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Conclusions and Recommendations

Some notable progress has emerged in the research pipelines for the treatment and prevention of gonorrhea, chlamydia, and syphilis. Efforts to develop novel treatment options for gonorrhea have been particularly productive; there is also some movement in prevention research with promising findings for doxycycline as PrEP and PEP for chlamydia and syphilis, as well as increased funding for vaccine research across all three diseases. Additionally, our glimpse into some promising developments in the area of rapid POC diagnostics may assist with better detection and early treatment of bacterial STIs.

Based upon this review, TAG makes the following recommendations for community advocates and other key stakeholders in the worsening gonorrhea, chlamydia, and syphilis epidemics:

• Advocacy to fight STIs must be more than repackaging condoms and behavioral interventions. Promoting condoms and behavior change will never be enough to make sustained, meaningful progress in the control and elimination of the three major reportable bacterial STIs in America. Additionally, the ethical implications of monitoring and altering the sexual behaviors of marginalized communities, particularly through fear- and shame-based campaigns, should be questioned. Advocates must learn from the field of HIV prevention and focus much more aggressively on the structural, social, financial, and research barriers that undermine our ability to successfully utilize existing tools and develop essential new tools.
• HIV PrEP and U=U activists must understand that their success is integrally linked to STI advocacy. Not only are bacterial STIs drivers of new HIV infections, fears of ‘risk compensation’ will continually undermine scale-up of PrEP and U=U messaging, particularly when STI epidemics are breaking records.
• Substantially more investment in new prevention modalities—particularly vaccine research—will be necessary. The biological plausibility of vaccination against all three STIs has been established, and $9 million in new NIH funding shows increased investment in these essential tools. Advocates must continue to push for increased government expenditure on vaccine research as well as other biomedical primary prevention options. Additionally, advocates must make the case for a ‘market’ for STI vaccines in order to attract the kind of pharmaceutical company investment necessary to fully develop and implement these essential tools.
• Doxycycline should be seriously considered for scale-up as a PrEP and/ or PEP for syphilis and chlamydia. Doxycycline is regularly prescribed for treatment of acne, yet health care providers remain concerned about prescribing it for STIs. Thus, the question remains as to whether the concern has to do with increased use of an antimicrobial in general or with how little we value sexual health in comparison to one’s facial attractiveness. Given the relatively high efficacy (over 70%) of doxycycline in averting syphilis and chlamydia infections as PrEP and PEP, this must be considered in partnership with affected communities as a serious option for addressing rapid increases in STI rates.
• Discussions on accessing zoliflodacin for treatment of MDR and XDR gonorrhea should begin now. Although phase III trials are just beginning, the promising findings for zoliflodacin indicate that advocates should already be paving the way for rapid access. The medication has already been awarded fast-track status by the FDA, but much more work needs to be done, including rapid integration of zoliflodacin into STI treatment guidelines and broad provider and community education on its uses. Most importantly, zoliflodacin must be priced in a way that ensures rapid and broad access while also providing a reasonable return on investment for Entasis Therapeutics.
• Reliable, easy-to-use, CLIA-waived rapid tests for chlamydia, gonorrhea, and syphilis should be developed and made widely available.
• Infrastructure for the delivery of sexual health services remains highly underfunded in the United States, and declining funding for sexual health clinics must be addressed. Although this recommendation is a bit beyond the scope of this report, existing and future tools for ending gonorrhea, chlamydia, and syphilis cannot be effectively implemented without increased investment in sexual health clinics in the United States, provider education, and appropriate curricula for providers-in-training