Condom use is declining among men who have sex with men. In a large survey of MSM in major urban areas, nearly two-thirds reported having condomless anal sex at least once during the past year, and a quarter said they had receptive anal intercourse without a condom the last time they had sex with a man. But there is also evidence that MSM use condoms at considerably variable rates depending on their own HIV status, the status of their partners, whether the partner is a main or casual one, and the sexual position.  

Meanwhile, 3.5 percent of HIV-negative MSM surveyed in major U.S. cities reported using pre-exposure prophylaxis (PrEP) in 2014.

These details are included in a new Centers for Disease Control and Prevention (CDC) report: the 2014 HIV Infection Risk Prevention, and Testing Behaviors in Men Who Have Sex With Men. This report from the National HIV Behavioral Surveillance (NHBS) project is based on surveys with MSM living in 20 major U.S. cities and is conducted every three years. (Because the survey is limited to urban areas, the findings cannot be generalized nationally.)

Because of differences in the structure of previous surveys, it is difficult to directly compare findings between reports. However, according to Cyprian Wejnert, PhD, senior epidemiologist within CDC’s Division of HIV/AIDS Prevention, the 2014 report "shows rates of condomless sex higher than those reported in previous NHBS reports. This finding is consistent with other NHBS analyses that suggest condomless anal sex is increasing among MSM in the United States.”

The current survey was conducted in 2014 among 9,640 MSM 18 years or older. Forty-two percent were under 30 years old. Thirty-eight percent were white, 28 percent black, and 26 percent Latino.

Survey participants were approached at sites where MSM congregate, provided an HIV test, and asked numerous questions about their sexual history. (The survey’s findings are also not necessarily reflective of the overall population of major cities, because, for starters, participants must be present at the locations where they are recruited.)

Twenty-two percent of the men surveyed in 2014 tested positive for HIV; 75 percent were already aware of their infection. Among racial groups, the respective rates of HIV prevalence and awareness of an HIV-positive status were: blacks, 36 percent and 67 percent; Latinos, 17 percent and 75 percent; and whites, 15 percent and 90 percent.

A total of 64.4 percent of men reported having condomless anal sex at least once during the previous year. The rates of men reporting condomless sex were about the same between the three main HIV-status categories, a respective 65 percent, 65 percent and 67 percent among HIV-negative men, HIV-positive men who were unaware of their infection before being tested during the survey (HIV-positive–unaware), and HIV-positive men who knew they had HIV before the survey (HIV-positive–aware).

MSM are more inclined to forgo condoms with a main sexual partner. A total of 43.3 percent of the men reported having anal sex without a condom with a main male partner at least once during the previous year, while 37.1 percent reported having anal sex without a condom with a casual male partner.

One safeguard against HIV transmission is being in a monogamous relationship in which both members receive negative HIV tests past the “window period” when false negatives are possible. However, those who practice condomless sex with main partners may actually open a considerable possibility for HIV transmission, especially when individuals cycle through short-term main sexual partnerships and do not get tested frequently enough. Estimates vary, but perhaps as many as two-thirds of transmissions among MSM occur within ongoing sexual partnerships, and the rate is estimated to be even higher among young MSM.

The CDC survey also asked about condom use during participants’ most recent sexual encounter. Responses to this question may provide a better idea of what proportion of sexual encounters among the overall population of MSM involves condoms. Answers to the question about whether men had condomless sex at least once during the previous year gives a better sense of what proportion of MSM uses condoms all the time.

Regarding their most recent encounter with a male, 14 percent of MSM reported condomless receptive anal sex—the sexual act that poses by far the greatest risk for HIV acquisition—and 9.8 reported both insertive and receptive condomless anal sex, or 23.8 percent total for those reporting receptive condomless intercourse.  (These figures are further broken down by HIV status later in this article; men who knew they were HIV positive were more likely to report having had receptive anal sex without a condom the last time they had sex with a male.)

HIV testing rates are rising among MSM. Looking at participants who did not previously report testing positive or who had tested positive within the previous year, the proportion of these men who reported getting an HIV test during the previous 12 months has risen in recent years, from 62 percent in 2008, to 66 percent in 2011, and 71 percent in 2014. Ninety-four percent of the 2014 participants said they had ever been tested.

The CDC’s 2014 report provides some of the first national data on PrEP use among MSM, at least among urban men. A total of 3.5 of the HIV-negative MSM reported having taken PrEP within the 12 months leading up to the 2014 survey. The researchers believe this figure can be used as a baseline figure from which to compare the future rate of uptake of PrEP among MSM. (Recent data suggests that rates of PrEP use have followed a dramatic upswing since 2014.)

The rate of reported PrEP use was lowest among 18-to-24-year-olds (2.5 percent), and ranged between 3.1 percent and 4 percent in the older age brackets. Whites were the most likely to report using PrEP, at 5.1 percent, compared with 2.4 percent among Latinos and 2.3 percent among blacks. This racial disparity is concerning, given the high rates of HIV acquisition among black MSM, young ones in particular, as well a recent CDC report finding that HIV acquisition rates are apparently rising among Latino MSM while they seem to have leveled off among black and white MSM. The rate of reported PrEP use was lower among those unaware that they were HIV-positive at the time of the survey, at 1.9 percent. (Since the study asked if the men had used PrEP at all during the previous year, this finding does not necessarily mean these men were taking PrEP when they contracted HIV.)

