- In high-income settings, what factors are associated with the willingness/ability of people living with HIV/AIDS (PHAs) to negotiate condom use, and to use condoms during sex?
Key take-home messages
- There is a controversial belief held by PHAs about the efficacy of HAART to reduce or prevent HIV transmission and/or an understanding of having an undetectable viral load.(1-4) These beliefs have been found to be associated with condom use (i.e. believing an undetectable viral load means HIV transmission is not possible, which translates into believing that condoms are not required).(1;3;4)
- Lack of adherence to HAART was found to be associated with increased instances of unprotected anal intercourse as well as more sexual partners as compared PHAs who adhered to their HAART regime.(2)
- Social and mental health factors such as HIV-related stigma, depression, negative beliefs about one’s self and low social support have been found to reduce a PHA’s ability or willingness to use condoms;(2;3;5)
- Some MSM-PHAs engage in intentional unprotected anal intercourse (i.e. ‘barebacking’) as a response to social stressors such as low social support and also face discrimination from both the mainstream and LGBT communities, which may make it harder for them to discuss risk reduction strategies;(3;5)
- Drug and alcohol has been found to be associated with lower motivation to use condoms and, as a result, increased incidence of unprotected sexual intercourse amongst PHAs with both sero-concordant and discordant sexual partners;(1;3;6-8)
- Condom and HIV ‘fatigue’ is a challenge for long-term PHAs regarding consistent condom use (i.e. tired of being responsible for having to monitor sexual behavior);(1-3;6) and
- Condom use amongst HIV-positive MSM is related to regular condom use being a subjective norm for themselves and their peers.(9)
The issue and why it’s important
On Friday 5 October 2012, the Supreme Court of Canada released two decisions regarding the criminal law obligation of PHAs to disclose their HIV status to sexual partners. Amongst other changes to the law, the Supreme Court decided that people living with HIV (PHAs) do not have a criminal law duty to disclose their HIV status to a sexual partner prior to sexual intercourse if: 1) a condom is used; and 2) the HIV-positive person’s HIV viral load is “low.” In high-income settings, access to condoms is not a resource issue, although it may be a cost issue for PHAs of low socio-economic status. However these are not the only factors associated with one’s willingness to negotiate condom use. Mental health challenges such as low self-esteem, lack of autonomy,(2;3;5) and a lack of cultural acceptance of condoms,(9) also impact condom negotiation and use. Based on the details of Supreme Court’s decision, the following groups may be disproportionately impacted: marginalized PHAs, women in abusive relationships, newcomers to Canada, members of African/Caribbean/Black communities, Aboriginal people, and other people who face challenges accessing health, social and legal services.
What we found
The majority of studies reviewed focused on individual and social factors that impact condom use. These include: self-efficacy; beliefs about HIV treatment; understanding what it means to have an undetectable viral load in relation to HIV transmission; drug and alcohol use; adherence to and beliefs about HAART; condom fatigue; HIV fatigue; emotional and relationship priorities; stigma and discrimination; and group norms.
Three studies, based in North America, looked at the sexual behaviours of HIV-positive MSM and found that MSM on the HAART regime who also believed that treatment reduces the risk of HIV transmission, were more likely to report instances of unprotected sex with partners.(1-3) One US-based study found that HIV-positive MSM who were non-adherent to their HAART regime were also more likely to report more sexual partners and more instances of unprotected sexual activity compared to MSM who adhered to their treatment regime.(2) Similar results were found in studies that focused on heterosexuals. One study based in Australia, looked at the beliefs of heterosexual sero-discordant couples about HAART as a form of HIV prevention.(4) Specifically, couples were asked whether they believed that with their HIV-positive partner on HAART and their viral load being undetectable if there was still a need to use condoms.(4) Results were mixed with some HIV-negative partners believing HAART and undetectable viral load was sufficient to prevent HIV transmission. Others, especially the HIV-positive partners were more cautious, with not wanting to take the chance of transmitting the disease to their partner and enforced condom use.(4)
Social and mental factors were also found to impact PHAs motivation to use condoms. A study from the United States that looked at barebacking among HIV-positive MSM found that engaging in unprotected anal intercourse for some MSM is a means of coping with the stresses they encounter in their daily lives,(3) such as living with HIV, social alienation and both internal and external homophobia. Furthermore, the study found that HIV-positive MSM who consider themselves to be barebackers, were more likely to report mental health issues and a low sense of overall well-being.(4) A French study that focused on self-identified ‘barebackers’ revealed that they experience discrimination from others in the LGBT community and they feel isolated as a result.(5) While the findings suggest that there is a desire from many in this group to engage in discussions around risk reduction strategies to employ while barebacking, there is no space to do so.(5)
Drug and alcohol issues further compound these social and mental issues. Five studies that examined PHAs willingness and ability to negotiate and use condoms found that it was negatively impacted by drug and/or alcohol use.(1;3;6-8) One study found that drug use be a stress coping mechanism for some (3) and other studies find consistent evidence that drug use plays a significant role in increasing high risk sexual behavior among both heterosexuals and gay men/MSM (e.g., by affecting judgment and ability to negotiate condom use).(6;7)
