Inconsistent Condom Use and Reasons for Non-Use in the Era of HIV Pre-Exposure Prophylaxis Among German Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) has shifted the paradigm of condom use and perceived risks for HIV and sexually transmitted infections (STIs) among men who have sex with men (MSM). We identified factors associated with inconsistent condom use and reasons for non-use among German MSM, with and without HIV, from two clinics in Germany between 2018 and 2024. Participants completed a questionnaire by computer-assisted self-interview every 6 months for up to 24 months. Multivariable robust Poisson regression models were fitted to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for the associations between factors of interest and inconsistent condom use and reasons for non-use. Inconsistent condom use was reported by 81% and 66% of 122 MSM during insertive and receptive anal sex, respectively. Inconsistent condom use was associated with (aPR [95% CI]) age >30 years (insertive: 31-40, 1.34 [1.13, 1.59]; ≥41, 1.27 [1.02, 1.58]), living without HIV (insertive: 1.28 [1.11, 1.47]; receptive: 1.32 [1.17, 1.49]), sex under the influence of drugs (insertive: 1.20 [1.04, 1.38]; receptive: 1.16 [1.03, 1.31]), and not worrying about STIs (insertive: 1.20 [1.06, 1.36]). Living with HIV, preference for condomless sex, and partner's HIV suppression were the most frequent reasons for non-use among participants with HIV. Using PrEP, preference for condomless sex, and partner's HIV status were the most frequent reasons for non-use among participants without HIV. Novel interventions tailored to specific high-risk subgroups, adjusted to address reasons for non-use, and adapted to mitigate risk compensation among MSM using PrEP are needed.