An increase in STIs is in the news once more. The HIV/STI congress in British Columbia is looking for answers.
Working in a sexual health clinic, I sometimes encountered men having sex with men (MSM) whose preference was frequent testing for HIV rather than condom use for oral sex with new partners. We agreed to test them frequently not only for HIV but also for syphilis. Testing and treatment is a critical factor in the reduction of transmission which was not addressed in the CBC article. Syphilis is a gateway to HIV infection as well as a factor in the progress of the disease, which makes testing for this bacterial infection so important.
These days, it is also useful to look at the issue of the use of Pre-Exposure Prophylaxis (PrEP) which prevents the spread of HIV. The CBC article quotes Dr. Julio Montaner who “warns against assuming that people use condoms less today because they think medication will keep them from getting infected. Montaner says past studies have shown that’s not the case.” However, it is not clear if he is referring only to HIV or to other STIs from which they would have no protection.
Another consideration is the fact that people with undetectable HIV levels may stop using condoms, which is perfectly reasonable; but they may remain unaware of other STIs they can continue to transmit.
Testing and treatment along with other prevention strategies, are a critical piece of the puzzle. Public Health agencies need to continue to inform people having sexual activity about how and where to get tested. For example, men may not know that they need only pee in a cup to test for gonorrhea and chlamydia. Bacterial infections can be cured with antibiotics. This is a secondary means of prevention.
But condoms and dental dams are not a universal answer even if people were willing to use them consistently. Many STIs are transmitted skin-to-skin, like Human Papillomavirus (HPV) and herpes simplex virus (HSV 1 and 2). Although there is treatment for viral infections there are no cures. (The good news here is that HPV tends to be self-limiting: a good immune system will clear it from the body within two years in 90% of cases.)
But what should (cisgender) women having sex with women (WSW) use? What should post-op trans men and women use? Protection is based on knowledge and negotiation. It is not a case of one size fits all.
When can we stop using protection?
Many sexual health educators have suggested for years that people use barrier protection for three months (the window period for HIV testing) although
“The window period for a 4th generation antigen/antibody test is four weeks. At this time 95% of infections will be detected (see Figure 7). There is a three month window period after exposure, for the confirmatory result to detect more than 99.9% of infections.”
After that time, with negative tests for HIV, gonorrhea, chlamydia and syphilis, they could negotiate the level of safer sex with which they were both comfortable and for which sexual activities.
We also know that there is ongoing reluctance to use barrier protection among certain populations. In the case of seniors, it may not even be regarded as an issue. Many older people back on the dating scene were in long-term relationships which may have ended in divorce or death. This population did not have the benefit of sexual health education and safer sex negotiation discussions. The uptick in their STI infections is well documented.
Finally, there is a tendency to blame young people for not protecting themselves. After all, they had the benefit of sexual health education in school, did they not? Although this article is somewhat out of date, it still gives one a snapshot of how unequally the Canadian Guidelines are applied.
Moreover, there are barriers to using barriers. For example, when we look at the social determinants of health, we see that young people raised in poverty tend to be risk takers. Children who were sexually abused are less likely to protect themselves. People in abusive relationships may not be able to negotiate safer sex.
We can only hope that the people sitting around the table in British Columbia will come up with some answers to the question of current increases in STIs. More to the point, what are the solutions to this complex problem?