PrEP Is a Great Advance, But It's Far From a Cure-All

Thanks to groundbreaking new legislation in California, we expect the Golden State -- like the city of San Francisco -- to get closer to zero new HIV transmissions. Assembly Bill 2640, sponsored by the Los Angeles LGBT Center and APLA Health, ensures that people who get tested for HIV receive information about how PrEP and PEP can help protect them from HIV infection. That's great, but the sexual health of our community is about more than preventing and controlling HIV. It's also about how to live and be healthy sexual beings in a world where there are other sexually transmitted risks to our health.

Before HIV crashed the party of our sexual freedom revolution in the late 1970s, syphilis and hepatitis B were the most feared scourges that lurked in bedrooms and bathhouses. Syphilis was treatable; hepatitis B was not. Though the vaccine for hepatitis B is now included in the mix of vaccinations that children routinely receive, a recent study among gay and bisexual men in Los Angeles found that about one-third haven't been vaccinated.

There is no vaccine, however, for syphilis. You can get it again and again -- and many people, in fact, do just that. Like HIV, syphilis is sneaky. It often does not immediately or obviously announce its presence in the body. It can be unknowingly transmitted to a sex partner. It can increase the likelihood of an HIV infection. It can lie, seemingly dormant, while damaging your brain, eyes, ears, blood vessels, and immune system until it is finally discovered and treated. Yes, it can be successfully treated with relatively cheap antibiotics, but like many infections, it can cause lasting damage to your body.

Hepatitis C is a particularly nasty scourge among the needle-sharing population, but it can also be sexually transmitted. The good news about hepatitis C is that now it can be successfully treated and eradicated. However, the cost of a course of treatment for hepatitis C is between $60,000 and $80,000! And you can get the infection again -- there is no vaccine and no immunity following infection.

Then there is gonorrhea. About 11 percent to 12 percent of the men who test for sexually transmitted infections at the Los Angeles LGBT Center test positive for gonorrhea, which is becoming increasingly resistant to antibiotics. In early September a highly resistant strain was reported by the Centers for Disease Control and Prevention to have appeared in Hawaii.

Chlamydia, an STI that does its worst damage in women by causing painful pelvic inflammatory disease and infertility, appears to be on the rise in gay and bi men. It is also becoming resistant to azithromycin, the simple, one-dose treatment currently in widest use.

Then there is Shigella, a really nasty bacterial bowel infection that has been recently reported in gay and bi men in Los Angeles. Shigella causes severe abdominal cramps, fever, and watery diarrhea that can land you in the hospital. You get this one very efficiently through oral-anal contact (rimming someone who is carrying the bacteria).

The last item on my short list of nasty bugs is the bacteria known as Neisseria meningitidis (also called meningococcus). We know that it is transmitted through even nonsexual, close contact and that in the past several years there have been sporadic outbreaks disproportionately affecting gay and bisexual men in major cities. Fortunately, this infection is preventable by a vaccine and every gay and bi man should get it.

Unfortunately, sexually transmitted infections are inescapable biological consequences of being sexually active outside a strictly monogamous relationship. And the more of any organism there is circulating in a community at any given time, the more likely it is that an individual will come home with one or more of them after sexual encounters.

So what should we do about all of this? How should we even begin to think about it?

First: We must stop associating sex between consenting partners with morality; they're completely unrelated. I'm also unaware of any credible evidence that trying to make people feel guilty about having sex, or slut-shaming them, has ever decreased HIV or other sexually transmitted infections. Through our efforts to promote PrEP, there has been admirable progress on this front, but we need to reframe our discussions about risks of infection. The issue isn't that sex is bad; the issue is that infections are bad.

Second: People need to understand the health risks associated with being sexual and the potential health consequences of not using condoms, which continue to offer the best protection from STIs. PrEP only prevents HIV infection.

Third: Those who are sexually active outside a strictly monogamous relationship should take responsibility for their well-being and the protection of others. That means, even if you aren't having any symptoms, you should get tested regularly for HIV, gonorrhea, chlamydia, and syphilis every three months and for hepatitis C every six to 12 months. And of course, all gay and bi men should get vaccinated for hepatitis B and meningococcus.

Finally, if you don't feel comfortable discussing your sexual practices with your health care provider, find a different one, assuming that's an option for you. If that's not an option, come see us at the Los Angeles LGBT Center's Sexual Health Program. You deserve to have a nonjudgmental health care provider who respects you, who listens to you, and who shares accurate and current information to help protect and maintain your health.

DR. ROBERT BOLAN is the medical director of the Los Angeles LGBT Center.