“This is to help me move forward”: The role of PrEP in harnessing sex positivity and empowerment among Black Sexual Minority Men in the Southern United States

Abstract

In the United States (U.S.), Black sexual minority men (BSMM) are disproportionately burdened by HIV. Prevention advances, such as HIV pre-exposure prophylaxis (PrEP), play a key role in reducing HIV transmission and improving our understanding of sexual expression and health. Despite these advances, little is known regarding the potential link between PrEP use and positive sexuality, including the benefits that BSMM see in accessing PrEP. We conducted a thematic analysis of 32 interviews with BSMM in the Southern U.S. regarding their PrEP beliefs. We developed five themes: (1) Sexual freedom, (2) Agency and empowerment, (3) Making PrEP normative, (4) Behavioral health practices, and (5) Committed relationship tensions. Our findings suggest that BSMM are increasingly concerned about freedom of choice and invested in sexual empowerment as related to their PrEP use. Further, unanticipated benefits, community support, and relationship tensions are salient factors in considerations of PrEP use among BSMM. These findings have implications for how we might understand a broader movement toward sexual empowerment and positivity, and the pivotal role that PrEP serves in this movement.

Due in part to historical systematic oppression and current structural barriers in the United States (U.S.), Black sexual minority men (BSMM) are disproportionately burdened by HIV relative to their White and/or heterosexual counterparts (Cortopassi et al., 2019). These disparities are exacerbated for BSMM who live in the Southern U.S.—in the South, HIV infection rates are higher, while health care access and utilization are lower, compared to other regions of the U.S. (Adimora et al., 2014; Cortopassi et al., 2021). Over the last several decades, the disparity in HIV rates among BSMM has led to a proliferation of a substantial literature on HIV research, HIV interventions, and continued research on pre-exposure prophylaxis (PrEP) use and adherence (Pinto et al., 2019). Research has also attended to constructs related to HIV, such as public health policies (e.g., policies that make access to healthcare more difficult) or geographic region (e.g., reduced disparities in HIV risk between Black and White adolescents in the Western but not Southern U.S.; Adimora et al., 2014; Cortopassi et al., 2021; Saleska et al., 2021), as people experience sexual health disparities relative to their counterparts. This literature has continued to grow and in turn informed new approaches to prevention and treatment. The emergence of a new era of bio-behavioral prevention in the previous decade (Grov et al., 2021) has led to advances in our understanding of HIV risk, prevention, and treatment (e.g., treatment as prevention, TasP; Cortopassi et al., 2019). These bio-behavioral approaches have served to encourage a broader sexual health revolution (i.e., cultural shifts in perceptions of sex, sexuality, and sexual health; Herron, 2020; Mowlabocus, 2020) related to people’s experiences with PrEP (Grov et al., 2019). As our society continues to experience this sexual health revolution, in part characterized by sex positivity (i.e., perspectives that value greater sexual diversity, health, and equity) and empowerment (i.e., greater agency or self-efficacy related to one’s sexual health; Williams et al., 2015), the potential of PrEP to dramatically alter the rate of HIV transmission in the U.S. (Mowlabocus, 2020) is increasingly relevant. Recent work suggests that sex positivity, or positive sexuality, is one of several factors related to improved sexual well-being—which includes sexual equity and justice (Mitchell et al., 2021). Along with an individual’s self-efficacy to take control of their sexual health (i.e., sexual empowerment), sex positivity may have the potential to reduce HIV transmission (via PrEP uptake and adherence, for example).

Over time, our understanding of sexual identity and pleasure has shifted (e.g., greater social acceptance of various sexual minority identities or kinks; Hammack et al., 2013), and with the continued success of antiretroviral-based prevention, it is important to investigate the intersection of changes in sexual empowerment and sex positivity. Scholarship that focuses on barriers to initiation of HIV prevention strategies among BSMM continues to grow (Hammack et al., 2018; Herron, 2020)—such as access to care, mistrust of healthcare practitioners, financial concerns, and stigma (Mayer et al., 2020). However, substantially less work has focused on the peripheral ways in which PrEP might impact BSMM’s lives, namely the positive ways in which it might encourage or promote sexual pleasure (Boone & Bowleg, 2020). Strengths-based approaches have found links between greater engagement with healthcare providers and better coping skills in the face of HIV stigma (Puppo et al., 2020; Quinn et al., 2019b). Although there is increasing emphasis on investigating the experiences of BSMM, research is needed to further identify areas for intervention with an approach defined by positivity among BSMM (Boone & Bowleg, 2020). Thus, the goal of this study was to investigate beliefs and perceptions (i.e., narratives; Adler et al., 2017) of PrEP use as well as how these beliefs may inform experiences related to sexuality, sexual health, and sexual pleasure from a strengths-based perspective.

PrEP is a tool with substantial potential to disrupt HIV transmission and may also encourage greater sexual empowerment among PrEP users and their surrounding communities, particularly BSMM (Grov et al., 2021; Sun et al., 2019). As with many other treatment and prevention methods currently available, barriers such as stigma (Dubov et al., 2018) or erroneous assumptions of prevention behaviors (e.g., serosorting without accurate knowledge of one’s HIV status; Eaton et al., 2009) impact individual behavior which reduces the likelihood of accessing or adhering to PrEP (Mayer et al., 2020). These different psychosocial barriers to PrEP have been an ongoing point of focus in developing best practices to maximize the effectiveness of PrEP and PrEP interventions (Cortopassi et al., 2019). Although affordable access to PrEP and HIV testing are important and necessary tools in HIV prevention, understanding the psychosocial barriers to PrEP use and people’s perceptions of PrEP is also critical for ongoing research on HIV prevention.

