For many years, the term “unprotected sex” has been synonymous with “sex without a condom,” and we’ve been told that the only real way for sexually active individuals to protect themselves from sexually transmitted diseases (STDs), including HIV, is to use a condom every time during sex.
Though we know everyone hasn’t followed this advice, the idea became so ingrained in our conversations about safer sex that it was clear protected sex equaled sex with a condom, while unprotected sex equaled sex without one. Some HIV advocates argue, however, that in this day and age of HIV treatment, pre-exposure prophylaxis (PrEP), and behavior changes that can decrease risk, this language is no longer accurate or precise. To that end, in December, a group of advocates, spearheaded by the HIV Prevention Justice Alliance, sent a letter to the Centers for Disease Control and Prevention (CDC) requesting a terminology change.
In January, the CDC announced on a call with more than 80 advocates that it would indeed change the decades-old language. Now, instead of referring to “unprotected sex” to mean sex without a condom, the CDC will refer simply refer to it as “condomless sex.”
The advocates’ argument hinges on the fact that there are now multiple ways to have safer sex when the goal is preventing HIV transmission. Condoms obviously still play an important role, but there are other ways individuals can protect themselves as well. Many HIV experts, for example, talk about treatment as prevention. Individuals who are on antiretroviral therapy (ART), which suppresses the replication of HIV, often have an undetectable viral load (a measure of the number of copies of HIV in a given blood sample). Though it is possible to transmit HIV even when one’s viral load is very low, it is much less likely.
Another, newly available prevention method for HIV is referred to as PrEP. In 2011, the Food and Drug Administration (FDA) approved the use of an existing HIV medication called Truvada, a once-daily pill designed to prevent infection. Studies have shown that it is effective. For example, one study among men who have sex with men (MSM) found that those who were given PrEP were 44 percent less likely to contract HIV than those who weren’t. Moreover, those who remembered to take their medication every day or almost every day saw a reduction in risk of 73 percent or even more (some up to 92 percent). Similar studies of HIV discordant, heterosexual couples found that PrEP reduced the risk of the uninfected partner becoming infected by 75 percent, or as much of 90 percent among those who took the pill every day or almost every day.
Advocates also note that some couples, men who have sex with men in particular, use practices knows as serosorting and seropositioning to reduce their risk. Serosorting essentially means limiting condomless anal intercourse to those partners with the same HIV status as themselves. The CDC, however, does not consider this to be a safer sex practice:
Serosorting is not recommended because: (1) too many MSM who have HIV do not know they are infected because they have not been tested for HIV recently, (2) men’s assumptions about the HIV status of their partners may be wrong, and (3) some HIV-positive men may not tell or may misrepresent their HIV status. All of these factors increase the risk that serosorting could lead to HIV infection.
Seropositioning is the practice by which men who have sex with men choose their position (as the insertive or receptive partner) based on sero-status; the HIV-positive partner would be receptive, as there is less risk that he transmits HIV in that position. Again, this assumes partners have accurate knowledge of their own and each other’s status.
Though there is some disagreement over the safety benefits of these behavioral practices, there is agreement that the landscape of HIV prevention has changed. Suraj Madoori, coordinator of the HIV Prevention Justice Alliance at the AIDS Foundation of Chicago, told RH Reality Check via email that the language change “opens doors for us to discuss the myriad of challenges and progress on effective methods of HIV prevention. By continuing to use ‘unprotected sex’ to mean ‘condom-less sex’ you fail to acknowledge and lose the breadth of the entire prevention narrative in how individuals and groups choose to protect themselves and mitigate risk.”
Jim Pickett, director of prevention advocacy and gay men’s health at the same organization, said in an email, “Of course, there are gradations of risk and safety. The only truly ‘safe’ act is to not have sex, right? Anything else has some level of risk—even oral sex (though you are more likely to get hit by lightning twice than get HIV from oral sex).”
A spokesperson for the CDC told the Bay Area Reporter that the changes have been under assessment for some time because, as “HIV prevention strategies evolve, the terminology needs to evolve as well.”
Other HIV experts welcomed the change as well. Dr. Kenneth Mayer, medical research director and co-chair of the Fenway Institute at Boston’s Fenway Health, told the Reporter, “Unprotected sex conveys a sense of irresponsibility that may not accurately reflect a person’s decision about how to avoid HIV and other STD’s.”
“For example,” he added, “someone in a committed monogamous relationship may decide not to use condoms after having been screened for HIV and STDs, and coming to an agreement with a partner about not engaging in intimate relations with others. It would be rare to refer to a heterosexual couple trying to conceive as engaging in ‘unprotected sex.’”
Todd Heywood echoes this in his piece for HIV Plus Magazine in which he writes:
Ultimately, this change holds the opportunity to shift the conversation in the gay community about clean and dirty gays, and good and bad gays — and instead put the focus on actual risk and prevention.
How this language change will play out in the long term is not yet known. For example, it’s not clear whether the CDC will continue to use the phrase “unprotected sex” to refer to sex in which no HIV prevention methods are used or when discussing STDs other than HIV, or whether it will simply retire the term altogether. The HIV Prevention Justice Alliance says it plans to meet with the agency later this month to discuss the change further.
It is also not clear how the rest of the public health community, specifically those who focus on other STDs, will react to the change or how likely they will be to adopt it, as the new prevention methods it is designed to include apply only to HIV. Condoms still remain the only way for sexually active couples to reduce their risk of chlamydia, gonorrhea, syphilis, and other diseases, which means that sex without a condom leaves individuals unprotected against these diseases. Moreover, many public health experts have feared that as alternative HIV-prevention methods become more popular among men who have sex with men, condoms will become less popular, leaving men open to other STDs. A recent study, however, shows that this fear may be unfounded, as people on PrEP were not more likely to engage in risky sexual behavior. That said, rates of other STDs are on the rise, and men who have sex with men are disproportionately affected.
It will be interesting to see how the new language becomes incorporated in messages about HIV and other STDs and if other organizations will follow the CDC’s lead.
Correction: A version of this article included an incorrect spelling of Suraj Madoori’s name. We regret the error.