We appreciate A. B. Algarin and G. E. Ibañez’s response to our commentary, “HIV Preexposure Prophylaxis and Condomless Sex: Disentangling Personal Values From Public Health Priorities,” published in the August 2017 issue of AJPH. They expressed largely complementary views and offered useful suggestions about how HIV preexposure prophylaxis (PrEP) services can be combined with other sexually transmitted infection (STI) prevention resources to maximize sexual health protection.
We share the authors’ concern about the spread of drug-resistant gonorrhea and other bacterial pathogens. Notably, rising rates of STI diagnoses predate PrEP.1 As discussed in our commentary, PrEP-related care facilitates STI education, diagnosis, and treatment, thereby helping to curb STI spread. Furthermore, PrEP may incentivize at-risk individuals to access such services when they otherwise would not. Because US guidelines for PrEP provision advise STI screening at least every six months,2 infections that would otherwise persist undiagnosed may be more frequently identified. A study modeling PrEP use among men who have sex with men suggests that even if accompanied by reduced condom use, PrEP would still help to reduce network-level gonorrhea and chlamydia transmission because of associated STI testing and treatment opportunities.3 Also, it is important to recognize that PrEP, which is composed of antiretroviral medication, will not select for antibacterial resistance.
Algarin and Ibañez highlight specific implementation strategies that can bolster the impact of PrEP services on the prevention of other STIs. We support their suggestion that PrEP be offered routinely to clients testing HIV negative in medical settings, and we (S. K. C. and K. H. M.) discuss the benefits of a routine approach to PrEP education and provision in our analytic essay “Integrating HIV Preexposure Prophylaxis (PrEP) Into Routine Preventive Health Care to Avoid Exacerbating Disparities,” published in the December 2017 issue of AJPH.4 We also share their opinion that HIV testers should be fully informed of the evolving HIV/STI landscape, which is indeed a goal of many existing training programs.
Finally, we concur that testers should offer both PrEP and condoms to support dual HIV/STI protection. However, we believe in a client-centered approach that empowers clients to make informed decisions about whether they prefer one, both, or neither prevention option. A client-centered approach entails respecting clients’ choices, even if those choices differ from the preferences and priorities of service providers.
In closing, we thank AJPH for the opportunity to respond and we encourage continued dialogue on this important topic.
ACKNOWLEDGMENTS
S. K. Calabrese and K. H. Mayer have received compensation for their efforts in developing and delivering medical education related to PrEP. K. H. Mayer has conducted research with unrestricted project support from Gilead Sciences, Merck, and ViiV Healthcare. S. K. Calabrese and K. Underhill were supported by award numbers K01-MH103080 and K01-MH093273, respectively, from the National Institute of Mental Health (NIMH). Additional support was provided through the District of Columbia Center for AIDS Research (P30-AI117870) and Harvard University Center for AIDS Research (P30-AI060354), both of which are funded by the National Institutes of Health (NIH).
Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the NIH.
REFERENCES
- 1.US Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. October 2016. Available at: https://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf. Accessed October 1, 2017.
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