Paul Kawata recently wrote that he is willing to live with the “trade-off” of increasing STDs if it means we can end the HIV epidemic. I thank Paul for publicly raising what so many have raised in private – but I think this is the wrong framing of the issue. I argue that we cannot end HIV without acknowledging an inconvenient truth: the HIV and STD epidemics are inextricably linked and without combatting both, we won’t end HIV.
Here are the facts. Reported cases of chlamydia, gonorrhea, and syphilis are at historic levels. Neuro and ocular syphilis are on the rise. Hepatitis A transmission is increasing among gay men. Rates of congenital syphilis are high and growing. And gonorrhea is on the verge of becoming untreatable. These are infections that have real health consequences, make people more vulnerable to HIV infection, and ultimately imperil the progress we have made against HIV.
The rise in STDs cuts across community lines. If you are having sex, regardless of your race, gender, and sexual orientation, you are now at an increased risk of acquiring an STD. Regarding STDs as eminently treatable but inconsequential—as some in our community do—guarantees that women, young people, communities of color, and many others who lack access to basic health care and sexual health services will not get an equal opportunity to live the healthiest life possible.
Women, too often ignored in the fight against HIV, bear an unequal burden of negative health outcomes from STDs. Pelvic inflammatory disease, infertility, and cervical cancer are just a few of the life-threatening outcomes. Congenital syphilis, once trending toward eradication, has roared back to the highest rates in decades with dire outcomes. Roughly seven times more babies are born today with congenital syphilis than with HIV. Forty percent of babies born to women with untreated syphilis may be stillborn, or die from the infection as a newborn. We should not — and need not — accept such a trade-off.
Paul writes that “not everyone wants or likes to use condoms,” and I agree; however, condoms are still one of the best ways to prevent STDs, HIV, and unintended pregnancy, and de-emphasizing their use has real consequences. A key lesson to be learned from the HIV epidemic is that we must be proactive and prepare for what new sexually transmitted infection may be around the corner. Let’s not pit biomedical interventions against condoms. Rather, let’s give our communities complete and honest information about both and provide the tools people deserve to fight HIV and other STDs, including PrEP, PEP, treatment, consistent testing, and condoms, so that people can make the choices that are right for them.
Biomedical advances have given us an unprecedented opportunity to end the HIV epidemic. To meet the full promise of PrEP, we must work hand-in-hand to address the intertwined HIV and STD epidemics. The same forces that drive HIV drive other STDs and fuel the same health disparities. There are real health and human costs to a sole focus on HIV and not a broader sexual health framework, one that includes STDs and sex positive approaches to informed decision making.
Thank you, Paul, for helping to raise the visibility of this important discussion. I urge our field to continue these conversations and work together to combat all sexually transmitted diseases, including HIV – lives depend on it.
David Harvey is the executive director of the National Coalition of STD Directors. We represent state health department STD programs and community-based partners across 50 states, seven large cities, and eight US territories.