Can a pill prevent HIV? Negotiating the biomedicalisation of HIV prevention

Are All Gay Men at Risk of Developing HIV/AIDS? Why China's Mass HIV Testing Has Majorly Targeted Gay Men in the Era of Biomedicalization

Global HIV/AIDS responses have been increasingly biomedically dominated over the past years. In line with this shifting paradigm, China has prioritized mass HIV testing as a practical approach to controlling its HIV/AIDS epidemics among at-risk populations, especially gay men and other men who have sex with men (MSM). This study analyzed why China's mass HIV testing mainly targeted gay men by understanding the perspectives of public health professionals, community-based organization (CBO) workers, and gay men. In addition, this study revealed the tensions and unintended consequences of HIV/AIDS prevention and the representation of gay men in China. The study involved fieldwork conducted in a major city in Eastern China from 2015 to 2019. Semi-structured interviews were held with participants from the three abovementioned groups (N = 25). The study identified four processes concerning why gay men are mainly targeted for HIV testing. Some public health professionals believe that being a gay man is equivalent to having HIV/AIDS risks. In addition, this study particularly noted tensions between public health professionals and gay men, including gay men-identified CBO workers, over whether mass HIV testing should target gay men or anyone who engaged in sexual risk behaviors. This study argued that a particular focus on gay men due to pursuing biomedical advances in HIV/AIDS prevention seems to have unintendedly stereotyped gay men based on the presumptions that they are at risk of developing HIV/AIDS. In addition, this study corresponded to the broader social scientific discussion concerning whether HIV/AIDS intervention should target specific sexual risk practices or sexual identity/population.

Navigating the Viral Divide: Sexual and Gender Minority Community Perspectives on Treatment as Prevention

Since it was established that HIV-positive individuals who maintain an undetectable viral load are unable to sexually transmit HIV (U=U), treatment as prevention (TasP) has become an important biomedical HIV prevention option. Many have remained optimistic that TasP, combined with pre-exposure prophylaxis (PrEP), will help close the "viral divide" between those living with and without HIV. This qualitative interview study of 62 sexual and gender minority (SGM) individuals of mixed serostatuses explored community perspectives regarding TasP, including the meaning of undetectability and how U=U impacts understandings of serodifference. Five key themes emerged from interviews: (1) undetectable does not equal HIV-negative, (2) PrEP is more promoted than TasP, (3) TasP increases openness to serodifferent sex, (4) rejection of TasP absolutism, and (5) the importance of layering prevention strategies. These findings suggest that while TasP is helping to bridge the viral divide, serostatus distinctions remain prevalent and important to many SGM individuals.

The use of PrEP among men who have sex with men and transgender women as Biomedical Prevention Work: A conceptual framework

Based on ethnographic fieldwork among men who have sex with men and transgender women in Tanzania, this article explores the various types of work that may go into enrolment into PrEP programming and using pre-exposure prophylaxis (PrEP). PrEP protects against HIV acquisition and is widely touted as an essential tool in 'ending AIDS by 2030'. While taking PrEP has often been portrayed as 'just taking a pill a day' in public health campaigns, a striking observation during fieldwork was that enrolling in PrEP programming and adhering to PrEP involved a wide range of tasks. Inspired by this fieldwork experience and the literature on sociology of work, more specifically illness work and patient work, we started to think of these tasks as work. This paper identifies the range of tasks that PrEP users in Dar es Salaam had to perform as part of their enrolment and usage of PrEP. We provide a description of these tasks, organised into three categories of work that we refer to as (a) readying work, (b) user work, and (c) social navigation work that jointly make up what we propose to call biomedical prevention work. We further suggest that this analytical framework can be applicable to other biomedical prevention methods in other contexts.

Barriers and facilitators to HIV Pre-Exposure Prophylaxis (PrEP) in Specialist Sexual Health Services in the United Kingdom: A systematic review using the PrEP Care Continuum

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) delivery in the UK is inequitable; over 95% of PrEP users were men who have sex with men (MSM) despite making up less than 50% of new HIV diagnoses. We conducted a systematic review to identify modifiable barriers and facilitators to PrEP delivery in the UK among underserved populations.

METHODS

We searched bibliographic/conference databases using the terms HIV, PrEP, barriers, facilitators, underserved populations, and UK. Modifiable factors were mapped along the PrEP Care Continuum (PCC) to identify targets for interventions.

RESULTS

In total, 44 studies were eligible: 29 quantitative, 12 qualitative and three mixed-methods studies. Over half (n = 24 [54.5%]) exclusively recruited MSM, whereas 11 were in mixed populations (all included MSM as a sub-population) and the other nine were in other underserved populations (gender and ethnicity minorities, women, and people who inject drugs). Of the 15 modifiable factors identified, two-thirds were at the PrEP contemplation and PrEParation steps of the PCC. The most reported barriers were lack of PrEP awareness (n = 16), knowledge (n = 19), willingness (n = 16), and access to a PrEP provider (n = 16), whereas the more reported facilitators were prior HIV testing (n = 8), agency and self-care (n = 8). All but three identified factors were at the patient rather than provider or structural level.

CONCLUSIONS

This review highlights that the bulk of the scientific literature focuses on MSM and on patient-level factors. Future research needs to ensure underserved populations are included and prioritized (e.g. ethnicity and gender minorities, people who inject drugs) and provider and structural factors are investigated.

