Familiarity and trust with partners, pleasure, substance use and expectations that partners were on PrEP were among the factors linked with little to no use of HIV prevention strategies among gay men in Australia. Awareness of Undetectable=Untransmittable (U=U) and incorrect information about HIV also affected decisions around using condoms or PrEP, according to a study published in the Journal Archives of Sexual Behavior. Researchers from the University of New South Wales analysed the factors contributing to little to no use of effective HIV prevention strategies among gay men despite the increase in available options.
In-depth interviews were conducted with 24 gay men from the greater Sydney metropolitan area. The research took place between October 2017 and May 2018, a period when PrEP use was rapidly expanding in Australia. The participants were recruited from among the respondents of the online Flux study. Nearly all men (22) interviewed identified as Anglo-Australian, half were on PrEP, and two reported living with HIV. Fewer than half had a regular partner, and all reported periods where they didn't use any HIV prevention strategies. The interviews lasted an hour on average and focused on participants' accounts of their non-use of HIV prevention strategies. PrEP users reflected on their experiences of not using condoms before starting PrEP.
Familiarity and trust with sexual partners emerged as one of the key factors.
"I think I've known them long enough and I think I, I think that they've been tested with ... I've never seen the forms or anything like that that they say, say that they've been HIV-free. But I just think, well, if they were positive, it's a case, well, wouldn't I be positive if they've lost, lost their loads up me arse, you know?" (age 70, HIV- negative, not on PrEP)
For some participants, this trust and familiarity was built over time, while for some it was assessed more quickly:
"So I'd be establishing, you know, how comfortable do I feel to have this person in my home. Then it ... to be honest, it would depend on how much they insisted on safe sex as to whether that would happen or not. I certainly wouldn't push the issue. I probably wouldn't bring it ... If I felt comfortable enough to be having sex with that person, I would, I would probably feel comfortable enough having bareback sex with that person before PrEP." (age 35, HIV-negative, on PrEP)
While most men said they intended to use an HIV prevention strategy, they found it difficult to do so during sex.
"Yeah. I think probably if you'd have asked me in advance 'Are you gonna use condoms?' it would have been 'Yes, of course. And ... in the heat of the moment, it was ... just didn't happen." (age 33, HIV-negative, on PrEP).
"I remember being in situations, going like, "Oh, no, no, no, like I, I only play safe." But, of course ... I guess knowing in the back of my mind, "I know that I'm probably not going to but I'll assess that as it goes along." and then, of course, you're high. ... and it just happens. And, "Oh well, we've already done that, gone that far so, you know..." (age 35, HIV-negative, on PrEP).
Some men said they accepted the possibility of an HIV diagnosis.
“Even before I went on PrEP, which I obtained myself, I had stopped using condoms because I had evaluated enough to think, "You know what? If it [HIV] happens, it happens." (age 51, HIV negative, on PrEP).
With the increasing PrEP uptake in Australia, some assumed their partners would be on PrEP.
"Look, I'll probably get a script but I don't know if I'll take it...Because everybody else would be using it" (age 53, HIV-negative, not on PrEP)
Others had stopped using condoms and preferred partners who are on PrEP or undetectable.
"I s'pose I don't use condoms anymore. I used to use condoms all the time. And that's because of PrEP. So most of the guys that I have sex with are either on PrEP or they're undetectable. And that seems to work for me and that's fine. It took me a while to sort of adjust to it but I'm quite happy not to use condoms now.” (age 51, HIV-negative, not on PrEP).
Most men did not perceive themselves at high risk of acquiring HIV: some were reassured by previous negative test results.
"The first time...it happened I was terrified. And then I... tested, and was [HIV] negative. And then..... I felt increasingly not at risk... I wasn't at any less risk but... it just felt less risky... I know it's not correct but it just felt like, because I'd had condomless sex and not become positive. Then the next time that was just the way it was." (age 33, HIV-negative, on PrEP)
Some participants believed there had to be physical signs such as bleeding to acquire HIV.
"I just don't see that you'd get it that way. I mean there'd have to be a lot of blood or there'd have to be a lot of mucous. There'd have to be all sorts of stuff. And, if there was, 'cause I have been on, not PrEP... what's the other one? [PEP] PEP. [Yeah] I've been on PEP twice, many years ago. So, if there's anything that goes wrong, I do go in and see Emergency." (age 51, HIV-negative, not on PrEP)
While some men were aware of U=U, they believed they could identify men living with HIV as potential partners.
"You know, at that point, you're thinking you're like, you know, it's fine. "I can pick people who have HIV. Like I know." And like, no, you don't. But, yeah, so I think that was my main protection method was my, my own ability to pick people out who have HIV. (age 22, HIV-Negative, not on PrEP).
Some men had recently started to take PrEP, often due to changes in their relationship status or after an STI diagnosis. These participants were able to reflect on the times when they used HIV prevention strategies inconsistently and how PrEP affected their well-being.
"I don't get to the end of the sex and feel concern or guilt. Why did I do that? Why did I have unprotected sex? It's made it so much easier or relaxing, or enjoyable in the moment and after the moment. On the few times prior to going on PrEP, a few times or occasionally when I would have unprotected sex I'd immediately regret it the moment I came. And then I'd regret it all the way through until I had my next HIV test. And then you'd have the test and there's the waiting for the results... Probably dealt with it better than some people but still, it really wasn't a pleasant experience... That doesn't happen anymore. I go to the doctor, have the test. In fact, I haven't thought about that for a while. It's so good to not freak out after sex or be freaking out in-between when you have your HIV test and you get the results. That is really been so worth it. (age 41, HIV-Negative, on PrEP).
“Participants indicated that the familiarity and trust that they built with their partners were strengths and positive aspects to their sexual relationships,” the authors emphasise. “However, in the absence of meaningful conversations about sexual health this same familiarity and trust with casual partners could expose men to increased HIV risk."
They add that some men in the study "described being caught up in the ‘heat of the moment’ during sex as the reason they did not consistently use a risk reduction strategy”. They conclude that "the 'heat of moment' rationalization highlights the need for health promotion interventions, at both the individual and social levels, to engage gay and bisexual men in planning for safe sex in advance of sexual experiences. This finding also suggests that strategies such as PrEP and TasP [Treatment as Prevention], which remove the impost on individuals to think about HIV risk during sexual encounters, could be effectively promoted as a solution to this necessity."
Kolstee J et al. Trust, Familiarity, Optimism, and Pleasure: Australian Gay Men Accounting for Inconsistent HIV Prevention Practices in the PrEP Era. Archives of Sexual Behavior, online ahead of print, 4 May 2022.