How PrEP users decide whether to use condoms

While over 80% of anal sex among pre-exposure prophylaxis (PrEP) users in Amsterdam was covered by PrEP alone, condoms and PrEP were used for nearly one in five anal sex acts with casual partners. Those who opted to use condoms did so in situations of perceived vulnerability to HIV and other sexually transmitted infections (STIs) and in instances when they did not want to talk about using PrEP with sexual partners. These findings from the Amsterdam PrEP (AMPrEP) demonstration project were published in AIDS by Hanne Zimmermann and colleagues from the Public Health Service of Amsterdam.

PrEP is highly effective at preventing HIV infection. However, there have been public health concerns that its use would lead to ‘risk compensation’ – that, due to PrEP’s effectiveness at preventing HIV, those on PrEP would stop using condoms altogether and that this would lead to an increase in other STIs. Public health guidelines in the Netherlands, as elsewhere, recommend using condoms alongside PrEP. The relationship between the use of PrEP and STIs is complex. For example, in AMPrEP, researchers observed decreasing condom use, but did not find a significant rise in STIs over two years of PrEP use. 

The study

Researchers collected mobile app-based diary data from 352 participants (351 gay and bisexual men and one transgender woman) from 2015-2019. Participants were asked two questions daily about taking PrEP and whether or not they had had anal sex. If the participant had had sex, they were asked further details about their partner and use of condoms.

The median age at the beginning of the study was 39; most participants identified as White (86%) and were college educated (77%). The majority opted for daily PrEP (74%), while the other participants opted to use event-driven PrEP, scheduled around the time of sexual encounters.

A total of 48,949 anal sex acts were reported over the course of the study: 11,632 with steady partners, 19,547 with known casual partners and 17,770 with unknown casual partners.

Additionally, 43 participants were interviewed to gain qualitative insights into their PrEP and condom use. The median age was 41 while other characteristics were similar to the larger sample. Two-thirds were taking daily PrEP.

PrEP only

Using PrEP only was reported by the majority of participants (81% of the time) for sex with any partner type, regardless of PrEP regimen or time since initiation. Participants spoke of trust in the effectiveness of biomedical prevention strategies and being able to rely on PrEP as one of the main reasons for no longer using condoms. Additionally, they spoke of the pleasure of condomless sex, the perceived curability of other STIs, condoms not being completely effective in terms of preventing STIs, and the difficulties of returning to condoms after getting used to condomless sex.

“It is this dilemma: either you choose something that is safe but interferes with sex, or you choose for something that is more enjoyable, but more risky. So you notice during sex it doesn’t feel as nice, so you notice you don’t want to use it. But with that, I choose for the possibility of getting other STIs.” – Taking daily PrEP

PrEP and condoms

In certain instances, participants felt that they needed to use condoms in addition to PrEP. This was occasionally the case with steady partners (6% of the time for event-driven PrEP users and 3% for daily users) but was seen more frequently with casual partners, especially unknown casual partners (21% of the time for event-driven PrEP users and 20% for daily users).

Reasons for condom use varied: some participants started to use them after having more STIs (especially hepatitis C), fear of contracting an STI in higher-risk situations (such as sex parties or during chemsex), as an added layer of protection when having sex with an HIV-positive partner, as a result of doubting their own adherence, and so forth.

“In Amsterdam, where I live now, the STIs are flying around, I am fed up with it. I will use condoms again.” – Taking daily PrEP.

“Physically I enjoy condomless sex. I do however need the mental reassurance of condoms. I would not enjoy sex otherwise, even with PrEP, it is really a reassurance thing to avoid what you’re most afraid of.” – Taking event-driven PrEP.

"Counsellors should recognize that PrEP alone is often the chosen HIV-prevention strategy, and should be treated as such."

One unexpected reason was to avoid telling a sexual partner that they were using PrEP. Interviewees anticipated stigma or even rejection, indicating that the use of PrEP continues to be stigmatised in certain instances.

“I wanted to do it without a condom and he looked at me like I was some fool. If it’s like that I don’t even want to tell someone I use PrEP, so I don’t and use a condom [along with PrEP].” – Taking event-driven PrEP.

“I learned from previous experiences that when I told someone I used PrEP it became a ‘thing’, and they block you [on dating apps] because they think you only do bareback, while if you just say you use a condom, there is no issue.” – Taking daily PrEP.

Condoms only

This was uncommon among participants in this PrEP study. It occurred more frequently for event-driven PrEP users (4% of the time vs 0.4% for daily PrEP users), usually with casual partners. Participants said that this would occur in instances where they used PrEP over the weekends but used condoms during the week, when PrEP-related stigma was anticipated, or when they felt it was redundant to take PrEP in addition to using condoms. Daily PrEP users would usually only revert to condoms in instances when they had difficulty adhering to PrEP.

“I try to use PrEP only for planned [risky] sex in the weekends. During the week I have safe sex with a condom.” – Taking event-driven PrEP.

“Online I try to figure someone’s opinion about PrEP. If he is negative about it, I use a condom instead.” – Taking event-driven PrEP.

Neither PrEP nor condoms

This only occurred around 1% of the time for daily PrEP users and 9% of the time for event-driven PrEP users, mostly with steady partners. Participants stated that they would most often use neither form of protection with a partner with HIV who had an undetectable viral load, or when sex was perceived as less risky. However, there were times when this occurred due to missing doses or not using a condom in the heat of the moment.

“We repeatedly discuss our agreements for having sex with others. Therefore with my partner I do not use condoms.” – Taking event-driven PrEP.

“I already have this group of undetectable friends and it is completely unnecessary to take it. So I use it intermittently [event-driven] for HIV-negative men.” – Taking event-driven PrEP.

Conclusion

“Our study carries important implications for counselling PrEP users. First, counsellors should recognize that PrEP alone is often the chosen HIV-prevention strategy, and should be treated as such. Excessive focus on preventing the decreasing use of condoms could undermine the potential for counselling, as some patients can feel uncomfortable sharing information on condomless sex that may result in criticism. Second, condom use remains an important tool for HIV/STI-prevention (including hepatitis C) and is still applied by PrEP users in a variety of settings,” conclude the authors. “Health professionals should steer away from counselling based on the assumption of ‘risk compensation’. Instead, counselling should concentrate on promoting condom use as a viable option when engaging in anal sex in specific contexts.”

They also add a word of caution: “The primary reason provided for using neither condoms nor PrEP was low perceived HIV risk, which may explain the relatively high proportion of uncovered sex acts with steady partners among event-driven PrEP users. However, previous studies suggest that 32–68% of all HIV infections occur in steady partnerships.”