Some Gay Men on PrEP May Stop Using Condoms. Does It Matter?

When I talk to my adolescent patients about sex and sexuality, there’s a line I usually include in my patter. I tell them that they’re in my office for medical advice, not moral guidance. The questions I ask and information I give are for the purposes of keeping them safe and healthy, not so I can pass judgment on their character.

Ironically, it’s when I have patients who are gay men like me that I sometimes need to keep any moralizing in check.

In 2016, the National LGBTQ Task Force Action Fund and the National Coalition for LGBT Health noted the need for ongoing education and treatment for sexually transmitted infections (STIs). Their guide specifically notes “People on PrEP may be less likely to use condoms, perceiving other STIs/STDs as easily cured despite the troubling rise of drug resistant gonorrhea.”

“PrEP” is short for pre-exposure prophylaxis. It’s a regimen of two different medications that, when taken daily, can substantially reduce the likelihood of being infected with HIV for those at increased risk, including men who have sex with other men (MSM). Reading that people taking it may be less likely to use condoms, I could feel my biases sneaking in and making themselves comfortable.

I’ve written about my conflicted feelings regarding PrEP before. I came out in 1994 when I was in college. (It was a memorable Christmas vacation.) At the same time that I was figuring out how to live my life as a gay man, HIV was shifting from a uniformly fatal diagnosis to a manageable chronic illness. I lost no friends of my own generation to AIDS but guys not much older than I was, who hung out in the same bars I did, had lost many. And the message I heard was clear: Practice safer sex. Even the drag queens closed out their show with the exhortation “If you’re gonna tap it, wrap it.” (Wherever you are, Miss Teal, I still remember.)

I heard it. I learned it. I lived it.

But of course, nobody asks for my backstory when they come to my office for care, because my personal history outside of med school isn't relevant to their needs. My gay male patients deserve comprehensive information about reducing their own HIV risk, not doctrine. I’ve started discussing PrEP with those who are young adults, though thus far I haven’t had any who’ve opted to start it.

However, my concerns about use of PrEP leading to increased risk of other STIs have persisted, and it took little prompting from the guide for my preconceived notions to gain new traction. With those notions firmly in mind, I approached several LGBTQ-focused health care providers with questions about whether the advent of PrEP had led MSM to abandon the lessons I had assimilated myself so long ago.

The answers weren’t nearly as tidy as I’d assumed.

“I think people who are either skeptical or naysayers about PrEP would immediately jump to the idea that because of PrEP people are no longer using condoms, and therefore STIs are on the rise,” said Kelsey Louie, CEO of GMHC. (Formerly Gay Men’s Health Crisis, GMHC was the world’s first HIV/AIDS care and advocacy organization.) “I think we need to be smart and responsible about that statement and that conclusion, because I don’t think that’s the only conclusion we can draw.”

An element of PrEP that is easy to overlook is the follow-up protocol that goes along with taking it. Patients don’t just walk out the door with a prescription and a fare-thee-well. Every three months, they need to return to their provider for a discussion of their sexual practices, for repeat HIV testing, and for other STI screening, even if they have no symptoms.

“We have to understand that STIs are often asymptomatic,” Louie continued. “More studies should be done around these diagnoses of STIs—are they happening because more people are getting tested? Is it a real increase in STIs, or just an increase in diagnoses, and the number of STIs that are being diagnosed that are asymptomatic. We can’t necessarily jump to the conclusion that higher rates of STIs are connected to the uptake of PrEP.”

The data that are available don’t convey a clear message. Louie made note of the iPrex study, which reported no increase in “risk compensation” even when study subjects knew they were getting real medicine rather than placebo. However, as reported earlier this year, a study of 600 MSM in San Francisco found that many reduced their use of condoms after starting PrEP.

Brian Bakofen, a physician at Fenway Health in Boston, had a similar dual explanation for increased STI diagnosis among his own patients.

“I think yes, there has been an increase in other STIs since PrEP has become more widely available, and there are a couple of studies showing this as well,” Bakofen told me. “I think there are a few reasons—of course more unprotected sex is one of them. Many of the patients on PrEP were having at least some unprotected sex prior to starting the medication. However, we also have patients on PrEP in for STI screening every three months under CDC guidelines, so we may be detecting more of what was already out there.”

