Of the nineteen HIV negative participants, eight had used PEP, seven had used TasP-facilitated viral load sorting, and two were using PrEP at the time of the interview. Each of the quotes presented below are identified by a pseudonym and the participant’s reported age.
Overall, participants expressed a range of complex and often conflicting perspectives on condoms, from outright disdain to approval. However, a general rejection of consistent condom use was evident, and contextual condom use within a combination prevention framework was the norm. First, we examine participants’ perceptions and use of condoms, beginning with the intrapersonal or individual factors they identified as contributing to inconsistent use and building to the policy-level. We then outline participants’ motivations for continued condom use within a combination HIV prevention framework.
Social Ecological Factors in Perceptions and Use of Condoms
Intrapersonal (Individual) Factors
McLeroy and colleagues [56 p355] describe intrapersonal factors as “characteristics of the individual such as knowledge, attitudes, behaviour, self-concept, skills, etc.” Participants in this study described a number of these individual factors as influencing their condom use, including the desire for increased sexual pleasure, eroticism and freedom, substance use, and perception of risk.
For many participants, condoms inhibited physical pleasure and they therefore disliked using them. For Curtis (age 25) sex without condoms simply felt better: “it’s hard to get used to … wear [ing] condoms when … the physical pleasure is so much more with not having a condom.” In addition to decreasing physical sensation, condoms were viewed as impeding sexual performance, as Jordan (age 25) noted: “a lot of guys when they hear the word ‘condom’ or just hear that wrapper, they immediately lose their hard-on there.” This suggests that condoms were also perceived not only as a physical challenge but as a challenge within the emotional realm of eroticism and sexual desire. CAI was deemed more exciting, with some participants, including Malcolm (age 34), noting that riskiness could itself be perceived as erotic: “there was probably an element of risk involved which, unfortunately, is quite exciting … [CAI is] more enjoyable.”
Ideas about sexual freedom and liberation were additional factors in inconsistent condom use. Some participants viewed condoms as a barrier to sexual liberation and expression, and highlighted their desire to explore sex more fully through CAI. Aaron (age 46) wanted to explore the “deeper and darker … parts of sexuality” and “push … the limits of the traditional ideas of sex” through HAART-mediated CAI. In addition to the “pull” of the liberating potential of CAI, participants also experienced a “push” away from condoms due to their association with anxiety and fear around sex, as Bob (age 58) indicated:
anything that … reduces the anxiety around sex and allows it to be this wonderful expression and experience of life is a really positive force … if the treatments are allowing that, permitting that … with the absence of anxiety and stress around it, the world is going to be a better place …
For Bob, condoms represented anxieties around sex whereas HAART-facilitated CAI allowed for a fuller, more positive expression of sexuality. Given this contrast, participants’ rejection of consistent condom use is not surprising. Indeed, many participants expressed fatigue and frustration with condom use, especially those who had been practicing safer sex for many years. While they acknowledged that condoms were effective, several participants described sex with condoms as “boring” (Aaron, age 46) or “unsatisfying” (Bryan, age 49). Dan (age 46) explained, “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 that in a lot of cases they just made it not worth it.”
With regards to individual behaviour, substance use strongly impacted condom use and sexual decision-making. Many participants stated that when using substances, they took sexual risks with which they would otherwise not be comfortable. As Russell (age 26) described: “I was into a lot of drinking and drugs and I was just really being very unsafe in general … becoming conscious to that situation really had me concerned.” In Kevin’s (age 31) opinion, “the drugs or the desire for pleasure exceeds the precaution in that moment. And I’ve regretted those decisions, very much so.” By altering the relative value of risk and pleasure in the decision-making process, participants felt that substance use decreased the likelihood of condom use in a given sexual encounter.
The final intrapersonal factor impacting condom use for participants in this study was their perception of HIV risk. Several expressed what Prestage and colleagues  refer to as treatment optimism, stating they were “less fearful” (Will, age 28) due to treatment advances that had rendered HIV a chronic condition, the management of which one participant likened to “brushing your teeth before you go to bed” (Bryan, age 49). For Kevin (age 31), HIV was
… no longer a death sentence, so even though the stress of becoming positive is still there, the severity of it, the weight of it, is no longer as strong or as heavy as it once was because there are solutions … I have a lot of friends who aren’t detectable … and they’re leading good lives.
