There has been a long-term decline in condom use by American gay men, researchers from the Centers for Disease Control and Prevention (CDC) report in AIDS. Similar declines have been seen in men whose sexual partners were of the same HIV status and in men who did not know their sexual partners’ HIV status – showing that the fall in condom use cannot be explained by serosorting or other seroadaptive behaviours.
Moreover condom use began to fall long before PrEP became available.
The survey data were collected in 2005, 2008, 2011 and 2014 in 21 American cities as part of the National HIV Behavioral Surveillance (NHBS). Between 1100 and 1600 men who have sex with men took part in each round. Men were recruited at bars and clubs, social organisations, gay businesses, bathhouses, parks, etc.
The researchers asked whether a condom was used with the respondent’s last anal sex partner.
In 2005, 28.7% of HIV-negative men reported sex without a condom, rising to 32.8% in 2008, 34.7% in 2011 and 40.5% in 2014.
Condomless sex with a partner who was believed to also be HIV negative rose (from 21.2% to 27.4%), as did condomless sex with a partner of unknown or HIV-positive status (from 7.6% to 13.1%).
With PrEP use only reported by 0.5% of men in 2011 and 3.5% of men in 2014, PrEP is unlikely to have contributed to the fall in condom use. A sensitivity analysis which excluded PrEP users showed that the trends remained unchanged.
The greatest increase in sex without condoms was seen in young men, aged 18 to 24.
The overall trend was similar for HIV-positive men: in 2005, 34.2% reported sex without a condom, rising to 37.3% in 2008, 39.8% in 2011 and 44.5% in 2014.
Again, condomless sex rose both with partners of the same HIV status (from 19.0% to 25.4%) and with partners of unknown or different HIV status (from 15.0% to 19.0%). The only hint of a seroadaptive behaviour is that condomless receptive anal sex with partners of unknown or different HIV status rose, while condomless insertive sex with those partners did not. (There is less risk of HIV transmission if the HIV-positive partner takes the receptive (bottom) role).
The rising trend of sex without a condom was seen both in men taking HIV treatment (which reduces the risk of onward transmission, regardless of condom use) and in men not taking HIV treatment.
"Our data suggests that condom use has decreased among MSM and that the trends are not explained by serosorting, seropositioning, PrEP use or HIV treatment,” the researchers conclude.
Paz-Bailey G et al. Trends in condom use among men who have sex with men in the united states: the role of antiretroviral therapy and sero-adaptive strategies. AIDS, online ahead of print, 2016.