Reasons for not Using HIV Pre-Exposure Prophylaxis (PrEP) among Gay and Bisexual Men in Australia: Mixed-Methods Analyses from a National, Online, Observational Study

Although approximately 31,000 Australian gay and bisexual men (GBM) are eligible for HIV pre-exposure prophylaxis (PrEP), only 18,500 people currently use it, indicating a need to investigate why GBM do not use it. This article uses data from a national, online, observational study. It adopts a mixed-methods analysis to responses to survey questions asking about reasons Australian GBM were not using PrEP in 2018, according to their level of HIV risk as delineated by the Australian PrEP prescribing guidelines at the time. Participants responded to check-box questions and had the option to respond to a qualitative free-text question. Results showed that just over one-fifth of men were at higher risk of HIV acquisition. Compared to lower-risk men, higher-risk men were more likely to indicate PrEP was too expensive and more likely to cite embarrassment asking for it. Reasons for not using PrEP included a lack of personal relevance, poor accessibility or knowledge, concerns about PrEP's inability to protect against STIs, potential side effects, and a preference for condoms. We conclude that health promotion more effectively targeting GBM who may benefit the most from PrEP may be valuable.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

"What other choices might I have made?": Sexual Minority Men, the PrEP Cascade and the Shifting Subjective Dimensions of HIV Risk

The PrEP Cascade is a dominant framework for investigating barriers to HIV pre-exposure prophylaxis (PrEP), an HIV prevention tool. We interviewed 37 PrEP users and 8 non-PrEP users in Ontario and British Columbia, Canada, about their decision-making through the Cascade. Participants were HIV-negative gay, bisexual, and queer men (GBQM). The data were analyzed using thematic analysis. PrEP decision-making was based on pragmatic considerations (logistics, costs, and systemic barriers), biomedical considerations (efficacy, side-effects, and sexually transmitted infections), and subjective considerations (identity, politics, and changing sexual preferences). Affective attachments to established versions of "safer sex" (condoms and serosorting) made some GBQM less likely to try PrEP. Some GBQM expressed increased social expectations to use PrEP, have condomless sex, and serodifferent sex. These findings support offering PrEP at no-cost, offering individualized counseling and community-based opportunities to discuss PrEP use and changing sexual practices, and improving communication on the manageability of PrEP side-effects.

Othering discourse and stigma amidst the identity formation process among gays, bisexuals and other men who have sex with men on HIV pre-exposure prophylaxis (PrEP)

With the global emergence of the HIV pre-exposure prophylaxis (PrEP), questions have emerged on which ways the social identity formation process among gays, bisexuals and other men who have sex with men on PrEP arise and constitute beyond exclusive sexual orientation expressions. We conducted a content analysis with thematic categories in a PrEP online group guided by group-web affiliation and individualization approaches. Individuals identify themselves as PrEPsters as part of a PrEP club, while dealing with conflicts on serosorting sexual partners and stigmatizing reactions towards people living with HIV/AIDS (PLWH). Self-worth and othering discourses towards PLWH emerged as complex themes in men's production of identity processes across four overlapping domains: (1) self-worth as a strategy to challenge individual HIV-acquisition-related anxiety and fear, (2) group-worth and group empowerment, (3) body control and reclaiming power on sexual health, and (4) othering discourses, HIV/AIDS stigma and criminalization of PLWH. Paradoxically, internal and external discourses to the group constitute and challenge identity differentiation; individuals on PrEP claim to fight against the HIV/AIDS stigma, while this reverberates alongst HIV-related discriminatory expressions in their discourses.

Dual pharmaceutical citizenship: Exploring biomedicalization in the daily lives of mixed HIV-serostatus couples in Canada

Positive Plus One is the first large-scale mixed methods study of mixed HIV serostatus couples in Canada. We aimed to understand how biomedicalization i.e., a social process of commodification and expansion of the jurisdiction of medicine over health, influenced the everyday relationships of these couples. We completed 51 semi-structured interviews among a purposive sample of HIV-positive (n = 27) and HIV-negative (n = 24) partners in current or past mixed-serostatus relationships. Participants were recruited after completing an online survey where they consented to be re-contacted for qualitative interviews. Participants represented a diversity of sexual orientations, gender identities, and other sociodemographic characteristics. Drawing on inductive thematic analysis to identify patterns within couples, across serostatus and sexual orientations, we argue that everyday lives of mixed-serostatus couples were shaped by biomedical knowledge and enacted through routine adherence to obtain and maintain viral load undetectability. Our findings illustrated the importance of learning biomedical knowledge for mixed-serostatus couples in this study, the empowering influence of undetectable = untransmittable (UU) discourse, and its role in rendering HIV mundane through routine ART adherence. We introduce the concept of 'dual pharmaceutical citizenship' to underscore a process by which particular biopolitical and biomedical expectations are fulfilled in mixed-serostatus relationships. These findings have implications for people who do not readily accept or have access to biomedical knowledge, particularly when treatment-as-prevention frames a "right" and "wrong" approach to HIV management. Future studies should focus on couples where at least one partner does not readily accept or have access to biomedical knowledge.

Moral practices shaping HIV disclosure among young gay and bisexual men living with HIV in the context of biomedical advance

Biomedical advances in diagnostics, treatment and prevention increase the means available to reduce HIV transmission risk. Subsequent shifts in HIV status disclosure obligation and ethics may impact how those living with HIV view, enact and experience disclosure. We analysed focus group and interview data to explore how these changes are reflected in disclosure decision-making to sexual partners among young gay and bisexual men living with HIV in the USA. Three interrelated themes were identified: engaging with partners' varying HIV knowledge; attribution of blame; and negotiating disclosure-related harms. Participants experienced blame from partners that questioned the timing of HIV testing, status disclosure and sex events without regards for viral suppression or use of pre-exposure prophylaxis. Substantial HIV stigma was described in response to disclosure, mitigated in some cases by partners' higher HIV knowledge. Overall, an uneven diffusion of HIV treatment and prevention knowledge and continuing HIV stigma seemed to limit the translation of biomedical advances into improved disclosure experiences. Our findings suggest that young gay and bisexual men living with HIV may continue to perform much of the moral labour involved in disclosure by managing others' reactions, correcting inaccurate sexual health information, and negotiating the risks of disclosure-related harm.

Desiring intimacy and building community: young, gay and living with HIV in the time of PrEP

The negative effects of stigma on men living with HIV within gay communities are well-documented. However, few studies have examined the experience of intimacy for men living with HIV as a consequence of the widespread availability of pre-exposure prophylaxis (PrEP). This study explores the effect of PrEP adoption on the lives of men living with HIV in one of the first cities that made PrEP widely available, and where adoption had already been in place in treatment trials prior to FDA approval in 2012. In-depth, semi-structured interviews were conducted with six gay men living with HIV under 40 years old in San Francisco, California. Transcriptions were coded using interpretative phenomenological analysis. Four key themes relevant to experiential changes within the gay community post-PrEP rollout were identified: (i) the desire for intimate connection; (ii) remembered experiences of stigma; (iii) men who do not take PrEP are suspect; (iv) and an awareness of the changing meaning of HIV. The findings suggest that, post-PrEP rollout, men living with HIV are experiencing dating, sex and community in ways that reflect a general reduction in the experience of stigma surrounding their HIV status. This suggests an important social impact of PrEP in reducing HIV-related stigma beyond the primary prophylactic effect.

