Can we screen less frequently for STI among PrEP users? Assessing the effect of biannual STI screening on timing of diagnosis and transmission risk in the AMPrEP Study

Abstract

Background: In many countries, HIV pre-exposure prophylaxis (PrEP) users are screened quarterly for STIs. We assessed the consequences of less frequent STI testing. We also assessed determinants of asymptomatic STI and potential for onward transmission.

Methods: Using data from the AMPrEP study, we assessed the proportion of syphilis, and genital, anal, and pharyngeal chlamydia and gonorrhoea diagnoses which would have been delayed with biannual versus quarterly screening. We assessed the potential for onward transmission by examining reported condomless anal sex (CAS) in periods after to-be-omitted visits when screening biannually. We assessed determinants of incident asymptomatic STIs using Poisson regression and calculated individual risk scores on the basis of the coefficients from this model.

Results: We included 366 participants. Median follow-up was 47 months (IQR 43-50). 1,183STIs were diagnosed, of which 932(79%) asymptomatic. With biannual screening, 483 asymptomatic STIs (52%) diagnoses would have been delayed at 364 study visits. Of these visits, 129 (35%), 240 (66%) and 265 (73%) were followed by periods of CAS with steady, known casual or unknown casual partners, respectively. Older participants had a lower risk of asymptomatic STI (incidence rate ratio (IRR) 0.86/10-year increase, 95% CI 0.80 to 0.92), while CAS with known (IRR 1.36, 95% CI 1.10 to 1.68) and unknown (IRR 1.86, 95% CI 1.48 to 2.34) casual partners and chemsex (IRR 1.51, 95% CI 1.28 to 1.78) increased the risk. The individual risk scores had limited predictive value (sensitivity=0.70 (95% CI 0.66 to 0.74), specificity=0.50 (95% CI 0.48 to 0.51)).

Conclusion: Reducing the STI screening frequency to biannually among PrEP users will likely result in delayed diagnoses, potentially driving onward transmission. Although determinants for asymptomatic STIs were identified, predictive power was low.

Keywords: Chlamydia Infections; NEISSERIA GONORRHOEAE; PREP; Pre-Exposure Prophylaxis; SYPHILIS.

Figure 1

Proportion of bacterial STI diagnoses that would have been delayed and that would not have been delayed if screening was done biannually rather than quarterly. Ct, Chlamydia trachomatis; Ng, Neisseria gonorrhoeae.

Figure 2

Incidence rate per 100 person-years (PY) of chlamydia, gonorrhoea and syphilis among PrEP users at all visits and at scheduled study visits only, AMPrEP cohort study, August 2015–February 2020, Amsterdam, the Netherlands. The week 54 visit was excluded due to the small number of participants who attended this visit. AMPrEP, Amsterdam PrEP demonstration project; PrEP, pre-exposure prophylaxis.