Alex Blaze

Gay men would use fewer condoms if an imperfect alternative were available

Filed By Alex Blaze | June 14, 2010 1:00 PM | comments

Filed in: Living
Tags: HIV/AIDS, MSM, New York, prep, study

A small study of HIV- New York gay men who use party drugs and have had unprotected sex recently looked into whether they'd be less likely to use condoms if PrEP (taking anti-retrovirals while negative to keep from getting HIV) could be shown to reduce the risk of HIV. Here's what they found:

The investigators found that the availability of 80% effective PrEP could reduce inhibitions about unprotected sex. Their results also showed that it could lead men to view unprotected sex as having an acceptable level of risk. [...]

Two psychological mechanisms could lead to PrEP increasing sexual risk taking. The first is "behavioural disinhibition". This means that individuals who desire unprotected sex would view PREP as a substitute for behavioural control, or condom use.

It is also possible that PrEP could lead to "risk compensation". Some individuals may consider that PrEP reduces the risk of HIV transmission to such an extent that they are willing to have unprotected sex when taking PrEP. [...]

A clear majority of men (69%) said that they would be likely to use PrEP if it was shown to be at least 80% effective.

Of course, this group isn't representative of all gay men. But people who have messed up recently and had sex with someone without a condom are the people this drug should be aimed at; while 80% isn't as effective as regular, proper condom usage, some people aren't using condoms regularly already. The question is whether they'll drop off condom usage in large enough numbers to cancel out any positive effect of PrEP.

PrEP seems like it'll be the next big thing. According to the CDC, thousands of people are involved in dozens of studies right now on the effectiveness on PrEP and various PrEP drugs, and promising results in non-human animals have been shown. Results for human populations should start being released soon, and the question will move from whether or not they work to whether or not they should be marketed, and how.

While they stress monogamy and abstinence as the first-line of defense against HIV, they don't work for everyone. And while condoms are still better than the results expected from PrEP, they don't work for everyone as well. People mess up. Few people like condoms more than condom-less sex (and I've never met any of them). They get drunk or take drugs before having sex. They assume that the person they're having sex with is HIV- even if they don't have a reason to. They make bad decisions, and lots of men are looking for excuses to not use condoms.

But it seems to me that if they're already messing up on the condom usage, taking a drug daily that has large side-effects might be hard as well. That is, of course, what these studies are probably looking into. It's easy to force a lab rat to take a drug, but a real human with a real life? Let's see if they actually do it.

People are in charge of their own bodies and are free to make their own informed decisions, but when it comes to public health the question is how best to advertise various safer sex measures. PrEP is available right now (at least in France, and the linked article mentions that several study participants had already tried it in New York), but for it to become a public health measure it still has to prove its effectiveness.

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This study asked men who already don't use condoms whether they'd be LESS likely to use condoms if PrEP were available? What's the point in that? If they're already not using condoms, who cares if something makes them even less likely to do so? The point is, THEY ARE NOT USING CONDOMS; a precaution like PrEP may make a difference in slowing the spread of HIV among this group.

The more important question, from a public health perspective, is whether men who DO use condoms would be less likely to do so if PrEP were available. If you just gave them the 80% effectiveness figure, you'd probably get quite a few takers. If you also included the fact that PrEP comes with such lovely side effects as uncontrollable diarrhea, stomach wrenching nausea, explosive vomiting, debilitating headaches, and crippling fatigue, I'd bet 99% of condom users would stick with condoms.

I'm so sick of HIV health policy built around the premise that if you give people more prevention options we're all going to blindly start having riskier sex. Do we not put air bags in cars because people would then drive more recklessly? Do we not put fire extinguishers in buildings because people would then be careless with their blowtorch? No. Why should PrEP be any different?

I agree largely, but I'll just point out that these men are people who had unprotected sex "recently," not people who never use condoms. While it's best to always use them, there is a difference between using them sometimes and all the time.

Plus PrEP is already available for people now. The question is how to market it.

My concern is that hepatitis, gonorrhea, syphilis, chylamidia, and others STDs also need to be a factor in designing such a program.

There's Peter LaBarbera's next headline....

My concern is that drug companies are aiming to treat people with a medication for treating a disease that they do not have. These drugs are powerful and have intense long term effects on the body.
Would we give smokers chemo to prevent cancer?
This is not a vaccine which helps the body naturally arm itself against an illness, this is a treatment drug.
I seriously question the ethics on giving a treatment drug to people who do not even have the illness. I even question the policies of treating new infections as heavily as they are suggesting right now. There are people who never advance or who advance very slowly who may never need drugs or who may not need them for years. Yet we start hammering them with the effects of dugs that they do not need right away.