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The potent protection from HIV afforded by Truvada as PrEP allows men to have sex with less worry and fear of HIV. But some worry that the inclusion of PrEP as a public health strategy will lead people to abandon condoms—which still have a role to play in further reducing risk of HIV and other STIs. In San Francisco—even before PrEP’s availability in 2012—rates of STIs among men who have sex with men have been steadily increasing and rates of condom use have gone down.

BETA wanted to know—what do PrEP providers think? How do these practitioners, who see clients every three months for sexual health screenings and STI testing, talk to their clients about condom use, STIs and navigating the complicated landscape of protected, or safer, sex?

To find out, BETA talked to Stefan Rowniak, MSN, PhD, a PrEP provider and nurse practitioner at San Francisco City Clinic and researcher and assistant professor at University of San Francisco; Pierre-Cédric Crouch, PhD, ANP-BC, the nursing director at the San Francisco AIDS Foundation health and wellness center Strut; Robert Blue, a PrEP program coordinator for San Francisco City Clinic; and Hyman Scott, MD, who leads the Ward 86 PrEP Clinic at San Francisco General Hospital.

Here’s what they said.

The rates of gonorrhea, chlamydia and early syphilis infection have been on the rise in recent years in San Francisco. Do you see this as a major problem?

Pierre-Cédric Crouch, PhD, ANP-BC

Pierre-Cédric Crouch, PhD, ANP-BC: Obviously nobody wants to get gonorrhea, chlamydia, or syphilis, but these are risks that we have from living. The only way to completely avoid them is to not have sex at all and that’s not who we are as humans. You can also get the flu from having sex, or strep throat. People die from the flu. People don’t die from gonorrhea, but there’s more stigma attached to gonorrhea than the flu. The levels of STIs are going up in San Francisco—and have been since before PrEP was available here—but they’re nowhere close to what they were in the 70s and 80s.

Stefan Rowniak, MSN, PhD

Stefan Rowniak, MSN, PhD: That’s a very difficult question—but one the community is going to have to answer. If people suddenly find themselves saying, ‘My god, this is the third time I’ve gotten gonorrhea in three months,’ they may think, ‘What can we do about this?’ It’s going to take people realizing that they don’t want to get gonorrhea over and over again every time they have a new sex partner. Health providers will be there to help the discussion along—but we’re not the sex police. We are there to inform and help people make those decisions themselves.

Since gonorrhea, chlamydia and syphilis can all be treated, how do you talk to clients about the potential harms associated with these STIs?

Hyman Scott, MD

Hyman Scott, MD: At this time, these STIs are all treatable with antibiotics, but just because they are treatable do not mean that they are benign.  What is a concern is that we are seeing rising rates of drug-resistant gonorrhea, and we shouldn’t forget that gonorrhea can cause sterility. And while syphilis is still treatable with penicillin, with the increase in total cases, we’re seeing more of the complications that come along with syphilis such as neurosyphilis, vision impairment, and vision loss. Giving people the full picture is important—not to spread fear, because we want to have a sex-positive approach when we’re talking about sex—but so that people have the information they need to make decisions about their sexual health.

Some people worry that PrEP is, or will, cause people to abandon condoms. Are your clients changing their condom use now that they’re on PrEP?

Robert Blue

Robert Blue: Yes and no. There are some people who start taking PrEP and they actually start thinking more about their sexual health. Their thought seems to be, ‘Well, I’m taking PrEP for my sexual health, why would I then go out and not use condoms?’ There are people who didn’t use condoms before PrEP, and that doesn’t change. And there are some people who, once they started taking PrEP decided to stop using condoms.

Crouch: We haven’t seen much change, but it’s difficult to measure. Some people will come in and report that they used condoms all the time before they started PrEP. But when you ask a few more questions, you find out that there were exemptions to it—the person didn’t use condoms with their main partner or those few times with their fuck buddy. So it wasn’t really 100% condom use to begin with.

Scott: I think for some clients, there is a change in the way that they decide to use condoms [on PrEP], but there’s a lot of variability. Some people may change their condom use with certain partners, but not others. With the rise in STIs and increased uptake of PrEP, there is a real desire of some to make that linkage and say that one is causal to the other. We have seen a rise in STIs before the increased uptake of PrEP. Studies that have systematically looked at this haven’t found much of an overall change in the level of condom use among PrEP users, but it will also be important to monitor as PrEP roll-out expands in more real-world settings. Anecdotally, we’ve had people who don’t change their condom use at all. It’s definitely something we need to keep track of, but at this point we don’t have data to say that initiating PrEP is the reason people change their condom use, if they change it.

Do condoms still have a role to play in gay men’s sexual health alongside PrEP?

