Introduction of PrEP Coincides with Drop in Condom Use

Martin Holt, PhD, of the University of New South Wales

Martin Holt, PhD

New research out of Australia shows that the introduction of pre-exposure prophylaxis (PrEP) among gay and bisexual men coincided with a drop in regular condom use.

The data paint a complicated picture for public health officials hoping to use the full array of HIV-prevention methods to suppress transmission of the virus.

The study is based on 4 years of surveys, from 2013 to 2017, in Melbourne and Sydney. Nearly 17,000 men who reported sex with casual male partners in the 6 months preceding the survey were included in the study.

Over the course of the 4-year period, the percentage of HIV-negative men who reported having condomless anal sex with casual partners while taking PrEP rose from 1% in 2013 to 16% in 2017. At the same time, however, the overall number of men who reported “consistent” condom use dropped from 46% to 31%. The rates of HIV-negative or untested men who were not on PrEP and had condomless anal sex did not change significantly, hovering at around 30% for the duration of the study.

Lead author Martin Holt, PhD, of the University of New South Wales, said the drop in condom use does not appear to be related to a drop in condom promotion by public health officials. He said local agencies continued to promote condoms, antiretroviral therapy (ART), and PrEP as the 3 best ways to prevent transmission of HIV.

“So I would say condom promotion has been maintained, while education about PrEP and HIV treatment have increased,” he told MD Magazine.

However, Holt said local public health agencies and advocacy groups need to tailor their public health campaigns to local epidemic circumstances.

“If condom use is already well established as a prevention strategy, our results suggest it is important to keep promoting it while PrEP is introduced (to affirm its ongoing importance, particularly for people not using PrEP),” he said.

Despite the drop in condom use, the overall number of new HIV diagnoses decreased, the data showed. Holt said he’s glad to see that PrEP is having a positive impact. However, he said the decrease in diagnoses will likely be even more pronounced if they can increase condom use among the population in the study.

Holt said it’s reasonable that PrEP users feel they’re less at risk, since PrEP is highly effective, but he said some non-PrEP users might be “overly optimistic about reduced risk, particularly if they are having sex with partners whose status they don’t know (or if they haven’t had a discussion about whether their partner is on PrEP or treatment). In those situations, we really would encourage those men to default to condoms, or to talk to their doctor about PrEP.”

Nittaya Phanuphak, MD, PhD, who led the rollout of PrEP in Thailand and wrote an accompanying editorial to Holt’s study, said one message from the study is that public health officials need to be more strategic, and need to encourage patients and their providers to seriously assess their personal risk profiles.

Phanuphak, who works at the Thai Red Cross AIDS Research Centre, told MD Magazine that putting such an approach into practice is very challenging. In areas with inadequate rates of testing, ART, and PrEP usage, condom use must be promoted as the key gold standard in HIV prevention, she said.

“In settings where risk has become truly lower, like New South Wales and Victoria, condom use may need to be positioned as the mainstay for 'STI' prevention (since even with [thrice]-monthly STI screening and treatment, it is unlikely that gonorrhea and chlamydia cases will decrease soon),” she said.

Phanuphak said the only caveat is that gay and bisexual men may be less inclined to be concerned about STIs, since most would not show symptoms, nor be subject to the most serious consequences, like pelvic inflammatory disease or infertility, as seen in women.

Holt’s study is titled, “Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013—17.” It was published this month in The Lancet HIV.