"We are studying a group of patients comparing STI incidence before and after PrEP initiation,” Robert Bolan, chief medical officer of the Los Angeles LGBT Center, told me. “This method can give a more comprehensive understanding of how attitudes and practices vary among those who use PrEP compared to other analyses that simply look at global STI incidence over time at a clinic or community level. In our study, each person serves as their own control. At this point our data is preliminary, mainly because not all have been followed for 365 days on PrEP. However, there does seem to be a slight increase in incidence of syphilis and rectal chlamydia, but not gonorrhea.”

It’s easy to react with dismay at indications that some gay and bi men may be exposing themselves to greater risk of STIs because they’re neglecting safer sex practices. Ideally, I’d want any given patient to be protecting himself as best he can. But having said that, it bears asking what reacting with dismay really accomplishes. No matter how insistently condom use may be promoted, there will be some who choose not to use them anyway. If ultimately the goal is to prevent HIV infections in as many people as possible, PrEP offers an alternative.

“Clients in our PrEP program are getting infections at about a 10 percent higher incidence but that is expected,” said Pierre-Cedric Crouch, Director of Nursing at Strut, a clinic for gay, bi, and trans men sponsored by the San Francisco AIDS Foundation. “If you have a PrEP program that has no infections, there is something wrong with the PrEP program, as you are not reaching people who have a chance of getting HIV. People on PrEP are getting screened more frequently than they ever have before so they benefit from having more infections identified and treated.”

Beyond the specific benefit of preventing a particular infection, however, many of the people I spoke to noted that PrEP offers gay and bi men, in general, a release from the stigma and anxiety that has attached to our sexuality since the AIDS crisis.

The campaign to promote PrEP awareness and use at the Center in Los Angeles is frankly named “F*ck w/out Fear.” (The asterisk is theirs.) “Do you want to be fearless?” their website asks. “The Los Angeles LGBT Center can help. It’s time for you to F*ck w/out Fear.”

“I don’t necessarily blame anyone for the situation,” said Crouch, “but everyone including the medical establishment and nonqueer communities have played a role in stigmatizing HIV and sex. PrEP is a way to heal from that trauma and have sex something that is celebrated and enjoyed again.”

It’s hard to deny how pervasively fear has insinuated itself into discussions of gay sexuality. I remember going to the movies to see Jeffrey, the film version of a play about a guy who chooses celibacy rather than let himself than fall in love with an HIV-positive man. (Spoiler: He changes his mind.) More than one loved one reacted to my coming out by immediately expressing concern that I would get AIDS. While it’s understandable that the grievous loss sustained by the gay community would naturally make people fearful, gay and bi men are no less entitled to sex lives without it than anyone else. And for some men, PrEP gives them that freedom.

“If we can now prevent most cases of HIV transmission by taking a safe, daily pill, why are we even having to entertain such questions?” asked Bolan about those who would naysay use of PrEP. “Untreated HIV kills. The burden of treating HIV once it has infected someone is a lifelong, very expensive reality. Lost productivity, depression, and other conditions accelerated by HIV infection (like heart and liver disease) are significant individual and societal burdens of HIV. Frankly, I have little patience for such so-called arguments. In fact, they are not arguments but rather reflexive and thinly disguised moralizing.”

Everyone I spoke to about PrEP was clear that discussion of overall sexual-risk behaviors is part of prescribing the medication. All made note that men who take it are coming in for STI screening they might otherwise miss, and that being on the medication meant routine visits to keep them as healthy as possible. If anything, PrEP may help spur renewed attention to HIV risk in the face of increasing complacency about it.

It’s obviously important to investigate STI prevalence among men taking PrEP and take steps to keep MSM as healthy as possible. While there are cures for many non-HIV STIs, untreated infections can be quite serious, and emerging drug-resistant strains of gonorrhea are cause for concern. But using those concerns as a reason to denigrate PrEP is missing the point.

"Why would we limit options for people to not only take care of themselves, but to help stave off one of the most impactful public health epidemics of the past few decades?” asked Louie. “We need all the tools we can in order to end this epidemic. Like birth control, these are individual choices people make around their HIV prevention strategy.”

If PrEP had been around two decades ago, I have no idea if I’d have taken it. But it would have offered a different message than the one I heard over and over at a profoundly formative moment in my life. No matter what I would have chosen for myself, however, it’s here now. And I’m glad I can offer it to patients who want it.