Dear Dr. Mermin:

The National Coalition of STD Directors (NCSD) continues to applaud the Centers for Disease Control and Prevention’s (CDC) ongoing efforts to highlight the significant role that other sexually transmitted diseases (STDs) play in the acquisition of HIV. Increasing attention to this critical intersection of the STD and HIV epidemics is all the more important as we witness increasing rates of STDs, including HIV, among young gay men and other men who have sex with men (MSM), emerging
condom- fatigue, and an increasing uptake in the use of Pre-Exposure Prophylaxis (PrEP) for HIV prevention.

We are writing at present to draw your attention to potentially inconsistent messaging from the CDC as it relates to general recommendations for HIV and STD testing for MSM and for those persons on PrEP. Currently, the CDC’s STD and HIV Screening Recommendations1 state that those who engage in risky sexual activities and MSM should receive STD and HIV screening every three to six months. However, that recommendation is not reflected in the CDC’s PrEP Clinical Practice Guidelines, which
state that while an HIV test should be performed every three months for those prescribed PrEP, STD testing should only take place every six months with STD symptom assessments being performed every three months.

We find the recommendation to conduct STD symptom assessments every three months, rather than an STD screening every three months for those taking PrEP problematic, considering that most people who acquire an STD may remain asymptomatic. Furthermore, the CDC’s recently released 2013 STD Surveillance Report indicates a significant increase in the rates of STDs among MSM, supporting the message that the routinization of STD testing is critical, especially among MSM and other
populations prescribed PrEP and engaged in risky sexual activity. We are also concerned that there is no CDC recommendation for routine monitoring of Hepatitis C (HCV) infection among patients on PrEP because while not common, sexual transmission of HCV does occur. Additionally, if a provider is seeing a patient taking PrEP in order to conduct an HIV test at three month intervals, why would we not take advantage of that same interaction to provide optimal sexual health care and recommend
full STD screening at all potential sites of infection? Advances in diagnostics, including self-collected urine and swab specimens, have and are paving the way for a more streamlined STD screening process which in turn makes the optimal delivery of care less onerous for providers and patients alike.

We also know we have a shared concern about the role of PrEP as a biomedical intervention and how it may impact condom usage, as well as subsequent increases in STDs that may follow. A recent article in the San Francisco Business Times highlighted the findings from a Kaiser Permanente AIDS prevention program in San Francisco. According to the article and the Kaiser program director, Dr. Brad Hare, none of the 500 men taking PrEP in the program acquired HIV. A subset of the patients
were surveyed and of the approximately 90 patients who responded, 45 percent of those reported a decrease in condom use since starting PrEP. While not definitive because we do not have any information on the consistency of condom use of this subset before their initiation of PrEP, many of us working to prevent the spread of STDs are concerned that this could be an emerging trend. We have also learned from the same program that they routinely screen for STDs every one to three months among individuals taking PrEP in their clinic and they are seeing very high incidence of STDs among this group. In addition, there have been two incident Hepatitis C (HCV) infections identified with no other risk factors reported other than sexual transmission.

Our hope is that the National Center for HIV/AIDS, Viral Hepatitis, STDs and TB Prevention (NCHHSTP), and more specifically the Divisions of HIV/AIDS Prevention, STD Prevention and Viral Hepatitis, can work together to harmonize the recommendations for STD screening among MSM, and specifically to recommend that full STD screening occur during the same health care provider visit as the three-month interval HIV test for those patients on PrEP.

Working together and with harmonized recommendations, we can move toward routinizing the testing performed by providers and improve the sexual health care consumer seeking behavior of MSM, ultimately creating a more sexually healthy population.

We thank you for your attention to this matter and all the work that you and your staff do to promote sexual health through STD and HIV prevention. NCSD would also welcome any opportunity to work with you and others on this issue.