The appeal of condomless sex
MANY PEOPLE, especially those of us who work around HIV, are generally unwilling to talk about condomless sex – the desirability of it and that many people find raw sex normal, natural, okay and fun.
Being tight-lipped about raw sex won’t achieve much and this year’s commemoration of World AIDS Day on December 1 is an opportune time for us to pause and reflect on the challenges faced by the community of people living with HIV (PLHIV) and the circumstances that contribute to the 1,165 newly reported cases in 2018.
The data show young people, 15-24 years, accounted for 16 per cent of these new cases, while men who have sex with men (MSM) accounted for 10 per cent. A total of 32 per cent of these cases came from Kingston and St Andrew, 22 per cent from St Catherine and 12 per cent from St James. Overall, 1.5 per cent of the population is living with HIV – that’s 32,617 Jamaicans!
Of course, the consequence of condomless/raw sex is well documented and significant resources have been invested in empowering and educating people to use condoms consistently with regular and non-regular partners as a result.
Sadly, despite all the public education, many people continue to have raw sex and are therefore putting themselves at risk of contracting HIV and/ or other sexually transmitted infections (STIs). A lot has been done to address this, but the interventions are seemingly not as efficacious as expected.
REDUCE QUALITY AND SPONTANEITY
A third of Jamaicans believe that condoms negatively impacted the experience by reducing the quality and spontaneity. Consequently, in 2017, according to the Knowledge, Attitudes, Practices and Behaviour (KAPB)
Survey, condom use at last sex encounter among males in a married or cohabiting relationship was 9.1 per cent (down from 12 per cent in 2012), while among females this increased from 5.7 per cent in 2012 to 37.7 per cent in 2017.
Condom use at last sex for females in visiting or casual relationship was 62.3 per cent in 2017 (down from 94.3 per cent in 2012), while this increased from 88 per cent in 2012 to 90.9 per cent in 2017. Importantly, though there has been an increase, the data show that “among males 15-19 years, last time condom use in relationships a year old or less declined between 2017 and 2012 (45.9 per cent 2017 versus 72.3 per cent in 2012).”
It is interesting to note that only 39 per cent of people engaged in multiple partnerships in relationships a year old or less used a condom at last sex, while 61 per cent of those in relationships over a year old used a condom.
Truthfully, knowledge about the risks associated with raw sex doesn’t necessarily result in people using condoms consistently or at all. Raw sex happens for various reasons – desirability, availability of condoms, transaction, under the influence of drugs and alcohol, do not like condoms (20 per cent), love and trust (51 per cent), condoms not liked by partner (11.8 per cent), etc.
I want to focus on the desirability of raw sex and how people negotiate and navigate this with their regular and non-regular partners. People develop their risk profile to help determine who to go condomless with or ask about HIV (that is, “yu clean?”). Some don’t care too much.
We have to acknowledge that raw sex is desirable and that regardless of what we think, people can’t be judged and shamed for going bareback. Our messages will not resonate with the people we desperately need to reach, especially with what’s being preached through popular culture.
PREP – PREEXPOSURE PROPHYLAXIS
Given the circumstances, biomedical approaches such as treatment towards viral suppression and Prep – pre-exposure prophylaxis – have been scaled up to aid efforts to prevent new HIV infection. The evidence shows both are very effective in this regard. PrEP is becoming more and more popular.
There is huge demand not simply because doctors and others are promoting its use but the fact that there are sexually active people who desire and want to have raw sex without the risk associated with HIV. These people who have or desire raw sex and go on PrEP are, in my opinion, unlikely to also use condoms. Use of PrEP is encouraged with use of condoms, given that it doesn’t protect you from contracting other STIs.
I have found, though, that when we talk about PrEP, we generally don’t talk much about those people who are likely not going to use PrEP with condoms and that these persons will be at risk of contracting other STIs.
I am yet to meet anyone who would use both methods. We should try to be a bit more nuanced in our discussions about PrEP, given the diverse circumstances. I think it will help us to be grounded and to tailor our interventions and promotions appropriately and support a wide range of individuals.
As Dr Yohann White from Caribe Wellness aptly said, “PrEP is not a pill, it is a part of a whole approach (and I don’t mean PrEP+condom), it is a way of empowering people who can test frequently for HIV and other STIs, be their sexual selves, fostering a culture of responsible and enjoyable sexual lives with easy access to support.”
PrEP, as he said, “is effective in stopping HIV if taken properly (adherence is important, so education is important); it does not stop 20+ other STIs or pregnancy [… but] if it is packaged in a fearmongering bubble and handed to people in that way – that is sex shaming and stigma, and it defeats the purpose.”
The success of PrEP in preventing new HIV infections hinges on a more sex positive and open approach to discussing these issues. We can’t resign in our old habits of talking about sex in our promotion of the use of PrEP as part of a holistic strategy. We have to be more sex positive. We have to be more open-minded in our approach to reach more people, to be real with them, and for our message to resonate with them.