New research from the 天美影视传媒 shows that condom use has been trending downward among younger gay and bisexual men over the last decade, even when they aren鈥檛 taking , or PrEP.

The study, , measures changes in sex without condoms among HIV-negative gay and bisexual men who are not taking PrEP. Using data from the 2014-19 cycles of the American Men鈥檚 Internet Survey 鈥� a web-based survey of cisgender men ages 15 and older who have sex with men (MSM) 鈥� researchers found that roughly half of HIV-negative men reported using condoms at least sometimes in the last year. That was higher than the 15% of respondents who reported using PrEP.

But HIV-negative MSM who are not using PrEP seem to be not using condoms increasingly often. The study found that the proportion of these men who had condomless sex increased 2.2% in the average year. Rates of people who weren鈥檛 using condoms was higher among younger and Latinos, 7.2% per year for young MSM ages 15 to 24, and 18.7% among young Latino gay and bisexual men.

Properly used condoms can prevent the spread of disease, including HIV; taking PrEP also reduces the likelihood of HIV transmission. The increase in condomless sex for men not on PrEP suggests potential new HIV transmission pathways, researchers said, and the concentration among young Latino men could expand existing health disparities.

UW News spoke with , lead author and UW professor of anthropology, to discuss the study, health equity and the importance of continued education about the benefits of using condoms during sex.

What are the barriers to PrEP uptake? Why is it important to not only remove those barriers but to also promote condom usage?

Steven Goodreau: Different things work for people in different circumstances and times of their lives. PrEP has many benefits. It鈥檚 something that doesn鈥檛 have to happen in the moment, something an individual can decide on instead of having to negotiate with a partner. Some people really don鈥檛 like condoms and aren鈥檛 going to use them, so PrEP provides another option for them. But like most pharmaceutical interventions, it means people need to know about it and be continuously tied to the healthcare system. There are all sorts of things happening in people鈥檚 lives 鈥� from unstable housing to dealing with mental health and substance use 鈥� that make taking a pill every day not the easiest thing to do. So, PrEP has positives but also challenges. The same with condoms. They鈥檙e far cheaper and much easier to access. For some people the lack of daily regimen is a plus. They prevent a much wider range of sexually transmitted infections, not just HIV. But they also take their own form of planning and negotiation. In the end, I see both as key to lowering HIV transmission rates.

Can you talk about the connection between condom promotion and health equity?

SG: The sense I have as a gay man working in public health research is that there鈥檚 a prevailing idea that everybody already knows about condoms and understands them, so there鈥檚 not much need to do any kind of further promotion anymore. There鈥檚 also this idea that they鈥檙e so readily available to everybody, that there isn鈥檛 much of an equity issue involved. In contrast, PrEP involves interacting with the healthcare system, with associated costs and time and ability to navigate and feel comfortable doing so. All those things are unequal in our society, so are a clear area for concerns about equity.

Our results show that a growing set of young gay and bisexual men, and especially young Latino gay and bisexual men, seem to be missing out on both interventions. And that pattern raises questions of equity. Our study can鈥檛 say exactly why, but the pattern is clear.聽 We must remember that every generation is starting anew with their knowledge about sexual health. If we have a generation that is coming of age when conversations about condoms that were common in the past haven鈥檛 been as present, then they aren鈥檛 starting with that broad familiarity. And if LGBTQ+ inclusive sex-ed, which covers HIV prevention for gay and bisexual men, isn鈥檛 evenly distributed in the population, then we indeed have equity concerns.

What kind of conversation do you hope this research sparks?

SG: Before PrEP came out, HIV prevention for gay and bisexual men had condoms as a central pillar 鈥� perhaps the central pillar 鈥� for about three decades. Of course, we were all tired of talking about them. So, I get why, when PrEP came out, it was seen as a miracle and the pendulum swung in that direction. But it鈥檚 a decade into PrEP delivery and I think it鈥檚 time to look at that and say, 鈥業s it time for the pendulum to swing back a bit?鈥� I鈥檇 like people to have open, honest, sincere conversations about how much condom promotion we鈥檝e been doing. What messages have we been putting out? What haven鈥檛 we been doing, and why? Is it because there aren鈥檛 folks who would benefit from those conversations, or are we just tired of having them? I hope for more conversations among folks at every level: federal, state and local health programs, community organizations and within communities themselves.

What strategies could potentially improve condom promotion?

SG: Some folks in public health think that gay and bisexual men just don鈥檛 want to hear about condoms anymore. That鈥檚 certainly true for some, but I don鈥檛 think it鈥檚 as broadly true as we assume. The first step is just a shift in that thinking. Beyond that, LGBTQ+ inclusive sex education is extremely important. Only about half of U.S. high schools have it, and that鈥檚 a key first place for young, gay and bisexual men to learn about the different prevention methods and what would work for them given where they are in life. This is a time when the barriers to PrEP are especially high for many people, so making sure that condoms are seen as a valuable and viable option is especially important.

