The Downside of PrEP: Syphilis Rates Are Up

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Looks like ol' Grandpa Savage was right.

After PrEP, the pre-exposure prophylaxis that prevents the contraction of HIV, came out on the market, Dan Savage, The Stranger's resident sexpert slash buzzkill, predicted that gay men were going to stop using condoms and sexually transmitted infections would eventually skyrocket.

Dan isn't a dummy (except when he votes for Jill Stein) and didn't argue that people shouldn't take PrEP, but he wasn't alone in criticizing the drug: Larry Kramer, the legendary playwright and founder of the advocacy group Gay Men’s Health Crisis, said in a New York Times interview that, "Anybody who voluntarily takes an antiviral every day [instead of using condoms] has got to have rocks in their heads."

This criticism, both Dan's and Kramer's, was not received well by some gay rights and AIDS activists, including Peter Staley, who, in 2014, argued that there was no evidence that PrEP would lead to a decline in condom use among men who sleep with men.

Turns out, Staley was wrong: Six years after the introduction of PrEP, condom use is down and STI rates are up—way up. According to Lindley Barbee, medical director of the Seattle & King County Public Health STD Clinic, between 2015 and 2017, King County saw a 50 percent increase in new cases of syphilis, as well as increases in both chlamydia and gonorrhea. And this is a problem that can't always be solved with a single dose of antibiotics due to antibiotic resistance, a phenomenon in which strains of bacteria evolve to be able to defeat the very drugs designed to kill them.

"Since about 2014 we've seen a pretty rapid rise in the portion of patients who have azithromycin [an antibiotic used to treat gonorrhea] resistance," she says. That doesn't mean, however, that for those 8 percent of patients, the STI is untreatable: When combined with ceftriaxone, another antibiotic, treatment failures are exceedingly rare... at least for now.

Still, gonorrhea and chlamydia won't kill you. Syphilis, on the other hand, will if left untreated. Symptoms, in the beginning, include enlarged lymph nodes near the groin, followed by small, painless sores. After that, you may develop skin rashes and more sores, as well as headaches, weight loss, fatigue, hair loss, and muscle aches. Later, after a period of latent syphilis (in which you may be asymptomatic) the really bad shit starts. The fourth stage of the disease is called tertiary syphilis and can include numbness, deafness, blindness, heart disease, and an array of neurological problems. People in this stage can go through vast personality changes as the disease attacks the brain. Untreated syphilis is rare (most people will get some kind of antibiotic in their lifetime, Barbee told me, which is still effective), but among some populations—specifically, pregnant women—it can still be exceedingly dangerous, and, if untreated, can result in fetal death.

Public Health is attempting to educate people, especially men who sleep with men, about the importance of condom use. But it's an uphill battle. Mandatory reporting laws mean that when someone tests positive for an STI, attempts are made to contact their sexual partners. However, according to Barbee, that's becoming increasingly difficult thanks to sex apps: People might be slightly less anonymous now than in the days of cruising public parks, but if you have sex with a man and then delete him from the app, it's hard to make contact when the doctor calls with bad news.

Besides the ease of anonymous sex, a gay man in the office (not Dan) told me that sometimes condoms are the difference between having sex and not having sex at all; some men can't get hard with a condom. He also said it's a risk analysis: if you want to bareback, a round of antibiotics every once in a while may be worth it. Of course, bacteria evolve, and there may well come a time when antibiotics no longer work. It's also possible, as Dan "Get Off My Lawn" Savage has long maintained, that a new, lethal disease will spring up. It's happened before.

If you do care about STIs (and you probably should), the best way to stay safe, Barbee says, is to get tested every three months and (sorry, boys) decrease your number of sex partners. That, or you could always use condoms.