The transformation of HIV into a treatable, livable condition deeply impacted participants’ concerns over HIV transmission and influenced their condom use habits as a result.
Other participants demonstrated transmission optimism , explaining that the availability and perceived efficacy of HAART-based interventions contributed to their views that consistent condom use was unnecessary, due to perceptions that the chances of HIV transmission were low. Curtis (age 25) was unconcerned about sex with partners who were currently using HAART because of his belief in the effectiveness of these treatments: “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.” Notably, this “nothing to prevent” seemed to extend to other STIs, against which biomedical HIV preventions offer no protection, although participants did not typically express any concern over this.
Interpersonal (Relationship) Factors
On the interpersonal level, participants’ perceptions of condoms were primarily shaped by their interactions with sexual partners. In encounters with new partners, several participants emphasized the need to maintain the mood or the “heat of the moment”, noting that discussing sexual safety and potential condom use disrupted or inhibited sexual interactions. Bob (age 58) felt that asking about HIV status “breaks the whole mood of sex and … how far you're going to go and what you're going to do … just by asking the question, it kind of for me resulted in holding back.” The “heat of the moment” could also result in a decrease in the perceived importance of safety, which was the case for Will (age 28): “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.” For the participants in this study, “good sex” and explicit conversations regarding condom use were often incompatible.
A small number of younger participants mentioned that imbalances in relationship power dynamics and the ceding of sexual decision-making to partners could contribute to reduced condom use. These young men indicated that pressure or coercion from sexual partners could lead to CAI, especially when sex was negotiated on uneven terms. Russell (age 26) noted:
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 or peer pressure or if there’s somebody they really feel a connection to and then say, yeah, but no condoms, period.
The suggestion that peer pressure and the threat of withholding sex could motivate CAI – especially when the partner advocating for condom use lacked sexual agency – described Kevin’s (age 31) experiences as well:
[It’s] like a back and forth, because I would like to use them [condoms]; well, I don’t want to use them. Well, I would like to, you know, can you try not using? No … And for the most part I end up not using them, because I feel like kind of … not pressured, but I want to have the sex.
In these instances, Kevin felt that his desire to have sex, even on terms with which he was not entirely comfortable, outweighed the risks of CAI and he therefore agreed to forego condom use despite his initial reservations.
Within primary relationships or for participants in search of such relationships, the pursuit of emotional intimacy was frequently cited as a reason for abandoning condom use due to the perception that CAI facilitated “closeness” (Kevin, age 31) and “more natural” sex (Curtis, age 25). According to Chris (age 51) this desire for intimacy could be a stronger motivator than physical pleasure:
… it's almost to the point [where] there's really no point without it being raw, without it being bareback … let's face it, it's not a huge feeling difference … But it's a huge difference for me in my mind, like the intimacy factor …
Related to the desire for intimacy and closeness, participants argued that CAI could provide an opportunity to build trust with a partner, since condomless encounters required a greater degree of communication. Curtis (age 25) explained:
[condomless encounters are] probably going to be much more of an opportunity to learn about things and maybe almost gets you closer with other people because it’s all … a trust thing, right? … I trust them and they can see that I trust them … it just kind of builds trust in a weird way. I feel like having sex with people definitely builds trust, always.
Here, Curtis describes trust not just as a motivation or requirement for CAI, but as something that could be expressed and developed through CAI. Within the context of longer-term relationships, not only did trust and intimacy facilitate CAI, but CAI could serve an important emotional function in interactions with partners.
One strategy that participants described as an alternative to practicing consistent condom use within primary partnerships was negotiated safety agreements that either ensured monogamy or placed limits on risky sexual behaviour outside of the relationship that could lead to seroconversion. In some cases, these agreements entailed getting tested and agreeing to monogamy with a partner before ceasing to use condoms, as Jordan (age 25) did: “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.” Monogamy was viewed as an ideal means of safely engaging in CAI by a few participants, although they acknowledged the potential for dishonesty. Bryan (age 49) stated
… when I’m with a partner … basically I flat out tell them that I want to be in a monogamous relationship. I don’t want to be sleeping with other people. But if I did ever sleep with somebody else I would tell you before I had sex with you again just out of pure respect for your sexual health and my sexual health … And I would want them to do the same thing to me.
