Is Better HIV Treatment Leading To Less Condom Use?
A study suggests that it might be — but not all experts are convinced that's a big problem
Over the past few decades, HIV treatment has been dramatically revolutionized, allowing people to live happier, healthier, and longer lives. It’s also been shown to reduce their likelihood of transmitting the virus to others. But a new study, published in the Archives of Sexual Behavior, warns of a potential side effect of these life-changing scientific advances: people increasingly not using condoms because of a growing sense of reduced risk.
“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,” said lead author Seth Kalichman of the University of Connecticut.
Antiretroviral therapy, or ART, treats HIV by inhibiting its growth — it doesn’t provide a cure, but it does reduce the virus’ presence in the body. It also consequently reduces a person’s viral load, meaning the amount of HIV in a person’s blood. That can reduce the likelihood of a person transmitting the virus and has led to the concept of “treatment as prevention,” or TasP: the use of ART to not only treat HIV but also to reduce transmission risk. Alongside this, there has also been the rise of pre-exposure prophylaxis (or PrEP), the pre-emptive use of antiretroviral drugs by an HIV-negative person to guard against HIV transmission.
This study looked specifically at beliefs around TasP. Over the course of nearly two decades, researchers surveyed 1,831 men who have sex with men at a gay pride event in Atlanta, Georgia. Between 1997 and 2015, they asked participants questions about their use of condoms, as well as their perceptions around HIV treatments and transmission risks. What they found over time, among both HIV positive and HIV negative men, was “increased beliefs that treatments prevent HIV and increased condomless anal sex.”
Now, correlation doesn’t equal causation — all we know is that as beliefs grew around the effectiveness of HIV treatment preventing transmission, so too did the incidence of condomless anal sex. That said, some research has suggested that there is a direct link between these beliefs and condom use — for example, a 2016 study showing that men who believe ART prevents HIV transmission are much more likely to engage in condomless anal sex. The researchers argue, “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.”
The reason this environment is “potentially problematic,” they argue, is that condomless sex can expose men to sexually transmitted infections (STIs), and STIs can increase the risk of HIV transmission. That is because, the paper explains, STIs can lead to “local genital tract inflammatory processes that increase HIV shedding in semen rendering an individual more infectious than is apparent from his blood plasma viral load.”
But not all experts are in agreement about the degree of risk here. “I think this study inflates the STI concern,” said Jim Pickett, director of prevention advocacy and gay men’s health at the AIDS Foundation of Chicago. “There is that worry, but it has not really played out in the science that has been published.” He points to two studies showing no new linked HIV transmissions among men with HIV positive partners on ART or among HIV negative men using PreP — and that is despite there being STIs in those study populations. (In fact, one of the papers did show rising STI rates.) “Papers like this, to me, come across as unfairly maligning and demonizing anal sex without condoms,” he said. “I strongly disagree that anal sex without condoms is inherently a bad thing.” His argument is that, with proper adherence to ART, anal sex without condoms has been shown to greatly reduce the risk of HIV transmission — the two studies he mentioned demonstrate no evidence of risk. Studies like this current one, he said, “can lead to problematic policies and programs that unfairly stigmatize people and scare people.”
The reality, he says is that many people simply don’t like using condoms, and won’t use condoms — and ART provides an effective and practical alternative in protecting against HIV. “In a perfect world everyone would just listen to what public health officials say,” he said. “But that’s just not where we live.”