Some gay and bisexual men see PrEP as a 'social problem'

Gay and bisexual men have differing attitudes towards men who are using pre-exposure prophylaxis (PrEP), according to US research published in Sociology of Health & Illness. A series of focus groups conducted in New York City showed that some men regarded PrEP users as immoral, irresponsible, naïve and vectors of disease.

In contrast, other men saw PrEP as a beneficial new option for preventing the spread of HIV. They had a nuanced view about the effectiveness of condom-based prevention campaigns and the epidemiology of sexually transmitted infections (STIs) among gay and bisexual men.

“By framing PrEP use as enabling gay and bisexual men to violate subcultural norms of sexual etiquette espoused in previous HIV prevention efforts, claims makers were able to present PrEP users as social problem villains,” write the authors. “Countering claims makers’ framing PrEP as a social problem, some men constructed PrEP as a helpful prevention tool in the fight against the HIV epidemic within gay and bisexual communities. Much of their discourse was couched within a harm reduction model in which PrEP medication is framed as significantly reducing the harm associated with engaging in risky sexual behavior.”

The use of emtricitabine/tenofovir (Truvada) as PrEP was approved in the US in 2012. Studies have shown that, with good adherence, it can reduce the risk of infection with HIV by almost 100%. While an estimated 25% of HIV-negative gay and bisexual men in the US would benefit from PrEP, uptake has faced significant barriers, including knowledge, access and affordability.

Moreover, the integration of PrEP within existing HIV prevention efforts based on behaviour change – especially consistent condom use – has encountered some moral challenges, much of which is related to the stigma associated with sexual promiscuity and “bareback” sex (unprotected anal intercourse with non-primary partners).

Investigators from the City University of New York wanted to make sense of the moral debates surrounding PrEP among gay and bisexual men, especially the extent to which PrEP has been constructed as a 'social problem'. They designed a study based on five focus groups, in which 32 gay and bisexual men were invited to share their views about PrEP, in late 2015 and early 2016. PrEP was not mentioned in recruitment advertising as the investigators wished to avoid only attracting men with very strong opinions about it. The focus groups lasted approximately 45 minutes each.

Participants had an average age of 35 years. Most (n = 28) self-identified as gay and eleven were HIV positive.

Overall, the men had a good awareness of PrEP. Many reported seeing adverts, discussion of PrEP on social media or said they had heard of PrEP from friends.

However, not all the participants discussed PrEP accurately. One participant believed that it was a lifetime commitment, while another believed that if you stopped taking PrEP and subsequently became infected with HIV the virus would be resistant to antiretrovirals because of previous exposure to medication.

Some of the men constructed PrEP as a social problem: its users were seen as promiscuous, irresponsible, immoral and naïve. By and large, these individuals believed that uptake of PrEP was undermining use of condoms and that PrEP users were responsible for ongoing epidemics of STIs among gay and bisexual men, as illustrated by these quotes from the focus groups:

"It’s just giving people a free pass. That’s how they take PrEP. They take it as a free pass to go just willy-nilly and do whatever the hell it is they want to do."

“And they think they can run to the clinic to go get that short [of antibiotics].”

PrEP users were framed as irresponsible “barebackers,” with some participants expressing moral indignation at the perceived sexual irresponsibility of PrEP users, who they characterised as licentious, irresponsible and vectors of disease.

“It’s kind of given people a license not to protect themselves, because 'Now I can just take this magical pill and I’m gonna be alright'.”

“Most of the people I know that are on PrEP they forget that there are a lot of STDs out there, and that’s the biggest mistake.”

There were also clear notions of “deserving” and “undeserving” PrEP users. Men in relationships with an HIV-positive partner fell into the former category. In contrast, concern was expressed about the use of PrEP by younger gay and bisexual men. Some participants believed that younger men seeking PrEP should “be educated thoroughly,” that there “should be mental health screening” and that “it has to be made harder to get the pill.”

Despite this, a number of other men viewed PrEP as a beneficial new option for preventing the spread of HIV. Their attitude was pragmatic:

“I think it’s bad to be judgemental... I think it’s a great method just to prevent the disease.”

They also argued that moral judgements about PrEP and its users erected unnecessary barriers to the control of the HIV epidemic. Some men pointed out that condom-based behaviour change HIV prevention campaigns had failed to halt the continued spread of HIV among gay and bisexual men.

The role of PrEP in the epidemiology of STIs was also questioned, with one man noting there was a well-established syphilis outbreak among gay and bisexual men years before PrEP was approved.

“By studying the construction of PrEP as a social problem, we were able to highlight how gay and bisexual men define what they consider appropriate ways to prevent the spread of HIV,” conclude the authors. “Public health organisations that design and disseminate HIV prevention messaging should strive to construct more inclusive definitions of sexual health practices in ways that seek to combat the stigma currently associated with those who make use of other preventions methods besides condoms.”

Pawson M et al. ‘It’s just an excuse to slut around’: gay and bisexual mens’ construction of HIV pre-exposure prophylaxis (PrEP) as a social problem. Sociology of Health & Illness, online edition, doi: 10.1111/1467-9566.12765, 2018.