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Ong JJ, Baggaley RC, Wi TE, et al. Global Epidemiologic Characteristics of Sexually Transmitted Infections Among Individuals Using Preexposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(12):e1917134. doi:10.1001/jamanetworkopen.2019.17134
What is the burden of sexually transmitted infections among individuals using preexposure prophylaxis (emtricitabine and tenofovir disoproxil fumarate) for the prevention of HIV infection?
This systematic review and meta-analysis identified 88 studies (71 published and 17 unpublished), with 26 (30%) from low- and middle-income countries.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.
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.
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.
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.
Nine databases were searched up to November 20, 2018, without language restrictions. The implementers of PrEP were also approached for additional unpublished data.
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).
Of the 3325 articles identified, 88 were included (71 published and 17 unpublished).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.
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