Subordinated agency: Negotiating the biomedicalisation of masculinity among gay men living with HIV

Health practices are shaped by gender relations and constructs. Utilising qualitative data, this study explores a shift in medication practices among gay men living with HIV (GMLH) in light of changing HIV/AIDS responses in Taiwan. In the 1980s and 1990s, the mobilisation of moralising discourses forged a gender hierarchy that subordinated HIV-positive gay males. In the 2000s, new state programmes on HIV/AIDS were implemented to enhance patients' adherence to treatment, but GMLH often expressed ambivalence towards medication, which could lead to HIV disclosure and, consequently, social exclusions under the gender hierarchy. Starting in the 2010s, the knowledge of HIV 'treatment as prevention' and a policy on early treatment have offered a new path for GMLH to navigate gender power dynamics and to strive towards an inclusive social life by taking medicine and optimising health, which facilitates a biomedicalisation of subordinated masculinity. This study contributes to the scholarship on HIV/AIDS by underscoring the significance of biomedicine for configuring masculine identities and practices among a subordinated group of men, as well as by highlighting the gender power relations and everyday 'nonbiomedical' negotiating practices that legitimise biomedicalisation.

Configuring the PrEP user: framing pre-exposure prophylaxis in UK newsprint 2012-2016

Pre-exposure prophylaxis (PrEP) has been hailed as a revolutionary intervention for HIV prevention. PrEP's controversial status in the UK has generated significant media coverage. It is important to understand what role the media plays in framing PrEP policy issues. We undertook a qualitative analysis of UK newsprint articles between 2012 and 2016 to examine how PrEP was framed as a public health intervention up until a controversial policy decision not to provide PrEP in England. We identified how scientific evidence was deployed to shape two narratives: ir/responsible citizens focused on imagined PrEP users and their capacity to use PrEP effectively; and the public health imperative, which described the need for PrEP. Our analysis demonstrates the particular ways in which scientific evidence contributed to the certainty of PrEP as an effective intervention within UK newsprint. Scientific evidence also played a key role in framing PrEP as an intervention specifically for cis-gendered gay and bisexual men, playing into wider debates about who is a deserving patient and the appropriate use of public resources. Practitioners in the UK and elsewhere should be aware of these constructions of the PrEP user to ensure equitable access to PrEP beyond gay and bisexual men.

The Biomedical Closet? Undetectability among HIV-positive Gay Men in India

The discourse of Undetectability, referring to the effect of HIV viral suppression on forward sexual transmission, is at the heart of the current paradigm of Treatment-as-Prevention and is invested with hopes of eliminating stigma. But ethnographic examination of the way HIV-positive gay and bisexual men in four major Indian cities experience Undetectability reveals a more complicated picture. Rather than resolve the problem of HIV stigma, Undetectability enables new ways of managing it, including ethical non-disclosure in the face of social danger. This reveals three paradoxes inherent in the universalism of Treatment-as-Prevention and its reliance on biomedical solutions.

Excitable models: Projections, targets, and the making of futures without disease

In efforts to control disease, mathematical models and numerical targets play a key role. We take the elimination of a viral infection as a case for exploring mathematical models as 'evidence-making interventions'. Using interviews with mathematical modellers and implementation scientists, and focusing on the emergence of models of 'treatment-as-prevention' in hepatitis C control, we trace how projections detach from their calculative origins as social and policy practices. Drawing on the work of Michel Callon and others, we show that modelled projections of viral elimination circulate as 'qualculations', taking flight via their affects, including as anticipation. Modelled numerical targets do not need 'actual numbers' or precise measurements to perform their authority as evidence of viral elimination or as situated matters-of-concern. Modellers grapple with the ways that their models transform in policy and social practices, apparently beyond reasonable calculus. We highlight how practices of 'holding-on' to projections in relation to imaginaries of 'evidence-based' science entangle with the 'letting-go' of models beyond calculus. We conclude that the 'virtual precision' of models affords them fluid evidence-making potential. We imagine a different mode of modelling science in health, one more attuned to treating projections as qualculative, affective and relational, as excitable matter.

Social determinants of quality of life among PLHIV in Australia: implications for health promotion

A cascade of care model is central to contemporary approaches to HIV prevention. The model prioritizes strategies to increase rates of HIV testing and promote early and sustained uptake of antiretroviral treatment (ART) among people living with HIV (PLHIV). The model aims to prevent new HIV transmissions by increasing the number of PLHIV who have achieved HIV viral suppression. However, good quality of life (QoL) among PLHIV has been proposed as an additional goal. This prioritizes the basic right of PLHIV to lead meaningful lives and acknowledges the relationship between better QoL and consistent ART use. A better understanding of factors associated with the QoL can thus inform health promotion programmes for PLHIV. In this study, N=465 Australian participants, recruited through social media and various HIV community organizations, completed an online survey that included a measure of QoL and a range of demographic, health-related and social variables. Overall, social factors accounted uniquely for the most variance in QoL (18%), followed by health-related (11%) and demographic factors (2%). Social support, HIV-related discrimination and treatment convenience were among the strongest determinants of QoL. These findings reinforce the importance of a more holistic approach to health promotion among PLHIV. Specifically, our results indicate that to improve the QoL of PLHIV and to boost related public health benefits, community advocates and healthcare professionals must be responsive to the broader psychological, social and functional needs of PLHIV.

