“Condoms are … like public transit. It’s something you want everyone else to take”: Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention

Despite concerted prevention efforts and the increased availability and uptake of biomedical advances, gay and other men who have sex with men (henceforth gay men) are disproportionately affected by the Canadian HIV epidemic, representing approximately half of all new diagnoses nationally [1, 2]. In British Columbia (BC), rates of new diagnoses among gay men have remained consistent despite a decline in overall numbers of new diagnoses [3], with consistent increases in diagnoses among young gay men (born after 1980) of particular concern [3, 4]. A 2016 study of gay men in Vancouver, BC estimated that 23.4% were HIV positive, of which an estimated 18.6% had an unsuppressed viral load [5]. Until recently condoms were synonymous with HIV prevention among gay men, but condom use is now declining and condomless anal intercourse (CAI) is on the rise both in total incidences and the number of different CAI partners over time [6–10].

Scholars have posited a number of explanations for this decline in condom use. Some have suggested that three decades of condom-based prevention messaging and interventions have caused safer sex fatigue or burnout, leading to inconsistent condom use. New interventions that focus solely on condoms may be viewed as ineffective or unrealistic, and may therefore be rejected, particularly among older gay men who are tired of prevention messaging focused primarily or exclusively on condoms [11–15].

The growth of a “barebacking” (intentional CAI) subculture is another potential contributor to inconsistent condom use. Studies have noted the growing prevalence of “bareback”-identifying gay men who are aware of the risks of CAI but choose to have condomless sex regardless, possibly due to the payoff of increased sexual pleasure [16–18], though motivations vary by age and ethnicity [19]. As “barebacking” has become normalized, with help from media like pornography [20], non-“barebacking” gay men may feel pressure to engage in CAI [17, 21].

Emotional and erotic factors may also influence condom use practices. Condoms are frequently perceived as a barrier to sexual pleasure and arousal, whereas CAI is viewed as facilitating sensation, physical pleasure, and deeper levels of eroticism and lust [21–24]. A desire for trust, intimacy, commitment, and love may provide further motivation, wherein CAI serves as a manifestation of these emotions and a representation of the depth of a given partnership [21, 23, 25, 26]; condoms by contrast are seen as a barrier to intimacy [7].

Existing literature also highlights the impact of substance use on consistent condom use. Excessive consumption of alcohol and crystal methamphetamine use in particular have been shown to increase incidences of CAI, with binge drinking and club drug use potentially leading to particularly high-risk encounters with casual, HIV-serodiscordant partners [27–29].

The final and perhaps most significant factor influencing condom use is the emergence of highly active antiretroviral therapy (HAART) - based biomedical interventions: Treatment as Prevention (TasP) – using HAART to treat HIV positive individuals and lower individual and population-level viral loads [30]; Pre-Exposure Prophylaxis (PrEP) – consistent use of HAART by HIV negative individuals to prevent seroconversion in case of exposure [31]; and Post-Exposure Prophylaxis (PEP) – a 28-day course of HAART taken by HIV negative individuals immediately following potential exposure to prevent seroconversion [32]. One explanation for the influence of HAART on condom use is a growing sense of “optimism” as HIV has been transformed from a death sentence to a chronic condition [11, 33]. This optimism may be due to the perception that HAART has made HIV more manageable and less frightening, or a result of a perceived decrease in the likelihood of transmitting or contracting the virus [33]. As antiretrovirals have been proven to be an effective prevention tool, incidences of CAI among gay men have increased, indicating that optimism may shift the relative balance of risk and pleasure in gay men’s sexual decision-making [6, 11, 33, 34].

Other scholars have explained the relationship between declining condom use and availability of biomedical interventions using the concepts of behavioural disinhibition – which emphasizes the emotional or physical determinants of sexual behaviour – and risk compensation – which emphasizes the rational weighing of risk in sexual decision-making [22]. Biomedical advances have potentially shifted both the rational risk balance and existing self-imposed behavioural constraints to the extent that the corresponding increase in CAI may offset the potential benefits of HAART-based interventions [22, 35]. The evidence for this explanation is conflicting, however; although condom use has increased among PrEP clinical trial participants, [36, 37] evidence for risk compensation outside the clinical setting is inconclusive [37, 38]. Some non-clinical studies have documented decreases in condom use ranging from 23% to 60% [15, 35, 39–41]; in other analyses, participants did not believe that access to PrEP would affect their own condom use, but believed that other gay men would likely have more CAI [8, 42]. A study of highly sexually active gay men in New York found little evidence of risk compensation, with the exception of a small, particularly at-risk group of gay men who were already having CAI, making them prime PrEP candidates [15]. Studies of PEP use have similarly found little support for risk compensation, with many participants describing their experience with PEP as a “wake-up call” that ultimately led to more consistent condom use [9, 43].

