018. Sexually transmitted infections in the era of antiretroviral-based HIV prevention: Priorities for discovery research, implementation science, and community involvement.
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2019. HIV-1 heterosexual transmission and association with sexually transmitted infections in the era of treat ment as prevention.
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2019. Global epidemiologic characteristics of sexually transmitted infections among individuals using preexposure prophylaxis for the prevention of HIV infection: A sys tematic review and meta-analysis.
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2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1.
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2008. Effectiveness of interventions for the prevention of HIV and other sexually transmitted infections in female sex workers in resource poor setting: A systematic review.
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Sexually Transmitted Infections 77(3)
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2010. Randomized controlled trials of interventions to prevent sexually transmitted infections: Learning from the past to plan for the future.
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2021. WHO recommends the dapivirine vaginal ring as a new choice for HIV prevention for women at substantial risk of HIV infection.
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