"Sex without a condom is no longer just a 'minority problem'. STDs are spreading across the population," warns the dermatovenereologist. What to watch out for?
Intimate health is one of the topics that is often discussed either sensationally or in whispers. It is all the more important to hear the voice of a doctor who can separate the myths from reality and describe what really happens in skin and venereal clinics. MUDr. Martin Lang graduated in general medicine at the 1st Faculty of Medicine of Charles University, gained his experience at the Skin Department of the Regional Hospital Kolín and today he works at the Dermatovenerology Clinic of the General University Hospital in Prague. He is interested in general dermatology and venereology, he is also professionally interested in dermatosurgery. In this interview, he talks openly about sexually transmitted infections, prevention, testing, myths surrounding HIV and why the fear of sexual diseases has been fading in recent years - and what the consequences of this may be.
Martin, do you experience an increase in patients coming in with intimate difficulties after Christmas - and generally after the holidays or longer vacations?
Not yet. In terms of the incubation period, it is too early to draw such conclusions, especially for the period after New Year's Eve. Moreover, during Christmas itself, there were fewer visitors, with rather fewer patients coming.
So we cannot say that, for example, on the fifth of January, whole crowds of people came into the surgeries to deal with something acutely?
No, we didn't see anything like that. The more significant increases tend to be associated with summer festivals. Colleagues from regions where there is one big event a year often describe a spike in cases. In Prague, however, the situation is different - due to the year-round tourism and the constant change of people, the occurrence of similar problems remains more or less constant.
Since you mention Prague as a large and touristic city with many foreigners - who predominates among the patients in the outpatient clinics? Are they more likely to be Czechs or foreigners?
Czech patients still predominate, but foreigners also appear. For them, the lack of health insurance is a common problem, which means that examinations are quite expensive for them.
Are we talking about amounts in the thousands to tens of thousands of crowns?
It depends on what is being examined. The examination itself is not that expensive, usually under a thousand crowns, but the PCR tests are expensive. From the days of covid, we know that a PCR test could cost up to two thousand. If we test for multiple pathogens and from multiple sites, it can run up to ten thousand.
How is this handled in practice for foreigners? Do they pay for the tests themselves, or are any costs recovered?
They pay for the examination themselves. It does not work as if the tests are carried out first and then the reimbursement is dealt with. The patient first pays at the cash desk and then the examination itself takes place. It also depends on whether they visit a hospital or a private clinic. At private clinics, reimbursement is automatic and they often work in the form of packages - for example, the patient pays around ten thousand crowns and has a complete set of tests included.
Recently, we often see headlines in the media such as "the number of patients with STDs is increasing" or "the number of HIV-positive people is rising". Do you see this in practice as well, that more patients are coming forward with these problems?
It is hard to say why this is happening, but we are seeing changes. The structure of patients is changing, and older people are coming in. A lot of it has to do with migration, especially from the East. Some people are already coming in with a diagnosis, they are healed, but of course it affects the overall numbers.
So the idea that these are people from the "bottom of society" is proving to be wrong?
Absolutely. When the first case of HIV appeared in the Czech Republic, it was reportedly a law student who had been sent to San Francisco under communism. On his return, the virus spread in a relatively small, select community. At that time it was spread mainly in certain social circles, certainly not only among people on the margins of society.
Is it still true that the most common STD patients are men who have sex with men?
This is a high-risk group, but at the same time it has to be said that these people are often very well informed. They know that there is a risk, and therefore they regularly go for testing. As a result, they are more likely to catch infections earlier. The heterosexual population, on the other hand, is often under the impression that they are not affected by such problems, and so they undergo less testing.
So is it fair to say that gay men are now taking a more responsible approach to their sexual health and getting tested more often?
Yes. With heterosexual couples, we often see that they do not take this risk at all. Of course, anyone who lives a riskier lifestyle or is in an environment with a higher incidence of infection should consider testing. But for this group it is often more difficult - if only because they are less likely to accept the risk.
It might be a good idea to clarify what the greatest risk of contracting an STD actually is. There are a lot of myths around this - I guess we can be honest and say that we don't catch it by sitting on the toilet seat.
Exactly. Most of these pathogens have very little viability outside the human body. Bacteria die quickly - gonorrhoea, for example, only survives very briefly outside the mucous membranes. Also, the syphilis pathogen is extremely sensitive, requiring a specific temperature, pH and environment, otherwise it dies very quickly.
So the various excuses like "I sat in the sauna" or "I wiped myself with someone else's towel" have no real basis?
Generally, no. Of course, it always depends on the specific situation, but in most cases these modes of transmission are not realistic. Pathogens do not survive outside the human body for long periods of time, so such scenarios do not make sense from a medical point of view.
