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Uptake of PrEP coincides with less condom use

Condom use fell by 15% between 2013 and 2017 as PrEP use rose

Adrian O'Dowd

Thursday, 07 June 2018

Increased use of the HIV preventative treatment pre-exposure prophylaxis (PrEP) in cities has coincided with reduced use of condoms during sex between men, according to a study* published today in The Lancet HIV journal.

Australian researchers have warned that declining use of condoms could reduce the population-level benefits that PrEP was designed to bring in the long-term.

PrEP is an HIV prevention strategy in which people at high risk of becoming exposed to HIV take antiretroviral drugs to reduce their chance of becoming infected.

Before PrEP’s effectiveness was demonstrated in clinical trials, there were concerns that it might promote riskier sexual behaviour and previous studies of PrEP users have shown that condomless sex becomes more frequent over time.

However, little was known about how PrEP might influence community behaviour, particularly condom use by gay and bisexual men not using PrEP.

Therefore, a team of researchers led by Professor Martin Holt at the University of New South Wales, Sydney, Australia, set out to assess the effect of PrEP on condom use at a community level, tracking safe sex behaviours before and after the widespread introduction of PrEP in Victoria and New South Wales in March 2016.

The researchers analysed data from the yearly Melbourne and Sydney Gay Community Periodic Surveys to investigate the uptake and effect of PrEP on condom use in the community, before (2013-2016) and after (2017) large-scale roll out of PrEP in publicly-funded projects across Victoria and New South Wales.

For the study, the researchers assessed trends in condom use, condomless anal intercourse with casual partners, and PrEP use in 16,827 gay and bisexual men.

Results showed that between 2013 and 2017, recent PrEP use by HIV-negative men increased dramatically from 2% (44 of 2,324 men) to 24% (783 of 3,290).

Looking only at men with casual sex partners, the proportion of men on PrEP who reported condomless anal sex with casual partners rose from 1% (26 of 2,692) in 2013 to 16% (652 of 4,018) in 2017; whilst consistent condom use declined from 46% (1,360 of 2,692 men) to 31% (1,229 of 4,018).

Importantly, among HIV-negative and untested men not protected by PrEP, condomless anal sex with casual partners increased from 30% (800 of 2,646) in 2013 to 39% (1,166 of 2,986) in 2017.

Analysis showed that the increase in PrEP uptake and fall in condom use coincided with a fall in the number of new HIV diagnoses in men who have sex with men (MSM) at a state level, although this observational study did not directly measure HIV infections among MSM.

Over this same period, there were also substantial but gradual increases in HIV testing, HIV treatment, and viral suppression.

This suggested that rapidly increasing PrEP use was effective in preventing new HIV infections and built upon improvements in HIV testing and treatment.

The authors noted that the rapid increase in PrEP use seemed to have outweighed the rapid decrease in condom use in this early phase of PrEP implementation, but that further monitoring over the long-term would be important.

Professor Holt said: “PrEP has been heralded as a game-changer for HIV, but declining condom use may impede its long-term population-level effectiveness. We need better monitoring and evaluation to assess the effect of PrEP on sexual practices at the community level in both PrEP and non-PrEP users.

“If sustaining condom use is important, it would be wise to implement community education campaigns to promote condom use as PrEP is being introduced.”

*Holt M, Lea T, Mao L, et al. Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013–17. Lancet HIV 2018. DOI:10.1016/S2352-3018(18)30072-9.

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