Investigation of barriers to PrEP access among populations at elevated risk of HIV (e.g., BSMM, Southern U.S.; Adimora et al., 2014) is an important area of research in reducing HIV transmission. Further inquiry into people’s beliefs about PrEP and the reasons why they choose to uptake and maintain adherence to PrEP may also be beneficial for improving PrEP related outcomes (e.g., greater trust with medical providers; Quinn et al., 2020). For example, although substantial work has emphasized the bio-medical characteristics of PrEP (Serota et al., 2018), relatively less research has focused on potentially empowering perspectives related to PrEP use (Boone & Bowleg, 2020). The available literature, however, has shown promise and promotive outcomes (e.g., greater engagement with healthcare; Quinn et al., 2020). Thus, a stronger focus on people’s beliefs about PrEP and how PrEP impacts their lives beyond the immediate HIV preventive benefit will inform HIV prevention interventions with strengths-based approaches.

Aspects of identity and culture around sex positivity, such as associations with what it means to engage in condomless sex (e.g., identifying with the subculture of bareback sex; Brisson, 2019), has been shown to influence PrEP use or beliefs about PrEP in positive and negative ways often due to PrEP stigma (Mabire et al., 2019; Puppo et al., 2020). For example, qualitative research suggests that identifying as a person who uses PrEP helps sexual minority men (SMM) push back against PrEP stigma which likely increases PrEP adherence (Puppo et al., 2020). Other cultural beliefs, such as the degree to which an individual expresses skepticism to the description of undetectable equals untransmittable (i.e., U=U [a person living with HIV with an undetectable viral load will not transmit HIV to someone who is HIV negative]; Goodreau et al., 2021) also plays a role in people’s perceptions of PrEP. Specifically, some SMM express the view that taking PrEP is equivalent to engaging in U=U for HIV prevention (i.e., in the sense that regardless of HIV status, individuals are taking an antiretroviral to prevent HIV) which may influence an individual’s beliefs based on their potential stigma towards people living with HIV (e.g., not wanting to have sex with an individual living with HIV regardless of whether they are undetectable; Grace et al., 2021). PrEP can play a pivotal role in reducing HIV transmission, thereby encouraging a sexual revolution and broader movement toward sexual empowerment. However, negative perceptions of PrEP users and/or misinformed beliefs (Herron, 2020) have hampered this progress.

One substantial barrier to PrEP uptake or adherence (Dubov et al., 2018; Franks et al., 2018) is intersectional stigma. The compounding of negativity based on different identities may unduly burden and impact BSMM relative to their White or heterosexual counterparts (Cortopassi et al., 2019). These disparities can be understood through intersectionality theory (Crenshaw, 1993) which posits that intersecting identities form unique positive and negative experiences. Thus, intersectionality theory underscores the ways intersecting identities can lead to distinct forms of marginalization that do not occur among other groups which can dramatically increase or reduce ongoing disparities (Cole, 2009). BSMM then are likely to experience substantial marginalization as they navigate racism and homophobia (Bowleg, 2021).

The intersectional marginalization and oppression that BSMM experience is likely further amplified in the Southern U.S. given a greater lack of public health resources relative to other regions of the U.S. (Adimora et al., 2014). Substantial research has investigated associations between various forms of stigma and sexual health outcomes. In particular, scholars have focused on the ways that individuals living with HIV may have higher levels of internalized stigma (Earnshaw et al., 2021). The extant literature has also found that, relative to their White or heterosexual counterparts, BSMM are at elevated risk for contracting HIV, have fewer resources and less access to care (Calabrese et al., 2021; Cortopassi et al., 2021). Further, research indicates that BSMM report lower awareness of PrEP and uptake of PrEP relative to their White or heterosexual counterparts (Mayer et al., 2020). Recent work does suggest that sex positivity as well as positive perceptions of PrEP may help to curb stigma and negative health outcomes (Curley et al., 2022). This may make interventions that promote sex positivity and PrEP important areas of interest to reducing HIV transmission rates (Calabrese et al., 2021; Mitchell et al., 2021). Thus, investigation of BSMM’s attitudes toward PrEP as it pertains to its intended purpose and potential tangential benefits is warranted.

Narratives of identity and sexuality

Research has found that positive identity narratives among BSMM are associated with promotive health outcomes such as greater sexual health practices (e.g., testing for sexually transmitted infections more regularly or more often) or adherence to PrEP (Whitfield et al., 2019). That is, believing in one’s own agency or feeling empowered to have the freedom to choose sexual partners (e.g., not needing to be concerned with HIV transmission risk) may be associated with promotive health outcomes. People who identify strongly with being a person that uses PrEP also report that PrEP encourages partners to communicate and address any lingering tensions within one’s relationship (Sun et al., 2019). In turn, narratives of one’s life course, particularly related to identity such as sexuality, race, (Hammack et al., 2009; Hammack & Toolis, 2015), or even PrEP-related narratives, are important areas of interest for further investigation. Understanding the narratives of those who hold multiple marginalized identities, such as BSMM, can provide a greater clarity of the relationship of PrEP in people’s lives (e.g., understanding motivating factors for PrEP initiation; Mabire et al., 2019). This clarity can help to develop interventions to encourage promotive outcomes. Thus, in addition to calls for research on sexual pleasure and sexual equity among BSMM (Boone & Bowleg, 2020), research on the positive and negative experiences of PrEP use among BSMM as a holistic and strengths-based approach is warranted. Our study aimed to contribute to this growing literature by investigating the impact of PrEP on BSMM beyond its intended purpose of reducing HIV transmission using a qualitative approach.

