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

Sex exceptionalism and erasure in porn health protocols

Porn production, like all forms of labour, entails certain occupational health and safety (OHS) risks. Porn production has generally not been subject to state occupational health oversight, and porn workers have instead implemented self-regulatory OHS systems. However, in California, where the industry is most established, governmental and non-governmental bodies have made several paternalist attempts to legislate standardised OHS protocols. Their proposed legislation exceptionalises sex work as uniquely dangerous while failing to tailor guidance to the specific needs of and practices associated with porn work. This is largely because: 1) regulators are ignorant of porn's self-regulatory processes; 2) industry self-regulation conceptualises the occupational hazard on porn sets as infectious bodily fluids, whereas external regulators perceive the hazard as sex itself; and 3) regulators devalue porn work and so do not take the viability of the labour into account when evaluating protocol effectiveness. Using critical-interpretive medical anthropology involving fieldwork and interviews with porn workers and a critical analysis of porn OHS texts, I argue that porn health protocols should be left to industry self-determination, to be developed by porn workers rather than for them.

Cultural discourses and HIV/AIDS activists' meanings about PrEP

Since the approval of pre-exposure prophylaxis (PrEP) for HIV prevention in 2012, research has increasingly considered how communities of men who have sex with men make sense of this prevention technology, often highlighting individual-level attitudes about PrEP. Drawing on interviews with 16 HIV activists, this study aimed to determine how activists make sense of advances in HIV prevention technology. Participants' sense-making about PrEP took the form of not merely the expression of individual attitudes, but rather reflections connected to their personal biographies and activist experience. Activists sustain seemingly contradictory discourses about PrEP, at once drawing on personal biographies and a discourse central to activist history to express scepticism about PrEP, but also other discourses to justify pharmaceutical intervention for prevention. Study findings provide evidence of the importance of attending to past and present cultural discourses when examining health advocacy groups' constructions of advances in science.

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.

Identifying Patterns of Discontinuing and Recommencing Pre-exposure Prophylaxis in the Context of Sexual Behavior Among Gay and Bisexual Men in Australia

We mapped gay and bisexual men's (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

Understanding how PrEP is made successful: Implementation science needs an evidence-making approach

After a decade of oral HIV pre-exposure prophylaxis (PrEP), the next generation of PrEP is being anticipated, including long-acting pills, injections, and implants. The unevenness of international PrEP implementation is increasingly recognised, with successful rollout in some settings and failure in others. There is a need to better understand conditions of PrEP implementation, and its localised (and sometimes unanticipated) effects. Implementation science explores how contexts and health systems shape the successful translation of health interventions. In this essay, we consider how PrEP is evolving and argue for an 'evidence-making' approach in relation to evidence and intervention translations. This approach emphasises how both interventions and their implementation contexts are co-constituted and evolve together. Unsettling the assumed universality of an intervention's effects and potential in relation to its implementation contexts helps to harness the localised possibilities for what PrEP might become. As the next generation of PrEP offers renewed promise, we must explore how PrEP is put to use and made to work in relation to its evolving situations. We urge implementation science to consider implementation processes as 'evidence-making events' in which evidence, intervention and context evolve together.

Clinician imaginaries of HIV PrEP users in and beyond the gay community in Australia

Through the development and implementation of HIV pre-exposure prophylaxis (PrEP), the characteristics of PrEP users have been configured in a range of ways. Drawing on the concept of 'imaginaries', we consider how clinicians imagine PrEP users and related communities. We conducted 28 semi-structured interviews in 2019-2020 with PrEP-providing clinicians based in New South Wales and Western Australia. Participants included general practitioners, sexual health nurses and sexual health doctors. We inductively developed three themes through a reflexive thematic analysis: 'PrEP users as 99% gay men/MSM', 'The informed and connected PrEP user', and 'Condom users in the PrEP era'. Participants imagined PrEP users primarily as gay men, and so we focused on how gay community was imagined in relation to PrEP users. Users were imagined as supporting one another to use PrEP effectively, but some were imagined as threatening norms of condom use amongst gay community. Analysing clinician imaginaries of PrEP users reveals insight into how clinicians speculate about and engage with changing community norms related to condom use and accessing PrEP. These imaginaries reveal ongoing tensions about who is believed to be best suited to PrEP, and PrEP's impact on norms of conduct in imagined biosocial communities like gay men.