For other participants, these agreements could involve CAI with more than one main partner while having the option of casual anal sex using condoms outside of these partnerships, as was the case for Dan (age 46): “If I am ever again going to play with somebody … other than my husband or boyfriend, I will use a condom with them. I’m just not willing to take that risk.” In addition to testing and monogamy, participants managed risk with casual partners through a variety of measures other than condom use, as George (age 51) explained: “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.” Regardless of the details of their safety agreements, participants viewed such agreements as safely facilitating CAI within primary partnerships.
Social (Community) Factors
Adding to the intra- and interpersonal factors affecting participants’ views on condoms were community-level factors, such as shifting norms around condom use, “barebacking,” and seroadaptive strategies. Dislike for condoms was not only an individual preference; participants suggested that their personal views reflected shifting community norms, though the extent to which this shift was in fact occurring or was overemphasized to legitimate personal desires for CAI is difficult to ascertain. In contrast to this personal preference for CAI, however, participants often expected that others would continue to use condoms, as Scott (age 48) stated:
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.
As well as highlighting the difference between men’s personal choices around personal condom use and their expectations of others’ use, Scott’s statement provides another example of the contrast between many gay men’s beliefs or intentions around condom use and their actual behaviours. The gap between behaviour and intention led to some participants questioning how effective condom-based strategies could be at a community level when used inconsistently. As Wayne (age 36) observed, “condoms … also depend on people being adherent and we know that regular condom use has been on decline for many years in the gay community.”
Participants’ condom use and perceptions were additionally influenced by the increasing prevalence of barebacking. Bob (age 58) remarked that this shift had occurred in a relatively short period of time: “ … 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.” In Scott’s (age 48) experience this shift had been so dramatic that “I really don’t know anybody who uses condoms. Like, I can hardly think of anybody.” Summarizing the impact of community norms on individual behaviour, Wayne (age 36) noted that the “social acceptability of barebacking seems to have evolved.”
The increasing prevalence of seroadaptive strategies within the gay community was mentioned by several participants as further evidence of shifting community norms. Along with negotiated safety agreements and viral load sorting, serosorting and strategic positioning were used, offering viable alternatives to condoms. For some, these strategies were presented as methods that could virtually eliminate risk. Cody (age 22) felt that this was the case for serosorting: “sex between people who are communicating their statuses isn’t risky at all because you know what's going on.” Similarly, George (age 51) expressed his confidence in the efficacy of strategic positioning for himself and his primary partner: “because we're basically only topping, I'd say we actually probably don’t care at all [about our partners’ HIV statuses].” Whether this level of confidence reflects community norms and/or an attempt to legitimize personal preferences, the frequency with which participants referred to these strategies indicates that they had gained a great deal of traction within the community as an alternative to condoms. While several participants questioned the efficacy of serosorting, most agreed that strategic positioning was effective, including Wayne (age 36), who noted “I mostly top … I think it's reasonably well-established that that is generally a lower risk than bottoming.” The description of strategic positioning as an “established” means of risk reduction supports the notion that seroadaptive strategies have become a norm within the gay community.
Within the broader context of shifting community norms, participants noted that specific social situations – such as the bathhouse setting – could contribute to decreased condom use. In their view, the bathhouse was a context in which CAI was expected, legitimizing personal preferences for CAI. Bob (age 58) cited an experience of receptive condomless group sex in a bathhouse as an example of how environment factored into the choice to engage in CAI: “Sometimes in sex you just can be totally taken away … so in the bathhouse, for example, I can just totally lose myself in sex … I wasn't expecting it, it just happened out of the blue, but I didn't stop it, that's the important thing.”
On the policy level of social ecological factors in health , participants’ attitudes towards condoms were shaped by the availability and quality of HIV treatment in BC, as well as their knowledge of these treatments, which was largely facilitated by various innovative community-based organizations . Since 2010, TasP has been actively promoted in BC, with free HAART available to HIV positive individuals province-wide . This policy clearly played a role in participants’ overall optimism regarding HIV, which they generally viewed as a treatable chronic condition due to the accessibility of HAART. While most did not explicitly state that public policy had contributed to their personal optimism, some did directly acknowledge the impact of policy on community and personal perspectives. Aaron (age 46) explained, “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.” For Aaron and many other participants, the proven efficacy and wide availability of HAART in BC had transformed seroconversion from a death sentence to a treatable condition, rendering HIV much less frightening than it had been in the past. Aaron went on to explain that
[HAART-based] strategies and these options that are out there now have definitely redefined
the traditional definitions of safe sex and riskier sex … I just think that people are … definitely redefining what they consider to be risky or what was considered risky has now become [safer].