Method

Design

This qualitative study investigates the positive and negative perceptions and beliefs about PrEP and PrEP use among BSMM in the Southeastern U.S. Using interview data, we investigated how participants came to develop narratives, or beliefs and attitudes, about their sexuality and PrEP as well as the role that PrEP plays in their health and communities. Primarily, we sought to understand how PrEP impacts the health of BSMM beyond the primary purpose of HIV prevention with a particular focus on sexual health including sexual freedom.

Procedure

Participants were invited to be part of an interview-based study involving BSMM to inform the development of interventions focused on PrEP uptake and use. Eligible individuals were Black/African American, assigned male at birth, 18 years or older, and had prior male sex partners in the previous six months. Participants did not need to be current or past PrEP users to be eligible to participate. Participants were recruited through targeted social media advertisements (e.g., Facebook and Instagram) and through participant referral. Advertisements featured images of diverse models and text that included a brief description of the study. Participants called into the study or filled out a brief contact form and subsequently study staff screened participants for eligibility. Additionally, recruitment was restricted to a large city in the Southeastern U.S. and surrounding regions as the Southern U.S. has disproportionately higher rates of HIV relative to other areas of the U.S. Following consent, semi-structured interviews were conducted by the fourth and seventh authors and other study personnel and transcribed by a third-party service. Interviews focused on participants’ experiences with PrEP use, healthcare systems, stigma, attitudes toward HIV, how best to provide PrEP services (e.g., asking how to increase HIV testing rates among BSMM), and how their sexual expression has changed over time. Interviews lasted for approximately 40 to 50 minutes.

Participants

Participants were 32 BSMM (M_age = 31.94) and were currently living in the Southeastern U.S. One participant was living with HIV, nine participants were current PrEP users, and five participants had previously used PrEP, with the other seventeen participants having never used PrEP (see Table 1 for additional description of participants). All participants resided in Atlanta, GA or surrounding cities and data were collected between February and April of 2019. The University of Connecticut Institutional Review Board approved this study.

Table 1.

Participant characteristics

Name	PrEP status	Age
Eric	Current PrEP user	Did not report
Darnell	Never used PrEP	47
Jay	Never used PrEP	28
Marcus	Current PrEP user	39
Cameron	Never used PrEP	27
Randall	Past PrEP user	26
Isiah	Past PrEP user	29
Terryl1	Past PrEP user	27
Kasim	Current PrEP user	34
Matthew	Never used PrEP	20
Owen	Past PrEP user	48
Andre	Current PrEP user	25
Xavier	Current PrEP user	29
Avery	Never used PrEP	34
Dominic	Never used PrEP	27
Liam	Current PrEP user	46
Kevin	Current PrEP user	25
Zahir	Current PrEP user	52
Jesse	Current PrEP user	32
Trey	Never used PrEP	33
Mason	Past PrEP user	32
Terrance	Past PrEP user	25
Derreck	Never used PrEP	39
Orion	Never used PrEP	31
Emmett	Never used PrEP	29
Jamal	Current PrEP user	28
Dimitri	Past PrEP user	35
Quinn	Never used PrEP	36
Reymond	Never used PrEP	33
Elijah	Never used PrEP	23
Jeremy	Never used PrEP	34
Miles	Never used PrEP	29

Note. All participant names are pseudonyms.

¹Although study participants self-reported an HIV negative status to enroll, during the interview Terryl reported that he was living with HIV.

Thematic analysis

Our thematic analysis was largely informed by a coding reliability approach, with some aspects of a reflexive approach throughout the analytic process (Braun & Clarke, 2021a). The first author conducted initial open coding of data (e.g., emphasizing short, meaningful phrases to represent developing themes; Braun & Clarke, 2006) following a familiarization process of reading through all transcribed interviews (Campbell et al., 2021). Through this process, and informed by our research question, one theme was anticipated and generated by the first author, specifically a theme indicative of positive perspectives on sex and sexuality (i.e., related to sex positivity). Following this step, two additional coders (in conjunction with the first author) began independently coding for initial evidence of our first theme (i.e., sex positivity) and developing themes independent of other coders’ perspectives. Coders read and analyzed the entirety of the interviews. One question in the interview guide served as a focal point in developing initial themes: “Some people consider PrEP as part of a larger sexual revolution, paving the way for greater sexual expression, while some people see PrEP as a bit more problematic. What would you say your specific take is on PrEP?”.

Coders also generated initial themes following review of transcribed interviews. Refinement of themes and reconciliation of codes occurred in a group setting, until all interviews were analyzed. The three coders met weekly to resolve disagreements and refine themes until consensus was reached for the presence or absence of each developed theme (i.e., identifying additional evidence in support, or against, developed themes; Brod et al., 2009). Each week all coders read a set number of interviews and coded independently before meeting, resolving disagreements, and refining themes as part of this iterative process. Codes were representative of themes such that the presence or absence of a code (i.e., 1 or 0) was indicative of the theme itself being present. While coders may have initially disagreed upon the presence or absence of a theme, resolution of disagreements led to the refining of each theme.

Throughout this process, coders discussed the ways in which their backgrounds and perspectives might have impacted their coding approach, including a discussion of how they generated initial themes (Goldberg & Allen, 2015). These discussions ranged from the impact of minoritized or marginalized identities among coders (e.g., one coder identifying as a queer person of color), as well as the ideologies that they hold when conducting their research (e.g., informed by queer and feminist theories; Acosta, 2018; Fish & Russell, 2018). Additionally, while one of the coders grew up in the Southeast, no coder had the same background as the sample (i.e., BSMM and residing in the Southern United States). These discussions also emphasized that coders’ perspectives should be conceptualized as a resource to be relied on, rather than a negative bias that may hamper stable or high levels of agreement, or reliability. This process was informed by a reflexive approach, rather than coding reliability (Braun & Clarke, 2021a).