Pleasure and PrEP: A Systematic Review of Studies Examining Pleasure, Sexual Satisfaction, and PrEP

Pre-exposure prophylaxis (PrEP) is an effective form of Human Immunodeficiency Virus (HIV) prevention for people at potential risk for exposure. Despite its demonstrated efficacy, PrEP uptake and adherence have been discouraging, especially among groups most vulnerable to HIV transmission. A primary message to persons who are at elevated risk for HIV has been to focus on risk reduction, sexual risk behaviors, and continued condom use, rarely capitalizing on the positive impact on sexuality, intimacy, and relationships that PrEP affords. This systematic review synthesizes the findings and themes from 16 quantitative, qualitative, and mixed methods studies examining PrEP motivations and outcomes focused on sexual satisfaction, sexual pleasure, sexual quality, and sexual intimacy. Significant themes emerged around PrEP as increasing emotional intimacy, closeness, and connectedness; PrEP as increasing sexual options and opportunities; PrEP as removing barriers to physical closeness and physical pleasure; and PrEP as reducing sexual anxiety and fears. It is argued that positive sexual pleasure motivations should be integrated into messaging to encourage PrEP uptake and adherence, as well as to destigmatize sexual pleasure and sexual activities of MSM.

"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.

'PrEP is like an adult using floaties': meanings and new identities of PrEP among a niche sample of gay men

PrEP, pre-exposure prophylaxis, is a novel HIV prevention strategy. Highly efficacious, its development and delivery has caused significant debate. This paper explores the ways in which PrEP is signified and some of the new identities it gives rise to through the analysis of PrEP discourses among 'bugchasers'. Bugchasers comprise a niche group of gay men who eroticise HIV and fantasise with or seek to get infected. The research explores how bugchasers negatively conceptualise PrEP as a barrier to thrill and masculinity and discusses PrEP as a positive intervention that allows them to understand their own desires for risk-taking. Finally, it addresses a new identity position, the 'poz pleaser' who identifies as a bugchaser yet uses PrEP. Findings link to current debates about PrEP meanings and signification by using bugchasing as a niche yet illustrative example of how men make sense of this intervention based on their existing frameworks. Discussion highlights how this helps us understand how people make sense of biomedical interventions, the importance of emotional 'side effects', and the development of new identity positions. In so doing, it advances existing work on PrEP signification and contributes to ongoing debates about bugchasing.

Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and "Undetectable = Untransmittable": A Systematic Review

People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression.

Review was pre-registered at PROSPERO: CRD42020153725

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.

Merging care and prevention: preventive properties of antiretroviral drugs and HIV chronification in the case of Switzerland

Medication is closely involved in the subjective experience of chronic diseases, but also in the chronification process of illnesses which is described in this paper in the specific case of HIV. The development of antiretroviral drugs (ARVs) and the progressive recognition of their potential dual use as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) reshape the experience of HIV and its transmission. Acknowledging the importance of a socioanthropological approach to drugs, this paper highlights how therapeutic strategies of treatment and prevention currently shape the process of HIV chronification and its experience for people concerned with ARVs in Switzerland, whether they are seropositive patients on lifelong treatment or seronegative people affected by the preventive properties of drugs.

How Has HIV Pre-Exposure Prophylaxis (PrEP) Changed Sex? A Review of Research in a New Era of Bio-behavioral HIV Prevention