Some dating apps that men use to find partners put the options for PrEP use or viral suppression upfront on the profile, and then the field indicating whether you want to use condoms either doesn鈥檛 exist or it isn鈥檛 nearly as prominent. That seems like a huge missed opportunity, both to actually share information condom use and to send the message that condoms are on par with these other sexual health tools. It also used to be easier to find condoms in every bar and club catering to gay men. They鈥檙e still there some of the time, but not as consistently, and there鈥檚 rarely any material explaining and promoting them.

In the end, it鈥檚 key to remember that things like condom use are highly subject to social norms 鈥� many people use what they see and hear from their peers and beyond as a guide for their own decisions. Even just a little bit more attention to the topic may help to get many of those conversations started again.

Co-authors of the paper were , a UW doctoral student of epidemiology; , UW senior research scientist and engineer in the Center for Studies in Demography and Ecology; Austin Williams, Li Yan Wang and Kevin Delany of the Centers of Disease Control and Prevention (CDC); , professor at Emory University; and , UW senior research scientist in the Department of Global Health. The study was funded by the CDC and the National Institute of Health.

For more information, contact Goodreau at goodreau@uw.edu.

Unfortunately, it could potentially undo the goal of social distancing, which is to give the COVID-19 virus fewer opportunities to spread. According to a website set up by researchers at the 天美影视传媒, easing the social distancing rules so that each household could have contact with just one or two others would reconnect most households in a community, providing conduits through which the COVID-19 virus could spread.

The site 鈥� first launched on April 3 and aptly titled 鈥溾�� 鈥� is the creation of a team led by , a UW professor of anthropology and adjunct professor of epidemiology, and , a UW professor emerita of sociology and statistics. Goodreau and Morris are network epidemiologists, studying how social connections influence the spread of infectious agents.

The COVID-19 virus can spread through many types of social interactions 鈥� from kissing and hugging to simply being in the same room 鈥� which is why health officials recommend rigorous social distancing measures like staying home, washing hands frequently, wearing face masks and keeping 6 feet from others during essential trips to grocery stores, pharmacies and medical appointments.

鈥淭here have been lots of discussions and articles about using social distancing to do things like 鈥榝latten the curve,鈥欌�� said Goodreau. 鈥淲e wanted to illustrate these principles at a community level, to help people visualize how even seemingly simple connections aren鈥檛 so simple.鈥�

鈥淐an鈥檛 I please just visit one friend?鈥� starts out by visualizing the effectiveness of these social distancing measures on a hypothetical community of 200 households. The researchers adjust the social connections in this community to demonstrate the effects of social distancing.

Here鈥檚 the community without social distancing: Each green dot is a household. The gray lines running between households are social connections 鈥� specifically the types that could spread the COVID-19 virus, such as close contact among people. In this community, each household has, on average, 15 connections to other households.

With no social distancing, social connections ensure that every household is directly or indirectly connected with every other household in the community, creating one giant cluster.

Here鈥檚 the community after social distancing: Most households are now isolated. But 10% of households, shown in blue, include a person with an essential job. These households still generate social connections that could potentially spread the COVID-19 virus. But the largest cluster created by these connections encompasses just 26% of households. For the vast majority of households, there is no social connection to potentially expose them to the COVID-19 virus.

Visiting 鈥渏ust one friend鈥� 鈥� which seems like it should be harmless 鈥� quickly reconnects this community. Here鈥檚 the situation if each household establishes one social connection with another household: Most households 鈥� 71% 鈥� are now reconnected in one large cluster. A single COVID-19 case in one of these households now has the direct or indirect social connections needed to spread to nearly three-quarters of the families in this community.

鈥淲e purposefully keep this quite simple to get the basic idea across to people,鈥� said Morris. 鈥淚t shows why connections can spread more than we realize, and much more than our instincts might tell us.鈥�

The team鈥檚 website shows additional scenarios, which they created using R, a programming language. One simulation shows how an average of two optional social connections per household reconnects more than 90% of households in the community.

Each of these connections is an opportunity for the virus to spread.

鈥淲ith COVID-19, many types of connections can transmit the virus,鈥� said Morris. 鈥淲hat we show is that you don鈥檛 need superspreaders to create network connectivity for transmission; visiting just one friend is equally effective for connecting a community into one large cluster.鈥�

By forgoing that visit with just one friend, people can help their neighbors both nearby and across town, and they will be helped in return, Morris added.

For more information, contact Goodreau at goodreau@uw.edu and Morris at morrism@uw.edu.