Sexual health literacy among gay, bisexual and other men who have sex with men: a conceptual framework for future research

Good sexual health requires navigating intimate relationships within diverse power dynamics and sexual cultures, coupled with the complexities of increasing biomedicalisation of sexual health. Understanding this is important for the implementation of biomedical HIV prevention. We propose a socially nuanced conceptual framework for sexual health literacy developed through a consensus building workshop with experts in the field. We use rigorous qualitative data analysis to illustrate the functionality of the framework by reference to two complementary studies. The first collected data from five focus groups (FGs) in 2012 (n = 22), with gay, bisexual and other men who have sex with men aged 18-75 years and 20 in-depth interviews in 2013 with men aged 19-60 years. The second included 12 FGs in 2014/15 with 55 patients/service providers involved in the use/implementation of HIV self-testing or HIV prevention/care. Sexual health literacy goes well beyond individual health literacy and is enabled through complex community practices and multi-sectoral services. It is affected by emerging (and older) technologies and demands tailored approaches for specific groups and needs. The framework serves as a starting point for how sexual health literacy should be understood in the evaluation of sustainable and equitable implementation of biomedical sexual healthcare and prevention internationally.

Ambivalence and the biopolitics of HIV pre-exposure prophylaxis (PrEP) implementation

Ambivalence, the vacillation between conflicting feelings and thoughts, is a key characteristic of scientific knowledge production and emergent biomedical technology. Drawing from sociological theory on ambivalence, we have examined three areas of debate surrounding the early implementation of HIV pre-exposure prophylaxis, or PrEP, for gay, bisexual, queer, and other men who have sex with men in Canada, including epistemology and praxis, clinical and epidemiological implications, and sexual politics. These debates are not focused on the science or efficacy of PrEP to prevent HIV, but rather represent contradictory feelings and opinions about the biopolitics of PrEP and health inequities. Emphasizing how scientists and health practitioners may feel conflicted about the biopolitics of novel biomedical technologies opens up opportunities to consider how a scientific field is or is not adequately advancing issues of equity. Scientists ignoring their ambivalence over the state of their research field may be deemed necessary to achieve a specific implementation goal, but this emotion management work can lead to alienation. We argue that recognizing the emotional dimensions of doing HIV research is not a distraction from "real" science, but can instead be a reflexive site to develop pertinent lines of inquiry better suited at addressing health inequities.

"Mini Dial-A-Nurses" and "Good Brands": What Are the Desirable Features of Online HIV/STI Risk Calculators?

A wide variety of risk calculators estimate individuals' risk for HIV/sexually transmitted infections (STI) online. These tools can help target HIV/STI screening and optimize clinical decision-making. Yet, little evidence exists on suitable features for these tools to be acceptable to end-users. We investigated the desirable characteristics of risk calculators among STI clinic clients and testing service providers. Participants interacted with online HIV/STI risk calculators featuring varied target audiences, completion lengths, and message outputs. Thematic analysis of focus groups identified six qualities that would make risk calculators more appealing for online client use: providing personalized risk assessments based on users' specific sexual behaviors and HIV/STI-related concerns; incorporating nuanced risk assessment and tailored educational information; supplying quantifiable risk estimates; using non-stigmatizing and inclusive framing; including explanations and next steps; and developing effective and appropriate branding. Incorporating these features in the design of online HIV/STI risk calculators may improve their acceptability among end-users.

The People vs the NHS: Biosexual citizenship and hope in stories of PrEP activism

Discourses of pre-exposure prophylaxis (PrEP) revel in its radical potential as a global HIV prevention technology, offering a promise of change for the broader landscape of HIV prevention. In 2018, the British Broadcasting Corporation (BBC) aired The People vs The NHS: Who Gets the Drugs?, a documentary focused on the 'battle' to make PrEP available in England. In this article we explore how the BBC documentary positions PrEP, PrEP biosexual citizen-activists, as well as the wider role of the NHS in HIV prevention and the wellbeing of communities affected by HIV in the UK. We consider how biosexual citizenship (Epstein 2018) is configured through future imaginaries of hope, and the spectral histories of AIDS activism. We describe how The People crafts a story of PrEP activism in the context of an imagined gay community whose past, present, and hopeful future is entangled within the complexities and contractions of a state-funded health system. Here, PrEP functions as a 'happiness pointer' (Ahmed 2011), to orient imagined gay communities towards a hopeful future by demanding and accessing essential medicines and ensuring the absence of needless HIV transmissions. This biomedical success emerges from a shared traumatic past and firmly establishes the salvatory trajectory of PrEP and an imagined gay community who have continued to be affected by HIV. However, campaigns about the individual's right to access PrEP construct the availability and consumption of PrEP as an end goal to their activism, where access to PrEP is understood as an individual's right as a pharmaceutical consumer.

The significance and expectations of HIV cure research among people living with HIV in Australia

Most people living with HIV (PLHIV) with reliable access to antiretroviral treatment (ART) have a life expectancy similar to uninfected populations. Despite this, HIV can negatively affect their social and psychological wellbeing. This study aimed to enhance understanding of the expectations PLHIV hold for HIV cure research and the implications this has for HIV cure research trials. We interviewed 20 Australian PLHIV about their expectations for HIV cure research outcomes and the impact a potential cure for HIV may have on their everyday lives. Data were analysed thematically, using both inductive and deductive approaches. The significance of a cure for HIV was expressed by participants as something that would offer relief from their sense of vigilance or uncertainty about their health into the future. A cure was also defined in social terms, as alleviation from worry about potential for onward HIV transmission, concerns for friends and family, and the negative impact of HIV-related stigma. Participants did not consider sustained medication-free viral suppression (or remission) as a cure for HIV because this did not offer certainty in remaining virus free in a way that would alleviate these fears and concerns. A cure was seen as complete elimination of HIV from the body. There is an ethical need to consider the expectations of PLHIV in design of, and recruitment for, HIV cure-related research. The language used to describe HIV cure research should differentiate the long-term aspiration of achieving complete elimination of HIV from the body and possible shorter-term therapeutic advances, such as achieving medication free viral suppression.

