Testing Paradox May Explain Increased Observed Prevalence of Bacterial STIs among MSM on HIV PrEP: A Modeling Study

Abstract: HIV pre-exposure Prophylaxis (PrEP) has become essential for global HIV control, but its implementation coincides with rising bacterial STI rates among men who have sex with men (MSM). While risk-compensation behavioral changes like reduced condom use are frequently reported, we examine whether intensified asymptomatic screening in PrEP programs creates surveillance artifacts that could be misinterpreted. We developed a compartmental model to represent the simultaneous spread of HIV and chlamydia (as an example of a curable STI), integrating three mechanisms: 1) risk-mediated self-protective behavior, 2) condom use reduction post-PrEP initiation, and 3) PrEP-related asymptomatic STI screening. Increasing PrEP uptake may help to reduce chlamydia prevalence, only if the PrEP-related screening is frequent enough. Otherwise, the effect of PrEP can be disadvantageous, as the drop in self-protective actions caused by larger PrEP uptake cannot be compensated for. Additionally, the change in testing behavior may lead to situations where the trend in the number of positive tests is not a reliable sign of the actual dynamics. We found a plausible mechanism to reconcile conflicting observational evidence on the effect of PrEP on STI rates, showing that simultaneous changes in testing and spreading rates may generate conflicting signals, i.e., that observed trends increase while true prevalence decreases. Asymptomatic screening, together with personalized infection treatment to minimize putative pressure to generate antibiotic resistance, is one of the key determinants of the positive side effects of PrEP in reducing STI incidence.