Krishen Samuel
A recent Australian study found that same-sex couples' agreements regarding casual sex outside their relationships have changed markedly in the era of pre-exposure prophylaxis (PrEP). Nearly 40% of PrEP users in relationships had agreements that allowed condomless sex with casual partners. Furthermore, 34% of PrEP users engaged in condomless sex despite being in relationships with agreements that prohibited it, and 13% of men who did not take PrEP also engaged in condomless sex outside their relationships when there was no agreement permitting it. This research by Dr. James MacGibbon and colleagues at the University of New South Wales was published in AIDS and Behavior.
“Negotiated safety” among HIV-negative men in long-term open relationships is a common practice. This refers to mitigating the risk of HIV and other STIs by partners agreeing to have unprotected sex with each other but using condoms when having sex outside the relationship. While controversial, negotiated safety has been found to be effective when practiced consistently. In Australia, the number of relationships (where both partners were HIV-negative) with negotiated safety arrangements decreased from nearly 40% in 2008 to 29% in 2017, according to behavioral surveillance data. This has coincided with the rise of biomedical prevention, including treatment as prevention (undetectable = untransmittable) and PrEP. As men now have other tools besides condoms available to them, this may affect how men negotiate condom use.
Acceptability and uptake of PrEP have generally been high among HIV-negative gay and bisexual men in Australia. In larger states, such as New South Wales and Victoria, uptake of PrEP has been rapid, rising from 2% in 2015 to 24% of all HIV-negative gay men in 2017. Since 2018, government-subsidized PrEP has been available to key populations, such as men who have sex with men.
While research has focused on the sexual behavior patterns of PrEP users in relation to casual sex, there is a lack of data on PrEP and men's sexual behavior in long-term relationships. Studies conducted in the US found support for PrEP use in the context of long-term relationships, but there were concerns about contracting other STIs. Another study indicated that PrEP use could encourage more open communication between partners regarding risk, thus providing a space to discuss sexual and emotional needs.
The study
The data were collected through Gay Community Periodic Surveys (GCPS) in Australia. These cross-sectional, community-based surveys collect a variety of information related to the behavior of gay and bisexual men and are conducted nationwide with repeated recruitment every one to two years.
The data were analyzed between 2013 and 2018 in a subsample of 21,593 gay men who reported being in a long-term relationship at the time of the study and reported a negative or unknown HIV status. A more detailed analysis of the most recent surveys (2017–2018) provided data on PrEP use in 3,764 participants.
Changes to condom use agreements
The median age of the 21,593 participants was 34 years; most were born in Australia (69%), were HIV-negative (90%), identified as gay (94%), had a university education (54%), and were employed full-time (70%). The majority (77%) reported their partner's status as negative, 5% as positive, and 12% did not know their partner's status.
Changes in agreements were tracked from 2013 to 2018. In terms of agreements related to sex within the relationship, there was a general trend toward a decrease in agreements requiring condom use. For example, the proportion of men who reported agreements that condoms should be used in the relationship for anal sex decreased from 25% to 13%, while the proportion of men who reported an agreement allowing anal sex without condoms increased from 46% to 50%.
Similar patterns were observed for agreements regarding casual sex outside of relationships. The proportion of men who reported an agreement allowing condomless sex increased from 3% to 11% during this period, while the proportion of men who reported an agreement on mandatory condom use decreased from 28% to 20% in 2018. While the proportion of men who reported casual relationships remained stable over time, those who reported having condomless sex with casual partners increased significantly, from 15% to 26%.
PrEP and agreements
Analysis of the most recent survey data showed that 19% had been prescribed PrEP in the past six months. PrEP users had similar demographic characteristics to the main group.
PrEP users in long-term relationships had different agreements about casual sex: no explicit agreement (26%), casual sex is not allowed (13%), anal sex is not allowed (2%), anal sex is allowed with a condom (17%), or anal sex is allowed without a condom (40%).
As expected, the majority of PrEP users reported having condomless sex outside of their relationships. Three-quarters of PrEP users without a formal agreement about casual sex had sex without a condom, indicating an unspoken agreement to a new norm for sex outside of these relationships. Nearly half of the other PrEP users who had agreements prohibiting condomless sex engaged in it.
PrEP use was independently associated with several factors, including a higher number of sexual partners, being in a non-monogamous relationship, having a relationship agreement that allowed for condomless sex, and having both HIV-negative and HIV-positive sexual partners.
Unprotected sex was also a significant issue among men not on PrEP: one-fifth of men without PrEP who did not have a casual sex agreement with their long-term partner reported having unprotected sex outside of the relationship. A similar proportion (22%) who had an agreement requiring condoms with casual partners also reported having unprotected sex outside of the relationship, thus violating their agreement.
Conclusion
The authors conclude by highlighting how the introduction of PrEP has made a notable difference in the relationship arrangements of gay men: “The protection offered by PrEP appears to have enabled many men to enter into agreements and permit a wider range of sexual relations with casual partners than would have been possible or acceptable in the era of ‘negotiated safety’ in the 1990s. This represents a shift in practice away from previous arrangements where condomless sex was sanctioned only between regular partners.”
They also add a word of caution regarding non-PrEP users: “A particular concern for HIV prevention is the proportion of non-PrEP users in relationships (13%) who had condomless sex with casual partners without an agreement permitting such behavior. This group… remains at risk of contracting or transmitting HIV to their casual or regular partners. Many of these men in relationships who do not consistently use condoms for casual sex may be good candidates for PrEP.”
References
MacGibbon, J. et al. Gay men's relationship arrangements in the era of pre-exposure prophylaxis: an analysis of Australian behavioral surveillance data. AIDS and Behavior, 2019: 1-11.
From: http://www.aidsmap.com/news/dec-2019/marked-changes-gay-mens-relationship-agreements-and-condom-use-prep-era