Results

Five themes were developed as a result of the research team’s coding which are presented in order of conceptual relevance to our research question (i.e., what is the impact of PrEP on BSMM beyond its intended purpose of reducing HIV transmission?): (1) Sexual freedom (2) Agency and empowerment; (3) Making PrEP normative; (4) Behavioral health practices; and (5) Committed relationship tensions (see Table 2 for additional theme descriptions).

Table 2.

Theme descriptions

Theme	Definition	Example	Exemplar Quote
Sexual freedom	References to increased sexual behavior as well as increased potential to have HIV+ partners	No longer concerned about HIV if someone is dating an HIV+ partner	“… I did see a spike in the number of sex partners I had… I was a little bit more carefree in terms of asking for a condom or asking for their most recent HIV status”
Agency and empowerment	Descriptions of how PrEP made participants feel more in control of their sexual health, or reduced negative emotions	Reduction in HIV anxiety	“It [taking PrEP] would make me more-a little more confident. And when I do like have situations, like I would be more confident that I won’t contract that particular disease”.
Making PrEP normative	References to already existing structures to improve community health through PrEP use	Describing PrEP in the form of a vaccine or comparing it to birth control	“I think it’s just like any other vaccination that people, that kids get when they’re growing up and you have to go to the doctor to get your shots. I think that’s something that, it should be introduced”
Behavioral health practices	Connections between general health behaviors and improvements as a result of PrEP use	Participant now takes their SSRIs regularly because PrEP is also taken regularly	“You know, because everybody is—you know, people’s brain[s] [are] trained to take vitamins, you know? It’s like, you know, we grew up with the One-A-Day, you know, the Flintstone gummies and things like that. So that’s already installed into the mind that that’s something that they need to take to better their health and their body”
Committed relationship tensions	References to how PrEP use served to exacerbate pre-existing tensions in committed relationships	A partner believes that PrEP use is a sign of infidelity	“Because he was afraid of transmitting it to his partner. So when his partner found out that I was taking it, his partner was really, really, really interested in it. And so that sort of was like, oh great. You know, now you’re going to turn my husband into a whore as well”

Sexual freedom

The first theme developed from participants’ narratives was Sexual freedom. The theme Sexual freedom emphasized participants’ belief that they now had the hypothetical option of having more sex or additional sexual partners, regardless of their ability to do so. Thus, Sexual freedom was broadly characterized by perceptions of increased sexual behavior and potential sexual partners. For example, Randall (past PrEP user, HIV negative, 26 years old) noted positive experiences that he recalled when he previously used PrEP. Specifically, he enjoyed PrEP because “it will also be able to knock the barriers down for if I am in a relationship and they do want to use-- without using condoms. It’ll be easier for me to actually go into that realm and actually do that...”.

Randall continued to describe that an important benefit of PrEP meant that he (and others) would, from their perspective, have the choice to pursue relationships with people who are living with HIV. Randall stated that “I feel like it’s a great pill to take, especially if you’re in a relationship with someone who is HIV positive. They could definitely stop it so your partner won’t be able to get the virus, as well.” However, and a minority perspective within this sample, some participants noted caution when acknowledging this greater potential for sexual freedom. For example, Terryl (never used PrEP, HIV positive, 27 years old) felt that:

Basically taking PrEP yes, it is the beginning of a revolution because it stops HIV and stuff. However, it doesn’t stop every disease. So it’s not like, oh, I’m on PrEP. I can have all types of sex. And that’s why people say it’s problematic. Because some people feel like because they’re on PrEP, they can have unprotected sex.

From Terryl’s perspective, while freedom of choice was an important step forward in reducing HIV transmission, it may also lead to an increase in other sexually transmitted infections (STI). Thus, while Sexual freedom as a theme was generally defined as an important and positive experience, some participants expressed skepticism or concerns. Specifically, the acknowledgement that PrEP may lead to negative health outcomes emerged among descriptions of freedom of choice, as noted by Terryl above. Fifteen out of thirty-two (47%) participants described experiences that were characteristic of the theme Sexual freedom.

Agency and empowerment

The second theme developed from participant narratives was Agency and empowerment. In this theme, participants described how PrEP use increased their agency surrounding who they chose as sexual partners, and made them feel empowered and confident when engaging in sexual behaviors. Agency and empowerment were also unique in that it emphasized one’s self-efficacy and subsequent benefits following a change in behaviors. self-efficacy and ability to change behaviors. For example, Owen (past PrEP user, HIV negative, 48 years old) noted that access to PrEP “made me feel very hope[ful], and that I could actually have a productive – a responsible sex life…”. In this instance, Owen was already aware that he had the choice to change his behaviors, but PrEP access provided him with the confidence and belief that he had the ability to make these changes in his life.

