A desire for lower-risk, condomless sex was the predominant
driver of PrEP use among the respondents. Most had sought out PrEP because they
had a history of inconsistent condom use (or no condom use) and recognised that
this pattern was unlikely to change, regardless of their intentions, as this
man explained:
“It’s the best choice
for the behaviour that I know is my behaviour … While I’m not always safe, I
certainly always want to stay HIV-negative.”
Many men expressed an aversion to condoms. They complained
of reduced physical sensation, less spontaneity, erectile dysfunction and a
loss of intimacy.
While most men felt that PrEP alone provided strong
protection against HIV, they also recognised that unlike condoms, PrEP does not
offer protection against other sexually transmitted infections. Some men
described selectively using condoms based on their perceptions of partners,
while other men saw being exposed to other sexually transmitted infections as
an acceptable risk.
“There are times when
I think to myself, ‘Well, even though I’m on PrEP, maybe I shouldn’t have
unprotected sex because I might catch something else.’ But there’s another part
of me that says, ‘Well, those aren’t so terminal. If I got those, I could
easily just get them cleared.’”
By lowering HIV risk and offering a more acceptable form of
HIV prevention than condoms, PrEP helped participants lessen feelings of
vulnerability, fear, and shame associated with pre-existing sexual behaviours.
Men described the anxiety they had felt about sex before using PrEP and the stress
this placed on their mental and emotional wellbeing.
“I had done the best
that I could and I still just felt like there was no winning, like every day
was a constant battle against this invisible thing that lives in our blood and
kills us. And I felt powerless. And it wasn’t just when I got tested. It wasn’t
just when I had sex. It was six days after I had sex. It was, ‘Should I have
done that? Should I have not?’”
Despite these intense feelings, they typically had not resulted
in sustained changes to sexual behaviour. Instead men tended to feel more shame
and self-judgement about their sexual lives. Moreover, they often led men to
become fatalistic about the likelihood of acquiring HIV. The man quoted in the
previous paragraph continued:
“I’d gotten to a point
where I was having sex almost with resignation of the fact that I was probably
eventually just going to get HIV. Like, it was just gonna have to happen
because the alternative is not to be intimate with anybody.”
Taking PrEP allowed men to experience their sexuality in new
ways. The interviewee who had the greatest experience of PrEP in the sample (19
months of PrEP use) described it in these terms:
“Being a gay
man—especially one as promiscuous as I am—there was always a very real
possibility of seroconverting. And so, while PrEP may not be 100 percent
effective, it’s still very effective. And being able to live without that
stress and fear was very liberating.”
Many men described how using PrEP helped them improve their
sense of self-efficacy. They saw their use of PrEP as empowering and proactive,
in contrast to previous experiences of constrained agency.
“I’d say it’s affected
me pretty profoundly. There are very few situations where I find myself feeling
like a victim anymore… I don’t feel like anything’s being done to me from the
outside that I’m not choosing to let happen.”
The lessening of shame and anxiety led to more satisfying
sexual encounters.
“In the past, when I
was having these condomless episodes with people, there was a bunch of
excitement and great physical feeling, but at the same time I was having this
internal turmoil and horrible feeling about what I was doing… Now on Truvada there’s at least the opportunity for me to
quiet some of that really fearful conversation that’s going on through my head,
and feel more connected and good about what I’m doing.”
Men saw PrEP as ‘sexually liberating’ in the sense that it
enabled them to explore sexual desires they had previously suppressed. For
many, PrEP allowed them to enjoy being the receptive partner.
“That’s something that
I never thought I would do and I never thought I could do without fear… Because
I’m on PrEP, allowing myself to bottom became an option. And then once I did, I
was like, ‘Okay, I actually like that!’”
Others talked about how they could now imagine themselves having
relationships with HIV-positive men. At the same time, men who had been in
long-established relationships with HIV-positive men talked about how PrEP had improved
sexual satisfaction by providing peace of mind and allowing the couple to stop
using condoms.
“[My partner] felt
obligated to protect me and to do everything in his power to make sure that he
didn’t transmit an infection to me. And while there still is a possibility,
that fear is gone. And it has improved our sexual relations, our intimacy, and
I think it’s had a positive influence on our relationship together.”
Alongside these positive effects, the interviewees also
experienced or worried about being stigmatised for their use of PrEP.
“Talking online with
other people that are cruising online websites and you tell them you’re on
PrEP, there was somewhat of that shaming, ‘Oh, you’re on PrEP, you must be a
slut. You must be irresponsible. You must be making really bad choices to think
you need to be on this.’”
There was evidence in a few mens’ accounts of this
stigma being internalised, with some expressions of shame, regret and internal
conflict in relation to their sexual behaviour while on PrEP. Stigma was also
experienced in healthcare settings, with men feeling judged by staff for using
or requesting PrEP. Doctors’ insistence that condoms should be used together
with PrEP was often felt to be impractical and paternalistic, and led some men
to misrepresent their condom use to their doctor.