Among those who self-reported being HIV positive in 2014, 98 percent said they had ever visited an HIV health care provider. Eighty-two percent did so within three months of being diagnosed with the virus, and 91 percent said they had visited a health care provider for HIV care during the six months prior to the interview. Eighty-seven percent of the men who self-reported being HIV positive said they were taking treatment for the virus.

Thirteen percent of the men in 2014 reported being diagnosed with a bacterial sexually transmitted infection (chlamydia, gonorrhea or syphilis) during the previous year. The diagnosis rate was highest among those who knew they were HIV positive, at 23 percent, and lowest among the HIV-negative MSM, at 11 percent. Differences in how frequently men get tested for STIs may partially account for the variability in these rates, considering that HIV-positive MSM likely make physician visits more frequently than other MSM.

In 2014, the median number of male sex partners that men reported having during the previous year was four (the 25th percentile was two partners and the 75th percentile was eight), with a low of three among HIV-positive–unaware participants and a high of four among HIV-positive–aware participants.

The rates of MSM in the 2014 survey who reported having only oral sex during their last sexual encounter rose steadily with each successive age bracket.

The nitty-gritties of the 2014 report:
Among HIV-negative MSM, 44.4 percent had condomless anal sex with a main male partner during the previous year, and 36.8 percent did so with a casual male partner. The respective rates for HIV-positive–unaware men were 42.7 percent and 39.7 percent; for HIV-positive–aware men the respective rates were 42.9 percent and 43.0 percent. Such rates were generally similar between the main racial groups, except for the rates of condomless anal sex with casual male partners among HIV-positive–aware MSM: In this category, 34.1 percent of blacks, 46.8 percent of Latinos and 54.8 percent of whites reported this behavior.

Among HIV-positive–aware MSM, 42.9 percent reported condomless anal sex with a main male partner, and 43.9 percent with a casual male partner. There was a racial disparity among HIV-positive–aware men in their rates of condomless anal sex with casual male partners: 34.1 percent of blacks, 46.8 percent of Latinos, and 54.8 percent of whites reported this behavior.

Participants were asked about their most recent sexual encounter with a male partner. Among HIV-negative MSM, 18.5 percent reported condomless insertive anal sex only, 13.5 percent reported condomless receptive anal sex, 9.4 percent reported both insertive and receptive anal sex, and 25.7 percent reported oral sex only. The rates of condomless receptive anal sex only among HIV-negative men declined among the older age groups, while the rates of just oral sex rose considerably, from 16.2 percent among 18-to-24-year-olds to 46.5 percent among men 50 and over. White HIV-negative men were the most likely to report oral sex only, at 32.4 percent, compared with about 20 percent among blacks and Latinos.

As for the HIV-positive–unaware MSM, 16.2 percent reported having insertive condomless anal sex during their last sexual encounter with a male, 12.4 reported condomless receptive anal sex, 13.7 reported both insertive and receptive anal sex, and 13.7 percent reported oral sex only. A total of 20.4 percent of the white HIV-positive–unaware men reported condomless receptive anal sex only, compared with 12.7 percent of Latinos and 10.8 percent of blacks. HIV-positive–unaware men were more likely to report just having oral sex as they got older, although the difference wasn’t as stark as seen among HIV-negative MSM: 6.9 percent of the 18-to-24 year-olds reported this behavior, compared with 26.3 percent of men 50 and older.

Looking at HIV-positive–aware MSM, 12.5 percent reported only have insertive condomless anal sex during their last sexual encounter with a male, compared with 18.7 percent who reported condomless receptive anal sex, 12.4 percent who reported both insertive and receptive condomless sex, and 20 percent who reported oral sex only (6.3 percent of the youngest age bracket reported this last behavior, compared with 36.4 percent of the oldest). A total of 25.3 percent of white HIV-positive–aware MSM reported condomless receptive anal sex only, compared with 21.7 percent Latinos and 12.9 percent of blacks. A total of 9.7 percent of whites reported both insertive and receptive anal sex, compared with 21.7 percent Latinos and 12.9 percent of blacks. And a total of 9.7 percent of whites reported only oral sex, compared with 21.7 percent of Latinos and 12.9 percent of blacks.

Perhaps unsurprisingly, the rate of those MSM reporting condomless sex during the previous year with someone of a different perceived HIV status was the highest among the HIV-positive–unaware group, at 28.6 percent, compared with 15 percent among HIV-negative men and 18.3 percent among HIV-positive men. The rates of HIV-positive–unaware men reporting condomless anal sex with someone they perceived to be HIV negative were 29 percent, 30.4 percent and 22.4 percent among blacks, Latinos and whites, respectively.

The rates of those MSM having condomless vaginal or anal sex with a woman, were, respectively, 8.5 percent and 3.3 percent among HIV-negative men, 12.2 percent and 4.9 percent among HIV-positive–unaware men, and 3.1 percent and 1.5 percent among HIV-positive–aware men. Blacks and Latinos were more likely than whites to report condomless sex with women.

HIV-negative men were the most likely to report binge drinking (56 percent), while HIV-positive men were the least likely (46 percent of those unaware of their infection, and 44 percent of those aware of it). Injection drug use was more commonly reported by HIV-positive–aware men (7 percent) than HIV-negative (2 percent) or HIV-positive–unaware men (2 percent). Non-injection crystal meth use was more commonly reported by HIV-positive men (unaware, 10 percent; aware, 17 percent) than by HIV-negative MSM (6 percent).

Ten percent of the participants reported exchanging sex for money or drugs with a casual partner during the previous year. The rate of those who did so was highest in among the HIV-positive–unaware participants (19 percent) and lowest among the HIV-negative men (9 percent).

To read the report, click here.