Data from the last ten years of the Australian Gay Community Periodic Surveys shows a steady decline in consistent condom use, with more gay men attempting to minimise their risk by serosorting or by having an undetectable viral load. While HIV-positive men appear to be increasingly confident in their low risk of HIV transmission, it is not clear that HIV-negative men have fully embraced the impact of antiretrovirals on HIV prevention.
“Our report highlights the urgent need for HIV prevention messages to reflect the expanding approaches gay men find most suitable,” commented Carla Treloar of the University of New South Wales. “These messages should include biomedical and behavioural tools and address diverse groups of gay men.”
Despite the long-term shifts in sexual behaviour, annual incidence (new infections) in gay men is stable at 0.89%, as are new HIV diagnoses (699 in 2015, compared to 631 ten years previously). Moreover, despite an increasing population of people living with HIV in Australia, there are fewer diagnoses being made proportionally over time. In 2015, for every 100 people living with diagnosed HIV, there were 4.5 new HIV diagnoses, which is 32% lower than the 6.6 in 2006.
The new report, released this week, also shows that regular HIV testing and comprehensive STI screening are both up, while recreational drug use is down.
The report reviews trends between 2006 and 2015. Data come from the Gay Community Periodic Surveys, which are conducted in urban areas with large gay populations. The surveys recruit men online, in sexual health clinics, and at gay venues and events. Different men take part in these cross-sectional surveys each year.
Fewer men always use a condom
Consistent condom use during anal sex is one of the most important risk-reduction strategies identified by the report, but it is in long-term decline.
Among HIV-negative men, 26% always used a condom, down from 34% ten years earlier.
The decline was even more marked in HIV-positive men, whether they had an undetectable viral load (13%, down from 30%) or a detectable viral load (10%, down from 25%).
Avoiding anal sex may be a risk reduction strategy for some men
Behavioural research often focuses on risky practices, but the report highlights the significant minority of men who did not have any anal sex in the previous six months or did not have any sex at all. For example, this was the case for 13% and 8% of HIV-negative men in 2015.
More men have condomless sex with regular partners
Condoms are less likely to be used with regular partners than with casual partners. Among men who had a regular partner, condomless sex was reported by 55% (up from 46%). Regular partners include ‘fuck buddies’ as well as ‘boyfriends’.
The rise in condomless sex with regular partners was especially notable in men under the age of 35.
At the same time, fewer men who reported not using condoms with a regular partner said that they had made a ‘negotiated safety’ agreement with their partner about sex outside the relationship: 30%, down from 35%.
… and with casual partners
Condomless sex with casual partners is also increasing: 41%, up from 33%. Again, the increase is most marked among younger men, in this case those under the age of 25.
But men appear to be trying to make it safer by discussing their HIV status with partners first. The proportion who say they always disclose HIV status is increasing, both among HIV-positive men (43%, up from 28%) and HIV-negative men (29%, up from 18%).
In the most recent survey, over half of both HIV-positive and HIV-negative men who had condomless sex with casual partners said that they tried to only do so with men of the same HIV status (i.e. serosorting).
Large differences in antiretroviral awareness between HIV-positive and HIV-negative men
Among men with diagnosed HIV who had condomless sex with casual partners, 75% said that knowing they had an undetectable viral load was one of their risk reduction strategies. The researchers think this is likely to partly explain the increasing number of HIV-positive men having condomless sex with casual partners.
However a much smaller proportion of HIV-negative men who had condomless sex with casual partners said that ensuring an HIV-positive partner was undetectable before sex was one of their risk reduction strategies (13%). Other surveys suggest that HIV-negative men’s understanding of treatment as prevention remains limited, but is improving over time.
The antiretroviral prevention methods for HIV-negative men are still only occasionally used. Among the men who had condomless sex with casual partners, 5% mentioned PEP and 4% mentioned PrEP as risk reduction strategies.
Behavioural surveys need to change
The researchers say that they need to refine the questions they ask in order to better capture the ways in which PrEP and treatment as prevention may affect gay men’s sexual behaviour. Existing measures such as ‘condomless anal intercourse with casual partners’ do not distinguish between potentially risky and safer forms of condomless sex, they say.
Future Australian surveys will categorise participants’ recent sexual behaviour as follows:
- No anal intercourse with casual partners
- Consistent condom use with casual partners
- Any condomless anal intercourse by HIV-positive men on HIV treatment and with an undetectable viral load
- Any condomless anal intercourse by HIV-negative men on PrEP
- Any condomless anal intercourse by HIV-positive men not on HIV treatment or with a detectable viral load
- Insertive-only condomless anal intercourse by HIV-negative or untested men not on PrEP
- Any receptive condomless anal intercourse by HIV-negative or untested men not on PrEP
Only the last three behaviours will be considered ‘risky’.
HIV and STI testing is up
Among men who have not been diagnosed with HIV, 66% had tested in the past year, up from 63% ten years earlier. Comprehensive screening for sexually transmitted infections (i.e. throat swab, anal swab, urine sample, and blood test for other than for HIV) is much more commonly reported: 44%, up from 26%.
Drug use is down
Despite media anxiety, the ten-year data show that the proportion of Australian gay men using most recreational drugs is stable or decreasing. This is the case for poppers (41%, stable), cannabis (28%, down from 36%), cocaine (12%, stable), ecstasy (12%, down from 30%), crystal meth (11%, down from 16%) and speed (10%, down from 25%).
However use of erectile dysfunction drugs is increasing: 26%, up from 21%.
By Roger Pebody
Mao L et al. HIV/AIDS, hepatitis and sexually transmissible infections in Australia: annual report of trends in behaviour 2016. Sydney: Centre for Social Research in Health, UNSW Australia.