Not all participants explicitly referenced greater agency as it pertained to their sexuality. Agency and empowerment was also indicated by the reduction of discomfort or anxieties that participants experienced during sex, such as the discomfort to ask about their partners’ HIV status or whether they choose to have sex at all. From the perspective of participants, reduction of discomfort was also associated with an increase in psychological well-being such as greater confidence or self-esteem. However, it is also relevant to note that a small number of participants who endorsed Agency and empowerment acknowledged that it initially reduced their inhibitions and resulted in greater risk. Pointedly, this outcome was often followed by participants later taking control of their sexual health. For example, Marcus (current PrEP user, HIV negative, 39 years old) noted that access to PrEP dramatically reduced the anxiety that he experienced related to potentially contracting HIV. He states that “once I was able to get a prescription for it myself, I did. And in the sense that it was a godsend for me, it alleviated so much of that concern and worry that I had about contracting HIV.” While Marcus felt empowered, he was also one of a small number of participants who had reduced inhibitions which resulted in negative consequences. This experience ultimately encouraged him to take control of his life and sexual health. When describing the importance of PrEP and its strengths and drawbacks, Marcus noted:

It’s also, you know, a double-edged sword, I will be honest and say that it has, at times, made me more risqué than I would have been otherwise. Like, you know, just an anecdote from my own personal life-- not too long after I started taking PrEP, it was pride celebration in Atlanta. And because I was on PrEP, I went out to a club, a sex club. And had a lot of sex with a lot of men that I had never seen before in my life. And I just felt like, well, I can’t contract HIV, knowing that there are other things that I could contract, but then also telling myself, yeah, well most of those other things can be handled with an antibiotic.

Marcus later states “after that [the sexual glamor of PrEP] wore off, I was like, OK, well that was dumb. That was stupid. And that night, I did contract gonorrhea. So that gave me a wakeup call and was like, OK. All right.” As described, once Marcus became accustomed to PrEP and the ‘sexual glamor’ of PrEP use wore off, he was able to seek STI treatment and learned to take greater control of his sexual health.

Finally, participants also reported that the empowerment granted through PrEP use encouraged them to explore their own sexuality and sexual identity. Thus, Agency and empowerment was characterized by aspects of improved mental health, harm reduction (e.g., reduced discomfort or anxiety), and identity exploration, regardless of the potential risks that may be involved in their sex lives. Sexual freedom and Agency and empowerment both included references to having partners living with HIV. Importantly, Sexual freedom provided individuals with perceived freedom of choice whereas Agency and empowerment was akin to an increase in psychological well-being while having a partner who was living with HIV. Further, while Sexual freedom was indicative of freedom of choice, Agency and empowerment was reflective of the participant’s perceived self-efficacy to follow through with choices and life changes (such as PrEP uptake). Agency and empowerment was represented by twenty-four of the thirty-two participants (75%).

Making PrEP normative

The third theme developed, Making PrEP normative, was characterized by the ways in which PrEP use or considerations of PrEP use changed their views of others. That is, by developing norms around who used PrEP, participants in turn had more positive associations with PrEP itself, and some participants noted how they believed that PrEP users were more health-conscious or proactive than those who did not use PrEP. For example, although Cameron (never used PrEP, HIV negative, 27 years old) was unable to access PrEP due to a variety of barriers, such as experiences of stigma, he did note that PrEP use would be the ideal situation for him and others in his life. Cameron states “that should really be the bigger picture. Everybody should be looking at taking any minute. Your health is important. This is to help me move forward. This is to help me keep my energy and do all the things I’ve been doing” when he describes his interest in having regular PrEP access for all people. From Cameron’s perspective, increasing PrEP uptake by removing barriers to care would allow him and others to live their fullest lives while maintaining their sexual health. That is, PrEP was not solely a medication to prevent HIV but also a medication to help him take control of his sexual health.

Participants also described how PrEP could be integrated into society. Structures and processes already in place, such as requiring conversations about PrEP in regular doctor’s visits, were especially salient. Eric (current PrEP user, HIV negative¹) stated “I think it’s just like any other vaccination that people, that kids get when they’re growing up and you have to go to the doctor to get your shots. I think that’s something that, it should be introduced” when asked how he thinks PrEP access could be expanded. In addition to integration into doctor’s visits, other participants reported that equitable and reasonable access was also needed. For example, when describing the potential for equitable access to PrEP to create a normative experience Isiah noted (past PrEP user, HIV negative, 29 years old):

It’s just like, we need one, like, the big bombs to just like break all the blocks, even [if] it’s just like, the [standard process of PrEP access] have a doctor outside, you know, let’s get this lab work done, let’s get our labs done, let’s do this, let’s do that. Let’s get you started. Because I used to like, if – man, if, everybody could just get one sample of the prescription, of course you’re going to have those side effects at first, you’re going to have those that might not like it, but I do believe the majority of the people, like, the majority of society will actually roll with it, especially in the community, they’ll definitely go with it, they’ll be on it. You know, because, I mean, who doesn’t want to live?

During the interview, Isiah explained that prior to moving to a different state for work, he did have access to PrEP. However, once relocating the process of PrEP access became so difficult due to time, procedure, or administrative delays out his control, that he no longer was able to use PrEP. In effect, Isiah suggested a ‘one stop shop’ for PrEP access in that all the steps needed to receive PrEP could be done in the same day, or same space. A ‘one stop shop’ by Isiah’s design would allow for the removal of unnecessary delays in healthcare and provide more efficient access to PrEP. This third theme, which emphasized the integration of PrEP into normative society, was referenced by twenty of thirty-two (63%) participants.

Behavioral health practices

The fourth theme, Behavioral health practices, was characterized by how participants wove PrEP into their daily schedules in the context of health practices, such as taking PrEP during their morning routines. That is, Behavioral health practices was dependent on changes in individual behavior rather than freedom of choice (i.e., Sexual freedom), greater confidence (i.e., Agency and empowerment), or structural changes in PrEP access (i.e., Making PrEP normative). There were also narratives that reflected different ways of thinking about PrEP (e.g., conceptualizing PrEP as a daily vitamin) or as an opportunity to develop a healthy routine. Although he chose not to use PrEP because he was not sexually active and did not know enough about PrEP, Dominic (never used PrEP, HIV negative, 27 years old) discussed the need to reframe his own perception of PrEP. Dominic also acknowledged that this reframing would impact his individual behavior and that this would potentially increase future adherence. Specifically, Dominic described how thinking of PrEP as a vitamin, rather than HIV-specific would likely increase his PrEP adherence if he were to uptake PrEP:

You know, people’s brains [are] trained to take vitamins, you know? It’s like, we grew up with the One-A-Day, you know, the Flintstone gummies and things like that. So that’s already installed into [the] mind that that’s something that they need to take to better their health and their body.

