1. Associate Prof. Dr. Jason Ong
STI incidence and prevalence in PrEP programmes – highlights from a systematic review
Associate Prof. Dr. Jason Ong

2. Acknowledgements LSHTM
Philippe Mayaud, Fern Terris-Prestholt, Joseph Tucker, Sabrina Rafael, Vanessa Anglade, Jane Falconer
East Virginia Medical School
Hongyun Fu
University of Minnesota Twin Cities
Kumi Smith
WHO
Rachel Baggaley, Teodora Wi, Ioannis Mameletzis, Michelle Rodolph
Acknowledgements

3. All investigators state they do not have any conflicts of interest
Funding from WHO HIV department to conduct the systematic review
Conflicts of interest

4. Background Aims Outline Methods Key messages
Full paper has been submitted -

5. BACKGROUND

6. PrEP works! i.e. safe and effective (esp when adherence is high) 1-4
WHO advocates PrEP for those with HIV incidence > 3 per 100 PY 5
1 Cohen (2011) NEJM 365(6):
2 Grant (2010) NEJM 363(27):
3 McCormack (2016) The Lancet 387(10013):53-60
4 Molina (2015) NEJM 373(23):
/en/
Background

7. Background Concern about rising incidence/prevalence of STIs globally
High incidence/prevalence of STIs in PrEP users 1-3
“Risk compensation” 4,5
Antimicrobial resistance
1 Liu. (2016) JAMA Intern Med 176:75-84
2 Kojima (2016) AIDS 30:2251-2
3 Traeger (2018) CID 67(5):676-86
4 Blumenthal (2014) Virtual Mentor 16(11):909-15
5 Hojilla (2016) AIDS Behav. 20(7):

8. Background Is PrEP contributing to this?
Can PrEP programs be harnessed to help mitigate these upward trends in STIs?
Is PrEP contributing to this?
Leads to behavioural changes i.e. more condomless sex?
Rising STI rates before PrEP implementation
Can PrEP programs be harnessed to help mitigate these upward trends in STIs?
Attracting groups already at high risk for STIs
Background

9. Could PrEP progams be a gateway for empowering comprehensive sexual health services?
Caveat that in some settings – PrEP is integrated into strong sexual health services … will discuss models later…

10. AIMS

11. Determine baseline STI prevalence of PrEP users
Need for better STI services?
Determine incidence of STIs during PrEP use
Ongoing high risk of STIs?
Aims

12. METHODS

13. Methods 2 sources of data Systematic literature review
Directly from PrEP implementers
Methods

14. Methods – systematic review
9 databases searched
Two key concepts: (STIs) and (PrEP)
Followed procedures as per Cochrane Handbook 5.1
Methods – systematic review

15. Methods – systematic review
Inclusion
RCTs
Observational/demonstrati on projects
Report on at least one of:
Lab-confirmed STI incidence/prevalence
Cost measures
Description of program to test STI
Methods – systematic review

16. Methods – systematic review
Pathogens
Chlamydia trachomatis
Neisseria gonorrhoeae
Treponema pallidum
Hepatitis A/B/C
Trichomonas vaginalis
Mycoplasma genitalium
Herpes simplex virus
Methods – systematic review

17. Methods – systematic review
Exclusion
Systematic reviews/Letter/editorials
Qualitative research about outcomes
Studies restricting study population e.g. men with urethritis, women with cervicitis
(No language or time restrictions)
PROSPERO registration: CRD
Methods – systematic review

18. Methods – systematic review
Meta-analysis using random effects model
Prevalence at baseline
Incidence during PrEP use
Subgroup meta-analysis and meta-regression
Methods – systematic review

19. Methods – Data from PrEP implementers
sent 14th December 2018 to 82 contacts
45 indicated willingness to share data
25 sent data by deadline (31st Jan 2019)
Data requested
In any form related to STI prevalence/incidence in PrEP users, STI services
Survey

20. RESULTS

23. Countries with PrEP programs (PrEP Watch)

30. Pooled STI prevalence at baseline
Our study
Global estimates 2016
Pathogen
Weighted average (95% CI)
Men
Women
Chlamydia
10.8 ( )
2.7 ( )
3.8 ( )
Gonorrhoea
11.6 ( )
0.7 ( )
0.9 ( )
Early syphilis
5.0 ( )
0.5 ( )
Hepatitis A
5.4 ( )
Hepatitis B
1.3 ( )
Hepatitis C
2.0 ( )
Any Ct/Ng/Tp
23.9 ( )

