PrEP is one way to prevent HIV from being passed during sex, but it’s definitely not the only way. These are exciting times for gay guys, because there are more HIV prevention options available for us than ever before, and that means that what doesn’t work for one of us might work for someone else- and HIM supports guys using whatever tools are out there that work best for them!
There’s a reason why we still encourage guys to use condoms for HIV prevention: THEY WORK! Condoms have a really unique place in gay men’s history, because they were the first crucial step that started to slow the HIV epidemic. In fact, we know that when condom use was at its highest rate among gay guys, new HIV transmissions reached their lowest rate in the entire history of the epidemic. We also know that condoms have to be used consistently and correctly, and that if they aren’t, guys are still at risk for HIV transmission when they have the kinds of sex where HIV can be passed. Most importantly, though, we know that when condoms are used consistently and correctly, they have about the same effectiveness at preventing HIV transmission as PrEP does- around 90%. For a great fact sheet on condom use and effectiveness, check out this CATIE resource HERE. Consistent condom use means that you use condoms every single time you have the kinds of sex where HIV can be passed. For gay guys, HIM considers this to be anal sex, including both topping and bottoming. HIV transmission from getting or giving head is what’s called a ‘theoretical’ risk for HIV transmission, because while it’s possible that it can happen, if it does, it’s so rare that it’s almost undocumented in HIV research. Using condoms ‘most of the time’ or only with certain guys is not the right way to use condoms- if you’re relying on condoms as your HIV prevention method, they should be used every single time you have anal sex outside of a monogamous relationship. Consistent condom use also means that you are able to negotiate using them, including with dates, hookups, fuck buddies, or boyfriends. We know this isn’t easy for all guys- if negotiating condoms WAS easy, way more of us would have an easier time using them! There are a lot of reasons that it’s hard to negotiate condom use: a guy might tell you he doesn’t like them, or doesn’t like the way they feel, and then you might find yourself feeling like you have to convince him- and that’s not only not sexy, it’s not fair. It can also be hard to stop the action and bring up condom use, especially if you’re having sex in a place where there might not have been a lot of communication- like a bathhouse. For some guys, it can be helpful to bring out a condom before any type of action, including kissing, takes place- this kind of sets the scene, like you’re non-verbally telling the guy ‘So, I’m going to put this here, because I use condoms and now it’s ready to go when we need it.’ This strategy might also be helpful in bathhouses, or where other types of more anonymous sex happens, like parks and cruising grounds. If you use hook up sites online, you could consider adding condoms to your user profile, so that guys you’re chatting with know that your expectation is that you use them when you have the kinds of sex where HIV can be passed. We know negotiating condom use can be hard- and we’re not trying to oversimplify it. We just want you to remember that condoms allow you to take control of your own sexual health, and that you’re ultimately the only person who has that power- whether you’re on PrEP, or whether you use condoms! Correct condom use is different than consistent condom use. Correct condom use means that you aren’t only using condoms during the types of sex where HIV can be passed, but you’re using them correctly. Condoms might not be ‘rocket science,’ but there’s definitely an art to using them right! When condoms don’t work (i.e., when they break or slip off), it’s usually because they haven’t been used correctly. Correct condom use means that you’re using a type of lube (silicon or water-based) that is specifically designed for condoms, because other types of lube (oil based ones) can degrade condoms and that might cause them to break. Lube is really important in another way: it needs to be applied to your dick or ass in sufficient amounts, because otherwise friction can cause the condom to break or pull off, and that can expose you to some of the body fluids that HIV can be passed through (like anal fluids or cum). Putting a drop of lube inside the condom can also help decrease friction, and can even make the condom feel more pleasurable for the top. If you’re uncut, you should pull back your foreskin before you put it on, because that will also help prevent the condom from getting too tight and breaking. And speaking of too tight, all jokes aside, if you have a big dick, make sure that you’re using a condom designed to accommodate your, ahem, ‘needs.’ That said, don’t, um ‘overinflate’ your dick size when it comes to condoms- just like they can break if they’re too tight, condoms that are too big can slip off. No matter what your size, even in the heat of the moment take a break once in a while to make sure that the condom is still on and doesn’t have any tears and hasn’t broken. And remember that if you’re ever in a group sex situation, a new condom needs to be used every time you switch partners- even if it’s back to a guy you were with moments ago. One thing a lot of guys don’t realise about condoms is that there are different types, and they can make a huge difference when it comes to sex! HIM offers a lot of different kinds, from insertive condoms (these are a type of condom that the bottom puts in his ass before sex) to latex free condoms. Some guys, especially bottoms, find that latex free polyisoprene or polyurethane condoms feel better than latex. Latex can cause skin sensitivity in some guys, and as we all know the ass is a particularly tender place!
