Systematic screening for STIs under PrEP: is France going against the tide?

📜🔗LINK to the source

1. ANALYTICAL SUMMARY

A quarterly routine shaken by evidence. Since the deployment of PrEP, systematic screening every three months (throat, anus, urethra) for gonococcus, chlamydia and syphilis has become established among highly exposed MSM — a practice based on modelling but never validated by randomised trial. The Belgian, British, Berlin and French session of the SFLS shows that this intuition is wavering. Belgium has already removed systematic screening for gonococcus and chlamydia from its recommendations, maintaining it only in four situations (symptoms, symptomatic partner, sexual relations with women, patient request). France, on the other hand, maintains an unchanged position: any asymptomatic infection must be treated, regardless of the site.

A trade-off between the fight against STIs and antibiotic stewardship. The document outlines the reasoning that has shifted Brussels: the Gonoscreen trial reveals that screening-and-treating silent infections has not reduced symptomatic infections, at the cost of overconsumption of antibiotics that fuels resistance. It broadens the comparison to London (screening of asymptomatic individuals moved online, self-sampling) and Berlin (where the primary obstacle is access to the healthcare system). For field actors, the contribution is a framework for understanding: to comprehend why the quarterly rhythm is being questioned, how DoxyPEP, screening and antibiotic resistance form a single knot, and to anticipate a possible evolution of French practices.

2. KEY POINTS OF THE DOCUMENT

1. The Gonoscreen trial overturns the founding hypothesis (section "Gonoscreen, the trial that shifted Brussels"). Multicentre randomised controlled trial published in The Lancet HIV (2024), conducted in 5 Belgian centres with 1,014 MSM and trans women on PrEP over one year: compared to quarterly screening "3×3" with treatment of all infections, the fact of only treating symptomatic infections did not not increase symptomatic infections. Untreated asymptomatic infections disappeared on their own, in ~2 months (gonococcus) and ~3 months (chlamydia).
2. A documented antibiotic cost (same section). In the systematically screened arm: +45% doxycycline, +44% ceftriaxone, +21% azithromycin. However, Belgian data (Sciensano, CNR) show increasing resistance of gonococcus, and staggering levels for Mycoplasma genitalium (~55% to fluoroquinolones, 94% to macrolides). A point of hope: according to The Lancet Microbe (2025), resistance may not necessarily be irreversible — the reduction in exposure to macrolides has been accompanied by a measurable decrease in resistance.
3. The French position remains firm and isolated (sections "French recommendations" and "France caught between two chairs"). HAS, CNS and ANRS MIE (2025) maintain: any asymptomatic chlamydia or gonococcus infection must be treated, regardless of the anatomical site. The real question raised is not "should we treat?" but "should we screen systematically?". The French trial Portaphar (AP-HP) on asymptomatic pharyngeal carriage of gonococcus could change practices.
4. London shifts screening rather than giving it up (section « London has moved testing outside the walls »). At the clinic 56 Dean Street (~25,000 PrEP users, >48,400 people seen in 2025, free via NHS), testing for asymptomatic individuals is referred to an online service (self-sampling, results by SMS). A British survey at the end of 2024 puts the quarterly ideal into perspective: less than a quarter of the affected MSM tested at least 4 times/year, ~29% not once.
5. DoxyPEP: the other side of the arbitration (section « DoxyPEP, proven effective… »). 200 mg of doxycycline within 72 hours reduce syphilis and chlamydia (>80% in the American DoxyPEP trial) but have little effect on gonococcus (~50%, a bacterium already largely resistant to tetracyclines). The HAS recommendation is the most restrictive of the countries reviewed: reserved for cis men and trans women who have had ≥2 partners and ≥2 episodes of bacterial STIs in 12 months. The less we test asymptomatic individuals, the more the place for broad antibiotic prophylaxis arises — and vice versa.

