Safe sex doesn’t just mean condoms anymore

Welcome to the golden age of STI prevention. Sure, condoms are still an effective strategy for lowering the risk of sexually transmitted infections (STIs) — but now, they’re just one of a smorgasbord of strategies for decreasing your chances of catching an infection spread by sex. That includes vaccines to lower your risk of certain STIs, and medications you can take to prevent infection — some with the ease of a morning-after pill, and many that can be mailed to your home after an online telehealth visit. It also includes new STI tests that people can take in their homes, with results available either instantly or within days to enable quick and discreet testing and treatment. In a world where getting sexual health care sometimes feels fraught with judgment, these new methods offer a level of discretion and convenience that feels nothing short of revolutionary. In-person care is still best for getting the most comprehensive and personalized evaluation and education, and we’ve got guidance on how to find that kind of care here. But even sexual health care clinicians recognize it’s annoying — or worse — to go to the doctor sometimes. “Inconvenience — whether it’s cost, or travel, or parking, or taking off work, or other competing demands — is probably a big factor in why people aren’t necessarily engaged in … sexual health care that they might otherwise benefit from,” says Douglas Krakower, an infectious disease doctor and HIV prevention researcher at Harvard Medical School. Stigma — that shameful sense that people who know you have an STI look down on you, whether real or imagined — also sometimes prevents people from getting high-quality sexual health care in person. The bottom line: People often prefer sexual health care that involves as few other humans as possible. Now, there are more ways to get that than ever. Not everyone gets to benefit equally from these advances. Some come with hefty out-of-pocket price tags or are still out of reach for pregnant or likely-to-be-pregnant people. Still, the changes represent a leap forward in an area of health care that needs as much help as it can get. Here’s what’s out there. You can greatly reduce your risk of HIV, syphilis, gonorrhea, chlamydia, and more STIs include a range of bacteria and viruses that cause unpleasant genital symptoms, threaten your ability to have pleasurable sex, and may endanger your ability to have healthy children. Barrier protections like internal and external condoms are still the best (and usually cheapest) way to protect yourself from STIs. However, if you anticipate having sex without condoms, there are now lots of other ways to prevent STIs. Vaccines have come a long way and several can prevent STIs, including HPV (a cause of genital warts and cervical cancer), mpox, and hepatitis A and B. Recent studies also suggest being vaccinated against meningitis can offer some gonorrhea protection, especially among gay men and the people they have sex with. There are also pills and injectable medications that can greatly reduce the risk a sexual partner will infect you with HIV, syphilis, gonorrhea, or chlamydia. HIV prevention is available in a few forms: as a daily oral or every-two-months injectable medication you take before sex (called PrEP, for pre-exposure prophylaxis), or as a month-long regimen of oral medicines you take immediately after sex. The latter option, called PEP, for post-exposure prophylaxis, has to be started within 72 hours of exposure to be effective. Both options work by entering the body’s cells and preventing HIV from replicating inside them. A smorgasbord of new STI prevention options * PrEP, a daily oral or every-two-months injectable HIV-prevention medication you take before sex * PEP, a month-long course of oral HIV-prevention medication you take after sex * DoxyPEP, a morning-after pill to prevent syphilis, gonorrhea, and chlamydia infections * Home-based testing for chlamydia and gonorrhea, syphilis, HIV, and other STIs (click here for free resources; some direct-to-consumer options are listed here) * Vaccines for HPV, mpox, hepatitis A and B There’s even more progress to come in this area: An every-six-months injectable drug for preventing HIV infection called lenacapavir has shown huge promise in preventing HIV infections in both women and trans and nonbinary people and could be available for US use as soon as late 2025. Krakower says an oral option isn’t far behind. Syphilis has been rising explosively in the US for the past few years, affecting gay men and the people they have sex with as well as heterosexual men and women, especially those whose sexual partners include sex workers and people who inject drugs. The trend has huge stakes: Women can spread syphilis to their pregnancies, leading to serious illness or death in their newborns. Earlier this year, the Centers for Disease Control and Prevention released guidelines for using doxyPEP, a morning-after pill to prevent syphilis infection. This breakthrough strategy involves taking the antibiotic doxycycline the morning after sex — and because this medication also fights other germs, doxyPEP also reduces gonorrhea and chlamydia transmission. The problem is that doxycycline’s effects on pregnancy are unclear, but there’s suspicion they’re not good. Many clinicians are therefore hesitant to prescribe it to younger patients in their care. Still, because congenital syphilis has become such a dire national emergency, scientists are seeking ways doxyPEP can protect pregnant people and their fetuses. One focus is getting more men who have sex with men and women to use doxyPEP; another approach may involve prescribing the drug to women at high risk of syphilis infection. In a Japanese study of female sex