In 2012, the U.S. FDA approved the first drug for use as HIV Pre-Exposure Prophylaxis (PrEP), which is nearly 99% effective when taken as prescribed. Although the manifest function of PrEP is to prevent HIV infection in the event of exposure, the drug has also had a significant impact on various facets of sexuality. In this review, we focus on research that emerged in the near decade since PrEP's approval, with a specific focus on the ways in which different elements of sex and sexuality have been impacted by gay, bisexual, and other men who have sex with men (GBMSM), cisgender women, and transgender individuals. We highlight evidence showing how PrEP has enhanced sexual self-esteem, improved sexual pleasure, reduced sexual anxiety, and has increased sexual agency for those taking it. For many, PrEP also serves as a gateway to improve routine health and increase sexual health-care utilization. Additionally, we review the question of whether PrEP is associated with increased sexual risk taking (i.e. risk compensation), and note that, although some data are mixed, PrEP is not intended as an intervention to reduce condomless anal sex or STIs: it aims to prevent HIV. Finally, our review highlights that, although the volume of research on PrEP among GBMSM is robust, it is underdeveloped for cisgender women and transgender populations and insufficient for inclusion in such a review for cisgender heterosexual men was. PrEP research with these populations is an important direction for future research. Finally, from 2012 to 2019, a single PrEP formulation and delivery method was FDA approved (oral emtricitabine/tenofovir disoproxil fumarate). As additional drug formulations (ie.g., emtricitabine/tenofovir alafenamide) and delivery methods (e.g., microbiocides, vaginal ring, injectable) come to market, it will be important to examine how these, too, impact the spectrum of sexuality.

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.

It's in Me to Give: Canadian Gay, Bisexual, and Queer Men's Willingness to Donate Blood If Eligible Despite Feelings of Policy Discrimination

Blood donation policies governing men who have sex with men have shifted significantly over time in Canada-from an initial lifetime ban in the wake of the AIDS crisis to successive phases of time-based deferment requiring periods of sexual abstinence (5 years to 1 year to 3 months). We interviewed 39 HIV-negative gay, bisexual, queer, and other sexual minority men (GBM) in Vancouver, Toronto, and Montreal to understand their willingness to donate blood if eligible. Transcripts were coded following inductive thematic analysis. We found interrelated and competing expressions of biological and sexual citizenship. Most participants said they were "safe"/"low risk" and "willing" donors and would gain satisfaction and civic pride from donation. Conversely, a smaller group neither prioritized the collectivizing biological citizenship goals associated with expanding blood donation access nor saw this as part of sexual citizenship priorities. Considerable repair work is required by Canada's blood operators to build trust with diverse GBM communities.

Gay and Bisexual Men's Perceptions of Pre-exposure Prophylaxis (PrEP) in a Context of High Accessibility: An Australian Qualitative Study

We report on Australian gay and bisexual men's (GBM) perceptions of preexposure prophylaxis (PrEP). Drawing on an online longitudinal cohort study, 1,404 free-text responses from HIV-negative or untested Australian GBM were qualitatively analysed. The chi-square statistic was then used to assess differences regarding PrEP-perceptions by participants' demographic and behavioral characteristics. Positive views of PrEP were twice more common than negative. Those with positive views thought PrEP helped overcome HIV fear and anxiety, enhanced sexual pleasure, and was a 'socially responsible' course of action. Those with negative views believed that people without medical conditions did not need medication and expressed concern that PrEP was replacing condoms, representing 'dangerous' behavior. Descriptive statistics revealed differences in PrEP-perceptions relating to age, recency of HIV testing, and PrEP eligibility. This study is the first to use free-text data to examine the frequency of Australian GBM's PrEP-perceptions, highlighting the potential benefits and challenges to its promotion.

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.

"Not a walking piece of meat with disease": meanings of becoming undetectable among HIV-positive gay, bisexual and other men who have sex with men in the U = U era

Gay, bisexual and other men who have sex with men (GBMSM) represent a key population disproportionately affected by HIV in various settings. While past studies have investigated how individuals negotiated their identities following their diagnoses of HIV, an emerging area of inquiry considers the implications of viral suppression, or becoming undetectable, on identity and well-being in an undetectable = untransmittable (U = U) era. We conducted 24 in-depth interviews with a purposively recruited sample of GBMSM living with HIV in Singapore. Interviews were analyzed through inductive thematic analysis. Participants viewed viral suppression as a clinical objective, and contrasted this with becoming undetectable as an identity and aspiration. Many participants saw becoming undetectable as a turning point for them post-diagnosis, and expressed a sense of achievement upon attaining the status. Participants shared that being undetectable was associated with several positive outcomes in coming to terms with their HIV-positive diagnoses that signified achievements in health, personal and social responsibilities, as well as equity in romantic and sexual relationships. The results of this study highlight the importance of becoming undetectable and its potential impact on the quality of life for GBMSM living with HIV.