This title is going to raise a few eyebrows, but keep reading and you might be surprised. In an abstract presented at the Fifteenth Conference of the British HIV Association in Liverpool, Fox and colleagues investigated the reasons behind irregular condom use in long term serodiscordant couples (where one partner is HIV-positive, the other HIV-negative).

Thirty of the 38 couples interviewed were gay men and amongst the reasons they gave for not using condoms were a failure to understand the mechanisms of HIV transmission, emotional reasons (intimacy and trust being important reasons for unprotected sex), and a low concern about the consequences of HIV transmission occurring. Remarkably, some couples told the researchers that they had never discussed the reasons for not using condoms.

The researchers concluded that “A blanket healthcare message of safer sex seems inappropriate for all HIV serodiscordant couples.”

There was also little awareness of Post Exposure Prophylaxis (PEP), or the relation between viral load and infectiousness. Dislike of condom was also reported as they were involved in what some term COINED syndrome.

So does this mean that “condoms do not work?”

No. not at all. Let’s say it again: does this mean that “condoms do not work?” No! Not at all!

What this does mean is that condoms are not always the most evident or most efficient prevention tool in serodiscordant couples for various reasons. Should condoms be used correctly and consistently by both partners, that they would be an efficient means to prevent HIV transmission.

No serious and honest HIV activist would say that condoms are the “silver bullet” in the fight against HIV. In this regard, it is worth reprinting what former UNAIDS Executive Director Peter Piot of Imperial College London, who also serves as an adviser on global health strategy to the Bill & Melinda Gates Foundation; Michel Kazatchkine, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria; Mark Dybul of the O’Neill Institute for National and Global Health Law at Georgetown University and former U.S. Global AIDS Coordinator; and Julian Lob-Levyt of the GAVI Alliance wrote for the Lancet in March 2009:

“An increasingly recurrent myth is that one solution, or a so-called silver bullet, will comprehensively prevent HIV transmission.

Elimination of concurrent partnerships, circumcision of all men, focusing of prevention efforts on sex workers, universal HIV testing, and provision of antiretroviral therapy as soon as possible after infection, have all received attention as potential solutions for prevention of HIV transmission.

Scaling up strategies for harm reduction, such as methadone substitution and the provision of clean needles for injecting drug users, remains neglected in many countries in which injection drug use is a major means of HIV transmission.

Although these strategies are all important, no approach will be enough on its own, and the promotion of one solution is, in our view, irresponsible.

If we have learned one lesson in the past 27 years, it is that effective HIV prevention depends on customising the right mix of interventions for every context and ensuring the necessary coverage of them.

If we are to successfully increase access to HIV prevention, we have to be prepared to come to terms with complexity, effectively use all the methods that are available, include affected communities, engage relevant business expertise, and foster leadership to help change harmful social norms.”

In other words, a responsible and efficient HIV prevention is not about condom-only, it is not about abstinence-only, it is not us against them. It is all of the above, it is a prevention tailored to those it is supposed to benefit.

When it comes to gay men several other options exist, not all as efficient as condom, it must be said and emphasized (detailed on the GMFA website):

• Have less sex
• Have different kinds of sex
• Sero-sorting
• Negotiating safety
• Get regular health check-ups
• Withdraw before cumming
• Use plenty of lube
• Monitor your viral load
• Be a top if you’re HIV negative or a bottom if you’re HIV positive
• Look after your arse
• Don’t use poppers

Some of these do apply to straight couples too. Most importantly, an efficient prevention will understand the context in which it will be used and what will motivate its users to use it. A good prevention will give its user a personal stake in the fight against HIV. As observed by Fox and colleagues, “provision of an open discussion of risk and identification of barriers to condom use may be more meaningful than promoting a 100% condom approach.”

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