Based on Aaron’s statement, policies that have increased the availability of TasP, PEP and PrEP have shifted both community- and individual-level perceptions of risk and safety surrounding HIV transmission, fundamentally altering the meaning of risk and safety. Aaron’s remark clearly demonstrates how policy-level factors interact with intrapersonal, interpersonal, and community factors to produce observable impacts on health behaviours.
In addition to reducing the fear of HIV transmission, policy shaped participants’ perceptions of the relative risk posed by HIV positive undetectable partners. While not all participants agreed on the efficacy of serosorting as a prevention strategy, viral load sorting – seeking out HIV positive undetectable partners – was deemed an effective means of prevention and an excellent alternative to condom use by many. Most participants expressed a preference for undetectable partners over HIV negative partners, and displayed considerable knowledge about TasP and undetectability that reflected the unusually high rates of TasP awareness among gay men in Vancouver generally . Chris (age 51), noted his confidence in viral load sorting as a prevention strategy, although he believed that viral load measurements did not always accurately reflect infectivity: “The transmission for that is extremely low as well. Even though it’s … done with things like saliva and blood whereas … [I'm more interested in] semen because the concentration of that I'm thinking would probably be a lot higher.”
Among participants who preferred viral load sorting to serosorting, the reasoning for this preference varied. One reason was the view that undetectable individuals were more likely to be aware of their sexual health in general, as Curtis (age 25) explained:
… they 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.
This statement points to the possibility that the availability of TasP in BC has contributed to the perception that not only are HIV positive undetectable individuals “low risk” with regards to HIV transmission, but lower risk in terms of all STIs. On a related note, Aaron (age 46) felt that the current, detailed sexual health information undetectable partners could provide as a result of routine testing made them more trustworthy than those who claimed to be HIV negative:
when it comes to negative guys … it can be a little bit harder to take their word for it. But … 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.
Overall, provincial public policy that has made TasP widely accessible and highly visible was an important factor in participants’ adoption of viral load sorting as a means of HIV prevention, demonstrating the considerable effects of policy decisions on individual perceptions and behaviour.
Provincial public policy also had a substantial impact on the uptake of PrEP and PEP among participants, albeit in a less positive manner. In contrast to the active promotion of TasP, participants noted that barriers to PEP and PrEP access and promotion were prominent at the policy level. For example, cost could hinder access to PrEP, and for both PrEP and PEP, interactions with healthcare providers, some of whom may be reluctant to prescribe these interventions, created an additional barrier. Regarding PEP, Scott (age 48) noted:
[PEP] doesn’t seem particularly effective … you have to go to Emergency, wait around for hours and hours … And then be shut down half the time … if it was accessible as hell we could just walk to the pharmacists and say give it to me … But that’s not how they do it.
Scott’s description of the arduous process of securing PEP contrasted sharply with participants’ general portrayal of TasP promotion, revealing gaps that may need to be addressed at the policy level.
Contextual Condom Use and Combination Prevention
Participants held complex and conflicting perspectives on condom use, shaped by numerous factors at all levels of the social ecological model of health, and most participants continued to use condoms in certain situations. While they generally felt that prevention strategies other than condoms could be highly effective, many nevertheless expressed continuing anxiety regarding HIV transmission. Jamie (age 30) noted that “I was very anxious about making sure that I don’t get HIV and like if there was any possible chance, even like 0.1%, I don’t want it.” This anxiety was particularly evident when participants described sexual encounters in which they had chosen not to use condoms, acknowledging the stigma that still existed around HIV seroconversion, and referring to condoms as a proven method of risk reduction that offered “peace of mind”. Although they may have had confidence in other methods, when asked to compare the effectiveness of various options the majority of participants agreed that condoms were either very effective or the most effective form of prevention.