Treatment as Prevention: Undetectable is Untransmittable
Over the past few years, you might have heard a couple new phrases being used when guys talk about HIV prevention: ‘Treatment as Prevention’ and / or ‘undetectable.’ Both of these phrases refer to the same thing: when poz guys are on HIV treatment, their viral load can drop to the point that it might not even be detected by some kinds of HIV tests. This means they are HIV undetectable. It doesn’t mean that the virus isn’t present, just that it is present at such low levels it doesn’t even show up in some HIV tests. More importantly, though, when a guy is practicing TasP and is undetectable, it means the virus cannot be transmitted, regardless of whether he is using other kinds of prevention tools like condoms or PrEP. Undetectable equals untransmittable! For more information on undetectability and HIV, check out this amazing resource from the Prevention Access Campaign’s U=U campaign HERE. Undetectable means different things in different places, but refers to the copies of the HIV virus that are present in a mL of an individual’s blood at the time of the test. In BC, undetectable refers to 40 copies of HIV per mL of blood, but in other places it is 50, or even 200. The number set in each jurisdiction is somewhat arbitrary, and is set differently because different jurisdictions may be taking more or less cautious approaches to HIV prevention. In a nutshell, we know more about the viral levels that CAN’T transmit HIV than the viral levels that CAN. When a guy is seroconverting to HIV, he might have millions of copies of the HIV virus in his blood, but this typically drops significantly even without medication. This number typically stays low for a number of years, before climbing again after the virus overwhelms the immune system. Until the development of HAART and TasP, this is the stage of illness when HIV clinically becomes AIDS. An individual with AIDS is a very sick individual; men still die of AIDS in Vancouver every year, despite the advances made through HAART and TasP. Talk about ‘viral load,’ ‘copies of virus / mL’ and other scientific jargon can make undetectability more complicated than it is. Here are the facts, and your one key takeaway: guys using TasP who are undetectable DO NOT TRANSMIT THE HIV virus, regardless of the use of other prevention mechanisms. Some medical providers recommend using secondary prevention strategies like condoms or PrEP with undetectable partners, and some medical providers feel that TasP works fine as a standalone HIV prevention tool, especially for monogamous couples where one guy is neg and the other guy is poz. If you have questions about this, you can always call us at HIM, or contact the BCCfE for more information. There have been two really important studies on undetectability over the past few years. The first one, HPTN 052, confirmed that undetectable individuals were 96% less likely to pass on HIV to a partner when having the kinds of sex where HIV can be passed. This study was groundbreaking, but had too few gay participants for it to be practically applicable to gay and bi guys, and other men who have sex with men. The second major study on TasP and undetectability, the PARTNER study, was more useful to gay guys because almost half the participants (40%) were gay couples. In the PARTNER study, all of the couples had to have condom-less sex at least some of the time, during the kinds of sex where HIV can be passed. The poz partner had to have a viral load below 200 / mL of blood, and had to be on-treatment and compliant (meaning they took their meds as directed) for at least five years. When the study completed, researchers announced that out of 16,400 sexual encounters where HIV could have been passed, not a single HIV transmission occurred. There were a couple HIV transmissions during the study, but when they analysed the virus in those participants, they learned that they had acquired it from someone other than the enrolled partner. Just like condoms and PrEP, it’s impossible to state that TasP and undetectability will work 100% of the time to prevent HIV transmission. That said, one of the study’s authors said it best: when she was asked what the study findings meant about the ‘real world’ chance of someone who is undetectable transmitting HIV, author Alison Rodger simply answered ‘our best estimate is it’s zero.’ And fellas, remember that your sexual health, and your needs and concerns, are your own. So remember to always use other prevention methods if you think you need them, and especially to help prevent contracting or transmitting other STIs.
PEP stands for ‘post exposure prophylaxis’ and is a series of HIV medications you take after you have had a kind of sex that would be considered high risk for HIV being passed- like condom-less sex with someone who’s status is unknown, or when a condom breaks, or if you’ve been sexually assaulted. If you think you could have been exposed to HIV and seek medical attention soon enough, a doctor can prescribe a course of powerful anti-HIV medications to take daily for four weeks. In some cases, this treatment stops the virus from taking hold. PEP needs to be taken as quickly as possible after exposure- ideally within 24 hours, but definitely within 72 hours, to be effective. If you would like to talk to someone about PEP, or if you think you may need PEP, call HIM at 604-488-1001. HIM has a whole site devoted to PEP, so if you need more information, click HERE.
Types of Sex Where HIV isn’t Passed
So we’ve covered PrEP, we’ve covered condoms (no pun intended), and we’ve covered TasP. What does that leave us? Lots of types of sex where HIV transmission just isn’t a concern. Just like we have more HIV prevention options than ever before, there are lots of kinds of sex that don’t involve any real risk of passing HIV. Some guys who like group sex might go to jack off nights, where they can enjoy a group sex experience without engaging in types of sex where HIV can be passed. Decades of research have consistently demonstrated that oral sex without condoms, even when someone ejaculates in someone’s mouth, is very low risk for HIV transmission. In a bathhouse, you might choose to jack a guy off or give him head instead of letting him fuck you- these can be great options if you have a hard time talking about condoms, because they’re not activities that condoms are necessary for. Sex toys can also be a great way to have sex without the risk of HIV or STIs, but remember that toys should ONLY be used by yourself- if you’re sharing toys with others, they can transmit HIV and STIs. And, one more time, remember that sex that is low risk for HIV prevention does not mean it’s low risk for STI transmission. Regardless of PrEP, TasP, Condoms, or lower-risk sex, one thing we want to remind you guys about is this: none of these things will prevent STIs, even though condoms and lower-risk sex can be a huge help. PrEP and TasP only work to prevent HIV transmission, and some kinds of STIs (gonorrhea, for example) can be spread through touch (so even condoms might not prevent transmission). The most important thing to remember is this: if you’re having sex- any kind of sex- you need regular testing for HIV and STIs. STIs are easily treated and usually don’t cause lasting complications if they’re caught early. And if you catch them early, it helps prevent you unknowingly transmitting them to someone else. At HIM, our rule of thumb is simple: we advise ALL people that if they are having any kinds of sex, they are at risk for contracting an STI. Test early, test often, and take control of your own sexual health!