Note: Some more cautious scientists: 

• 1. The result of Gonoscreen itself is more cautious than it appears: A point often overlooked: the trial did not demonstrate that non-testing is non-inferior to testing 3×3 — it failed to demonstrate this. The authors did not manage to establish the non-inferiority of non-testing compared to testing 3×3 among MSM and trans women on PrEP in Belgium. This is a major methodological difference: absence of evidence of a benefit ≠ evidence of absence of benefit. The authors themselves acknowledge that their study does not provide solid support for testing, but that other randomised trials are necessary to evaluate benefits and risks. → https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(23)00299-0/abstract PubMed Central
• 2. A correspondence in The Lancet Infectious Diseases highlights the “open questions”: Direct response to Vanbaelen, who emphasises that the cessation of screening for asymptomatic chlamydia and gonorrhoea infections in MSM could represent one of the greatest revolutions in the field of STIs — a major international debate that remains open. The authors call for caution before generalising. → https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(24)00528-0/fulltext
• 3. The “arrested immunity” hypothesis is contested: Argument put forward by the Antwerp camp: too much screening would hinder the development of immunity and paradoxically increase reinfections. However, the article specifies that this epidemiological basis remains contested, and a recent modelling study proposes a competing explanation (“testing paradox”): testing artefacts could explain the observed increase in STI prevalence, even when the actual prevalence is decreasing. In other words, the debate on the mechanisms is not settled. → https://arxiv.org/pdf/2505.24433
• 4. On the ground, clinicians remain divided: An Australian qualitative study from 2025 confirms that the reduction of screening does not reach consensus among practitioners, despite Gonoscreen. → https://www.medrxiv.org/content/10.1101/2025.10.15.25337966v1.full

3. ACTION POINTS FOR LOCAL STAKEHOLDERS

1. Update the prevention discourse by integrating the idea that the quarterly rhythm of screening for asymptomatics is now being discussed on evidence-based grounds (section “Gonoscreen”), without announcing any change to the French recommendation, which has not occurred.
2. Anticipate the questions of the people being followed : have a simple argument on why an asymptomatic bacterium can disappear on its own and why treating less can reduce antibiotic resistance (sections "Gonoscreen" and "The blind spot of transmission").
3. Identify the relay populations for which screening still makes sense — notably men who have sex with men and women — in order not to feed a reservoir of infection towards other groups (section "The blind spot of transmission").
4. Systematically inform about the existence of DoxyPEP : a shared decision is only possible if the person knows the tool; the lack of information effectively locks in the choice (section "DoxyPEP"). Remind of the restrictive framework of the HAS.
5. Explore the shift of screening asymptomatics outside of consultation (self-sampling, remote results) to free up clinical time for initiation, symptoms, and support, based on the London model (section "London").
6. Address access before rhythm : for vulnerable, migrant, or uninsured populations, the priority is not the frequency of screening but the act of crossing the threshold of the healthcare system, in a community and non-judgmental logic (section "Berlin"). Identified unmet need : the document does not propose any operational tool for this outreach — to be built locally.

4. ADDITIONAL REFERENCES 

🔍➕ For more information, see the articles referenced by "Health Practices" on the topic of screenings ➡️🔗 https://pratiquesensante.odoo.com/7-4-prevention-medicalisee-depistages-vaccinations

1. HAS — Doxycycline for the prevention of bacterial sexually transmitted infections (good practice recommendation, published online on 29 January 2025). French normative framework for DoxyPEP, with direct access to the text cited in the article.
   → https://www.has-sante.fr/jcms/p_3586490/fr/doxycycline-en-prevention-des-infections-sexuellement-transmissibles-bacteriennes
2. Public Health France — Surveillance of HIV and bacterial STIs in France in 2024 (national bulletin, 23 October 2025). Epidemiological data 2024 (screenings, diagnoses, territorial disparities) to objectify the French context.
   → https://www.santepubliquefrance.fr/sites/default/files/rdd/document/bullnat_vih_ist_20251023_final.pdf
3. CNS / ANRS MIE — Epidemiology and biological diagnosis of STIs (argument, expert report, November 2025). French methodological basis on the epidemiology and diagnosis of bacterial STIs, complementary to the debate on screening.
   → https://cns.sante.fr/sites/cns-sante/files/2025-11/Epidémiologie%20prévention_Argumentaire_Rapport%20d'experts_%2020251112.pdf

