Gay and bisexual men are using condoms
less than ever
, and the decline has been particularly pronounced among young people and Hispanics, according to a new study.
The worrying trend signals an urgent need for better prevention strategies as the nation struggles to defeat the HIV epidemic, researchers said.
Over the past decade, prevention medications known as
PrEP
(pre-exposure prophylaxis) have helped drive a modest reduction in HIV rates.
And yet, despite persistent public health campaigns promoting the medications, they
have not been adopted
in substantial numbers by black and Hispanic men who are gay or bisexual.
The use of condoms, which prevent HIV and other sexually transmitted infections, has been declining across the board in recent years, not just among gay men, which has contributed to an
increase in
sexually transmitted infections.
Some HIV experts worry that public health attention to preventative medication has accelerated the decline in condom use.
(Tony Cenicola/The New York Times)
Researchers said that by focusing so much on PrEP, public health officials have overlooked condoms, contributing to the decline in their use.
“The goal of promoting PrEP is valuable, but it has overshadowed other prevention strategies like condoms,” said Steven Goodreau, an HIV expert at the University of Washington.
Goodreau led the new study and co-wrote a related paper.
A spokesperson for the Centers for Disease Control and Prevention (CDC) acknowledged a decline in condom use but said the agency continues to promote them.
For example, local health departments that receive federal money for HIV prevention must include condom distribution in their strategies.
HIV rates have decreased in recent years thanks in part to PrEP.
But the decline in the United States — 12 percent between 2017 and 2021, according to government estimates — has lagged behind that of many other wealthy Western nations and even some hard-hit African countries.
Gay and bisexual men are
disproportionately affected
:
They represent only 2 percent of American adults and 70 percent of new HIV cases.
Additionally, infection rates are much higher among black and Hispanic gay men than among white gay men.
Change
In 2012, PrEP debuted amid landmark research showing that, when taken daily, antiretroviral medications
virtually eliminate the risk
of contracting HIV.
Within a few years, researchers established that people with successfully treated HIV could not transmit it through sex.
These advances eased
gay men's
concerns and probably accelerated their abandonment of condoms, Goodreau said.
Public health agencies, clinics, nonprofit organizations, and pharmaceutical companies funneled hundreds of millions of dollars into promoting PrEP, contributing to its widespread use among white gay men.
But the drugs' popularity has remained relatively low among black and Hispanic men, who are insured at lower rates and tend to harbor greater distrust of doctors.
New study
The new study on condom use, published Tuesday in the journal
AIDS and Behavior,
examined responses to a massive online health survey of gay and bisexual men and teens between 2014 and 2019.
About 10 percent of each year's respondents came from the previous year's group, allowing researchers to track changes over time.
Among HIV-negative respondents, condoms were more popular than PrEP.
In 2019, about half of participants reported using condoms inconsistently and 17 percent reported consistent use.
In contrast, only 12 percent of respondents reported having recently used PrEP.
Next, the researchers looked at the three-quarters of respondents who were most at risk: those who were HIV negative and had not recently used PrEP.
In a given year, about two-thirds of these people said they had
recently had sex without a condom.
And among the subset of men who responded to consecutive surveys, the proportion who reported having sex without a condom increased 3 percent between the first and second years.
The pattern was most striking among Hispanic youth ages 15 to 25, who had a 19 percent increase in condomless sex in just one year.
Around the same period, HIV rates among Hispanic gay men rose 3 percent per year, even as rates plateaued among black gay men and declined among white gay men, according to government estimates.
Carlos Saldana, an infectious disease expert at Emory University School of Medicine, said schools and public health leaders are not addressing the sexual health needs of young Hispanics, including migrants.
“When I arrived in Atlanta in 2020, there were no Spanish-language campaigns or
culturally sensitive
sexual health messages related to Hispanic communities,” she said.
According to the CDC, only half of high schools provided LGBTQ-inclusive sex education in the 2019-20 school year.
Since then, some Republicans have stepped up efforts to remove LGBTQ content from schools.
LaRon Nelson, an HIV researcher at Yale University, pointed to one such law in Florida, which has a large Hispanic population and the nation's third-highest rate of new HIV diagnoses.
Florida community organizations should fill the educational gap to ensure at-risk youth learn about PrEP and condoms, Nelson said.
“We must find new ways to stimulate young people's interest in condoms and expand their accessibility,” he said.
The federal government is also neglecting to shore up condom use, Goodreau said, noting that condoms are not mentioned in official strategic plans to combat HIV issued by multiple health agencies.
Carl Dieffenbach, director of the AIDS division at the National Institute of Allergy and Infectious Diseases, disputed that premise, saying condoms are “a key part of the message in all of our studies.”
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