March 19, 2021
By Julie Gould
Study findings published online in the Journal of the International AIDS Society show that gaps remain in the provision of sexually transmitted infection (STI) testing services within HIV pre-exposure prophylaxis (PrEP) programs.
Although the integration of these services has the potential to reduce the incidence of both HIV and STIs, implementation challenges still remain.
To better understand the study design and related findings, we spoke with lead study author Jason Ong, PhD, sexual health physician, Melbourne Sexual Health Centre. Dr Ong breaks down major barriers to integrating STI services in PrEP programs, including financial matters, poor access to diagnostics, and other program logistics.
What existing data led you and your co-investigators to conduct this research?
As HIV PrEP continue to be scaled up globally, there has been more publications (particularly from routine implementation of PrEP). Given the high rates of STIs among PrEP users, we were interested in quantifying the STI testing services among PrEP programs.
Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?
We conducted a systematic review of studies in 9 databases (up to 8th December 2020). We found 91 studies that reported STI testing among PrEP users. The majority of programs (70%) reported testing for STIs on starting PrEP – but surprisingly this was much lower in publications reporting from routine implementation programs (46%), compared to cohort studies (82%), demonstration projects (77%) or randomized controlled trials (86%). Programs from high-income countries provided more comprehensive STI testing (chlamydia, gonorrhoea and syphilis) to PrEP users.
What are the possible real-world applications of these findings in clinical practice?
We found major barriers to integrating STI services in PrEP programs. These included financial matters (expensive diagnostics for chlamydia/gonorrhoea), poor access to diagnostics (especially for point-of-care testing), and program logistics (lack of trained personnel, lack of simple equipment (light source, examination couch), lack of a system to manage STIs). We must consider innovative financial models (e.g. bulk purchasing of diagnostics to reduce unit cost), pooled STI testing, and ongoing advocacy that PrEP is not just a pill but a holistic program to ensure sexual health (including testing and managing STIs).
Do you and your co-investigators intend to expand upon this research?
We are doing a systematic review on behalf of the World Health Organization to look the performance of pooling samples for STI testing which may reduce the costs related to diagnostics in resource limited settings.
Is there anything else pertaining to your research and findings that you would like to add?
It is now indisputable that STIs are highly prevelant among PrEP users. This suggests we are targeting the right people to prevent HIV acquisition, however, we must not ignore STIs. At the minimum, PrEP users should have regular STI testing and management. Ideally, PrEP users should receive holistic sexual health care including vaccinations (HPV, hepatitis A/B), counseling, and mental health/substance use support if needed.
About Dr Ong:
Associate Professor Dr Jason Ong is a sexual health physician based at Melbourne Sexual Health Centre and an academic with joint appointments at Monash University, University of Melbourne and the London School of Hygiene and Tropical Medicine. His research focuses on economic evaluations and demand creation strategies to improve the uptake of HIV and sexually transmitted infection (STI) testing and management services.
Ong JJ, Fu H, Baggaley RC, et al. Missed opportunities for sexually transmitted infections testing for HIV pre-exposure prophylaxis users: a systematic review. J Int AIDS Soc. 2021;24(2):e25673. doi:10.1002/jia2.25673