Kevin (current PrEP user, HIV negative, 25 years old), like Dominic, also noted reframing his own perceptions of PrEP as vitamins and how he integrated PrEP into his daily routine. Kevin noted that being able to link different individual behaviors to encourage PrEP uptake was “kind of like arithmetic. So what I did was I started connecting that [taking PrEP] to things that I do every day. So in the morning, I brush my teeth, so therefore, my medicine is right there so I can take my medicine.” While only a minor change in his own behavior, this change ultimately led to an increase in PrEP adherence.

Participants also noted that the regimen of taking PrEP daily and required blood tests encouraged them to develop habits to improve their health more broadly. Although these tests are already part of using PrEP, the increased engagement with the healthcare system is what encouraged him to care more about their general health. For example, Andre (current PrEP user, HIV negative, 25 years old) noted that taking PrEP improved his health and interpersonal relationships because he felt more health conscious and was more comfortable discussing sexual preferences:

I guess it [PrEP] just made me be more conscious and more aware of my status in general, and just about my health overall. Because I go over the blood pressure and they tell you if anything has changed with your body. So I think it has made me more health conscious since I started taking PrEP and just have more open conversations about the types of sex I have and the type of sex I enjoy, and just different ways and makes me be safer doing those things if I’m going to do them.

Behavioral health practices was represented by cognitive reframing to improve future PrEP uptake (e.g., Dominic’s perception of PrEP) as well as broader health benefits as a result of PrEP adherence. While Making PrEP normative was characterized by references to structural changes or increasing PrEP access to anyone who may be eligible, Behavioral health practices was distinct in that it characterized participants’ individual behaviors. For example, vaccine engagement as noted in Making PrEP normative is a structural change as only healthcare professionals can administer vaccines compared to vitamins as they are dependent on individual behavior. Seventeen of thirty-two (53%) of participants reported experiences that characterized the theme of Behavioral health practices.

Committed relationship tensions

The fifth, and final, theme Committed relationship tensions was characterized by how PrEP use might uncover or exacerbate underlying issues that are present in an individual’s committed relationship causing relationship difficulties. Participants often noted that using PrEP—or even showing interest in PrEP—when one was already in a relationship may be perceived as a lack of commitment. In other instances, PrEP use (or interest) was perceived as a sign of (potential) infidelity, even when individuals were in sexually open relationships. Marcus described a particularly negative experience when he suggested that PrEP may support his friend’s relationship as he was living with HIV and his partner was not living with HIV:

And he was married. And I think a lot of it was that he was concerned – he was married in an open relationship. And his husband frequently sought sex outside of their marriage because this particular friend, who I later found out was HIV positive, was afraid to have sex with his husband because he was HIV positive. Even though he was taking the medications and was undetectable, it had killed their sex life… Because he was afraid of transmitting it to his partner. So, when his partner found out that I was taking it, his partner was really, really, really interested in [PrEP]. And so that sort of was like, oh great. You know, now you’re going to turn my husband into a whore as well…

From Marcus’ perspective, PrEP would allow for his friend and his friend’s husband to have sex comfortably which in turn would improve their relationship, but this was not well received. Other participants also noted how PrEP could lead to the dissolution of a relationship (or be a driving factor), if the relationship was already not working. That is, PrEP had the potential of exacerbating ongoing tensions that were the result of HIV stigma. For example, Darnell (never used PrEP, HIV negative, 47 years old) described how he views some couples, reflecting his broader perceptions of one of the reasons why HIV negative SMM enter a relationship with one another:

A lot of couples stay together because of the fact that both of them are HIV-negative and they don’t want to catch anything. But if they’ve got PrEP at their disposal, they’re not going to be thinking on that that way any longer… I think they would be more likely to cheat. I mean, if you’re going to cheat… you’re more likely to do it if you know you’ve got PrEP at your disposal

Darnell’s acknowledgement that the relationship dissolution or tension was not due to PrEP itself, rather the possibility of infidelity that was already present in relationships, was an important characteristic of how participants described Committed relationship tensions.

Although few participants referenced Committed relationship tensions as part of their perceptions of PrEP use, acknowledgment of relationship tensions was salient to these participants. This saliency led to the perception of relationship difficulties as a major barrier to PrEP uptake for others or themselves. At the same time, others such as Randall acknowledged that PrEP use could also serve as a way of reducing tensions and anxieties as they pertain to infidelity. Randall described how his previous partner encouraged him (along with the partner) to uptake PrEP as a means of ensuring fidelity within their relationship. Specifically, Randall noted that “yeah. Basically, if you start using condoms you think I’m out here doing something else, or [expletive] with somebody else or probably got something”. In this way, condom use became a sign of infidelity, from the partner’s perspective as the use of condoms indicated a need to prevent the transmission of STIs. Three of thirty-two participant narratives (9%) were characterized as Committed relationship tensions either in their own or peers’ relationships due to PrEP use or interest in PrEP.

Discussion

Our findings from a thematic analysis of interviews with BSMM in the Southeastern U.S., represent a step forward in understanding PrEP-related narratives. Our developed themes suggest that PrEP users are increasingly concerned about sexual empowerment, in addition to the benefits of PrEP as an HIV risk reduction tool. Future research must consider the ever-changing cultural landscape of how people make decisions surrounding their sexual health needs, sexual equity, and freedom of choice (Boone & Bowleg, 2020).

