In the final part of our three-part STD series, we’ve finally arrived on the topic on everyone’s minds and the reason I began this quest— has the onset of PrEP (Pre-Exposure Prophylaxis) being prescribed as a HIV prophylactic contributed to the rumored horror stories of STD strains called “superbugs.” Read on for Dr. Evan Goldstein’s medical opinion on the topic.
(Check out the rest of our STD series—Part I: Gonorrhea, Syphilis and Preventative Care and Part II: The Truth about HPV and Herpes.)
Adam Baran: When PrEP became popular in 2014, naysayers were crowing about the rise of “superbugs.” Antibiotic-resistant strains of gonorrhea, for example, or drug-resistant types of HIV. What’s the truth about superbugs, and should people be worried?
Dr. Evan Goldstein: Personally, I haven’t seen them. But you hear stories about different bugs [that are now] requiring alternative types of treatments [to be effective], and we don’t necessarily know how they will respond. There are two components here. One is that bacteria and viruses are naturally evolving on their own. Two is that there are certain approaches that may precipitate that evolution, or improve the chances they will occur.
You need to live in the present, and know how to create community-based practices that are effective. I’m a huge proponent of prophylactic or preventative doxycycline, for example, that helps prevent chlamydia and syphilis when taken within 48 hours of exposure. But there are those who argue even this can create superbugs [through over-prescription of antibiotics, which may help treatment-resistant strains to evolve].
Where the medical profession has failed is by not providing risk-assessing tools for both physicians and patients. If you have three to four STDs a year, then there needs to be an approach that doesn’t change your habits, but does everything we can to decrease your chances of getting the STD. Preventative approaches, like PrEP, for example. Otherwise, it’s a snowball effect, especially in our community. There are physicians not testing the right way for STD screenings, and patients living their life not knowing that they would test positive for something—you could be harboring an anal STD that’s asymptomatic for a long time.
Super gonorrhea is the big boogeyman superbug. As far as I know, doxycycline only prevents syphilis and chlamydia. It doesn't prevent gonorrhea.
Correct. Doxycycline is around 80% effective against syphilis and chlamydia, versus 15–30% for gonorrhea. I think all STDs have the capacity to mutate, but it’s fundamental to understand that and decide what works best for you.
our goal is to encourage people to ask themselves, based on their habits, how they can mitigate risk and bring them as low as possible.
When you look at azithromycin – another treatment for STDs – there are definitely times that you can potentially use that as a preventative treatment. At my medical practice, Bespoke Surgical, our goal is to encourage people to ask themselves, based on their habits, how they can mitigate risk and bring them as low as possible.
There are reports of an uptick in STDs, but also a counter argument from HIV science professionals that this trend is invalid, citing it has resulted from an increase in STD testing and therefore detection. What’s your view?
Yes, there's definitely some truth to the fact that we're now testing more often, and we're potentially getting more positive results. Let's say I tested you in three months and you were positive for chlamydia. You may have had chlamydia for the entire year, but on record it's only one time for that year versus the separate infections that you had each time you were infected. So appropriate testing is actually giving us a true picture of the extent of STDs in our world. And if you look at it as a snapshot, there's more.
The anecdotal evidence of my own life says yes, we're getting STDs more because we're not using condoms.
Right. And also the perception from people on PrEP is that they’re invincible, which is really tough. There’s also a lack of education among practitioners, who aren't testing the right way. With Future Method, we want to empower people to play the way they want and love the feeling, but also to take social responsibility for themself and the community to make sure that we're all safe.
the perception from people on PrEP is that they’re invincible, which is really tough.
This is an issue I deal with, as somebody who has a lot of fun. I get STDs way more frequently, as are other people in my circle. Recently, someone I hooked up with messaged me on an app at 2:30 AM. They re-read my profile, freaked out, and asked the last time I was tested. My opinion is that if you’re on the apps, you should know how to get yourself treated and tested. And guess what? Everything is treatable. You can see how all these things are swirling around everybody in the community.
I also think about it on the flip side, from a shaming perspective. I could be hooking up once a year outside of a relationship and in that one encounter I want to be as risk-averse as possible. I also think it's analyzing—like we’ve discussed in previous conversations about prepping for bottoming, how you're preparing for fun, how you’re engaging in the act itself, and what situations you're putting yourself in. Are they risky? Is it app-based, is it drug-based, is it play party-based?
The goal for me would be like walking through a metal detector. Before a play party, can you walk through something that quickly identifies if you have any STDs? I always think apps should have some verification system because someone may look at your habits in the bedroom and think you're a promiscuous individual, but yet you may be doing STD screenings every week and doing the preventative work.
So I think, at the end of the day, it's as simple as social responsibility.