STIs in a post-condoms world

Words by Matthew Hodson | @Matthew_Hodson 

Let’s talk about PrEP. Or, let’s talk about how HIV treatment prevents the virus being passed on to sexual partners. When our virus is undetectable it is untransmittable (U=U).

How long do we go down either conversational road before someone starts talking about STIs? I was told by someone who works for an HIV support organisation that we shouldn’t let HIV-positive people with an undetectable viral load know that they aren’t a risk to sexual partners. “If you do that,” I was told, “they may not use condoms.” The condom argument is also used against PrEP. It’s perfectly possible to wear a belt and braces at the same time, but most people don’t.

It’s true. HIV-negative men who are protected by PrEP, or HIV-positive men who are armed with the knowledge that they can’t pass it on, may not use condoms. You know what else is true? Many people who are not armed with this knowledge might choose not to use condoms.

Whatever your own stance is on condom use, you’d be blind if you haven’t noticed that condom use is far from universal. The proportion of gay men who don’t use condoms every time they have sex is going up. That’s a trend that we observed, here and overseas, long before we knew that U=U or we started popping PrEP. Does this matter? When you’ve removed the risk of HIV transmission, which PrEP and treatment do, very effectively, the remaining risk is STIs. So let’s be absolutely clear: PrEP doesn’t protect us from other STIs. Similarly, a hard hat doesn’t protect you from a kick in the balls, nor a crotch-guard from a bonk on the head.

Even though biomedical HIV prevention itself doesn’t stop STIs, it doesn’t mean that their use is going to increase STIs. People who get their PrEP use monitored will also get regular STI screens. In one major London clinic they’ve seen a 24% decline in cases of gonorrhoea among their PrEP users because more gay men are getting screened regularly and, if they’re found to have the infection, they get treated and cured before they pass it on.

Getting people into clinics is vital. It’s easy to have infectious gonorrhoea, particularly in the throat or arse, without any symptoms. This is why it’s so important that PrEP is available, free of charge, through our NHS services. When individuals choose to buy PrEP online, they may or may not go to their GUM clinic to get these tests done. And before you throw your hands up in horror at the thought of gay men having sex without condoms remember that this was how most gay men had sex for centuries before the HIV crisis hit. When HIV risk is removed from the equation we can celebrate how much more likely we are to use condoms now than we were in the pre-AIDS era.

I get angry when so-called experts decide that people aren’t entitled to know the factual information that will protect them or their partners. I do not believe it is justifiable to lie or conceal so that you can keep people scared and compliant.

HIV remains a virus with an almost mythological level of stigma attached. We should be throwing our energies into fighting that, into preventing new infections and improving the lives and emotional health of those who are living with the virus. If we want to end the harms of HIV, let’s do that. If we want to reduce STIs, let’s do that. Talking honestly about STI risk isn’t the same as withholding vital information about HIV risk; talking about STIs isn’t the same as discouraging people from accessing an intervention that can prevent them from getting HIV.

Let’s talk about STIs. Let’s talk about how much we, as gay men, value our sexual health and how we can take care of each other within our communities. Let’s talk about STIs and condom use and vaccinations. Let’s talk about regular sexual health check-ups, prompt diagnosis and treatment.  Let’s talk about STIs when we need to talk about STIs but let’s keep our eye on the prize of ending HIV.

Matthew Hodson (@Matthew_Hodson) is the Executive Director of NAM aidsmap. This article is Matthew’s own opinion and not necessarily the view of NAM as an organisation.