What STDs are most common in practice today?
The most common STD is condylomata, which are genital warts caused by HPV. They are widespread, tend to recur, are treated by removal and often have a chronic course. In younger patients, especially in adolescence, molluscum - viral skin growths - are quite common.
At the same time, there has been a lot of talk recently about the increase in cases of gonorrhoea and also about strains that are resistant to antibiotics. Could this be a serious problem in the future?
Yes, it could. There are already strains that are resistant to third-generation cephalosporins, which are currently the treatment of first choice. This is a major complication because gonorrhoea has a high capacity to develop resistance over the long term. Antibiotics that worked before are often no longer effective today.
Fifty years ago, all it took was one dose of penicillin and you were done. Today, neither quinolones nor some other antibiotics work. Even tetracyclines, such as doxycycline, have greatly reduced effectiveness.
Could the so-called DoxyPEP - the prophylactic use of the antibiotic doxycycline after risky sexual contact, which is much debated today precisely because of fears of a rise in resistance - also contribute to the risk of antibiotic resistance?
Yes. We recently had patients who came back from Berlin where they had taken DoxyPEP, and they all brought back gonorrhoea. These were strains resistant to tetracyclines, the antibiotics used in DoxyPEP. I'm very sceptical about that. Antibiotics are not candy. They should not be used prophylactically without a clear indication, because we are encouraging the emergence of resistance.
To summarise: if we want to have safe sex, there is basically no choice but to use a condom. Right?
Yes. While there is PrEP, the preventive use of antiretroviral drugs, which protects against HIV infection, there is no other reliable protection against other sexually transmitted diseases. So the condom remains the only truly effective tool that significantly reduces the risk of transmission of most infections.
And it's also important to remember that most of these diseases are also transmitted through oral intercourse. The most common carriers of gonorrhoea are asymptomatic individuals. In women, this is the case in up to 60% of cases. Very often throat infections are asymptomatic, so the infection is easily transmitted during oral sex.
Does that mean we should use a condom during oral sex?
Yes, ideally yes. But for herpes infections, genital warts or papillomaviruses, a condom still doesn't guarantee 100% protection because the lesions may not just be on the penis, but also around the genital area or in the groin.
In the last year, there has been some hope in the form of a vaccine against gonorrhoea. Will we soon see it in the Czech Republic?
No. These vaccines are more focused on meningococci and the effectiveness of gonococci is low. It has been tried, but the results are not very convincing. The effectiveness is around 30%, so it's not a solution yet.
There is also talk of a 'vaccine' against HIV, but it is very expensive. What is the current situation in this respect?
It is not a vaccine in the true sense of the word, but a long-acting treatment. A two-month form is now available in the Czech Republic - two injections that last two months in the body. It is mainly used for patients who are unable to reliably take tablets every day.
Half-yearly and yearly forms are being developed. The six-monthly one is thought to be mainly for treatment, while the annual version is also being investigated for prevention - a form of PrEP. In theory, one injection a year could be enough, for example before travelling to areas with higher HIV prevalence, but it is not yet widely available.
Is this form preferable for people precisely because they don't have to think about taking pills every day?
Yes, exactly. The bi-monthly injections are already widely used in our country. I had a patient with me just recently who switched to this form precisely because he was not comfortable with daily tablets for a long time.
This is dealt with in HIV centres, where it is standard practice to work with double or triple combinations of antiretroviral drugs. This approach is one of the more modern treatment options - it is a combination drug given as two injections, each injected into one side of the body. Application takes place once every two months.
We often mention the term PrEP in conversation, but it may not be clear to some readers exactly what it means. Could you explain it briefly?
PrEP stands for pre-exposure prophylaxis. It is a combination of antiviral drugs that are commonly used to treat HIV, but at a lower dose to serve as preventive protection. It is most commonly taken in tablet form - one a day - and when taken correctly and regularly, significantly reduces the risk of contracting HIV.
How reliable is this protection?
It is not 100%. For men, protection is reported to be sufficient after about seven days of regular use. For women, protection is lower, especially during vaginal intercourse, and it takes longer for the drug to reach the mucous membranes in sufficient concentration - sometimes up to around 20 days.
So who is PrEP for? Who should consider this form of prevention?
It should be considered by anyone who has a loose sex life and is at increased risk of infection. This is not a question of sexual orientation or identity, but of specific behaviours and the level of risk they entail.
According to recent statistics, the number of HIV-positive patients and other sexually transmitted diseases is increasing. In your opinion, is this also related to the fact that people today are less concerned about sexual prevention than in the past?
Yes, definitely. In the 1980s and 1990s, when HIV began to spread massively, the fear of infection was much greater and condom use was more commonplace. Today, this caution is gradually easing, which is reflected in the rising numbers of infections.
