Shifting social norms around what “safer” sex is: perspectives of HIV-negative men in Canada

HIV-negative men who have sex with men (MSM) living in Vancouver, Canada are redefining ways to negotiate sexual safety and risk, according to qualitative research recently published by Dr Benjamin Klassen and colleagues in BMC Public Health. Condoms are no longer seen as the only means of preventing HIV infection.

Biomedical prevention strategies –  including the use of pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) – emerged as important reasons for inconsistent condom use among HIV-negative men. These men also adopted “seroadaptive” strategies such as selecting partners based on their HIV-negative status) and selecting HIV-positive partners who had an undetectable viral load. Ongoing concern over possible HIV infection and the belief in the high efficacy of condoms were some reasons to continue using them.

Semi-structured interviews were conducted with 19 HIV negative men (aged 22-58, median age 36). Eight men had used post-exposure prophylaxis (PEP), seven had engaged in sorting based on partners’ viral loads and two were on PrEP. Interview questions focused on prevention strategies participants had used, their perceptions of these different strategies and how they rated different strategies in terms of efficacy. Researchers conducted thematic analysis considering factors influencing choice of prevention strategy ranging from individual to policy levels. These themes are expanded upon below:

Individual factors

Participants expressed varied views regarding condoms but there was a widespread rejection of the notion of consistently using condoms for all sexual encounters. For most men, a combination prevention approach was used.

A desire for increased sexual pleasure and freedom emerged as an important individual-level factor when it came to rejecting condoms.

“A lot of guys when they hear the word ‘condom’ or just hear that wrapper, they immediately lose their hard-on there.” Jordan, 25

“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…” Dan, 46

Men cited more instances of condomless sex when using substances.

“The drugs or the desire for pleasure exceeds the precaution in that moment. And I’ve regretted those decisions, very much so.” Kevin, 31

Men also explained that their perceptions of risk had changed in light of biomedical advances. HIV was no longer seen as a death sentence and men who were on antiretroviral therapy, either on PrEP or undetectable, were seen as ‘safer’ sex partners.

“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.” Curtis, 25

Relationship factors

In interactions with sexual partners, participants talked about the need to maintain the mood and said that discussing condom use would disrupt the interaction. Men wanted to maintain intimacy in the “heat of the moment”:

“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.” Will, 28

Power dynamics and coercion could also affect condom use.

“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…” Russell, 26

Additionally, some men reported using negotiated safety arrangements or strategic positioning in order to minimise chances of infection.

“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.” Jordan, 25

“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.” George, 51

Community factors

At the community level, the widespread acceptability of “barebacking” was evident from many of the men’s responses. Interestingly, men often referred to condoms as a prevention strategy that others could use but that did not necessarily work for them. For many men, there was a mismatch between intentions regarding condom use and reality.

“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.” Bob, 58

“Social acceptability of barebacking seems to have evolved.” Wayne, 36

“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.” Scott, 48

“I mostly top…I think it's reasonably well-established that that is generally a lower risk than bottoming.” Wayne, 36

Here, “well-established” indicates that there is a broader community-level understanding of the risk associated with certain sexual positions. Thus, the sero-adaptive strategies referred to do not merely exist at the individual level but are prominent at broader levels too.

Policy factors

The widespread availability of HIV treatment in the province of British Columbia, where Vancouver is located, as well as public education regarding undetectable viral load impacted sexual decision making by these HIV-negative men.

“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.” Aaron, 46

Some participants expressed that they sort for partners based specifically on undetectable viral load and feel comfortable with condomless sex in those encounters. In fact, for many men in this study, seeking out undetectable partners was seen as an effective means of prevention and was often preferred to condoms. Additionally, men commented on the fact that HIV-positive men would also be screened for other STIs routinely, thereby making them ‘safer’ sexual partners not just in terms of HIV, but also in terms of other STIs.

“…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.” Aaron, 46

“They [people with HIV] 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.” Curtis, 25

The role of condoms in combination prevention

Many men expressed continuing anxiety regarding contracting HIV and did not abandon condom use altogether. Despite shifting social norms and confidence in biomedical prevention methods, condoms were still seen as the most effective way to prevent HIV infection. Condoms were described as an accessible and reliable prevention method.

“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.” Kevin, 31

Concerns were also raised regarding issues around trustworthy disclosure when it came to sero-adaptive prevention strategies and the drawbacks of relying on methods such as PrEP without knowing a sexual partner’s adherence. Thus, it was evident that condoms still had an important, albeit diminished, role to play in the men’s overall prevention approach.

“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.” Curtis, 25

Conclusion

This study illustrates how some MSM’s perceptions of what constitutes ‘safer’ sex are changing, in step with shifting social norms and biomedical advances. For most of the men interviewed, a combination prevention approach appeared to be most realistic as it was able to account for crucial factors at the individual and community levels. Policies regarding treatment as prevention also shaped decision-making more indirectly.

While there was still a large amount of anxiety surrounding HIV infection (despite it no longer being seen as a death sentence) and while condoms were frequently cited as the most effective means of preventing infection, the men’s best intentions and real-life behaviours often did not match up.

The authors suggest that research of this nature has important public health implications and that HIV interventions that rely solely on condoms will be seen as obsolete for MSM such as those in this study. The expansion of preventative means available to men has resulted in new definitions of what constitutes “safer sex”, with undetectability emerging as an important factor. While the condom has not been discarded completely, it is important for public health and community-based interventions to acknowledge the role of multiple, combined prevention strategies and to effectively translate this into HIV prevention messaging aimed at MSM.