\u201cCondoms are \u2026 like public transit. It\u2019s something you want everyone else to take\u201d: Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention

Benjamin J Klassen,Karyn Fulcher,Sarah A Chown,Nathan J Lachowsky,David M Moore,Robert S Hogg,Heather L Armstrong,Eric A Roth

doi:10.1186/s12889-019-6452-7

Abstract

BackgroundThe emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men.MethodsWe undertook a social ecological analysis of condom use and perceptions using nineteen semi-structured interviews with HIV negative gay men in Vancouver, Canada who used HAART-based prevention strategies.ResultsContributors to inconsistent condom use were found at various levels of the social ecological model. Ongoing concern regarding HIV transmission and belief in the proven efficacy of condoms motivated contextual use. When condoms were not used, participants utilized seroadaptive and biomedical prevention strategies to mitigate risk.ConclusionsThese findings indicate that notions of “safety” and “risk” based on consistent condom use are eroding as other modes of prevention gain visibility. Community-based and public health interventions will need to shift prevention messaging from advocacy for universal condom use toward combination prevention in order to meet gay men’s current prevention needs. Interventions should advance gay men’s communication and self-advocacy skills in order to optimize these strategies.

Highlights

The emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men
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
Pre-Exposure Prophylaxis (PrEP) and – to a lesser extent – Treatment as Prevention (TasP) were associated with substantial decreases in consistent condom use, and participants felt on the whole that these strategies were useful alternatives to condoms

Summary

Introduction

The emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men. Despite concerted prevention efforts and the increased availability and uptake of biomedical advances, gay and other men who have sex with men ( gay men) are disproportionately affected by the Canadian HIV. 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 be rejected, among older gay men who are tired of prevention messaging focused primarily or exclusively on condoms [11,12,13,14,15]. 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]

Methods

Results

Discussion

Conclusion