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Clinician Recommendations Regarding Condom Use Are Not Uniform

With the proper use of antiretroviral therapy and pre-exposure prophylaxis, the risk of HIV transmission has never been lower. So why do some practitioners hesitate to endorse condomless sex?

Despite recent research revealing that antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) both greatly reduce the chances of HIV transmission, the “Undetectable Equals Untransmittable” message is not being promoted by all providers who work with HIV patients or those at risk of HIV.

In October 2017, investigators based at the University of Nebraska Medical Center in Omaha conducted a survey of practitioners who had attended a continuing education activity sponsored by the International Antiviral Society-USA. Out of 3238 attendees surveyed about their views on condomless sex and its safety, the team received 478 responses. Slightly more than half (51%) of respondents believe that evidence proves, strongly supports, or supports the claim that condomless sex with someone who has HIV but is virally suppressed will not result in disease transmission. More than three-quarters (76%) of respondents usually or always tell patients to use condoms. Even fewer respondents expressed full confidence in PrEP, with 42% agreeing that evidence proves, strongly supports, or supports the idea that condomless sex involving a person who takes PrEP will not result in disease transmission; 81% usually or always suggest condom use in these situations.

Why are so many practitioners sticklers for condom use even though ART and PrEP have proven effective at preventing HIV transmission? The answer may lie with other sexually transmitted infections (STIs). “We know that there is a high incidence of STIs among patients with HIV and among patients on PrEP, and condoms are the only way to prevent STIs other than HIV,” Sara Bares, MD, assistant professor at the University of Nebraska Medical Center and the lead author of the study, told Contagion®.

Sara Bares, MD

Another issue is uncertainty over whether people actually are able and willing to use ART and PrEP to their fullest advantage. Bares discussed concerns expressed by providers at a recent symposium about people in resource-limited settings. “[T]opics that came up included questions surrounding whether or not we can be as confident about ‘Undetectable Equals Untransmittable’ in resource-limited settings as we are in high-income settings, the idea that competing priorities in life can compromise adherence, and questions surrounding what level of adherence is sufficient to minimize transmission given some patients only have viral loads measured on a yearly basis in other countries,” Bares said.

There were notable differences between certain groups of respondents, two-thirds of whom were female. Eighty percent of the female practitioners in the study indicated that they were likely to recommend condoms “often or usually” compared with 71% of male respondents. Physicians were more likely to recommend condoms than other practitioners; 81% of MDs said they typically recommended condoms to patients, while 59% of pharmacists and 72% of nurses did likewise. Providers with fewer years of experience and providers in the Midwest were more likely to express the belief that the research on HIV transmission is settled science, although the investigators indicated that addressing the reasons behind this would be speculation.

Because this study was fairly small, the hope is that an upcoming study from another investigative team will address the factors that affect providers’ decisions to talk about “Undetectable Equals Untransmittable” with their patients.