Our first theme, Sexual freedom, was characterized by participants who reported the belief that once one begins PrEP that they will engage in more sex. Pointedly, this theme centered around one’s belief that they would have freedom of choice, regardless of the choice they ultimately made around their sexual behavior. Previous work has found that some SMM report concerns regarding engaging in sex with individuals who are living with HIV regardless of PrEP status, which is likely a product of PrEP and HIV related stigmas (Grace et al., 2021). Our findings may suggest that PrEP can serve as a tool to reduce PrEP and HIV stigma if interventions can utilize the sex positivity that emerges with PrEP use.

Past literature also notes that how sexual behavior is assessed changes PrEP users’ interpretations of their experiences in research, with the theme of Sexual freedom being no exception (Grov et al., 2021). That is, participants’ sexuality and sexual health in this theme was represented by changes in perceptions of choice related to how participants had sex and who they had sex with (e.g., engaging in condomless sex with a partner who is living with HIV without risk of transmission). Further, acknowledgement of increased sexual well-being as a method of improving public health is growing (Mitchell et al., 2021). Freedom of choice as a distinct experience from other aspects of sex positivity can further our understanding of how sex positivity can improve public health as it pertains to HIV- and PrEP-related outcomes. Thus, future research should attend to the reasons why individuals may choose to change their behavior when using PrEP and whether changes in sexual behavior apply to multiple or a subset of partners (Grov et al., 2021).

For many participants, experiences that characterized the theme Agency and empowerment were especially salient. That is, in addition to preventing HIV transmission, using PrEP provided participants with a greater sense of Agency and empowerment over their sexuality and sexual health. Agency and empowerment was also characterized by decreases in anxiety and more frequent harm reduction behaviors as they relate to sexual health (Whitfield et al., 2019) as well as increases in well-being. From participants’ perspectives, PrEP use gave them a greater sense of control over their sexual health and the confidence to talk more pointedly about HIV and STI status with their potential partners. In this way, Agency and empowerment reflects the previous literature on SMM’s experiences with PrEP (Quinn et al., 2020).

As with our theme, Sexual freedom, we find that one’s self-efficacy around engaging in sex (e.g., sexual position) is intimately tied to the way in which risk reduction is managed among BSMM. Thus, empowering potential PrEP users and noting unanticipated benefits to PrEP use (Quinn et al., 2020) may be one way in which to further support an ongoing movement toward sexual positivity. Separating beliefs about choice (i.e., Sexual freedom) and one’s perceived self-efficacy to make informed decisions about one’s sexual health (i.e., Agency and empowerment) are also important contributions. While PrEP may be widely available in some contexts, if an individual doesn’t believe they are capable of overcoming barriers to care then PrEP uptake will stagnate. Thus, future research should investigate gaps in the link between PrEP awareness, PrEP access, and ultimately PrEP uptake among BSMM. It may be that promotion of self-efficacy, rather than promotion of choice, as it pertains to sexual health, will have a stronger impact on encouraging PrEP uptake and adherence.

Past quantitative work has found that sexual esteem or satisfaction does not change based on PrEP use (Whitfield et al., 2019); however, our findings suggest additional interpretation may be needed in this area. One possibility is that aspects of agency or empowerment are related to psychological well-being, but may not overlap with the ways in which sexual satisfaction is associated with well-being (Boone & Bowleg, 2020; Grov et al., 2019). For example, our theme of Agency and empowerment pointedly focuses on the importance of vulnerability and self-efficacy whereas assessments of sexual pleasure or behavior may not capture this experience (Whitfield et al., 2019). Thus, our work suggests that there are additional nuances within this area of research and that complexities of sexuality, sexual pleasure, or sexual empowerment are not fully understood (Mitchell et al., 2021). Future research should investigate these distinctions as previous findings suggest that sexual pleasure does play a role in PrEP use, adherence, and uptake (Mabire et al., 2019).

Although a small number of participants believed that their PrEP use led to poor decision making early on in their experiences with PrEP, this was generally followed by the participant exerting greater positive control over their sexual health. While some research suggests that PrEP use may lead to increased STI transmission (Powell et al., 2019), the psychological (e.g., reduced anxiety, greater confidence) and health benefits outweigh this potential risk from the perspective of participants. Broadly, our theme of Agency and empowerment indicates that solely focusing on inequities obscures the possibility to change our understanding of sexual pleasure and sexuality on a societal scale (Boone & Bowleg, 2020; Mitchell et al., 2021). Given BSMM’s experiences with the healthcare system, research has overwhelmingly focused on experiences of stigma surrounding PrEP use and access (Dubov et al., 2018). However, emphasizing how PrEP can provide people with greater self-efficacy can also be a tool to combat future stigma. The potential for a sexual revolution does not necessarily indicate that all people’s experiences are uniformly good. Rather the act of learning and developing one’s own relationship to sexual behavior (e.g., having a deeper understanding of STI risk) within communities (Cortopassi et al., 2019) is an ongoing process indicative of sexual empowerment and positivity.

