How Do We Negotiate Condom Usage in the Age of PrEP?
When I have anal sex, I'm always a top, and I usually use condoms, even after being on Truvada (tenofovir/FTC) for two years. There are several reasons for this, but HIV isn't one. PrEP (pre-exposure prophylaxis) and, just as important, treatment as prevention (TasP) and the undetectable status have freed me from concerns about contracting HIV.
Some people think my sexual history makes me a poor authority to talk about sex, HIV and PrEP, even though I'm a gay man who's had many sexual partners. Others say I'm the poster kid for the HIV generation, someone programmed by our culture to be vigilant against sexually transmitted infection (STI) transmission, to worship the condom as a little latex saint that will protect me from everything if I just believe hard enough and act right, as though condoms are almost equivalent to abstinence.
My last PrEP article for TheBody.com focused on the straight world's obliviousness to PrEP's very existence. Now, I can focus on how PrEP is used, not on whether it's used or even known about.
I decided to write this article after a conversation with my friend Josh. Josh and I hooked up once after I'd gotten on Truvada, and he started on PrEP shortly afterward. The sex was hot, "intimate" in his words, and I'm always happy to hear that. When he asked me over to hook up again, he said he didn't want to use condoms. I told him that I'm still using them. I was surprised that he then turned me down after bringing up sex in the first place.
I've interviewed scores of people on PrEP, mostly cis gay men, and the majority either never use condoms or only use them at a partner's request. I've been thinking lately that I'm in the minority of PrEP users as far as my use of condoms.
Damon L. Jacobs, a PrEP activist in an open relationship, is a bareback guy. "There are many reasons why two people may not be a sexual match. Perhaps they are both bottoms or both tops. Perhaps one likes to kiss, and one doesn't. For me, latex barriers are incompatible with the kind of pleasure I enjoy. If someone insists on that ... we can say 'thanks but no thanks' with respect for one another's choices."
My friend Siege Lehman approaches it differently. "I use [condoms] rarely. I'm grateful they exist ... if a partner asks for a condom, we absolutely use one." Siege is on PrEP and in an open relationship with a poz boyfriend. Most of his partners are poz. He says that he doesn't care if he were to contract HIV in the era of TasP, that he observes HIV-positive people living lives as healthy as HIV-negative people, but he stays on PrEP to avoid "becoming a vector for transmission," i.e., he doesn't want to spread the virus.
Kelly, a woman in a monogamous heterosexual relationship with a poz-undetectable partner, told me that her current boyfriend used condoms with her at one time due to his own worries for her health, but other than that, she only used them as birth control when she was younger. PrEP has been empowering to her. "People need to know they have a choice [in prevention]," she told me.
I've written previously about why condoms don't diminish my enjoyment of sex, but I'm apparently in the minority there. In fact, I've been surprised to notice that bottoms object to condoms as often or more often than tops do. I had expected the opposite.
To look at the bigger picture, throughout my research and coverage of PrEP in the last two years, I keep finding the same pattern: Those who avoid condoms while on PrEP were already avoiding condoms before PrEP. The hair-tearing and hand-wringing that we've heard about PrEP potentially leading to a widespread rejection of condoms is simply a bunch of fear and bluster, and it's years too late. There was already a widespread rejection of condoms.
I interviewed many more people than could be included in this space. The site BarebackRT.com (BBRT) and its app came up several times in interviews for this article. Guys who want to have condomless sex know they can go there specifically for the sex they want. There's no condom negotiation applicable.
Another term that came up continually is "skin on skin," the intimacy of feeling their partner's body without a barrier, as well as the intimacy of fluid exchange (being bred, cumming inside, whatever you may call it). People want to have sex without condoms; they always have; and many gay men have always had condomless sex, even during the height of the AIDS crisis. The human need to feel intimacy outweighs the fear and social pressure to be "safe." Of course, many agree that sex on PrEP is absolutely protected sex.
The problem isn't condom use; the problem is HIV and the stigma around it.
"Shame," "guilt," and "fear" are also terms that came up frequently in these interviews. PrEP is assuaging these. Nearly all the poz folks I've interviewed have experienced reduced stigma because of PrEP.
"When I find out someone is on PrEP, my fear of rejection diminishes tremendously," said "Adam," an HIV-positive man who preferred to remain anonymous. He's had a different experience with condoms.
"I use condoms fairly consistently. It helps me avoid other STIs; I don't mind it much; and it seems to feel generally safer to my partners."
PrEP has made a much greater difference in HIV stigma than TasP and undetectable viral loads. Why? The simplest answer is control. PrEP users are in control of their own health. They take their own pill every day, and taking a pill in privacy is easier than pulling out a condom and putting it on during sex. I mean that socially and physically -- clearly, cost is still a barrier to access, but that's a topic for another article.
Individuals can't monitor a partner's use of TasP (or PrEP), but they can monitor their own. This is why PrEP has made the social difference that TasP hasn't. I wish we could all just take one another's word for it, but after 30 years of AIDS terror, exacerbated hugely by a homophobic world, we don't. However, between PrEP and TasP, we're in an era in which condoms are commonly considered redundant.
"I understand that PrEP only prevents HIV transmission, not STI transmission ... I view an STI as a form of 'sexual flu,'" David, a gay man in his fifties, told me. David is a bottom, he barebacks exclusively, and he makes this clear in his online profiles -- his primary method of connecting to sexual partners. For him, his quarterly PrEP check-ups and STI tests are sufficient prevention.
In an era when most STIs are easy to diagnose and treat, some still worry me. I suspect I'm being more vigilant than I need to about these STIs, and I certainly don't believe that condoms are even close to foolproof.
As with all sexual and health choices, it's my decision about my body. That doesn't mean I judge you for your choice not to use them. We live in a time when HIV, the greatest physical threat to the gay and trans community outside of direct violence, has been nullified. Condoms aren't redundant, but fighting about them sure as hell feels redundant to me.
Evan J. Peterson is the author of the forthcoming safe(r) sex memoir The PrEP Diaries (Spring 2017, Lethe Press), as well as the chapbooks Skin Job and The Midnight Channel_. He edited the Lambda Literary Award finalist_ Ghosts in Gaslight, Monsters in Steam: Gay City 5_, and more of his essays can be found in_ The Stranger, The Rumpus, Queers Destroy Horror_, and the_ Queer South anthology. He is a Clarion West alum, and you can find more at his personal website.