Crouch: Condoms still have value. They do a good job of reducing transmission of gonorrhea and chlamydia—less so for syphilis. They don’t provide 100% protection, but they do have value. All in all, we don’t know five years from know how people will use condoms when they’re on PrEP. I could see it being similar to what happened for oral sex—in the 90s, when people thought you could get HIV from oral sex, there was a big push for people to use condoms for oral sex. I don’t know if that’s what people really did, but now that we know the risk of HIV transmission from oral sex is so rare, I think people in general gave up on feeling like they should use condoms for oral sex. Of course there’s still a risk of getting or transmitting other STIs but the risk of HIV is so slight with oral sex. It’s the same way for anal sex if you’re on PrEP.

Rowniak: I don’t believe people will completely abandon condoms in favor of PrEP. Rather, I think people will use condoms with some partners and in some instances and not in others. I think people feel, to a certain extent, a little frightened after spending years and years using condoms, and all of a sudden not using them at all. So the pendulum might swing back and forth until it reaches a place to settle.

Blue: We know that while PrEP is highly effective in preventing HIV transmission, it is not 100%. Many people still feel more comfortable using condoms while taking PrEP. We also know that PrEP doesn’t prevent the transmission of other STIs and that condoms can be an effective STI-prevention strategy.

Scott: Condoms absolutely have a role to play. One thing to remember is that we’ve never studied PrEP versus condoms—PrEP has always been inclusive of condoms. The package that includes PrEP is not just one pill per day. It’s about condom promotion, too. There are a variety of ways that people can have protected or safer sex, and we want to give people the tools that fit within their sex lives and support them with all of these options.

Do you advise your clients to use condoms? And if so, how do you have those conversations?

Blue: Yes, we do. Ultimately, we want people to think logically or rationally about their sex lives (acknowledging that sex is not often our most rational form of self-expression!). We want people to be able to evaluate their risk of HIV and STIs and decide on what prevention strategies make sense for them.

Rowniak: I make a point to talk with clients about when it might be appropriate to use condoms—and when it might make sense to reintroduce condoms back into sex. These conversations help get people to think about using condoms, and that’s really the first step. Introducing this new thought about condoms helps people think about ways they might like to be a little more circumspect.

Crouch: Our job is to provide education and have the client come up with their own informed sexual health plan. We tell clients that PrEP isn’t 100% effective at preventing HIV infection, even though we haven’t had any infections on PrEP yet—because nothing in life is 100%. Condoms provide extra protection against gonorrhea and chlamydia. We frame it as, ‘Using condoms with PrEP is your best overall protection.’ But we don’t lecture anyone to do, or not do, anything. We’re here to inform and help support people in whatever they decide to do. If condoms haven’t been a problem for a client, they should definitely continue to use them—though condoms aren’t always easy for people to use. They can break. Some people tell us they have trouble maintaining an erection with them. Some say condoms reduce intimacy in relationships. It’s ultimately an individual decision. There is no right or wrong answer.

Scott: I’m humble enough to know that I only get the opportunity to spend 30 minutes, maybe an hour, talking with patients about a variety of medical conditions including their sexual health, which is balanced with all the other needs and considerations in their daily lives. I give them guidance and recommendations but I don’t try to convince them to use condoms if they’ve already made up their mind about condom use. I meet my patients where they’re at and see how open they are to exploring condom use. Recently, I saw someone who was diagnosed with early syphilis. We started treatment [for syphilis] but then also talked about why he didn’t use a condom with this new partner, despite his ‘rule’ to use condoms with new partners. His response that, ‘The guy was just my type’ was incredibly  insightful and understandable. So there was something powerful about desire and passion, and wanting to make a connection with his partner that influenced his decision making. So I explore the barriers and facilitators people may have for condom use, but never pass judgment on their decision.

Want to read more about PrEP, STIs and other issues related to gay men’s sexual health? Read a commentary by Hyman Scott, MD MPH and Jeffrey Klausner, MD, published in AIDS Research and Therapy.  Sexually transmitted infections and pre-exposure prophylaxis: challenges and opportunities among men who have sex with men in the U.S.

Providers can find more information about counseling new PrEP clients, discussing risk and helping clients choose prevention strategies on BETA and in Gilead Science’s Information for Health Care Providers: Truvada for a PrEP Indication publication. Read more about how to create an inclusive health care environment for LGBT people and how to take sexual health histories in a way that is sensitive and inclusive with these resources from The Fenway Institute.

For more information about PrEP services at the gay men’s health and wellness center in the Castro, Strut, visit www.strutsf.org. Find out more about the Ward 86 PrEP Clinic at San Francisco General Hospital. Continue learning more about PrEP at www.prepfacts.org or on BETA.