High incidence of curable sexually transmitted infections among persons accessing oral PrEP at an integrated sexually transmitted infection/PrEP clinic in Lilongwe, Malawi

Sarah E Rutstein; Jane S Chen; Edward Jere; Laura Limarzi-Klyn; Zakaliah Mphande DipClinMed; Esther Mathiya; Naomi Nyirenda; Gabriel Banda; Grace E Mulholland; Mina C Hosseinipour; Irving F Hoffman; Mitch Matoga

doi:10.1097/OLQ.0000000000002170

High incidence of curable sexually transmitted infections among persons accessing oral PrEP at an integrated sexually transmitted infection/PrEP clinic in Lilongwe, Malawi

Sex Transm Dis. 2025 Apr 22. doi: 10.1097/OLQ.0000000000002170. Online ahead of print.

Affiliations

¹ Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
² UNC Project, Lilongwe, Malawi.
³ Lighthouse Trust, Lilongwe, Malawi.
⁴ Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
⁵ Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

PMID: 40261957
DOI: 10.1097/OLQ.0000000000002170

Abstract

Background: Understanding the burden of incident sexually transmitted infections (STIs) among persons in Eastern and Southern Africa after initiating HIV pre-exposure prophylaxis (PrEP) is critical to allocate scarce STI testing and HIV prevention resources.

Methods: Participants were recruited from an STI clinic in Lilongwe, Malawi (March-December 2022). Eligibility reflected oral PrEP eligibility per contemporary guidelines, limited to persons seeking STI services. We enrolled three groups: "index participants" who initiated PrEP, "PrEP-eligible decliners" who declined PrEP, and PrEP-initiating "referred partners" referred by index participants. Surveys and PrEP use assessments were conducted at baseline, 1, 3, and 6 months; Chlamydia trachomatis, Neisseria gonorrhoeae, and syphilis testing done at baseline, 3, and 6 months. A subset of participants completed in-depth interviews that were thematically analyzed.

Results: We enrolled 238 participants (174 index, 37 PrEP-eligible decliners, 27 referred partners); most were male (58%), median age 27 (IQR 22, 31). Forty-seven incident STIs were identified during 89.3 person years (py) of follow-up (52.6/100py). Men had a higher incidence versus women (55.8/100py versus 48.6/100py). Index participants had the highest STI incidence (61.3/100py), compared to PrEP-eligible decliners (26.4/100py) and referred partners (27.1/100py). Most incident infections were asymptomatic. Nearly all 27 interviewed participants described an STI as related to perceived HIV risk and need for PrEP.

Conclusions: Incident, asymptomatic STIs in the six months following PrEP initiation were common. STI testing contextualizes perceived HIV risk and may encourage PrEP persistence. Integrating bacterial STI testing within PrEP care may reduce transmission via expedient treatment and should be considered alongside PrEP program expansion.

Keywords: HIV prevention; bacterial STI; integrated services; risk perception.