Recent insights suggest the need for the STI field to embrace a more eco-social conceptual framework: A viewpoint

Abstract

A large number of countries are being confronted with twin epidemics of increasing STI incidence and antimicrobial resistance (AMR). This has led to calls to intensify STI screening of high STI prevalence populations. The available evidence suggests that this will have little impact on STI prevalence but a significant deleterious effect on AMR. We suggest that this call to intensify STI screening is one of the several errors that stem from the way that the STI-field has been dominated by a biomedical individualistic conceptual framework. This framework views STIs as obligate pathogens that can and should be eradicated by intensive seek-and-destroy activities. We evaluate five types of evidence that suggest that a multi-level, socio-ecological framework would provide a more accurate portrayal of the important determinants of STI prevalence and AMR spread. By incorporating concepts such as limiting STI screening to scenarios with clear evidence of net-benefit and considering ‘antimicrobial footprint’ thresholds, this framework would be more likely to result in a better balance between targeting STI prevalence whilst minimizing the risk of AMR emerging.

Would men who have sex with men support less frequent screening for asymptomatic chlamydia and gonorrhoea to improve antibiotic stewardship? A qualitative study

“…16,29 As previous literature suggests, this is likely due to the fact that while 3-monthly screening may reduce prevalence/transmission in the short term, it is not addressing key drivers such as changing sexual practices such as decreased condom usage and dense sexual networks that are maintaining STIs at their endemic state in the MSM community. 24,43 Our participants suggested that acceptability of a change in screening frequency is possible with transparent communication delivered by a trusted healthcare professional.…”

“…25 Instead, the high prevalence of STIs in the MSM community is likely linked to sexual network connectivity. 24,25 Intensive screening in MSM on PrEP has resulted in very high consumption levels of azithromycin and ceftriaxone. 15 Both are broad-spectrum antibiotics that can also cause resistance in other non-STI organisms and, according to the WHO, should be reserved for infections where there is clear evidence of benefit, and no alternatives exist.…”

“…15 AMR has been identified as a global health issue. 24,25 Macrolide resistance in Mycoplasma genitalium (MG) has occurred in response to the widespread prescription of azithromycin for asymptomatic chlamydia. 26 Widespread use of azithromycin for asymptomatic chlamydia is also thought to have contributed to outbreaks of azithromycinresistant syphilis in Australian communities and globally.…”

“…15 Concerns about the harms of such regular STI screening have prompted calls by some to reconsider the frequency of asymptomatic screening for chlamydia and gonorrhoea among MSM. 15,16,24,[27][28][29][30][31] However, sexual public health campaigns in Australia targeted at MSM have predominantly focused on the importance of regular STI screening. 32,33 As such, the receptivity of MSM to reduce STI testing frequency as a way of improving public sexual health may be a barrier to implementing changes in guidelines.…”

Trends in Testing and Self-Reported Diagnoses of Sexually Transmitted Infections in Gay and Bisexual Men in Australia, 2017-2021: Analysis of National Behavioural Surveillance Surveys

“…Undoubtedly, STI testing is important among GBM to reduce time between infection and treatment, and to disrupt chains of transmission. Conversely, it has been argued that frequent universal screening of GBM may not be feasible or cost-effective for clinics, and even in context with increased STI testing among GBM, STI prevalence did not necessarily decrease at the population level 9,33 . In particular, Williams et al 34 argued that reducing asymptomatic screening for chlamydia and gonorrhea may have potential benefits to address growing antimicrobial resistance and burden on health care services, but should also be considered against potential harms from reduced screening.…”