PrEP programmes are ‘missing opportunities’ to test people for sexually transmitted infections
Global evidence review finds wide variation on STI testing, despite people on PrEP being at greater risk of sexually transmitted infections.
An analysis of 90 HIV prevention programmes, trials and demonstration projects offering pre-exposure prophylaxis (PrEP) in 32 countries has revealed the challenges facing PrEP providers in relation to testing for sexually transmitted infections (STIs), particularly in low- and middle-income countries.
People who use PrEP are more likely to be exposed to STIs, so providing STI services within PrEP programmes is a good way to prevent and treat STIs. As PrEP programmes specifically target people at heightened risk of HIV, they also provide an opportunity to reach people who often find it hard to access general STI services.
Most of the PrEP programmes analysed (69%) were from high‐income countries, and 64% specifically targeted men who have sex with men or transgender women. Around half (55%) were based in hospitals.
Although 70% of PrEP programmes offered some form of STI testing, the type of tests available, and the related services on offer, varied widely.
The most common STI tests offered were for gonorrhoea (86%), chlamydia (84%) and syphilis (84%). Some PrEP programmes also tested for hepatitis B (53%), hepatitis C (36%) and hepatitis A (13%), but only when people first began PrEP.
In high-income countries such as the UK, Australia, the USA and France, PrEP services tended to be integrated into existing sexual health services and STI testing was free of charge. These PrEP programmes were the most likely to test for multiple STIs and provide related services, such as vaccinations for human papillomavirus (HPV), counselling, and substance use support.
In countries including Vietnam, Japan, Brazil, Thailand – and, in some instances, Kenya and South Africa – PrEP programmes tended to offer STI services but charge for them, and the type of STI screening was limited.
Other PrEP programmes, for instance in Morocco, Kenya and South Africa, did not have access to any biomedical STI testing so diagnosed on symptoms alone. This approach is less accurate as some people with STIs are asymptomatic.
Overall, high-income countries were more likely than lower- or middle-income countries to test for gonorrhoea (92% vs. 71%), chlamydia (92% vs. 64%), syphilis (87% vs. 75%), hepatitis A (18% vs. 4%) and hepatitis C (43% vs. 21%).
Higher-income countries were also more likely to offer regular three‐month testing for gonorrhoea (72% vs. 45%) and chlamydia (72% vs. 45%) and tested for a higher number of STIs (mean 3.75 vs. 3.04).
A lack of resources and basic equipment for STI testing, logistical difficulties, and inadequate training were the biggest barriers to providing comprehensive STI services in PrEP programmes.
A lack of accurate, affordable and easy to use point‐of‐care STI tests for chlamydia and gonorrhoea was identified as a particular issue, even in high-income countries. This has led to a greater reliance on symptom-based diagnosis, resulting in missed opportunities for treatment as well as overtreatment, which can lead to antibiotic-resistant STIs.
The study’s authors have used the findings to call on the World Health Organization to release “clearer and more unified recommendations” on STI testing for people who use PrEP, particularly regarding the frequency of testing, which STIs to test for, and the type of tests to conduct.