Bringing back condoms

When did you last see a public health campaign in the United States promote condoms as a tool for preventing HIV and other STIs among MSM and/or trans women? If you are like us, the answer is long ago – perhaps a decade or two. You may be already thinking: ‘So what? We have PrEP and U = U for HIV now, and doxyPEP and improved screening for STIs. Plus, gay men aren’t interested in condoms anymore’. If so, read on.

Two findings from a recent article [1] examining 6 years of nationwide surveys of cis-gender MSM may surprise you. First, in the most recent data (from 2019, thanks to COVID), roughly half of HIV-negative MSM reported using condoms at least sometimes in the last year – a figure higher than the number who used PrEP (15%). (Most other reported PrEP-use rates are higher because they limit to ‘high-risk’ MSM, that is, those not using condoms regularly.)

Second, among 15 to 24-year-old HIV-negative respondents who were not taking PrEP at all for two consecutive years, the proportion reporting recent condomless anal sex increased by 7.2% from 1 year to the next. Young Latinx MSM saw the highest increase: 18.7%. These changes were not directly driven by awareness and utilization of U = U, as they mostly involved partners of unknown or presumed negative HIV status. Transmission risk among MSM overall seems to have declined, as many already having the most frequent condomless sex have initiated PrEP or HIV treatment; but for an important subset, things seem to have gone in reverse. The full set of predictors (including residence outside urban cores) paint a picture of that subset, and how public health may be failing them.

Taken together, these findings suggest that condoms continue to be acceptable and accessible to the broader MSM population, even as usage falls within a subset of those who have not adopted newer biomedical prevention strategies. In short, the messages we have heard from some public health colleagues – including many gay male colleagues – that ‘MSM prefer PrEP over condoms’ seems to be a supposition that generalizes from some MSM to all.

And yet, many public health professionals and advocates seem to have grown tired of promoting condoms. The ‘key strategies’ section of the US's ‘Ending the HIV Epidemic’ plan emphasizes ‘prevent[ing] new HIV transmissions by using proven interventions’ [2]. PrEP is then mentioned repeatedly, whereas condoms never appear. A recent NACCHO report on STI research priorities also never mentions condoms, despite covering numerous intervention-related behavioral and epidemiological topics [3]. Nor does NIH's latest HIV-related strategic plan, despite highlighting all other major prevention modalities [4]. Too often, the businesses facilitating sexual connections also downplay condoms. One of the world's biggest hook-up apps for gay, bi and trans men prominently provides a space where users can indicate whether they are on PrEP or virally suppressed – but this list does not include whether they use, or will consider using, condoms. Meanwhile, one of us has repeatedly found the longtime condom bin at his local gay bar completely full, but only with lube packets.

Biomedical interventions – PrEP, U = U, and doxyPEP – are wonderfully effective. They continue to get better – witness the advent of long-acting injectable PrEP. But, for example, we have to ask: over a decade in, do we really believe we can get PrEP continuously to every HIV-negative person it might benefit, especially the youngest at risk? Imagine the following scenario. An 18-year-old gay male lives with his parents but does not feel safe coming out to them. He is lucky enough to be on their insurance plan. Even if he knows where to get PrEP and is told his parents will not find out, he feels he cannot risk it. Maybe he does not think he really needs it – he has only had sex twice, and does not know when he will again. Meanwhile, he has never had LGBTQ-inclusive sex education, all the porn he sees is bareback, his favorite app does not include a condom option, and his partners, also his age, do not mention them. Are we really helping him by remaining virtually silent ourselves about such an inexpensive, easily accessible and effective prevention strategy? Other barriers to continuous PrEP are not hard to imagine: queer youth with unstable housing, someone who does not trust big pharma, a guy whose live-in girlfriend does not know he also sleeps with men. Simply put, we are not going to succeed in getting everyone at risk for HIV on PrEP and everyone with HIV suppressed in the foreseeable future, if ever. Nor will we screen and treat our way out of every STI.