Studying the "sexuality-health-technology nexus": a new materialist visual methodology

A school of critical sexual health scholars argues that biomedical and digital technologies need to be understood not as mere objects of use, but as having the agentic capacity to effect new senses of the self and transform social/sexual health relations and outcomes. Such a call to grapple with the multidimensionality of technologies, their affects and effects poses a challenge to current methodological frameworks. To address this challenge, we introduce a novel visual methodology called "embodied mapping" that builds on the arts-based method of body mapping. Drawing from new materialism scholarship, embodied mapping extends the scope of inquiry of sexual-health research and conventional qualitative methods. It does so by interrogating the capacities and properties of sexual agents, technologies and readily available discourses on sexual health and HIV prevention as co-constitutive within the sexual-health-technologies nexus itself. Embodied mapping's research process is collaborative and emergent; researchers, together with an artist and research participants co-create a visual collage tracing the thick moments of sexual/health encounters. Embodied mapping's methodological and analytical capacity to approach sexual health phenomena as performative and immanent to the research process could open new sight lines for comprehending and intervening in this globalised era marked by an increasing technologising of sexual health care.

Pleasure and HIV biomedical discourse: The structuring of sexual and drug-related risks for gay and bisexual men who Party-n-Play

Party-n-Play (PNP) is a social practice that refers to sex that occurs under the influence of drugs. This study critically examined the risk and pleasure discourses of gay and bisexual men who PNP to explore how epistemic shifts associated with advancements in HIV biomedical sciences influence gay and bisexual men's perceptions of HIV risks and their sexual and drug-related practices. This study also aims to provide a more nuanced understanding of how sexual and drug-related risk practices of gay and bisexual men are entangled with their search for pleasure. The study was framed within poststructural Critical Discourse Analysis (CDA) methodology. In-depth one-hour interviews were conducted with 44 self-identified gay, bisexual, queer, or Two-Spirit men, who lived in Toronto, and who reported using drugs before or during sex with another man. The findings from this study demonstrated the capacity of biomedical discourses to affect respondents' HIV risk perceptions and practices. The transition from condom-centered prevention to today's context where new highly effective biomedical tools for HIV prevention are available created possibilities for greater intimacy, increased pleasure, and less anxiety about HIV tranmission, while challenging many years of preventive socialization among gay and bisexual men. However, this new context also rekindled deep-seated fears about HIV risk and viral load verifiability, reinforced unequal forms of biomedical self-governance and citizenship, and reproduced practices of biopolitics. While discourses on risk and pleasure were interwoven within complex PNP assemblages, the notion of pleasure was mobilized as a discursive tactic of self-control, and the division between normative and non-normative pleasures highlighted the consequence of biopolitical forces governing the production of discourses on sex and drugs. Future HIV social science research needs to attend to the fluid nature of the discursive environments of HIV prevention science, and consider how both the material context of PNP and its social/discursive elements operate together.

Motives for choosing, switching and stopping daily or event-driven pre-exposure prophylaxis - a qualitative analysis

INTRODUCTION

In settings where both daily and event-driven pre-exposure prophylaxis (PrEP) are offered to men who have sex with men (MSM), a clear understanding of the motives to choose between the different dosing-regimens can facilitate more effective PrEP implementation. We therefore studied the motives for choosing for, switching between, and stopping daily or event-driven PrEP.

METHODS

We used data (August 2015-June 2017) from the prospective, longitudinal, open-label Amsterdam PrEP demonstration study, in which daily (dPrEP) and event-driven PrEP (edPrEP) were offered to 374 HIV-negative MSM and two transgender persons. Participants self-selected the preferred PrEP-regimen at baseline and could switch regimens at three-monthly follow-up visits. We measured motives for choosing PrEP-regimen at baseline and for switching and stopping PrEP at follow-up visits. Open- and closed-end items were combined and qualitatively analysed.

RESULTS

Choices of PrEP-regimens were determined by personal and contextual factors, involving the perceived self-efficacy concerning adherence, the risk-context, and the anticipated impact of PrEP on physical and sexual wellbeing. dPrEP was preferred because of the anticipated better adherence and the fear of side-effects relating to edPrEP re-initiations. Moreover, dPrEP was perceived to be more effective than edPrEP. Motives to choose edPrEP were the expected physical burden of dPrEP, anticipated side-effects of dPrEP, and fear to forget daily doses. Regarding the risk-context: dPrEP was preferred for unplanned and/or frequent sex, while edPrEP was chosen when risk was predictable and/or less frequent. While some chose for dPrEP to gain more sexual freedom, others chose for edPrEP to minimize sexual risk episodes. Changes in the above factors, such as changing risk patterns, changing relationships or changing physical conditions, resulted in switching regimens. Choices to stop PrEP were related to lower sexual risk, adherence issues and side-effects.

CONCLUSIONS

The great diversity of motives illustrates the importance of offering a choice of PrEP-regimens. In counselling of MSM starting PrEP, choices for PrEP-regimens may be addressed as a continuum of flexible and changeable options over time. This may help individuals choose the PrEP-regimen that best fits their current sexual context, priorities and personal capabilities and therefore will be more easily adhered to.

The non-positive antiretroviral gay body: the biomedicalisation of gay sex in England

