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

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.”

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
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.”