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    Original Investigation
    Infectious Diseases
    December 11, 2019

    Global Epidemiologic Characteristics of Sexually Transmitted Infections Among Individuals Using Preexposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
    • 2Central Clinical School, Monash University, Melbourne, Victoria, Australia
    • 3Department of HIV, World Health Organization, Geneva, Switzerland
    • 4Community Health and Research Division, Eastern Virginia Medical School, Norfolk
    • 5Division of Epidemiology and Community Health, University of Minnesota Twin Cities, Minneapolis
    JAMA Netw Open. 2019;2(12):e1917134. doi:10.1001/jamanetworkopen.2019.17134
    Key Points español 中文 (chinese)

    Question  What is the burden of sexually transmitted infections among individuals using preexposure prophylaxis (emtricitabine and tenofovir disoproxil fumarate) for the prevention of HIV infection?

    Findings  This systematic review and meta-analysis identified 88 studies (71 published and 17 unpublished), with 26 (30%) from low- and middle-income countries. For studies reporting a composite outcome of chlamydia, gonorrhea, and early syphilis, the pooled prevalence was 23.9% at initiation of HIV preexposure prophylaxis, and the pooled incidence was 72.2 per 100 person-years during HIV preexposure prophylaxis.

    Meaning  These estimates indicate a high burden of sexually transmitted infections among individuals initiating preexposure prophylaxis and persistent users of preexposure prophylaxis for the prevention of HIV infection, highlighting the opportunities for active integration of services for sexually transmitted infections and HIV preexposure prophylaxis.


    Importance  Despite a global increase in sexually transmitted infections (STIs), there is limited focus and investment in STI management within HIV programs, in which risks for STIs are likely to be elevated.

    Objective  To estimate the prevalence of STIs at initiation of HIV preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate) and the incidence of STIs during PrEP use.

    Data Sources  Nine databases were searched up to November 20, 2018, without language restrictions. The implementers of PrEP were also approached for additional unpublished data.

    Study Selection  Studies reporting STI prevalence and/or incidence among PrEP users were included.

    Data Extraction and Synthesis  Data were extracted independently by at least 2 reviewers. The methodological quality of studies was assessed using the Joanna Briggs Institute critical assessment tool for prevalence and incidence studies. Random-effects meta-analysis was performed.

    Main Outcomes and Measures  Pooled STI prevalence (ie, within 3 months of PrEP initiation) and STI incidence (ie, during PrEP use, after 3 months).

    Results  Of the 3325 articles identified, 88 were included (71 published and 17 unpublished). Data came from 26 countries; 62 studies (70%) were from high-income countries, and 58 studies (66%) were from programs only for men who have sex with men. In studies reporting a composite outcome of chlamydia, gonorrhea, and early syphilis, the pooled prevalence was 23.9% (95% CI, 18.6%-29.6%) before starting PrEP. The prevalence of the STI pathogen by anatomical site showed that prevalence was highest in the anorectum (chlamydia, 8.5% [95% CI, 6.3%-11.0%]; gonorrhea, 9.3% [95% CI, 4.7%-15.2%]) compared with genital sites (chlamydia, 4.0% [95% CI, 2.0%-6.6%]; gonorrhea, 2.1% [95% CI, 0.9%-3.7%]) and oropharyngeal sites (chlamydia, 2.4% [95% CI, 0.9%-4.5%]; gonorrhea, 4.9% [95% CI, 1.9%-9.1%]). The pooled incidence of studies reporting the composite outcome of chlamydia, gonorrhea, and early syphilis was 72.2 per 100 person-years (95% CI, 60.5-86.2 per 100 person-years).

    Conclusions and Relevance  Given the high burden of STIs among individuals initiating PrEP as well as persistent users of PrEP, this study highlights the need for active integration of HIV and STI services for an at-risk and underserved population.