How do you explain this?
I think the changing media image of sex is also playing a role. In the past, protection was common in adult films, whereas today, on platforms like OnlyFans, unprotected sex prevails. People subconsciously adopt this image and it can influence their own behaviour.
In the 1980s and 1990s, HIV was a real bogeyman. Is there no such fear today?
It's not. Back then, people saw young men dying around them and it was a very powerful and traumatic experience. Today, thanks to modern treatment, there is a feeling that 'nothing is really happening' because HIV is no longer seen as an imminently fatal disease. In fact, if diagnosed early and treated correctly, and if a person achieves a so-called undetectable viral load, he or she can live to a full age. Moreover, these patients are monitored very closely, often even more closely than the general population. Their cholesterol, blood sugar, blood pressure and other parameters are checked regularly. In many respects, they have a very high level of health care.
You mentioned the term "undetectable viral load". What exactly does that mean?
If a person is properly treated, they have such a low amount of virus in their blood that laboratory tests cannot detect it. Such a person is not infectious. The virus is still in the body, but in such small amounts that it is not transmitted to others.
So if a person is well treated and has a long term undetectable viral load, they can't transmit HIV even during sex?
Yes, exactly. The "U = U" principle applies, i.e. undetectable equals untransmittable. If the viral load is undetectable, one does not transmit HIV. Thanks to modern treatment, people living with HIV can lead full lives, including sexual and partner life. However, it is essential to adhere to treatment and attend regular check-ups. From a medical point of view, HIV is now a chronic disease that is very manageable with the right treatment.
However, if the disease is not caught in time, it can develop into AIDS. When does this happen? Is it very much an individual process?
Yes, it is very individual. The infection always has a progressive course, but the pace can vary considerably. For some people, the transition to AIDS can happen within two years of infection, for others it takes much longer. However, most patients are now diagnosed early and start treatment at an early stage. Of course, if the infection is detected late and is detected at the AIDS stage, the situation is much more complicated.
We agreed that the best prevention remains the condom or PrEP in a situation where the person knows that he or she is at higher risk. In practice, however, this is often more of an ideal that is not always followed.
Yes, it is an ideal that is not always easy to meet.
So if a person has an active sex life, regardless of orientation, they should get tested as a precaution. How often? After every risky contact?
This is very individual. Everyone should consider whether and when the risky contact occurred. If a person has not had any risky sexual contact, there is no reason to get tested. In addition, with blood tests, it is necessary to take into account the so-called diagnostic window, i.e. the period when the infection cannot yet be reliably detected.
What exactly does this mean?
With blood tests, you have to leave a certain time gap. A few weeks is indicated. While today's tests are more accurate and can detect infection earlier, only a test carried out about three months after the risk contact gives 100% certainty.
What about other STDs?
Common STIs usually show symptoms quite quickly. Some are detectable in as little as four to seven days. For chlamydia, the incubation period is about seven to 14 days.
So what are the warning signs that should bring a person to the doctor?
Gonorrhoea is typically a yellow to yellow-green purulent discharge that appears in an average of four days, sometimes as early as two. Gonorrhoea is a bacterium that multiplies very quickly, about every fifteen to twenty minutes, so the discomfort builds up quickly. With chlamydia, it is more of an itching and cutting sensation when urinating, the discharge is less pronounced. In syphilis, the first stage may be quite subtle - a small ulcer that you may not even notice, and enlarged ganglia, perhaps in the neck or groin.
And what are the typical symptoms of HIV?
In HIV, non-specific, flu-like symptoms often appear in the early stages. This is sometimes called 'flu-like syndrome'. This includes fever, chills, chills, muscle and joint pain. These are symptoms that are easily mistaken for a common virus.
Do people with these symptoms come straight to you, worried that it might be HIV?
Most of the time, no. They're more likely to go to a GP thinking they have a virus. Few people come straight in with the fear of HIV. If they do suspect, they tend to be referred directly to HIV centres.
What type of sex poses the greatest risk in terms of HIV transmission?
The highest risk is unprotected anal sex, especially in a passive role. The mucous membrane of the anus is not adapted to the mechanical stress of penetration and is easily injured, thus increasing the risk of transmission.
There is still a strong stigma around HIV. Can we say, then, that a person who knows about his diagnosis and is properly treated poses no risk to those around him?
Yes. If a person is well treated and has a long term undetectable viral load, they are not infectious. HIV is not transmitted by kissing or normal everyday contact. Paradoxically, it may be safer to be with a partner you know is HIV positive and on treatment than with someone whose health status you do not know. If a partner has an undetectable viral load, HIV is not transmitted - the risk is always higher with a casual partner without this information.