The development of various seroadaptive prevention strategies that enable CAI while mitigating sexual risk may be further affecting rates of condom use [44]. These strategies are possible because of biomedical advances, and include: serosorting – seeking seroconcordant partners or selectively engaging in specific sexual behaviours based on a partner’s known HIV serostatus [7]; viral load sorting – actively seeking partners with low or undetectable HIV viral load or using this information to determine the type of sexual beahviours between serodiscordant partners [33, 45]; negotiated safety – monogamy agreements between primary partners or the exclusion of high-risk behaviours outside of the primary partnership [19, 46]; and strategic positioning – taking the insertive role as an HIV negative partner in CAI with HIV positive or unknown status partners [44]. While these measures are increasingly common among gay men, their effectiveness is not well-studied; furthermore, these strategies rely on explicit communication, disclosure, and trust, none of which are guaranteed in a given sexual encounter [19]. Rather than communication and trust, many gay men tend to assume or infer the HIV status of their partners without explicit conversation [21]. Further, negotiated safety agreements are not always upheld as a large proportion of HIV transmissions (as much as 68%) occur within the context of primary relationships [47–49].

In this paper, we offer a further qualitative contribution to the literature on condom use trends and perceptions with a particular focus on the impacts of HAART-based interventions on gay men’s HIV prevention practices. Using a social ecological model of health [50], we examine the current place of condoms within gay men’s sexual risk management practices, and explore the motivations for their use and disuse. We then suggest possible improvements to current sexual health interventions that take into account the various interrelated factors affecting condom use among gay men and the shifting definitions of sexual safety and risk.

Participants were drawn from the Momentum Health Study, a longitudinal bio-behavioural prospective cohort study of HIV positive and HIV negative gay men in Metro Vancouver, BC, Canada (inclusion criteria: age ≥ 16 years, live in Metro Vancouver, identify as a man (including trans men), have had sex with a man in the last six months, and able to answer a questionnaire in English) [5, 51]. Participants were eligible to take part in an interview if they were HIV negative and had reported prior use of PEP, PrEP, and/or viral load sorting. In total, nineteen individuals ranging from the ages of 22 to 58 (median average: 36 years) agreed to be interviewed. Trained peer research associates [52] who had prior experience working with gay men conducted the interviews. Participants provided written informed consent prior to the interview, and an honourarium of $50 CAD was given upon interview completion.

Interviews were semi-structured [53]; questions focused on participants’ perceptions and use of various HIV prevention strategies, particularly PEP, PrEP, and viral load sorting [see [54]. Participants were asked to describe what HIV prevention meant to them, what strategies they utilized to prevent HIV, and how they would compare the overall effectiveness of various prevention strategies. Finally, they were asked to consider how their knowledge of biomedical prevention strategies had affected their conceptions of sexual “risk” and “safety,” particularly with respect to condom use.

Interviews were audio recorded, transcribed verbatim, anonymized, and coded through in-depth thematic analysis Additional file 1. To maximize the trustworthiness of our analysis, we followed Lincoln and Guba's evaluative framework for qualitative work via the establishment of credibility, transferability, dependability, and confirmability [55]. Four readers generated a master code list based on multiple readings of the transcripts, with frequent discussion to ensure consistency. At least two readers coded each interview and discrepancies were resolved within the dyad or via a third coder. Codes were revised and expanded as needed through an iterative engagement with the data [54] and grouped into themes and subthemes. We then organized these themes within a social ecological model based on McLeroy and colleagues’ [50] outline of five stratified factors impacting health promotion; while McLeroy and colleagues distinguish between institutional and community factors, we chose to merge the two. On the interpersonal level, we focused on interactions and relationships with sexual partners, as these were most frequently cited by our participants as influencing their condom use practices.

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.