31. Pooled STI prevalence at baseline
Our study
Global estimates 2016
Pathogen
Pooled prevalence (95% CI)
Men
Women
Chlamydia
10.8 ( )
2.7 ( )
3.8 ( )
Gonorrhoea
11.6 ( )
0.7 ( )
0.9 ( )
Early syphilis
5.0 ( )
0.5 ( )
Hepatitis A
5.4 ( )
Hepatitis B
1.3 ( )
Hepatitis C
2.0 ( )
Any Ct/Ng/Tp
23.9 ( )

32. Paper’s appendices Subgroup analyses Meta-regression
Pathogen
Anatomical site (Pharyngeal vs. Rectal vs. urethral)
Subpopulations (MSM only vs. mixed)
Type of study (Routine vs. “trial”)
World Bank Income group (High-income vs. LMIC)
Meta-regression
Funnel plots/Egger’s test

33. Gonorrhoea prevalence by anatomical site

34. Gonorrhoea prevalence by country income level

35. Gonorrhoea prevalence by study type

36. Meta-regression results for the predictors of gonorrhoea prevalence
Characteristic
Variable
OR (95% CI)
p value
AOR (95% CI)
Anatomical site
Oral 1
All sites
1.06 ( )
0.05
1.08 ( )
0.09
Genital
0.92 ( )
0.02
0.97 ( )
0.57
Anorectal
1.02 ( )
0.63
1.05 ( )
0.35
Population
Mixed
MSM only
1.02 ( )
0.66
1.11 ( )
0.04
Country income level
LMIC
High
1.01 ( )
0.74
0.97 ( )
0.26
Study type
Routine
RCT
0.96 ( )
0.18
0.94 ( )
0.22
Cohort
1.00 ( )
0.95
0.96 ( )
0.33
Demonstration
0.73
0.52

38. Pooled STI incidence Our study Global estimates 2016 Pathogen
Our study
Global estimates 2016
Pathogen
Pooled incidence per 100 PY (95% CI)
Men
Women
Chlamydia
21.5 ( )
3.3 ( )
3.4 ( )
Gonorrhoea
37.1 ( )
2.6 ( )
2.0 ( )
Early syphilis
11.6 ( )
0.2 ( )
Hepatitis A -
Hepatitis B
1.2 ( )
Hepatitis C
0.3 ( )
Any Ct/Ng/Tp
72.2 ( )

39. Pooled STI incidence Our study Global estimates 2016 Pathogen
Our study
Global estimates 2016
Pathogen
Pooled incidence per 100 PY (95% CI)
Men
Women
Chlamydia
21.5 ( )
3.3 ( )
3.4 ( )
Gonorrhoea
37.1 ( )
2.6 ( )
2.0 ( )
Early syphilis
11.6 ( )
0.2 ( )
Hepatitis A -
Hepatitis B
1.2 ( )
Hepatitis C
0.3 ( )
Any Ct/Ng/Tp
72.2 ( )

40. Limitations Most STI data were from high income countries
Data gaps from major parts of the world – be careful about extrapolation
Selection bias
rectal STI may be a inclusion criteria e.g. some US programs
Others did not – NSW-EPIC
Detection bias for incidence rates
More frequent STI screening in PrEP users
Limitations

41. Limitations Lack of uniform measures in reporting (esp. incidence)
By pathogen, subpopulations
Inaccessible data
A lot of data out there
Many are still behind “locked” doors – needing ethics or not easily obtained by implementers
Limitations

42. Key messages

43. Key messages Incredibly high burden of STIs (compared to non- PrEP)
Prevalence and incidence
Key messages

44. And also have ongoing risk for STIs
We have an opportunity
PrEP is attracting people with behaviors that put them at high risk for HIV/STIs
And also have ongoing risk for STIs
So, ‘basic’ STI services for prevention, early detection and Rx of STIs should be a priority
Ideally extra-genital testing Ct/Ng (Mg)

45. STI service models in PrEP programs
PrEP services with Rapid or POCT for STI
UK – Dean St Express
PrEP integrated into STI services
UK, Australia
Multi-site Ct/Ng screening
PrEP services with minimal STI screening
Japan, Brazil, Thailand
Syphilis only
Often no CT/NG screening due to costs
PrEP services with syndromic management +/- presumptive treatment
South Africa, Kenya
PrEP services with referral to another clinic sites STI services
Thailand (some sites)
PrEP services with no STI service

46. Barriers/Facilitators for providing STI services for PrEP users
Barriers/Challenges
STI diagnostics
PrEP program logistics
STI capacity building
Facilitators
Money
Training
Research

47. PrEP programs can be a gateway for empowering comprehensive sexual health services
Caveat that in some settings – PrEP is integrated into strong sexual health services … will discuss models later…

48. Thank you
Finally I want to thank you for your attention.