“The Main Concern is HIV, Everything Else is Fixable”: Indifference toward Sexually Transmitted Infections in the Era of Biomedical HIV Prevention

Abstract

With the advent of biomedical HIV prevention, attitudes toward and cultural norms around condom use and sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM) are changing. Participants of 2GETHER, a randomized controlled trial of a relationship education and HIV prevention program for male couples, have acknowledged that having condomless anal sex put them at increased risk for STIs. Nonetheless, facilitators of the program have increasingly observed that participants were indifferent toward STIs and unmotivated to engage in preventative behaviors, particularly if they used pre-exposure prophylaxis. Participants’ reasons for their lack of motivation to take precautions against STIs are reviewed. Implications of these attitudes for public health interventions to reduce rates of STIs among MSM, including frequent screening and treatment of STIs and potential messaging around condom use, are discussed.

Introduction

In the era of biomedical HIV prevention, a frequent topic of conversation among researchers and practitioners is changing attitudes toward condom use and sexual transmitted infections (STIs). The authors and our research team observed this change first-hand as we conducted a randomized controlled trial of 2GETHER, a relationship education and HIV prevention program for male couples. As part of the intervention, couples participate in individualized sessions, facilitated by a coach, in which they discuss prevention strategies for HIV and STIs (1). Initially, our goal was to describe what we called “STI ambivalence,” or mixed feelings participants had about protecting themselves from STIs. However, in reviewing audio recordings of sessions, we realized that “ambivalence” was not accurate, as participants’ feelings did not seem mixed at all – for most, their attitude toward STIs was one of complete indifference.

Pre-Exposure Prophylaxis and Motivation to Use Condoms

Since we launched recruitment in 2018, participants of 2GETHER, particularly those who use pre-exposure prophylaxis (PrEP; a once daily pill to prevent HIV infection), have acknowledged that having condomless anal sex (CAS) put them at increased risk for STIs. Nonetheless, facilitators have increasingly found that participants were unmotivated to engage in preventative behaviors. These reactions were not uncommon: of 58 sessions reviewed, 33% involved discussion of indifference toward STIs. In 63% of sessions that featured STI indifference, one or both partners used biomedical HIV prevention (i.e., PrEP or treatment as prevention). As facilitators of a sexual health intervention tailored to the needs of male couples, we felt conflicted about how to respond. For gay, bisexual, and other men who have sex with men (MSM), initiating PrEP has been shown to enhance sexual pleasure and intimacy by reducing the fear of HIV and removing the physical and symbolic barriers that condoms pose (2). However, STIs remain an important public health concern, and condoms remain the most effective prevention method. MSM have a greater incidence of STIs than that reported in women or men who have sex with women only (3). MSM have also recently been shown to be at increased risk for extragenital STIs (i.e., chlamydia and gonorrhea in the throat or rectum), highlighting the need for more frequent STI screening and increased condom use during anal sex (4). The impact of decreased condom use has become more of a topic of debate since the advent of PrEP. Studies of physician attitudes have revealed concerns that PrEP users may be less likely to use condoms, leading to increased incidence of other STIs (5, 6). Research on risk compensation, or increased risk behavior (e.g., CAS) after adopting a preventative measure such as PrEP, however, has had inconsistent results. Early studies reported no evidence of decreased condom use among PrEP users (7-9). However, longitudinal studies and meta-analyses have found higher rates of receptive CAS and increases in STIs after PrEP initiation (10-13). In addition, MSM are less likely to use condoms when they are in relationships (14), which can increase risk for STIs, particularly among non-monogamous couples.

To better understand why this indifference was occurring, we first turned to existing theory on health behavior change. Although there has been considerable research on attitudes toward HIV (15), much less has examined perceptions of other STIs. The Health Belief Model (HBM), a theory proposed to explain processes of change in health behaviors, has been widely used to predict condom use (16). The HBM consists of five dimensions, one of which is perceived susceptibility (17). With high levels of adherence, PrEP has been shown to reduce HIV acquisition by more than 90% (7, 18), meaning those on PrEP accurately assess their susceptibility to HIV to be low, even when engaging in CAS (19). In addition, the effectiveness of treatment as prevention and the concept of Undetectable = Untransmittable (U=U), meaning that people living with HIV who achieve and maintain an undetectable viral load by taking and adhering to antiretroviral therapy cannot sexually transmit the virus to others (20), may decrease perceived susceptibility for those who engage in CAS with partners who are living with HIV. Another dimension of the HBM is perceived severity, or an individual’s assessment of how serious or dangerous a threat may be (17). A qualitative study used focus group discussions among MSM to ask them to rank their perceived severity of 11 STIs (21). HIV was consistently ranked as the most severe. Other STIs, including gonorrhea and chlamydia, were ranked as less severe, because they were more familiar to participants, and had effective treatments and/or cures (21). Low perceived severity of STIs, paired with low perceived susceptibility to HIV, may translate to decreased motivation to use condoms among PrEP users, even though perceived susceptibility to STIs was not necessarily low, as seemed to be the case among 2GETHER participants.