Drawing on testimonies from oral history interviews, this paper analyses the implications of pre-exposure prophylaxis (PrEP) practices for gay men in England. Through perspectives on biomedicalisation, the paper focuses on three aspects relevant to the construction of technoscientific identities in the realm of HIV prevention: (i) the question of agency of PrEP users in the context of what has been defined as a biomedical intervention, (ii) practices of freedom framed within neoliberal narratives of personal responsibility versus responsibilisation and (iii) the governance of risk in the era of biomedicalisation. The paper concludes that biomedical governmentalities, even those shaped by the rhetoric of personal responsibility, can be understood as rationalities linked more to solidarity and care of the other. Despite this, the use of PrEP in England is also giving way to the configuration of new sexual scenarios shaped by zero-risk mentalities. It will be important to remain alert to the implications of zero-risk scenarios for HIV-related stigma.RésuméEn s'appuyant sur des témoignages provenant d'entretiens centrés sur des histoires orales, cet article analyse les implications des pratiques de la PrEP chez les hommes gays en Angleterre. À travers les points de vue sur la bio-médicalisation, il se concentre sur trois aspects de la construction des identités technoscientifiques dans le royaume de la prévention du VIH : i) la question de la capacité à agir des utilisateurs de la PrEP dans le contexte de ce qui a été défini comme une intervention biomédicale, ii) les pratiques de la liberté, encadrées par les récits néolibéraux sur la responsabilité personnelle, versus la responsabilisation, et iii) la gouvernance du risque à l'ère de la bio-médicalisation. En conclusion de leur article, les auteurs soutiennent que les << gouvernementalités >> biomédicales, y compris celles qui sont déterminées par la rhétorique de la responsabilité personnelle, peuvent être comprises comme des rationalités plus en rapport avec la solidarité et le souci des autres. Malgré cela, l'usage de la PrEP en Angleterre laisse la place à la configuration de nouveaux scénarios sexuels déterminés par les mentalités du risque zéro. Il est important de rester attentif aux implications des scénarios du risque zéro au regard du stigma lié au VIH.ResumenA partir de testimonios obtenidos a través de entrevistas de historia oral, el presente artículo analiza las repercusiones de la PrEP (profilaxis preexposición para el vih, por sus iniciales en inglés) en las prácticas de hombres gais en Inglaterra. Partiendo de perspectivas sobre la biomedicalización, el artículo se centra en tres aspectos pertinentes a la construcción de identidades tecnocientíficas en el ámbito de la prevención del vih: i) la cuestión de la gestión (agency) de los usuarios de la PrEP en un contexto identificado como de intervención biomédica; ii) las prácticas de libertad enmarcadas en narrativas neoliberales de responsabilidad personal versus responsabilización; iii) el manejo del riesgo en la era de la biomedicalización. El artículo concluye que los manejos biomédicos, incluso aquellos moldeados por la retórica de responsabilidad personal, pueden entenderse como racionalidades vinculadas más con la solidaridad y el cuidado de los demás. A pesar de esto, el uso de la PrEP en Inglaterra está cediendo espacio a la configuración de nuevos escenarios sexuales determinados por esquemas mentales de riesgo cero. Debemos permanecer atentos ante las implicaciones que conllevan los escenarios riesgo cero para el estigma vinculado con el vih.

Thematic synthesis HIV prevention qualitative studies in men who have sex with men (MSM)

BACKGROUND

Qualitative studies on HIV prevention strategies and methods among men who have sex with men (MSM) allow identify knowledge gaps and improve preventive actions.

OBJECTIVE

To make a thematic synthesis of the scientific productions that use the qualitative methodology in the strategies and methods of HIV prevention area among MSM.

METHODS

We conducted a literature review following the guidelines of the ENTREQ protocol. The analysis included 48 empirical studies published in Portuguese, English and Spanish between 2001 and 2018 available in the Medline, Embase, Scielo, Scopus, Bireme and Web of Science databases.

RESULTS

Where an increased production in the last six years and concentration in northern countries. Seven prevention methods were part of the study, with emphasis on pre-exposure prophylaxis, testing, condoms and behavioral strategies. The main topics discussed were stigma and support and care networks.

CONCLUSION

we notice that an increasing production on prevention in the men who have sex with men segment results from the emergence of multiple preventive methods and strategies and their combined actions beyond the star role of condoms.

Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare

Psychological therapy today plays a key role in UK public mental health. In large part, this has been through the development of the (specifically English) Improving Access to Psychological Therapies (IAPT) programme. Through IAPT, millions of citizens have encountered interventions such as cognitive behaviour therapy, largely for the treatment of depression and anxiety. This article interrogates how this national response to problems of mental ill-health - and the problematization itself - was developed, accounted for, and sustained. By imbricating economic expertise with accounts of mental ill-health and mechanisms of treatment, IAPT has revivified psychological framings of pathology and therapy. However, it has done so in ways that are more familiar within biomedical contexts (e.g. through recourse to randomized controlled trial studies). Today, the initiative is a principal player in relation to which other services are increasingly developed. Indeed, in many respects IAPT has transformed from content to context within UK public mental health (in a process of what I term 'contextification'). By documenting these developments, this paper contributes to re-centring questions about the place and role of psychology in contemporary healthcare. Doing so helps to complicate assumptions about the dominance of linear forms of (de)biomedicalization in health-systems.

A tale of two epidemics: gay men's mental health and the biomedicalisation of HIV prevention and care in Toronto

There is mounting urgency regarding the mental health of gay, bisexual and other men who have sex with men (GBM). We examined how GBM are understanding the relationship between HIV and their mental health given the increasing biomedicalisation of HIV prevention and care. Our Grounded Theory analysis derived from qualitative interviews with 24 GBM living in Toronto, Canada, including both HIV-negative and HIV-positive men. Participants understood biomedical advances, such as undetectable viral load and pre-exposure prophylaxis (PrEP), as providing some relief from HIV-related distress. However, they offered ambivalent perspectives on the biomedicalisation of HIV. Some considered non-HIV-specific stressors (e.g. unemployment, racial discrimination) more significant than HIV-related concerns. These men expressed HIV-related distress as being under control due to biomedical advances or as always negligible when compared to non-HIV-specific stressors. Others emphasised the ongoing mental health implications of HIV (e.g. enduring risk and stigma). We describe a tension between optimistic responses to biomedicine's ability to ease the psychosocial burdens associated with HIV and the inability for biomedicine to address the social and economic determinants driving the dual epidemics of HIV and mental distress amongst GBM. We argue for more socio-material analysis over further sexual behavioural analysis of GBM mental health disparities.

Community-Based Care in the ANRS-IPERGAY Trial: The Challenges of Combination Prevention

ANRS-IPERGAY was a community-based randomized trial investigating the efficacy of sexual activity-based HIV pre-exposure prophylaxis (PrEP) in a population of males and transgender females who had sex with men and were at high risk of HIV infection. We qualitatively analyzed the support provided to participants by community-based health workers (CBHW) throughout the trial's double-blind and open-label extension phases. In particular, we showed that the relationship between participants and CBHW strongly influenced self-managed pill intake. The delicate construction of this relationship, balanced between trust and dependence, played an important role in PrEP adherence. CBHW had to deal with various issues surrounding participants' feelings of empowerment regarding their role in the trial, as well as related tensions between various logics and rationalities. They were essential to participants' continued involvement.

Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men

Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52-59 years) and younger (18-25 years) generations endorsed positive views, compared with 32% of men in the middle (34-41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men's narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men's sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men.

What are the motivations and barriers to pre-exposure prophylaxis (PrEP) use among black men who have sex with men aged 18-45 in London? Results from a qualitative study

BACKGROUND

Black men who have sex with men (BMSM) have higher HIV incidence and prevalence when compared with other men who have sex with men, despite similar risk profiles. New prevention technologies, including pre-exposure prophylaxis (PrEP), may be effective in responding to these inequalities, provided they are appropriately targeted and acceptable to their intended beneficiaries. This study aims to understand the motivations and barriers of BMSM aged 18-45 to PrEP uptake.

METHODS

Twenty-five BMSM recruited through geolocation social networking apps took part in in-depth interviews between April and August 2016. Intersectionality theory was used as an organising principle. Interviews were transcribed verbatim and analysed using a thematic framework analysis.

RESULTS

For BMSM with heterogeneous social groups, discussions about sexual health were challenging because of the intersection of ethnic background, family history and religion. This limited conversations about PrEP to gay male friends who often held stigmatising views of condomless anal intercourse. BMSM reported exclusion from gay male spaces (online and offline) which could serve to restrict exposure to PrEP messages. Stereotypes of BMSM intersected with negative conceptions of PrEP users, limiting acknowledgement of PrEP candidacy. For those who had attempted to or successfully accessed it, PrEP was framed as a strategy to mitigate risk and to guard against further stigma associated with HIV infection.

DISCUSSION

BMSM operate within a complex set of circumstances related to the intersection of their sexual, ethnic, cultural and religious identities, which shape PrEP acceptability. Interventions which seek to facilitate uptake in this group must be attentive to these. Health promotion and clinical services could seek to facilitate nuanced discussions about the merits of PrEP for those at frequent risk, perhaps while also providing publicly visible PrEP role models for BMSM and other marginalised groups.

Is HIV prevention creating new biosocialities among gay men? Treatment as prevention and pre-exposure prophylaxis in Canada

The advancements of "treatment as prevention" (TasP), "undetectable viral load" (UVL) and "pre-exposure prophylaxis" (PrEP) are redefining HIV prevention standards. Relying on the concept of biosociality, this article explores how gay men rally around, debate, and sometimes disagree about these emerging HIV prevention technologies. This article is based on data from the Resonance Project, a Canadian community-based research project. Twelve focus groups (totalling 86 gay and bisexual men) were held in three Canadian cities (Montreal, Toronto, Vancouver) in 2013-2014. Respondents view UVL and PrEP through the prism of their generational experience of HIV prevention. In this respect, biosocialities highlight an experiential dimension that is tied to the context of the HIV epidemic. The biosocialities of HIV prevention are also built around serological identities. However, our study shows the diversity of these positions. Analysis grounded in biosocialities is useful for better understanding how scientific information circulates, is made sense of, and generates debate among gay men.

Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era

The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs - and bodies - were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.

"Is it making any difference?" A qualitative study examining the treatment-taking experiences of asymptomatic people living with HIV in the context of Treat-all in Eswatini

INTRODUCTION

Treat-all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat-all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat-all policy, including how they navigate treatment-taking over the longer term.

METHODS

A longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat-all pilot in Shiselweni, southern Eswatini. The Treat-all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment-taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub-sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11.

RESULTS

It was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment-taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re-interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment-taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment-taking.

CONCLUSIONS

These findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment-taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat-all care, with communication of suppressed results emphasized to patients.

Clinical exigencies, psychosocial realities: negotiating HIV pre-exposure prophylaxis beyond the cascade among gay, bisexual and other men who have sex with men in Canada

INTRODUCTION

Notwithstanding the efficacy of oral pre-exposure prophylaxis (PrEP) in clinical trials, a number of obstacles exist to achieving population-level impact among gay, bisexual and other men who have sex with men (GBM). However, few studies have explored the subjective experiences of GBM PrEP users and non-users in the community, outside of clinical trials. The objectives of this study were to explore GBM's experiences of considering, accessing and using (or not using) PrEP, and to understand emerging sexual health, social and community issues among GBM in the PrEP era.

METHODS

From October 2015 to March 2016, we purposively sampled PrEP-naïve and PrEP-experienced GBM from community organizations and health centres in Toronto, Canada. In-depth, 45- to 90-minute semi-structured interviews explored PrEP perspectives and decision-making, access, initiation, use over time, sexual practices and psychosocial considerations. Interviews were recorded, transcribed verbatim, uploaded into NVIVO, reviewed using thematic analysis and then contrasted with the PrEP cascade.

RESULTS

Participants included PrEP users (n = 15) and non-users (n = 14) (mean age = 36.7 years; SD = 8.2), largely gay-identified (86.2%), cisgender male (89.7%) and white (79.3%). Themes indicate not only correspondences, but also limitations of the PrEP cascade by complicating a user/non-user binary and challenging the unilateral presupposition that HIV risk perception leads to PrEP acceptance. Findings further call into question assumptions of a linear stage progression and retention in care as a universal endpoint, instead revealing alternate trajectories of seasonal or intermittent PrEP use and, for some, an end goal of terminating PrEP. GBM's narratives also revealed potent psychological/affective experiences of untethering sex from HIV anxiety; multifaceted PrEP stigma; and challenges to sexual norms and practices that complicate existing behavioural prevention strategies and sexual and social relationships.

CONCLUSIONS

An expanded PrEP cascade should consider alternate trajectories of use based on dynamic relationships and behavioural risks that may call for seasonal or intermittent use; systemic barriers in access to and sustaining PrEP; and multiple end goals including PrEP maintenance and discontinuation. Incorporating GBM's lived experiences, evolving preferences, and psychosocial and community-level challenges into PrEP implementation models, rather than a circumscribed biomedical approach, may more effectively support HIV prevention and GBM's broader sexual and psychological health.