Consistent with previous research, participants in this study cited numerous social ecological factors that motivated CAI and inconsistent condom use: the desire for intimacy and pleasure, condom fatigue, the normalization of barebacking, feeling unable to negotiate with partners, event-level loss of control due to drug use or “heat of the moment” sexual urges, and the belief that biomedical interventions offered an effective alternative to consistent condom use. When not using condoms, participants employed various seroadaptive strategies to reduce risk, including negotiated safety agreements, serosorting, viral load sorting, and strategic positioning. While biomedical interventions and seroadaptive strategies could facilitate CAI and sexual exploration, many participants expressed anxiety over the efficacy of these strategies in light of ongoing HIV transmission concerns. As a result, despite generally disliking condoms, most participants acknowledged that they were a highly effective form of prevention and continued to utilize them contextually, particularly with higher-risk, casual partners.

With regards to biomedical prevention strategies, HAART did influence participants’ condom use, but the nature of this impact varied based on the form of treatment participants accessed. PrEP and – to a lesser extent – TasP were associated with substantial decreases in consistent condom use, and participants felt on the whole that these strategies were useful alternatives to condoms. These results support previous studies that associate PrEP use outside of clinical trials with risk compensation and declining condom use [15, 35, 39–41]. Within clinical PrEP trials, where PrEP access is paired with extensive risk counselling, this decline in condom use has not occurred [36, 37], indicating the potential value of packaging broader PrEP rollout with extensive HIV prevention education and behavioural interventions [8, 22, 35, 38, 40]. In contrast to the risk compensation found among PrEP and TasP users, risk compensation has not been found among PEP users [9, 43], and this was true of participants in this study who had used PEP but not PrEP or TasP. The condom-affirming, “wakeup call” aspects of PEP may be due to its perceived role as a “last resort” to be used only when other forms of prevention fail or during abnormal lapses in prevention regimens [43]. Additionally, the relative intensity and associated side effects of HAART dosing under a PEP regimen may serve to discourage individuals from having to use PEP again, reaffirming their commitment to consistent condom use [43].

The findings of this study also align with recent research that highlights gay men’s balancing of risk and pleasure within the context of an expanding arsenal of prevention tools, and the influence of numerous socioecological factors on individual behaviour. Contradicting the assumption of HIV optimism and risk compensation models, however, declining rates of condom use may not be due to declining concerns about HIV risk but may instead be a result of having a wider variety of prevention methods to draw from in ensuring sexual safety. The majority of participants in this study expressed considerable concern about HIV transmission, even as they described it as a chronic, treatable condition, a finding consistent with existing scholarship [12, 57]. While gay men may still be concerned about HIV transmission, this expansion of prevention options has broadened the concept of sexual “safety” [23]. As a result, interventions that focus on traditional definitions of safer sex and condom use do not reflect the breadth of prevention strategies now utilized by gay men, nor the influence of social environments on safer sex practices, and may therefore be less likely to be used by many. Given the imperfect protection offered by condoms [58] and the number of prevention options available, HIV intervention work should strive to advance the concept of combination prevention, in which condoms and other behavioural interventions are promoted alongside biomedical and seroadaptive advancements [59]. Specifically, future prevention work should build upon the array of prevention strategies actually being used by gay men and encourage strategic, as opposed to consistent, condom use [46]. Providing gay men with multiple strategies to optimize safety while also leaving space for subjectivity and agency in sexual decision-making would potentially improve intervention uptake.

The importance of emotional factors in sexual decision-making described by the participants in this study indicates that optimal HIV prevention work must also expand beyond knowledge promotion and cognition. Consistent with the existing literature [7, 23, 60], participants’ desires for intimacy, trust, and erotic pleasure – especially within the perceived safety of primary relationships – served as strong motivators for CAI, often taking priority over avoiding sexual risk. However, a large proportion of HIV transmissions among gay men occur within primary relationships, challenging the notion of such relationships as low risk [48, 49]. There is therefore a need for intervention work that addresses the emotional motivators of sexual risk and speaks to ongoing relationships as a potential HIV risk context [7, 26, 34, 47].