Reasons for STI Indifference among 2GETHER Couples

Next, we reviewed 2GETHER intervention sessions in which participants discussed STI indifference in order to characterize the context surrounding these attitudes. Couples identified several reasons for their indifference toward STIs. Perhaps the most common was that because bacterial STIs are curable, they are perceived as a temporary inconvenience, which decreases participants’ motivation to take precautions against them (i.e., use condoms). Instead, many participants brought up frequent STI testing as their preferred form of prevention or management. For example, one participant stated, “Fortunately, there’s good treatment still for [STIs]… it’s kind of like, passé at this point, for both of us, probably. It’s not a major concern… if you are having some issues with something and you think it might be an STD, you go to the doctor, get tested, and get treated.” Although participants discussed that if they were to have an STI, they would simply get tested and receive treatment, rarely did they acknowledge that having an STI themselves could potentially mean transmitting it to their relationship or sex partners. Participants using PrEP also highlighted their motivation to take precautions against STIs in the context of the protection afforded to them from HIV, which is viewed as more permanent: “I fully accept the risks that come with not using a condom. With respect to HIV, it’s because I’m on PrEP, and I’m confident that that will stop anything permanent from sticking.” Another participant succinctly summarized his perception of the contrast between the perceived severity of HIV versus that of other STIs: “The main concern is HIV, everything else is fixable.” However, in their perception that STIs are curable, participants often ignored that viral STIs, such as hepatitis, genital herpes, and HPV, are not. Symptoms of HPV, such as anogenital warts, can have devastating effects on sexual intimacy, as one participant explained, “I am the one who got the genital warts… I just sort of hate life at the moment. It makes me feel incredibly unsexy. It makes me feel not only gross, but like I deserve it, like I’m a bad person who has done bad things and is being punished.”

Participants have also expressed that their dislike of using condoms outweighs their concern about the risk for STIs. Participants’ most often cited reasons for disliking condoms were that they were unpleasant to use and interfered with sexual pleasure, consistent with previous research (22). However, attitudes of participants’ sexual partners, particularly partners who use PrEP, have also been discussed as a barrier to condom use: “I think culturally in the gay community, asking anyone to use a condom now is difficult… people just don’t want to use them anymore because people are like, ‘Oh, I have PrEP, I don’t need a condom anymore.’” Participants have also stated beliefs that getting an STI at least once is inevitable and, for some, perceived as unavoidable. This was particularly relevant for participants who had been diagnosed with an STI in their throat, who often commented that however unlikely it was for them to use condoms for anal sex, it was even less likely that they would use one, or feel comfortable asking a partner to use one, for oral sex.

Conclusion

Despite the prevalence of these attitudes among 2GETHER participants, few studies have examined indifference toward STIs among MSM using biomedical HIV prevention. This represents an important area for continued research, given the increased risk for STIs among MSM, and that having an STI increases the risk of acquisition or transmission of HIV (3, 4). Through the lens of the HBM (17), it appears that although 2GETHER participants did acknowledge susceptibility to STIs when they engaged in CAS, this was outweighed by lack of severity, because of the perception that STIs are curable, and that getting tested and treated are minimal inconveniences, which has been echoed by previous qualitative studies (19, 23-25). This was concerning, given that viral STIs, such as hepatitis, genital herpes, and HPV, are incurable, and can have detrimental effects on sexual pleasure and intimacy in relationships. Although participants seemed to perceive the benefits of condom use in reducing their risk for STIs, they often felt that the barriers to using condoms, such as decreased sexual pleasure, were more salient.

Notably, although participants often accepted their own risk for STIs when they did not use condoms, they seldom acknowledged their role in spreading STIs to others, including their relationship partners, with whom they were participating in the 2GETHER intervention. A similar phenomenon was found in one previous study in which a couple described prioritizing protecting themselves and each other from HIV, and, in contrast, were more tolerant when either of them introduced a curable STI into their relationship (25). However, this does not address the potential consequences, both individually and for the relationship, of being infected with an incurable STI, and is concerning from a public health standpoint, given increased rates of antibiotic-resistant gonorrhea among MSM (3). It was also striking to us that indifference toward STIs was prevalent even in a sample of MSM who presumably prioritized their own sexual health and that of their partner, given their self-selection to participate in a randomized controlled trial of a relationship education and HIV prevention program. In addition, these attitudes persisted even among couples who had participated in the didactic portion of the intervention, which includes information about HIV/STI risk reduction, and had worked with a facilitator who was trained in motivational interviewing techniques to encourage participants to engage in additional risk reduction strategies. This stands in contrast to the samples of MSM from qualitative studies describing indifference toward STIs among those who use PrEP (19, 23-25), and illustrates the urgency with which new interventions are needed, as our traditional approaches to STI prevention are no longer working in the biomedical HIV prevention era.

This leaves us with a question for which we do not have a clear answer: how do we prevent STIs among MSM in the era of biomedical HIV prevention? It is likely that 2GETHER participants represent a larger subset of MSM on PrEP whose indifference towards STIs affects their willingness to use condoms, and messaging about prevention must take this into account. If we are to advocate for increased condom use, we must be realistic and acknowledge that under certain circumstances (e.g., oral sex), it is far less likely. We must also consider that, for some, frequent screening and treatment may be the most effective approach (4). However, it is also important to acknowledge that for other MSM, changing norms around condom use may be damaging. Those who are motivated to use condoms may be stigmatized or experience rejection by asking their partners to use this prevention approach. Even worse, others may feel uncomfortable asking their partners to use condoms at all, and thus feel pressured to have condomless sex. Further, those who cannot access or consistently use PrEP may be at elevated risk for HIV/STIs, given the decline of condom use in communities in which PrEP use is common (13). Addressing STI indifference among PrEP users is a complex endeavor, and existing public health campaigns that focus exclusively on consistent condom use are unlikely to be effective. Future research exploring the nuances of STI attitudes would not only address a significant public health need, but also benefit the physical, emotional, and relationship health of this at-risk population.