For some participants, the accessibility of condoms in comparison to the relative inaccessibility of biomedical interventions factored into their perceived effectiveness. The issue of accessibility was compounded in some participants’ views by worries that the growing prevalence of biomedical interventions would have adverse effects on prevention efforts as a whole. Cody (age 22) was concerned that new interventions might lead to decreased communication between partners: “PrEP makes sex much less risky but also is something that makes you not have to communicate as much either.” Other study participants felt that the potential lack of communication could increase levels of sexual risk taking. Bob (age 58) suggested that the increase in CAI facilitated by PrEP would potentially lead to a net increase in HIV transmission: “HIV is still real, it is still being transmitted presumably … allowing for [greater] access to sex suggests to me that there is a possibility of … higher transmission rates.”
In contrast to the perception of condoms as a proven prevention method, participants discussed biomedical treatments in more conflicted terms. They had similar concerns regarding seroadaptive strategies, predominately due to the reliance on accurate, trustworthy disclosure. Several participants noted that casual partners may be dishonest about their serostatus or may be unaware of their status, therefore undermining serosorting as a prevention strategy. As Curtis (age 25) put it, “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.” Participants had similar worries regarding communication with undetectable partners: Scott (age 48) suggested, “You have to know a person very, very well to have much confidence in [treatment as prevention].” This statement indicates that relying on TasP disproportionately placed the burden of responsibility on the HIV positive partner; while this was seen as a benefit by some participants, it produced anxiety in others.
Participant perspectives on biomedical prevention strategies as an alternative to condom use further varied depending on the specific method in question. Among PEP-experienced participants, condom use was reinforced by the experience of seeking out biomedical treatment. This group described PEP as a “wake-up call” that highlighted the potential consequences of CAI and the value of consistent condom use. Using PEP offered a window into the burdens of HAART-based treatment and the necessity of adherence for HIV positive individuals, as Aaron (age 46) acknowledged:
even having to do the regimen of PEP, I think there was three different pills you had to take and it really … made me aware of wow … this could be a lifelong part of your life, right? Not that was good or bad but it just was something that would impact your original previous way of living.
Participants also noted the anxiety and fear of these experiences and wished to avoid those feelings in the future. Kevin (age 31) stated, “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.” Cameron’s (age 26) experience with PEP likewise reaffirmed his decision to use condoms: “you just kind of look out for yourself more, or you just don't make stupid decisions … I mean you know you never want to repeat that ever again, so, yeah it is more of a conscious choice.”
Despite their concerns about the effectiveness of biomedical and seroadaptive strategies, many participants used condoms only in casual, higher-risk encounters while relying on other forms of prevention in other contexts. Russell (age 26) noted:
I think the best method, in terms of random hook-ups or bath houses, parties, things like that; I think, really, condoms is the best way to go just because it’s accessible. Anybody can use it, really. It’s just really practical … if we’re going to hook-up just because we’ve had a few drinks or the chemistry is right or feeling casual that day or whatever … condoms is typically my go-to.
Russell’s statement suggests that the accessibility of condoms and their utility within casual encounters may account for their continued use in certain contexts. Participants also acknowledged that no singular form of prevention was completely effective and suggested that combining multiple strategies provided the most protection. For some, including Wayne (age 36), the combination of PrEP and condoms offered “reassurance”:
PrEP is not 100 percent certain either … but it's a great deal more certain than most of the other options … there are some who say it's more certain than condom use, if you assume adherence is high on PrEP side and if you accept that adherence on the condom use side is - and correct use of condoms and breakage and all those sorts of things - is not 100 percent. So it - it certainly has added a significant layer of reassurance.
Other participants combined forms of prevention as an alternative to condoms. In Dan’s (age 46) case, he and his HIV positive partner employed a combination of strategies that he felt rendered condoms unnecessary:
My boyfriend is positive, but he’s undetectable and he and I both get checked every three months, just in case, and I always top, and I feel comfortable with that; I’m not worried about catching anything from him with that kind of a setup.
By combining viral load sorting, strategic positioning, and frequent testing, Dan and his partner were able to manage risk without condoms, despite being in a relationship that may have typically been considered “high-risk.” Presumably, this enabled Dan to optimize pleasure and intimacy within his relationship while still allowing for “comfort” in terms of sexual safety and the minimization of risk.