Another Advance for HIV Prevention: STD Testing

William Smith

Nearly 15 years ago the Institutes of Medicine called for development of a national STD strategy to address the destructive links between STDs and HIV. To this day, it remains mostly unheeded.

Wednesday, December 1st, 2010 is World AIDS Day.

Another World AIDS Day.  A day I know many of us will look forward to committing to the ash heap of history in the not too distant future.  However, until then, we’ve got to figure out how we continually recast and reassess our basic messages around research, prevention, care, treatment and a cure lest we be cast further down the ever increasing priority list of needs and the ever shrinking pots of money tapped to bring this horrible disease to an end.

Last week brought great news about the success of preventing HIV infection by proactively delivering medications pre-exposure (PrEP).  It is a major advance in the HIV prevention toolbox, but at present, I am hard pressed to embrace the news with enthusiasm when, according to my friends at NASTAD, 4,157 people living in 9 states are on waiting lists to receive the same or similar drugs that will prolong and enrich their lives. 

The news of PrEP’s success however, as well as news earlier this year of a successful trial of a microbicide gel to prevent infection, should renew all our hopes that preventing HIV is possible when we continue to pursue the right research.

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And so it was this year that during my preparations for a number of presentations at annual state-wide meetings of my organization’s members, I was hit over the head with a mallet of frustration that the connection between STD infection and HIV acquisition remains too far down the priority list of our prevention focus.

This frustration crystallized when I was perusing the 1997 Institute of Medicine report titled The Hidden Epidemic: Confronting Sexually Transmitted Diseases.  Nearly 15 years since this report was released, I was reading critical clarion calls for development of a national STD strategy – inclusive of HIV and that called for getting to the bottom of understanding and undoing the destructive role of other STDs in HIV acquisition and transmission.  To this day, it’s a call mostly unheeded.

Why has there been so little progress in focusing and prioritizing STD prevention as HIV prevention?

At about the same time of the dispelling of the myth that “poppers” were the cause of Gay-Related Immune Deficiency (GRID), the outwardly stigmatizing and despicable early name for AIDS, we have also known that being currently infected with another sexually transmitted disease (STD) raised the biological stakes of acquiring what would become known as HIV.  No one questions this fact.

If you go to the CDC’s website and look up the general consumer-focused information about HIV and STDs, you find supportive messages that encourage testing for other STDs in addition to HIV testing.  The CDC’s STD Division is even more explicit that STD screening and treatment IS HIV prevention.  They have a fact sheet underscoring the biological susceptibility to acquiring HIV if you have an existing underlying STD infection as well as describing how someone with HIV and another STD are more likely to infect a partner with HIV as a result of having the additional STD infection.

Still, it’s a bit like the chicken and the egg — we have not been able to nail down in any concrete way which came first?  Was a person infected with HIV and then another STD or was an underlying STD the culprit in exacerbating HIV acquisition.  It’s an interesting question to ponder, but in the real world, we know that the vast majority of the 19 million new STD infections in the US each year go unnoticed because their direct symptoms are minimal or non-existent.  Yet, the compromising connection of these undiagnosed and untreated STD infections to acquiring HIV is indisputable.

In part, this has been the case because screening for some of the most common STDs, like Chlamydia and Gonorrhea, have rightfully had the dubious distinction of not creating the most pleasurable experience for the patient.  Visions of giant sized Q-tips linger in the minds of too many.  But advances in technology – such as simple urine tests and self collected swabs – have made STD testing less intrusive and more easily carried out.   The issue is that the public relations push for how much easier STD testing can be is virtually non-existent.

I am not suggesting in any way that we take our eyes off the important task of continuously scaling up HIV testing.  Knowing one’s HIV status, getting on treatment when positive and driving down viral load is also HIV prevention.  But what I am suggesting is that the jettisoning of testing and screening for other STDs as a separate type of work – of lesser import perhaps – has done nothing but exacerbate the HIV – and other STD – epidemics in this country.

It’s a sobering and perhaps even a provocative statement, but it’s a factual one.  And sadly, it is a consistently neglected one. 

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