workers, this strategy led to plummeting syphilis and chlamydia rates. You can get at-home testing for a range of STIs It used to be that if you’d had unprotected sex with a new partner or had unusual genital symptoms — like painful urination, funky discharge, or skin changes like a bump, ulcer, or rash — you’d have to jump through a lot of hoops to figure out whether you had an STI. You would start by visiting a clinic or emergency room; getting your parts swabbed by a clinician (or peeing in a cup or getting blood drawn); waiting for a lab to process those results; waiting for the doctor’s office to communicate those results to you; going back to the clinic for medicine or picking it up at a pharmacy; and then potentially going back again to be retested once treatment was done. Now, a variety of new testing options allows clinics to get test results within hours for a range of STIs. Once these get adopted broadly by clinics and emergency rooms, it’ll be a lot easier for people to get testing and treatment all in the space of one health care visit. Hopefully, that will lower the number of people who get diagnosed with an STI but never get treated for it. Another huge step forward: New tests now enable people to do most or all of the STI testing and treatment process at home, online, or through the mail — without a doctor or another clinician having to get involved. “Agency is what home testing gets people,” says Yuka Manabe, an infectious disease doctor at Johns Hopkins School of Medicine who leads the home-based HIV and STI testing program, I Want the Kit. The FDA has only approved a handful of these tests, and they’re not perfect. For example, the only FDA-approved test that screens for chlamydia and gonorrhea with home-based sample collection is the Simple 2 test — it’s only approved to test samples from penises and vaginas. That means the test can’t be used to diagnose throat and rectal infections, which are more common in men exposed through oral or anal sex with other men. So while the Simple 2 is a great choice for people who engage only in heterosexual sex, it leaves out gay men and people they have sex with. Another important innovation is the First to Know Syphilis Test, which can detect within minutes syphilis-fighting antibodies in blood samples collected at home with a simple skin prick. The FDA approved the test in August. However, it has a catch: The test doesn’t distinguish between new syphilis infections and old, already-treated infections. That means people who’ve had syphilis before can’t use the test to rule out a new infection. It’s worth noting that home-use HIV tests have been FDA-approved for more than a decade, although they also require follow-up testing for positive results. Just because these tests are FDA-approved doesn’t guarantee they are covered by insurance; you can check with your insurer to find out what it will cost you. If it’s not covered, it’s worth checking to see if you live in a part of the country where free HIV, gonorrhea and chlamydia, or trichomonas test kits are available (the American Sexual Health Association lists free HIV and STI home test kit resources). Most of this testing would be free or low-cost if you got it in person, says Elizabeth Finley, the senior director of communications and programs at the National Coalition of STD Directors. “There’s some equity implications” in the reality that higher-income people can afford to pay out of pocket for the convenience of home-based testing, while lower-income people often cannot, she says. Choosing a test is just the beginning An array of companies have created home-based STI tests that haven’t yet been approved by the FDA, including ones for hepatitis B and C, which are often overlooked. Non-approval doesn’t mean a test is garbage — it just makes it harder to be certain that it’s effective at doing what you want it to do. “There are no real guardrails for the companies in terms of the quality they have to offer to customers,” Finley says. “The tests have to work, but I’m not sure customers are fully informed about, if they see a test available on social media, ‘Is this a good one? Is this a bad one?’” The appeal of these tests is strong for people who hate having someone else get their genital sample. Many of them have you pee in a cup, pinprick your own finger and blot blood on a card, or swab a range of body parts at home (including your vagina or penis, your butt, or your throat), then mail that sample to a lab that runs the usual tests on it, which can be retrieved in an online portal. Home testing kits also often make an end-run around the process of getting to a brick-and-mortar clinic to figure out next steps or pick up medication. Many use a telehealth platform to connect people who test positive for an STI with clinicians, who can provide counseling, suggest ways to get partners tested, and mail some medications directly to patients. Curing many STIs requires one or more antibiotic injections, and experts sometimes recommend additional evaluation after a diagnosis. Both of these scenarios require an in-person visit with a clinician. If you test positive for one of these STIs, your test company’s telehealth provider should direct you to a clinic where you can see an in-person clinician. Giving people the option of self-directed sexual health care isn’t just good for people’s sense of autonomy — it’s also a sensible response to impending health worker shortages. Out of concern for an inadequate global supply of clinicians, the World Health Organization has recently recommended a range of self-care interventions for people all over the world, among them many of the latest innovations in STI self-sampling and testing. It’s about time, Manabe says: “We’re not trusting the public enough.”