A survey spanning 19 years of participants at a gay pride event in the US notes a consistent increase in the occurrence of condomless anal sex among men, as well as a rise in how many sex partners they have.
Condomless receptive anal sex among HIV uninfected men has doubled, while insertive condomless anal sex has more than tripled among HIV-positive men.
The findings show that, although antiretroviral therapies (ART) have revolutionised the treatment and prevention of HIV infections, knowing that they have ART as a protective back-up against contracting or transmitting the disease makes people complacent. This complacency can lead to increased risks when it comes to sex and their health, says study leader Seth Kalichman of the University of Connecticut.
Trials have shown that early treatment with ART prevents HIV transmission. This shifted the focus of HIV prevention campaigns away from condom use as a form of protection toward detecting and treating those already infected. Despite these efforts there have not yet been significant reductions in new HIV infections in major cities, for instance. In addition, HIV infections remain stable or are rising among gay men in countries that have scaled-up HIV testing programmes and access to ART.
Kalichman and his team analysed surveys conducted in 1997, 2005, 2006, and 2015 at the Atlanta Gay Pride Festival. Through self-administered surveys 1,831 gay men provided anonymous information about their substance use, sexual behavior, beliefs about HIV treatment, and how they perceive sexual risks in relation to the HIV treatment status of potential sex partners.
Among uninfected men and those who did not know their HIV status, condomless anal sex increased from 43% in 1997 to 61% in 2015. The number of those having multiple sex partners also rose from 9% in 1997 to 33% in 2015.
This pattern is also reflected among HIV-positive men. Condomless anal sex increased from 25% in 1997 to 67% in 2015. In 1997 only 9% of men in this group reported having had unprotected intercourse with two or more partners in the six months before the survey.
By 2015 this figure rose to 52%. In 1997 condoms were used about eight out of ten times (82%) when HIV-positive men had intercourse, but it dropped by 2015 to less than one in two (47%) instances.
These shifts in behavior create increased risks for sexually transmitted infections, which in turn can increase risks for HIV transmission.
HIV-positive men as well as those who had not tested positive held increased beliefs reflecting public health messages that ART prevents HIV and therefore make condomless anal sex safe. Also consistent with public health messaging, they believed their risk of contracting HIV to be much lower when their partner had an undetectable blood plasma viral load.
“Treatment-related behavioral beliefs in this study paralleled a resurgence in condomless anal sex among men who have sex with men measured over nearly two decades,” explains Kalichman. “The current study adds to the mounting evidence that substantial changes have occurred in community-held beliefs that condomless anal sex is safer in the era of HIV treatment as prevention.”
Community-wide awareness that antiretroviral therapies (ART) provides protection against HIV has the potential to increase perceived safety and thereby increase condomless anal sex among men who have sex with men (MSM). Furthermore, reductions in condom use can increase exposure to sexually transmitted infections, which in turn can reduce the protective effects of ART on HIV transmission. The current study extends previous community-based behavioral surveillance research on beliefs regarding use of ART for HIV prevention and sexual practices among MSM. Anonymous cross-sectional community surveys were collected from 1831 men at the same gay pride event in Atlanta, GA four times over nearly two decades; 1997, 2005–2006 (the 2006 survey over-sampled African-Americans to diversify the study), and 2015. Results indicate clear and consistent trends of increasing beliefs that HIV treatments reduce HIV transmission risks, reflecting the dissemination of HIV prevention research findings. Changes in treatment beliefs coincide with increased rates of condomless anal intercourse. Increased beliefs that treatments prevent HIV and increased condomless anal sex were observed for both HIV positive men and men who had not tested HIV positive. Results illustrate the emergence of an era where ART is the focus of HIV prevention and community-held beliefs and behaviors regarding definitions of risk create a new and potentially problematic environment for HIV transmission.
Seth C Kalichman, Devon Price, Lisa A Eaton, Kaylee Burnham, Matthew Sullivan, Stephanie Finneran, Talea Cornelius, Aerielle Allen