Differential Reasons for Condom Use and Non-Use at Last Anal Sex Encounter Among Gay and Bisexual Men Who Use the Internet to Seek Sex with Men in Ontario, Canada

Background and Purpose:Internet websites and mobile applications have become the most common venues for gay and bisexual men (GBM) to find sexual partners. The use of the Internet to seek sexual partners is associated with increased HIV risk behaviours, such as condomless anal intercourse (CAI). This is worrisome, given that GBM face the highest burden of HIV infections in North America. In this analysis, we sought to examine how an existing strategy (condom use or non-use) was differentially reasoned by GBM in Ontario (Canada’s largest province). 

Method:Data were drawn from the province-wide community-based Cruising Counts study of GBM aged 16 or older, who completed a 15-minute anonymous online questionnaire (n=1830). Participants, recruited through online sites and mobile apps (e.g., Squirt.org, Grindr®), provided demographic information, and responded to questions about their most recent anal intercourse event with another man.  Participants described their last anal sex encounter and qualitatively described reasons a condom was used or not used. These qualitative data were coded into categories collaboratively between three reviewers. Qualitative responses were coded non-exclusively and differences in terms of event-level (substance use, HIV sero-concordance) and individual-level factors (e.g., the participant’s age in years, sexual identity, race/ethnicity) were determined quantitatively using manual backward stepwise multivariable logistic regression (p<.05 considered significant).

Results: Among 1,830 participants, 1,460 (79.8%) reported a recent anal sex event, during which condoms were used in 60.5% encounters. Reasons for condom use included protection/safety (82.4%), norm (30.5%), and combination prevention (6.2%). Reasons for non-condom use were grouped non-exclusively as intentional non-use (43.2%), trust (28.1%), unintentional non-use (25.4%), and other prevention strategy such as undetectable viral load or negotiated behavior (20.0%). Event-level substance use was associated with all non-use reasonings: e.g., participants who used substances were more likely to reason non-use as unintentional (AOR=1.70, 95%CI:1.04-2.78) and partner substance use was negatively associated with trust as the reason for non-use (AOR=0.53, 95%CI:0.31-0.90). Participants were more likely to explain condom non-use with partners met online (versus not) as intentional (AOR=2.43, 95%CI:1.62-3.67) and less likely due to trust (AOR=0.25, 95%CI:0.15-0.40). Younger men were less likely to reason non-use due to other prevention strategies (AOR=1.03, 95%CI:1.003-1.05) and also less likely to explain condom use as a norm (AOR=1.01, 95%CI;1.001-1.03). Bisexual men and men who didn’t self-identify as White were also less likely to explain condom use as a norm (AOR=0.59, 95%CI:0.40-0.87 and AOR=0.62, 95%CI:0.42-0.92, respectively). Participant-partner sero-concordance was an important predictor across all condom use and non-use reasons: e.g., discordant partnerships were more likely to explain condom use as part of combination prevention compared with negative concordant partnerships (AOR=13.40, 95%CI:5.09-35.32). 

Conclusion: GBM described various reasons for using condoms or not. As prevention options develop beyond the use of condoms, social work practitioners and researchers should pay attention to the differences in reasons for condom use and non-use among GBM. This understanding supports the need for targeted, culturally appropriate health promotion to optimize combination HIV prevention for GBM.