5. FREQUENTLY ASKED QUESTIONS (FAQ)

1. Has France changed its screening recommendations?
   No. As of the date of the article, HAS, CNS and ANRS MIE (2025) maintain quarterly screening for highly exposed MSM and treatment of any asymptomatic infection (sections “French recommendations” and “France between two chairs”).
2. What exactly did the Gonoscreen trial show?
   That screening and treating asymptomatic gonococcal and chlamydia infections did not reduce symptomatic infections over one year, among 1,014 MSM and trans women on PrEP (section “Gonoscreen”).
3. Why would not treating an asymptomatic infection pose less of a problem than one might think?
   Because most of these infections go away on their own — ~2 months for gonorrhoea, ~3 months for chlamydia — without causing symptoms (section "Gonoscreen").
4. What is the risk of continuing to screen and treat everything?
   An overconsumption of antibiotics (+45% doxycycline, +44% ceftriaxone, +21% azithromycin in the screened arm) which maintains antibiotic resistance (section "Gonoscreen").
5. Should screening be maintained for certain people?
   Yes: symptomatic individuals, with symptomatic partners, who also have sex with women (relay populations), or who request it — the four Belgian exceptions (sections "French recommendations" and "The blind spot of transmission").
6. What is DoxyPEP and who is it recommended for in France?
   A dose of doxycycline 200 mg within 72 hours after intercourse; in France, reserved by the HAS for cis men and trans women who have had ≥2 partners and ≥2 episodes of bacterial STIs in 12 months, in a shared decision (section "DoxyPEP").
7. How does London organise screening for asymptomatic individuals?
   Outside the walls: self-sampling via an online service, results by SMS, with clinical time reserved for initiating PrEP and for symptoms (section "London").

6. REWRITING IN PLAIN LANGUAGE

What the document says

People taking PrEP are tested every 3 months. We look for germs called STIs. PrEP is a medication that protects against HIV.

Some germs do not show signs of illness. They are called "asymptomatic".

In Belgium, a large study was conducted. It tested many people over a year.

What the study found

• Treating asymptomatic microbes does not better protect people.
• Often, these microbes go away on their own. It takes about 2 to 3 months.
• Searching for and treating all these microbes leads to a lot of antibiotics being taken.
• Too many antibiotics make microbes more resistant. Resistant means: the medication works less well.

What Belgium does

Belgium tests asymptomatic people less often. It still tests in 4 cases:

• the person has signs of illness;
• their partner has signs of illness;
• the person has sexual relations with men and women;
• the person requests a test.

What France does

France is not changing anything for now. In France, testing is done every 3 months. And all found microbes are treated.

Another tool: DoxyPEP

DoxyPEP is an antibiotic. It is taken after a sexual encounter. It protects against certain STIs. In France, it is reserved for a few people.

7. CROSS-SECTIONAL ANALYSIS — VALUES OF HEALTH PRACTICES

• Literacy : the document is technical and journalistic; it does not offer a tool suitable for low levels of understanding, but makes a complex scientific debate accessible.
• Empowerment : the issue of information on DoxyPEP is raised as a condition for a truly shared decision — without information, there is no informed choice.
• Participation : no co-construction mechanism is described; the content reflects debates among experts and clinicians.
• Community health : the collective dimension is present through the Checkpoint BLN model from Berlin (community-based and non-judgmental approach) and the notion of reservoir/relay populations.
• Ethics : the document honestly exposes a "blind spot" (poorly understood transmissibility of asymptomatic STIs) and presents the Belgian choice as a calculated risk.
• Human rights : access equity is central in the Berlin framework (uninsured users, migrants, precarious individuals), presented as the first inequality to address.
• Intersectorality : partnerships between associations, practices, hospitals, and public health are mentioned through the fragmented German system and the British NHS model.
• Partnership : the London model (nurse delegation, online service) and the Checkpoint BLN formalise collaborations, without detailing the modalities.
• Combating discrimination : the document names often stigmatised groups (MSM, transgender individuals, migrants) and explicitly values a "non-judgmental" logic (Berlin).

8. EVALUATION OF THE RELIABILITY OF THE RESOURCE

Scientific relevance : high. The article relies on recent randomised controlled trials (Gonoscreen, The Lancet HIV 2024; real-world data The Lancet Microbe 2025 ; American trial DoxyPEP) and cites named institutional sources (HAS, CNS, ANRS MIE, BASHH, Sciensano). The speakers are identified and linked to verifiable structures. Specialist associative media backed by public institutions.

Point of vigilance : this is a session report combining evidence-based data and personal positions explicitly indicated (Romain Palich, Charles Cazanave). These opinions do not constitute recommendations. Some contextual data (transmissibility of asymptomatic individuals) remain uncertain and are presented as such.

Operational relevance : average. The document enlightens and equips reflection, but does not provide either a protocol or a directly applicable checklist. Its value is strategic (anticipate, argue), not procedural.

10. STRATEGIC HASHTAGS

#healthpractices #PrEP #STI #AntimicrobialResistance #SexualHealth #DoxyPEP #Screening #HIVPrevention