Choices: A New Take on the Use of Condoms in the Age of PrEP

A new take on the use of condoms in the age of PrEP
by John Francis Leonard

Photo by Alina Oswald

I find myself, as a gay man with HIV, in a position that I never expected to be in. Under effective treatment and with an undetectable viral load, condom usage is not necessary to prevent me from transmitting HIV to my partner. When I picture a relationship for myself, as an HIV-positive man who’s undetectable and in no danger of transmitting it to my partner, I hope that, once trust is established, condoms won’t be necessary.

Now, in the age of PrEP and U=U, condoms are a choice, but not too long ago they seemed like a burden.

Somewhere along the line in gay culture, condoms became less cool. I remember back in the late nineties and the early millennium hearing the phrase “condom fatigue.” Certainly for myself years of caution and care started going out the window. And, guess what happened? You got it, the reason I’m writing this column. Given the choice today, I’d always use a condom, or take PrEP. I’d also ask a lot more questions as a rule.

In the early millennium, you also began to see a lot more bareback porn. Now, it’s ubiquitous, with even major studios and directors producing condomless films. And perphaps the difference is that now actors use PrEP, serosort, or undergo regular and rigorous testing—we know that we have safer-sex choices other than condoms. Regardless, I think that as gay men, our pornography says a lot about the sexual zeitgeist and condoms are not seen as sexy onscreen. I know, for me, I just don’t respond to condoms on film anymore. No matter how hot the guys, how intense the sex, a condom just turns me off.

Whatever the reason, though, condom usage is down. Per the CDC, in a wide reaching survey of urban, gay men, two-thirds of the men report having anal sex without a condom at least once in the previous year, with a quarter of men having been the receptive partner without a condom during their last sexual encounter. Also increasing is sex without a condom between two ongoing sexual partners. Unfortunately, two-thirds of transmission of HIV occurs among men in relationships.

So, by all accounts, condomless anal sex among gay men is on the rise. The good news is that, while overall condom usage among MSM may be down, the use of PrEP, testing, and disclosure are on the rise. In the fight against HIV, regular testing and treatment, as well as disclosure, are equally effective prevention methods—especially considering the 1.4 percent failure rate of the condom. If everyone who was positive was being treated effectively with medication, the fight would be over, the battle won. However, there is vast room for improvement. PrEP usage is still only at 3.5 percent among negative MSM in urban areas, according to the CDC, and, if sexual partners aren’t undetectable or on PrEP, then of course a condom should always be used. Of course, condoms are still the most effective method of preventing the list of other sexually transmitted infections, many of which are on the rise as condom use decreases.

I currently have plans to spend some time with a particular man when I’ll be in New York City this month. We’ve had an honest and frank discussion about the precautions we will take and, as I feel that it’s ultimately the negative partner’s decision, we will always use condoms in the beginning. If and when things progress, he will go on PrEP as an extra measure of safety and we will forgo condoms. And that’s what it takes, open and honest dialogue. Of course this becomes more challenging if we’re talking a quick one-night stand, but as HIV-positive individuals we’re already used to giving up a certain level of spontaneity.

As a community, we have lots of work to do still. Education and outreach must continue. This is even more important when you think of the much higher levels of HIV transmission among young men of color. We can’t leave anyone behind. Seventy-one percent of MSM have been tested, but this leaves a substantial number who haven’t.

We need to understand who these men are and what barriers they face. As it stands there is no one solution that is being fully utilized when it comes to HIV prevention and until that is, all methods must be embraced. My mind always goes back to the incredibly effective safer sex campaigns of the late eighties and early nineties in New York City. Safer sex was marketed incredibly effectively and we need to do the same with testing and treatment. We too often still hear of individuals who were never tested falling ill and passing away. And we cannot forgo the condom, not yet anyway. It’s still a highly effective tool in prevention that is much more accessible than PrEP. Not everyone is insured or has access to good healthcare and we are dealing with a political party that is making that situation even worse.

John Francis Leonard is an advocate and writer, as well as a voracious reader of literature, which helps to feed his love of the English language. He has been living with HIV for fifteen years and he is currently at work on his first novel, Fools Rush In. His fiction has been published in the ImageOutWrite literary journal and he is a literary critic for Lambda Literary. Follow him on Twitter @JohnFrancisleo2.