Two new studies from Toronto have concluded that despite PrEP users having an “overwhelmingly positive” experience, reports NAM’s AIDS Map, the stigma associated with PrEP has kept many young gay men from practicing it further.
PrEP is the practice of a daily pill, Truvada, that when taking once a day can prevent an HIV-negative person from contracting HIV. But since it was approved by the U.S. Food and Drug Administration in 2012, it's been wrongly associated with promiscuous condomless sex, labeling users as "Truvada Whores."
The first study, published in Anthropology & Medicine, included fieldwork from researcher Julien Brisson of the University of Montreal, whereby he did in-depth interviews with 10 young gay men in a gay neighborhood in Toronto through interactions at gyms, social events, and other meetings. Brisson’s research was conducted in 2014, before PrEP was approved by Canadian regulators in February 2016, notes NAM’s AIDS Map.
Overall, Brisson reports that these men were well-informed about HIV prevention, including the practice of PrEP. He writes that all of them claimed to not have condomless sex. In fact, many of them said it was “bad” or “reckless” behavior, and associated it to problems with depression, self-esteem, or drug use.
However, one 25-year-old man in particular, noted Brisson, said during his meeting (where other men were present) that he disapproved of condomless sex, but in a private interview with Brisson, he later shared he in fact does engage in condomless sex.
“I do get tested regularly, and I’m aware of the transmission risks of HIV,” the man added to Brisson. “I’m not aware of the exact numbers, but I know, even if the person is HIV-positive and on ART and I’m the top [insertive partner], which I generally am, the risk is very low for me.”
After interviewing more men, Brisson realized many others shared the sentiments of the 25-year-old man, and over the course of his fieldwork, Brisson reported, none of them were interested in practicing PrEP, though they supported other men who do.
“PrEP embodies the idea of ‘HIV prevention,’ which is attached to virtuous qualities, and PrEP simultaneously represents the idea of bareback sex, which has traditionally been saturated with problematic elements,” Brisson reports, adding, “It is quite clear that the young gay men in this research do not want to be associated as a barebacking subject. This is one reason why they did not want to use PrEP.”
A second study, published in AIDS Patient Care and STDs, led by researcher Daniel Grace of the University of Toronto, was conducted over a year later with a different group of gay men who were practicing PrEP. In Canada, they’d be considered “early adopters,” notes NAM’s AIDS Map.
Grace’s interviews consisted of 16 gay men, mainly white and nearly all were college educated. Collectively, Grace reports that all men claimed to consistently manage other people’s assumptions about why they practiced PrEP. Some described it as being in a “PrEP closet” among family and friends because of an idea people have that PrEP always choose to have condomless sex.
“I don't disclose that I am on PrEP to most family and most friends,” one man told Grace. “That's maybe because I am married and I have kids, so for his [husband's] sake, I am not really, we are not open—fully open that we're open if you know what I mean. So I mean I should be able to be, but I don't think we're there yet. So I wouldn't say that I feel ashamed for it but I definitely have to hide it.”
The same man also shared that it’s hard to even disclose his PrEP use among sexual partners. The assumption is that while he might be protected from HIV, wider engagement of condomless sex could lead to other STIs: “One of the regulars that I had previous to going on PrEP decided to stop doing me because he assumed that I would instantly become like a receptacle for every gay plague known to man. So I mean that was kind of an uncomfortable conversation, but I was not ashamed about it.”
Overall, Grace says his respondents had pride in practicing PrEP, and have used their practice to challenge stigma. “Sex isn't meant to be something you're ashamed of or fearful of. It's meant to be enjoyable and PrEP has made sex enjoyable for me, which is fantastic,” one man said.
“These accounts of PrEP use help to shed light on broader stigmas and moral panics around sex and sexuality,” concluded Grace. “Successfully advocating for broader PrEP access requires that societal and structural stigma surrounding gay sexuality be addressed head on.” He added, “Some men said that PrEP use both led them to experience stigmatizing reactions within their social and sexual networks, while also helping to remove stigma, shame, and fear related to HIV, sexuality, and sex with gay men living with HIV.”