The emergence of community-developed seroadaptive strategies provides further opportunity for intervention work as gay men increasingly utilize these strategies in the absence of condoms [44]. The vast majority of our participants used seroadaptive strategies as a major part of their prevention regimen, despite their concerns that the effectiveness of these strategies relied on trust and honest communication. This reliance on accurate, honest disclosure can be problematic: many gay men fail to have explicit conversations about serostatus and viral load, relying instead on social cues and intuition with both casual and longer-term partners [12, 14, 19, 33, 61]. The effectiveness of seroadaptive strategies can be further complicated by factors such as substance use and peer pressure to engage in CAI or limit communication prior to sex [21, 44]. Interventions aimed at decreasing CAI should therefore teach gay men to improve their communication and sexual negotiation skills [17]; such skills could also increase the efficacy of seroadaptive strategies by minimizing incidences in which a partner’s serostatus is incorrectly assumed [61]. Intervention efforts should offer strategies to enable disclosure conversations between partners and assist gay men in advocating for their own sexual safety. Since seroadaptive strategies are already widely used and will presumably continue to be so, improving the efficacy of these strategies and promoting them within a broader combination prevention approach will likely improve prevention efforts as a whole.

With the decline in consistent condom use and the increasing prevalence of other prevention strategies, intervention efforts must also aim to clearly and succinctly convey the efficacy of these strategies [6–10, 62, 63]. In their review of seroadaptive practices, Cassels and Katz suggest that 14–44% of HIV positive gay men and 25–38% of HIV negative gay men already engage in serosorting alone [61]. Participants in this study utilized a variety of seroadaptive strategies ranging from established modes of prevention – like serosorting and seropositioning – to methods less supported by scientific evidence [46, 64] – such as withdrawal prior to ejaculation, urination after sex, and limiting the duration of sex while in the receptive role. Existing research suggests that seroadaptive strategies are more effective than indiscriminate CAI and less effective than consistent condom use, but additional work is needed [61–63]. With accurate data, health officials and community organizations would then be able to provide gay men with the information required to make educated risk evaluation decisions. Since seroadaptive strategies rely on accurate knowledge of one’s HIV status, education efforts should also continue to encourage regular HIV and STI testing [61, 63].

Finally, our analysis indicates that HAART-based advances may be shifting gay men’s perceptions of “risky” sexual partners. Study participants viewed sex with HIV positive undetectable partners as lower risk than sex with those who claimed to be HIV negative and argued that disclosure of HIV status was more trustworthy when it came from an undetectable partner. They also believed such partners to be more connected to healthcare and therefore more aware of their holistic sexual health. While this trend toward utilizing a partner’s viral load to inform sexual risk decisions has been observed in other studies [33, 44, 45, 61], the dominance of viral load sorting over serosorting among our participants seems unusually high compared to previous research [63]. It is likely attributable in large part to the promotion of TasP in BC [51, 65], which emphasizes that the use and acceptability of various prevention strategies is highly contextual.

As with all analyses, the strengths and limitations of this study must be considered. A qualitative examination of condom use habits among a small group of HAART-experienced participants in Vancouver, BC is not generalizable to other contexts or even to Vancouver’s gay population as a whole. However, the findings of this study provide a detailed picture of the complex and contradictory perceptions and practices influencing gay men’s condom use with nuances that quantitative models are not able to capture. While participants’ disclosure of condom use habits and CAI may have been influenced by social desirability bias that would likely have produced an overrepresentation of stated condom use, we endeavoured to minimize the potential impacts of this bias through the use of peer interviewers and a semi-structured interview technique [52, 53, 55]. Our team approach to thematic analysis and use of Lincoln and Guba’s trustworthiness criteria for evaluating qualitative research supports the validity of our analysis [54, 55].

The findings of this study indicate that the expansion of prevention options available to gay men has begun to redefine traditional interpretations of sexual “risk” and “safety,” with perceptions and use of condoms influenced by multiple factors on all levels of the social ecological model of health. Condoms, once synonymous with safer sex, are no longer viewed as the sole effective means of HIV prevention; many gay men feel that combining biomedical and seroadaptive strategies is an effective alternative that allows for greater sexual freedom and pleasure. Simultaneously, the notion of “risky” HIV positive partners has shifted in light of viral load sorting and the emerging category of undetectability. In this context, public health and community-based interventions that advocate solely for strict condom adherence will likely be viewed as obsolete. Future research must address the full range of gay men’s prevention strategies, providing evidence on the efficacy of these individual strategies and their optimal use within a combination prevention approach. In turn, future public health and community-based intervention work will need to translate this information into prevention messages while assisting gay men in developing the communication and advocacy skills needed to optimize these emerging strategies.