Factors affecting the decision to initiate antiretroviral therapy in the era of treatment-as-prevention: synthesis of evidence from qualitative research in high-income settings

The emergence of treatment-as-prevention has made early initiation of antiretroviral treatment (ART) a "universal" policy. This review synthesizes qualitative research findings on barriers and facilitators of ART initiation in Organization for Economic Co-operation and Development (OECD) countries published since 2010. Ten articles describing seven research studies were included in the review. Findings confirmed ART initiation as a complicated process involving careful deliberation of the personal risks and benefits of treatment within the broader contexts of everyday life for people living with HIV (PLHIV). They also highlight interpersonal dynamics and concern for the public as increasingly important factors in shaping the decision to initiate treatment. The review provides valuable information for understanding treatment behaviour and maximizing treatment options brought forth by new biomedical advances.

DIY HIV prevention: Formative qualitative research with men who have sex with men who source PrEP outside of clinical trials

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to ‘DIY PrEP’, purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club.

'WTF is PrEP?': attitudes towards pre-exposure prophylaxis among men who have sex with men and transgender women in New York City

In the USA, gay and other men who have sex with men and transgender women are disproportionately affected by HIV. Uptake of pre-exposure prophylaxis (PrEP), anti-retroviral therapy to prevent HIV-negative individuals from seroconverting if exposed to HIV, by members of this population remains low, particularly among African-Americans. We conducted two focus groups to assess responses to an online social media campaign focusing on PrEP use in New York City. We designed, produced and disseminated the campaign to address knowledge of PrEP; its physical and psychological side effects; and psychosocial barriers related to PrEP adherence and sex shaming. Focus group participants demonstrated a relatively high knowledge of PrEP, although considerable concern remained about side effects, particularly among Black participants. Participants suggested that stigma against PrEP users was declining as PrEP use became more common, but stigma remained, particularly for those not using condoms. Many focus group participants reported distrust of medical providers and were critical of the commodification of HIV prevention by the pharmaceutical industry. Participants reported that those in romantic relationships confronted unique issues regarding PrEP, namely suspicions of infidelity. Finally, Black participants spoke of the need for more tailored and sensitive representations of Black gay men in future programmes and interventions.

'On December 1, 2015, sex changes. Forever': Pre-exposure prophylaxis and the pharmaceuticalisation of the neoliberal sexual subject

The global scale-up of AIDS treatment initiatives during the first decade of the twenty-first century has been referred to as a kind of 'pharmaceuticalisation' of public health, a trend that is now building in the area of HIV prevention. This paper traces the emergence and increased uptake of pre-exposure prophylaxis (PrEP), antiretroviral medications that can keep HIV negative individuals from becoming infected, placing it within the broader (re)casting of HIV prevention as a medical and technological problem that has been central to the recent 'end of AIDS' discourse. While HIV prevention discourses have been grounded in a neoliberal calculus of individual responsibility since the late 1990s, PrEP constitutes a pharmaceutical extension of the responsibilised sexual subject. Central to this extension are the acknowledgment of one's risk and a willingness to take pre-emptive medical action to secure a future without HIV. For men who have sex with men, a population heavily targeted for biomedical interventions in the United States, PrEP marks a shift in moral discourses of what it means to be a responsible sexual subject. Characteristics of the pharmaceutical extension of the neoliberal sexual subject are explored through an examination of a New York City-based PrEP promotional campaign.

Science, technology, power and sex: PrEP and HIV-positive gay men in Paris

The pre-exposure prophylaxis (PrEP) drug Truvada is a new HIV prevention technology that is predominantly promoted as relevant to HIV-negative gay men. This paper explores what PrEP represents for HIV-positive gay men living in Paris, based upon data collected through interviews and ethnographic research. While HIV-positive gay men do not directly consume Truvada through PrEP, they nonetheless hold opinions and understandings of this drug, specifically as it relates to their own sexuality. This paper expands the representations and meanings of this new technology in a different light through the voices of gay men living with HIV in Paris. The main argument of this article is that PrEP as an additional HIV prevention tool blurs the lines between science, technologies and human sexuality.

Risk, reassurance and routine: a qualitative study of narrative understandings of the potential for HIV self-testing among men who have sex with men in England

BACKGROUND

HIV testing has seen a rapid evolution over the last decade with multiple modalities now in use globally. In recent years HIV self-testing (HIVST) has been legalised in the UK paving the way for further expansion of testing. Interventions are delivered in particular social contexts which shape uptake. It is therefore important to understand how novel interventions are likely to be received by their intended users. This study aims to understand how HIVST compliments existing testing strategies considered or adopted by men who have sex with men (MSM). We do this by analysing normative discourses surrounding HIV testing and their perceptions of HIVST's potential future roles.

METHODS

Six focus group discussions (FGDs) were conducted with 47 MSM in London, Manchester and Plymouth. One focus group included only MSM who reported higher risk behaviours and one with those who had never tested for HIV. Data were analysed through a thematic framework analysis.

RESULTS

Three main narratives for testing for HIV were identified: (i) testing in response to a specific risk event; (ii) as reassurance when there was a small amount of doubt or anxiety related to HIV; and (iii) in response to social norms perpetuated through peers, HIV community groups and the medical establishment to test regularly for HIV. HIVST had limited utility for men when testing in response to specific risk events except in the case of significant structural barriers to other testing opportunities. HIVST was considered to have utility when seeking reassurance, and was thought to be very useful when testing to satisfy the needs and expectations of others around regular testing. There was some ambivalence about the incursion of a clinical intervention into the home.

CONCLUSIONS

HIVST following risk events will likely be limited to those for whom existing service provision is insufficient to meet immediate needs based on structural or personal barriers to testing. Obligations of biological citizenship are central to MSM's understanding of the utility of HIVST. In the context of discourses of biocitizenship, men perceive HIVST to have dual roles: firstly as a tool to manage (mild) anxiety around one's HIV status based on an acknowledgment of HIV vulnerability arising from being homosexually active. Secondly, HIVST is useful in complying with social norms and meeting the perceived demands of biomedicine.