What is safe sex now? Does it include undetectable viral load and PrEP?

Treatment as prevention and pre-exposure prophylaxis (PrEP) provide new ways to safely avoid HIV, but this poses challenges to the ways in which communities understand and practice ‘safe sex’, Martin Holt of the University of New South Wales told a public lecture in Sydney last week. Gay men’s awareness and understanding of the new prevention methods has developed rapidly, but history suggests that people may continue to define safe sex as condom use for a long time to come.

Holt said that the creation of ‘safe sex’ as a norm in the 1980s and then keeping it going for decades was a remarkable achievement. In the early days, the concept was particularly important for asserting that people – especially gay men – could continue to have sex, despite the threat of HIV. Condom use was rapidly adopted by gay male communities and their use in casual partnerships was sustained for many years.

Safe sex is usually defined as the use of condoms during penetrative sex as well as being sexual in non-penetrative ways. But the latter part of the definition is often neglected when people are asked what safe sex is, suggesting that decades of condom promotion have had a profound effect.

Condom use became a norm – a standard that people are expected to conform to. This has both benefits and costs, Holt said. A norm can guide us about what to do in unfamiliar situations and reassure us that other people will behave in the same way. The flip side is that people who don’t adhere to the standard are judged, labelled as irresponsible, or seen as problematic.

Moreover, what many people don’t realise is that condom use during anal sex has never been universally practised by gay men. “That’s the power of a norm: it can fool us into thinking that everyone is doing the same thing,” Holt commented. The uptake of condoms in the 1980s and early 1990s was dramatic, but it was not uniform.

Behavioural surveys – such as the Gay Community Periodic Surveys, which Holt manages – soon observed that few gay men used condoms with their boyfriends, even if they did use them with casual partners. While American researchers tended to see this as a problem to be fixed, Australian researchers developed the concept of ‘negotiated safety’ to clarify how men could use HIV testing and agreements with their primary partners to safely dispense with condoms within their main relationship but continue to use condoms with casual partners.

Similarly, other ways to lower the risk of HIV being passed on when condoms are not used were observed and described. These include ‘serosorting’ (not using condoms with men of the same HIV status) and ‘strategic positioning’ (in a couple of mixed HIV status, the HIV-positive man taking the bottom role).

But people’s understanding of what ‘safe sex’ is has never really evolved to incorporate these practices. Qualitative research suggests that most people continue to equate safe sex with condom use, and to see not using condoms as ‘unsafe sex’.

This has implications for treatment as prevention and PrEP. Despite their widespread promotion and visibility in Australian gay communities, and rapid enrolment to a PrEP trial, only a minority of men are using them as protective strategies. Martin Holt said he was not sure whether people’s understandings of ‘safe sex’ will really shift.

He asked, how many people need to use the new methods before they are considered to be ‘normal’? How long will it take to create a new norm? And noting the range of ways that people can be safe, he asked whether it’s possible to establish a norm about multiple strategies?

While behavioural surveys show increases in awareness and understanding of the impact of HIV treatment on infectiousness, the way this influences HIV-negative men’s behaviour is complex. Surveys show that men living with HIV continue to face rejection by potential sexual partners and half of HIV-negative men say they would not be willing to consider sex with an HIV-positive man. While some PrEP users are more accepting of HIV-positive partners, one-third would still not have sex with a man with HIV.

“Growing awareness of treatment as prevention does not necessarily translate into comfort or confidence in having sex with positive men,” Holt said.

PrEP users also report being rejected by sexual partners. While Australia has avoided the PrEP controversies seen in the United States, with PrEP users either vilified or celebrated as ‘Truvada whores’, there is still stigma. PrEP users may be seen as disreputable or irresponsible.

While attention may be given to people using PrEP or an undetectable viral load as preventive strategies, Holt said there is a much larger cohort of men who may find that what they assumed was normal practice has changed. “This kind of disruption can lead to misunderstandings, rejection and upset if people are unprepared,” he said.

He therefore welcomed ACON’s new ‘How do you do it?’ campaign which presents condoms, PrEP and undetectable viral load together. No one strategy is presented as superior to the others. Men are encouraged to choose the strategy that is right for them and to respect the choices that other men make.

“To transform safe sex and make it work, we will need kindness, generosity and patience – qualities that can be hard to find in the brutal, rollercoaster world of sex and dating,” Holt said. “I’m optimistic that we can make this happen but we will need to guard against our baser instincts to judge and reject others because they do things differently.”