The Epidemiology of STIs in the HIV and AIDS Era A/Prof Darren Russell Cairns Sexual Health Service James Cook University

Conflict of Interest No conflicts of interest to declare

Epidemiology of STIs versus HIV You only find what you look for… Generally poorer testing and notification systems for STIs Many countries have no STI surveillance system in place Where data exists, it may be patchy, or not current STIs are ‘the poor cousins’ of HIV

WHO regional estimates of new cases of 4 curable STIs Figure 1 WHO regional estimates of new cases of 4 curable STIs Data are estimated numbers of incident cases in millions for chlamydia, gonorrhoea, syphilis, and trichomoniasis in 2012, by WHO region. The Lancet Infectious Diseases 2017 17, e235-e279DOI: (10.1016/S1473-3099(17)30310-9)

Historic Trends in Gonorrhoea in the UK Penicillin G AIDS Hughes and Field, Future Microbiol. (2015) 10(1), 35–51

Crude mortality rates for syphilis and AIDS USA 1900-1996

Syphilis diagnoses in high income countries USA Canada Sweden Germany

Reported STIs in France: National Data for Syphilis and Gonorrhoea increasing at an alarming rate among MSM INVS Santé Publique France 2016

Syphilis incidence in two MSM cohorts in Sydney HIM (HIV neg) pH (HIV pos) Incidence per 100 person years 0.5 3.6 95% confidence interval 0.3 - 0.7 1.7 - 6.5 After adjusting for age: HR if HIV+ 9.2 (95% CI, 3.6 - 23.3) Jin F et al. Sexual Health 2009; 6: 281

New diagnoses of STIs from 1996 to 2015 in MSM in England Figure 10 New diagnoses of STIs from 1996 to 2015 in MSM in England New diagnoses of HIV infection, early syphilis, gonorrhoea, and chlamydia Data are new diagnoses from 1996 to 2015 in men who have sex with men (MSM) in England.402–406 Early syphilis includes primary, secondary, and early latent infections. New diagnoses of bacterial STIs and HIV were stable immediately after the introduction of cART and cPEP. Syphilis and HIV increased from 2000 onwards. Publication of the Swiss statement407—that people taking cART with suppressed viral load do not need to use condoms—coincided with increases in new diagnoses of gonorrhoea and chlamydia and further increases in syphilis, but no change in HIV infections. These trends have continued since the introduction of the TasP recommendation and the PROUD trial.408 PROUD=PRe-exposure Option for reducing HIV in the UK, immediate or Deferred trial. cART=combination antiretroviral therapy. cPEP=combination post-exposure prophylaxis. TasP=treatment as prevention. The Lancet Infectious Diseases 2017 17, e235-e279DOI: (10.1016/S1473-3099(17)30310-9)

Reported STIs in the US: National Data for Chlamydia, Gonorrhoea and Syphilis 2015: Second year in a row with an increase in all 3 STIs 1.5 million cases of chlamydia, 400,000 gonorrhoea and 24,000 syphilis, increasing “at an alarming rate” among MSM CDC fact sheet October 2016

PrEP and STIs The QPrEPd study is based in Queensland, Australia >1800 MSM on PrEP at 22 sites STI rate at entry = 12.4% At 3 months =12.1% At 6 months = 13.3% At 12 months = ??

Condom use for anal sex in MSM in Sydney, 1997-2016 Figure 11 Condom use for anal sex in MSM in Sydney, 1997-2016 Condom use for anal sex in men who have sex with men Data are for Sydney, Australia, in 1997–2016.424 The Lancet Infectious Diseases 2017 17, e235-e279DOI: (10.1016/S1473-3099(17)30310-9) Copyright

Infectious syphilis in Queensland by Indigenous status, 2002-2016 Source: NOCS, Australia

Proportion of Australian born women diagnosed with genital warts at first visit, by age group, 2004-2013 85% 96% Ali H et al. BMJ 2013 (extended data)

Acknowledgements Pr Jean-Michel Molina (Paris) Prof Basil Donovan (Sydney) Simon Doyle-Adams, Michael Rodriguez, Rohan Pratt (Cairns)