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Monday 10 April 2017

Condoms are working!

Posted in: Health & HIV, Features
By Dr Peter Saxton - 5th June 2015

Yesterday, it was announced that the annual number of HIV diagnoses amongst men who have sex with men has increased over the past three years to become the highest since the HIV epidemic reached New Zealand.


In a strongly-worded criticism of the current NZ AIDS Foundation-led prevention campaigns which place maximum emphasis on condoms as the best prevention measure, HIV-positive gay man and ex-NZAF chair Michael Stevens took prevention programme strategists to task for what he believes is their narrow and unchanging approach.

However, Dr Peter Saxton, Director, Gay Men’s Sexual Health research group at the University of Auckland, totally disagrees...

Prevention must build on, not replace, condoms

Dr Peter Saxton
Let’s get one thing absolutely clear. Condoms are working incredibly well. The existing level of condom use is preventing hundreds more gay men from acquiring HIV and other STIs each year. If our collective level of condom use disintegrates, models (no, the mathematical kind) predict a 400% increase in HIV infections.

Throwaway lines like “whatever it is they are doing it is clearly not working” directed at NZAF and LYC reveal a worryingly shallow understanding of HIV prevention and HIV epidemiology.

Failing to appreciate the number of HIV and STI transmissions that are already being averted across the community – the collective effectiveness of condoms - is a classic paradox of successful public health campaigns. Most people don’t wake up in the morning and thank their lucky stars they haven’t got measles today, and that’s because of population-wide vaccination efforts. And most gay men in New Zealand don’t wake up each morning with the thrill they haven’t got gonorrhoea, because of high uptake of condoms across our interconnected communities, not just their own individual efforts.

When people say simplistic things like “it’s not working”, I always wonder who they’re thinking of. Clearly they’re not thinking of all the gay men who, as a result of using condoms, haven’t acquired HIV and other STIs. Nor, more provocatively, are they thinking of all the gay men who’ve been protected from HIV and other STIs because of other gay men’s condom use: stopping HIV and STIs from spreading around the community so that these viruses and bacteria never reach you in the first place.

Our great success as a small community is adopting condoms at much higher rates than straight men and women. As we all know, this isn’t the result of effective high school safe sex education. It’s because of decades of reimagined but consistent prevention efforts led by NZAF, using language and imagery and frankness that makes many non-gay peoples’ toes curl, and championed and enacted by individual gay men every time we have sex. If NZAF and LYC don’t do this, who will?

It’s much easier of course NOT to talk about condoms and anal sex. I suspect that the majority of GPs and government officials are more comfortable having uncontroversial conversations about testing and treating. It’s nicer. Everyone becomes a patient. Our sexuality (or status as drug user, sex worker) fades away. Some gay men probably prefer this. It’s also exactly the wrong thing to condone given the central driving role condomless anal sex plays in the overall health status of gay men: HIV, STIs, hepatitis and some cancers.

Talking about anal sex and condoms does challenge some gay men at a very personal level, who are fearful, squeamish, uninformed, unconvinced, reject the notion they’re at risk or just plain don’t want to do use them. That’s a challenge for NZAF and for each of us; we’re all partners in prevention.

A favourite canard of mine is the claim that gay men are uniquely sophisticated at engaging in personal risk assessment – more so than other groups - and that simple, inexpensive, verifiable, accessible, sustainable, effective prevention advice like condoms is patronising and puerile. Apart from being an outrageous insult to the 78 million individuals who’ve contracted HIV globally – most did not intentionally place themselves at risk – it fails to account for how similar we are during sex.

HIV is frighteningly but predictably adept at exploiting shared human qualities activated during sex: privacy, intimacy, desire, vulnerability, silences. Condoms, and community programmes to encourage respect, consent and pleasure provided by NZAF over three decades respond extremely well to these realities.

HIV prevention isn’t a fashion show. Regardless of our personal preferences, there are just some things we’ve got to enjoy wearing as much as we can if we care about our collective wellbeing. To paraphrase, NZAF’s objective isn’t to be popular and echo what some individuals want to hear. Its objective is to be as effective as it can be at reducing the number of gay men involved in HIV transmission in this country. New diagnoses have risen last year, and that’s very concerning. New Zealand’s HIV prevalence is relatively low internationally and we all want to keep it that way.

The more constructive question that should have been asked is how can we all make HIV prevention even more effective? Those in the audience at the 30th Anniversary HIV Conference last month heard a full day of challenges and opportunities. One in particular from NZAF’s Scientific Director - and also life member - Tony Hughes stood out for its utterly comprehensive overview. If New Zealand is to respond cleverly and effectively then any proposed solutions must address those challenges, including the intelligent use of PrEP. That requires conversations and engagement from the whole community, not pithy undermining.

The 30th Anniversary HIV Conference presentations can be accessed here.

- Dr Peter Saxton

Dr Peter Saxton - 5th June 2015

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