In addition to social stresses, and drug and alcohol use, persons living with HIV/AIDS for a long period of time (i.e. long-term survivors) also have to contend with issues relating to condom fatigue (1) and HIV fatigue.(2;3;6) Condom fatigue is a term that describes the reduced use of condoms during sex, and based on the findings of a US study found, this may explain why there is a marked increase in unprotected sexual activity among white, educated HIV-positive MSM (especially when drugs or alcohol are used).(1) The study also found that this group is less likely to use condoms if alcohol is used prior to intercourse, as well as if they believe that they are impervious to the impact of possible HIV transmission due to their race and social standing (1). However, conclusions were not able to be drawn about whether this belief of protection from legal charges, the use of drugs or alcohol, or a combination of the two were the principal factors driving the lack of use of condoms.(1)
HIV fatigue is related to both the challenges of living with HIV over a long period of time,(2;3) as well as feeling the pressure of being the caretaker in a sexual relationship.(6) In a systematic review that assessed the sexual risk behaviours of HIV-positive MSM (including views about the efficacy of HAART against HIV transmission) found that many long-term HIV-positive MSM become fatigued in the sense of having to always monitor their sexual behavior.(6) This finding is similar to those of another study that found that engaging in unprotected anal intercourse is used by long-term HIV-positive MSM as a means of gaining some measure of freedom from the rigid care and behaviours that have had to consistently follow and adhere to.(3)
Finally, normalizing condom use was found by a Swiss study to be a major factor in explaining the use of condoms during sexual intercourse by PHAs.(9) The study found that among HIV-positive MSM with casual sex partners that behavior skills (i.e. communicating about condom use and sexuality), and information (i.e. knowledge of transmission risk and how to use condoms) were not significant factors in predicting condom use.(9) Instead, the use of condoms was found to be directly linked to the long-term habitual behavior of a participant (i.e. using condoms with steady and casual partners in the past helped predict future use). Another study assessed condom use among African-American heterosexual crack smokers and found that the ability to discuss HIV risk and condom use amongst their peers increased the likelihood of using condoms as well awareness of the risk of HIV transmission.(8)
What we did
We searched for HIV and condom in the Cochrane Library and Health-Evidence.ca by combining the categories for HIV and Acquired Immunodeficiency Syndrome categories with condom as a text term to identify relevant systematic reviews. We also searched Medline by combing two MeSH terms as the focus of the document (*Condoms/ut [Utilization] AND *Health Knowledge, Attitudes and Practice).
Factors that may impact local applicability
Most of the studies included in this summary were based in the United States. The majority of studies also focused on gay men or men who have sex with men (MSM), which may limit the generalizability of the findings to other populations, given the socioeconomic differences between them and other marginalized groups, such as African, Caribbean and Black populations, Aboriginals and newcomers to Canada. These groups are known face other social and cultural factors that may negatively impact their ability to negotiate and use condoms with their sexual partners. However, the available research on these factors within a Canadian context is limited.
- Brennan DJ, Welles SL, Miner MH, Ross MW, Rosser BRS. HIV treat-ment optimism and unsafe anal intercourse among HIV-positive men who have sex with men: Find-ings from the Positive Connections Study. AIDS Education and Preven-tion 2010;22(2):126-37.
- Joseph HA, Flores SA, Parsons JT, Purcell DW. Beliefs about transmis-sion risk and vulnerability, treat-ment adherence, and sexual risk behavior among a sample of HIV-positive men who have sex with men. AIDS Care 2010;22(1):29-39.
- Kelly BC, Bimbi DS, Izienicki H, Parsons JT. Stress and coping among HIV-positive barebackers. AIDS & Behavior 2009;13(4):792-7.
- Persson A. Reflections on the Swiss Consensus Statement in the con-text of qualitative interviews with heterosexuals living with HIV. AIDS Care 2010;22(12):1487-92.
- Rojas CD, Coquelin V, Sempe S, Jablonski O, Le Gall JM, Andreo C et al. Barebacking and sexual health in the French setting: “NoKondom Zone” workshops. AIDS Care 2012;24(8):1046-51.
- van Kesteren NMC, Hospers HJ, Kok G. Sexual risk behavior among HIV-positive men who have sex with men: A literature review. Patient Educ Couns 2007;65(1):5-20.
- Weller SC, Davis BK. Condom effec-tiveness in reducing heterosexual HIV transmission. Cochrane Data-base of Systematic Reviews 2002;(1).
- Williams M, Bowen A, Atkinson JS, Nilsson-Schonnesson L, Diamond PM, Ross MW et al. An assessment of brief group interventions to in-crease condom use by heterosexu-al crack smokers living with HIV infection. AIDS Care 2012;24(2):220-31.
- Niderost S, Gredig D, Roulin C, Rickenbach M, Swiss Hiv CS, Study Group. Predictors of HIV-protection behaviour in HIV-positive men who have sex with casual male part-ners: A test of the explanatory power of an extended Information-Motivation-Behavioural Skills mod-el. AIDS Care 2011;23(7):908-19.
Rapid Response Service. The willingness of PHAs, living in high-income settings to negotiate condom use & use condoms during sex. Toronto, ON: Ontario HIV Treatment Network; January, 2013.
Shani Robertson and Stephanie Bell.