Contrary to what we have heard some colleagues imply, we see condom promotion as crucial to health equity – whether age, class or race. We fully support reducing all barriers to PrEP and testing and treatment, and addressing broader structural inequities, especially when public health has the ability to use data-driven interventions to do so. But if we truly care about equity, we cannot rely solely on a prevention modality that requires repeated interactions with the healthcare system (and gives the pharmaceutical industry enormous sums) while we abandon one that is far cheaper and easier to access, and far simpler for health departments and community-based organizations to implement.

We have heard many explanations for downplaying condoms from colleagues, but we find all of them unpersuasive. We have heard that queer men and transfolk are not interested in condoms now because other STIs have never felt as threatening as HIV. Yet whereas the other STIs do not kill, their explosion is the clearest sign the current approach has problems, while mpox reminds us that new, potentially deadly STIs can appear anytime.

We have heard that any suggestion for queer people to self-regulate their sexual behavior smacks of homophobia or transphobia – but we have known since the 1980s how to do condom promotion that affirms queer sexuality. Many people report that anal sex feels better and more intimate without condoms – but sex-positive health promotion has long highlighted myriad forms of creative, intimate, pleasurable sex. We have heard that everybody already knows about condoms – but the concentration of the decline among youth reminds us that every new generation starts from scratch. We have heard that condoms are not that effective, but we repeatedly hear apples-to-oranges comparisons of PrEP efficacy (assuming the user takes it perfectly) with condom effectiveness (accounting for human error or misreporting). We have heard that people are relying on their partners being on PrEP or virally suppressed. But this assumption is surely not universally accurate for casual or anonymous partners, especially when it is often derived from an app profile written long ago.

Most curiously, we have heard the belief that condoms are an individual decision in which public health has little role. We wholeheartedly disagree; public health is maximally effective when it works on multiple levels at once, from individual to system – think of eliminating food-system inequities while also supporting individuals in making healthy diet choices. And indeed, condoms are not an individual decision; they are negotiated by two (or more!) people each time. Wherever that occurs – in an app, over dinner, in bed – it is rarely easy, and often involves fear of sexual or social rejection. Shared decisions are inherently vulnerable to cascading effects of social pressure – an area where public health can play a particularly valuable role. We realize this negotiation is likely a key reason why many prefer PrEP, as it places more control in their hands. But the fact that PrEP and other biomedical approaches have some advantages over condoms does not make them a perfect substitute. Both must be a meaningful part of any sexual health package that replaces either/or with any or all, supported without bias or assumption. Although the CDC and other agencies do promote this standard [5], we have not seen it being widely accepted and practiced in community and medical settings.

Thankfully, there are places where we see condoms being emphasized appropriately. The White House's latest National HIV/AIDS Strategy highlights them throughout [6]. A recent New York Times article spotlights a Black male entrepreneur in Atlanta whose condom company and accompanying sex-positive Instagram posts are, in one customer's words, charting a path towards ‘Black-owned sexual health’ [7]. And, of course, there are the findings mentioned above that more MSM use condoms than PrEP, even as unmet need and disparities by age and ethnicity persist or even grow.

With some men still eschewing all of these prevention strategies, our list of areas for improvement is long. We need comprehensive LGBTQ-inclusive sex education, including all the ways to prevent STI and HIV transmission. We need more online and offline promotion of condoms that highlights their relative advantages again. Ensuring that all hook-up apps include condom options alongside PrEP and viral suppression is a one-time intervention that costs public health nothing, has long-lasting impact, and reflects what most users want [8]. We need to lower prices and increase donations from condom manufacturers and distributors. We need to unlock condoms in more stores, and ensure people know where to get them free or relatively cheaply. We need condoms in home test kits and PrEP prescriptions. We need every bathhouse, sex club and sex party organizer to hand them to every entering customer, and have them readily available in bars and clubs again.

It will take a relatively small amount of effort and funds to re-invigorate condom promotion. Increasing our willingness to do so may be the hardest part. Continuing to remove societal and economic barriers to biomedical interventions – especially those rooted in inequities – is crucial. While we keep building the tools to do so, we cannot ease up on other approaches that are easy to distribute, low-cost and effective.

Acknowledgements

The authors would like to thank NCSD and NASTAD for providing support to ensure Open Access for this piece.

Conflicts of interest

There are no conflicts of interest.