HIV-negative men who have sex with men (MSM) living in Vancouver, Canada are
redefining ways to negotiate sexual safety and risk, according to qualitative
research recently published by Dr Benjamin Klassen and colleagues in BMC Public Health. Condoms are no longer
seen as the only means of preventing HIV infection.
Biomedical
prevention strategies – including the use of pre-exposure prophylaxis (PrEP)
and treatment as prevention (TasP) – emerged as important reasons for
inconsistent condom use among HIV-negative men. These men also adopted “seroadaptive”
strategies such as selecting partners based on their HIV-negative status) and selecting
HIV-positive partners who had an undetectable viral load. Ongoing concern over
possible HIV infection and the belief in the high efficacy of condoms were some
reasons to continue using them.
Semi-structured
interviews were conducted with 19 HIV negative men (aged 22-58, median age 36).
Eight men had used post-exposure prophylaxis (PEP), seven had engaged in
sorting based on partners’ viral loads and two were on PrEP. Interview
questions focused on prevention strategies participants had used, their
perceptions of these different strategies and how they rated different
strategies in terms of efficacy. Researchers conducted thematic analysis considering
factors influencing choice of prevention strategy ranging from individual to
policy levels. These themes are expanded upon below:
Individual factors
Participants
expressed varied views regarding condoms but there was a widespread rejection
of the notion of consistently using condoms for all sexual encounters. For most
men, a combination prevention approach was used.
A desire
for increased sexual pleasure and freedom emerged as an important
individual-level factor when it came to rejecting condoms.
“A lot of guys when they hear the word ‘condom’
or just hear that wrapper, they immediately lose their hard-on there.” Jordan, 25
“I’ve always understood the necessity for
condoms but I’ve always hated them; they take so much away from the experience
and make it such a pain…” Dan, 46
Men cited
more instances of condomless sex when using substances.
“The drugs or the desire for pleasure exceeds
the precaution in that moment. And I’ve regretted those decisions, very much
so.” Kevin, 31
Men also
explained that their perceptions of risk had changed in light of biomedical
advances. HIV was no longer seen as a death sentence and men who were on antiretroviral therapy,
either on PrEP or undetectable, were seen as ‘safer’ sex partners.
“If…they’re on PrEP or they’re…undetectable…I
don’t really think about it…I don’t really see that there will be
a…transmission, therefore there’s nothing to prevent.” Curtis, 25
Relationship factors
In
interactions with sexual partners, participants talked about the need to
maintain the mood and said that discussing condom use would disrupt the
interaction. Men wanted to maintain intimacy in the “heat of the moment”:
“I'm conscious of having safe sex, and that's
important to me, and then I find myself in the moment it's not important to me,
and…I like the way it feels without a condom, so I push past that.” Will, 28
Power
dynamics and coercion could also affect condom use.
“If somebody is a little more submissive, then
I know there are some people that kind of try to bully people into not using
protection…” Russell,
26
Additionally,
some men reported using negotiated safety arrangements or strategic positioning
in order to minimise chances of infection.
“I am only with one partner…when we decided
that we wanted to be in a monogamous relationship [we agreed] to go…and get
tested together and be able to drop the condom.” Jordan, 25
“We try to look for people that are negative or
undetectable and we tend to just be tops only. But do whatever with each
other.” George, 51
Community factors
At the community
level, the widespread acceptability of “barebacking” was evident from many of
the men’s responses. Interestingly, men often referred to condoms as a
prevention strategy that others could use but that did not necessarily work for
them. For many men, there was a mismatch between intentions regarding condom
use and reality.
“Certainly five years ago you would just never
come across it. And today… the number of requests to bareback is
just…exponentially over where we were two years ago.” Bob, 58
“Social acceptability of barebacking seems to
have evolved.”
Wayne, 36
“Condoms are one of those things that, you
know, like public transit. It’s something you want everyone else to take…They
don’t like using them themselves necessarily but they certainly don’t think
anybody else should be able to get away with not using them.” Scott, 48
“I mostly top…I think it's reasonably
well-established that that is generally a lower risk than bottoming.” Wayne, 36
Here, “well-established”
indicates that there is a broader community-level understanding of the risk
associated with certain sexual positions. Thus, the sero-adaptive strategies referred
to do not merely exist at the individual level but are prominent at broader
levels too.
Policy factors
The
widespread availability of HIV treatment in the province of British Columbia,
where Vancouver is located, as well as public education regarding undetectable
viral load impacted sexual decision making by these HIV-negative men.
“The treatment for maintaining…undetectab [ility] is of such high quality here in BC, and if your story is about you know
just how great the care is…maybe the idea of turning positive isn't as scary as
it once was.”
Aaron, 46
Some
participants expressed that they sort for partners based specifically on
undetectable viral load and feel comfortable with condomless sex in those
encounters. In fact, for many men in this study, seeking out undetectable
partners was seen as an effective means of prevention and was often preferred
to condoms. Additionally, men commented on the fact that HIV-positive men would
also be screened for other STIs routinely, thereby making them ‘safer’ sexual
partners not just in terms of HIV, but also in terms of other STIs.
“…When somebody is sharing their status and
their viral load and all those things with me, I feel there’s a level of
honesty there…I could be giving too much trust, possibly…but I feel safer in that
situation than with negative guys.” Aaron, 46
“They [people with HIV] have to get tested every month, every three months or something. They
do routine blood work, which means they’re probably going to catch any other
STI’s they have, therefore…they’re most likely going to be…either STI free…or
they’ll be treated.” Curtis, 25
The role of condoms in combination prevention
Many men
expressed continuing anxiety regarding contracting HIV and did not abandon
condom use altogether. Despite shifting social norms and confidence in
biomedical prevention methods, condoms were still seen as the most effective
way to prevent HIV infection. Condoms were described as an accessible and
reliable prevention method.
“If I were to choose to have sex…in a casual
setting, I would have a condom, because I don’t want to go through that stuff
again, the stress of not knowing whether I’ve contracted something.” Kevin, 31
Concerns
were also raised regarding issues around trustworthy disclosure when it came to
sero-adaptive prevention strategies and the drawbacks of relying on methods
such as PrEP without knowing a sexual partner’s adherence. Thus, it was evident
that condoms still had an important, albeit diminished, role to play in the
men’s overall prevention approach.
“No one is really HIV negative unless you got
tested that second and had sex the next minute, right? Because that’s the only
way of knowing you had sex with someone else who is HIV negative.” Curtis, 25
Conclusion
This study
illustrates how some MSM’s perceptions of what constitutes ‘safer’ sex are
changing, in step with shifting social norms and biomedical advances. For most
of the men interviewed, a combination prevention approach appeared to be most
realistic as it was able to account for crucial factors at the individual and
community levels. Policies regarding treatment as prevention also shaped
decision-making more indirectly.
While there
was still a large amount of anxiety surrounding HIV infection (despite it no
longer being seen as a death sentence) and while condoms were frequently cited
as the most effective means of preventing infection, the men’s best intentions
and real-life behaviours often did not match up.
The authors
suggest that research of this nature has important public health implications
and that HIV interventions that rely solely on condoms will be seen as obsolete
for MSM such as those in this study. The expansion of preventative means
available to men has resulted in new definitions of what constitutes “safer
sex”, with undetectability emerging as an important factor. While the condom
has not been discarded completely, it is important for public health and
community-based interventions to acknowledge the role of multiple, combined
prevention strategies and to effectively translate this into HIV prevention
messaging aimed at MSM.