Making PrEP normative was characterized by the ways in which participants felt that PrEP use could be expanded to protect their community. One approach through which participants believed PrEP use could be expanded was to integrate PrEP access into existing structures such as including discussions of PrEP in annual doctor’s visits. Importantly, community as defined by participants ranged from loved ones or their surrounding community upward to entire demographic groups (e.g., all SMM or all sexually active people). That is, beliefs about PrEP became a prosocial narrative about improving the health and well-being of as many people as possible, rather than solely benefiting one group. This furthers the conversation on the ways in which sex positivity and normalizing PrEP as an indicator of positive health (in addition to its intended use) can impact public health more broadly (Curley et al., 2022; Mitchell et al., 2021). For participants, normalizing PrEP meant that proactively caring for one’s sexual health before it was needed (i.e., prevention over treatment) were pre-requisites to, rather than representative of, a hypothetical sexual revolution. Fundamentally, Making PrEP normative was developed from participants’ desire to imagine a world that is not hindered by health risks posed by under supported sexual health programs in the U.S.

The theme Behavioral health practices was defined by the ways in which secondary aspects of being a PrEP user benefited participants. Like many other daily medications, PrEP served the role of helping people regulate their lives to be more consistent and health conscious. Past research has shown that some individuals develop an identity around PrEP use, which may be a promotive factor (e.g., better coping strategies when experiencing HIV stigma; Puppo et al., 2020). Endorsement of Behavioral health practices may be one path through which individuals later come to join these developing communities. Thus, the potential for sex positive experiences or narratives driven by PrEP use may also be part of a broader movement toward sexual ‘self-care’ as a form of empowerment. While society has increasingly discussed aspects of self-care in the context of mental health broadly, these findings suggest that including discussions of sexual health (and PrEP use) is also needed (Wood et al., 2019).

Committed relationship tensions was especially salient to the few participants whose experiences characterized this theme. Pointedly, no participants noted that PrEP use itself would lead to any problems within a relationship, rather to some people PrEP is believed to be a symbol of potential infidelity. For example, one participant described how two men in a committed relationship chose to not have sex with one another due to risk of HIV (as one of the men was living with HIV). PrEP use was perceived as something that would lead to infidelity rather than allowing the relationship to thrive by covering unmet sexual needs. Conversations surrounding PrEP use, for this couple, become a discussion of relationship concerns and seldom ever focused on PrEP itself. However, the relationship ruptures associated with PrEP may also provide an opportunity to advance one’s understanding of their own sexuality and relationships (Grace et al., 2021)—that is, the loss of one form of relationship may in turn lead to the development of a new kind of relationship with the same (i.e., developing a supportive friendship) or another intimate partner (Farr et al., 2020).

Ideally, conversations about PrEP could also lead to the development of a stronger and deeper intimate relationship with the same partner. Specifically, a relationship that is indicative of sex positivity, the reduction of PrEP stigma, and, in turn, representative of sexual empowerment. Participants who described these relationship tensions, or ruptures, often acknowledged that the perceived cost of PrEP (i.e., stigmatizing perceptions of PrEP) was not worth the potential benefit (i.e., HIV risk reduction) that PrEP might bring. Thus, future research should investigate barriers to PrEP that may be associated with PrEP stigma within the context of already existing relationships as they may be important areas for intervention. Interventions that focus on relationship improvement may be sparse, identification of this area of concern furthers our understanding of how BSMM perceive PrEP and PrEP use.

Although the overall goal of PrEP use is to reduce HIV transmission, the impact of PrEP on people and society broadly, extends beyond HIV. PrEP use and adherence, and people’s beliefs about these behaviors, informs our understanding of sex, sexuality, and sexual health in people’s everyday lives (Boone & Bowleg, 2020; Quinn et al., 2020). This work can further inform relevant HIV intervention research through differentiation of sexual choice and self-efficacy, normalization of PrEP, promotive health practices, and reduction of relationship tensions. However, it also challenges future research to investigate the ways in which the pursuit of a promotive narrative of sexual health or pleasure may in turn lead to positive health outcomes among BSMM. Thus, the themes presented here indicate that although navigating difficult conversations among BSMM do emerge, the predominant narratives surrounding PrEP are ultimately impactful and positive for people.

An important consideration to our findings is that approximately half of the sample reported never having used PrEP, and only one participant reported living with HIV. There is likely a distinction in attitudes toward PrEP and sex positivity between people living with HIV and people who are not living with HIV, given differing experiences of stigmatization. Although this difference was not apparent when developing themes, this may be because there was only one participant who was living with HIV in our sample. History of PrEP use may also have contributed to the development of our themes. For example, Behavioral health practices was in part characterized by changes in health that were not explicitly related to PrEP use. Thus, for those who have never used PrEP, understanding the tangential benefits of PrEP may not be salient to their considerations of PrEP uptake. Future research should investigate the ways in which HIV status, history of PrEP use, and experiences of stigmatization shape people’s attitudes toward PrEP and sex positivity.

These findings can also be understood within the context of a broader HIV and PrEP stigma framework (Calabrese, 2020; Cortopassi et al., 2019; Pinto et al., 2019) that focuses on PrEP acceptability, uptake, and adherence (Holt et al., 2019). An emphasis on changing perceptions of PrEP to become more normative (as represented by our theme Making PrEP normative), may also reduce negative attitudes toward PrEP and encourage greater PrEP acceptability. Further, themes such as Sexual freedom and Agency and empowerment indicate that stakeholders should continue advertising PrEP as a medication that provides freedom of choice and greater self-efficacy related to one’s sexual health. Acknowledging that there are multiple benefits to PrEP may increase PrEP uptake as individuals weigh the trade-offs of PrEP uptake. If PrEP is perceived as more valuable because of these additional promotive benefits, then individuals may also be more likely to seek out and begin taking PrEP. This perspective may encourage individuals who are able to remove barriers to PrEP access but are still ambivalent about PrEP uptake.

Our theme of Behavioral health practices also suggests that describing PrEP as being promotive of general health, may lead to greater PrEP adherence. As adherence plays a crucial role in reducing HIV transmission rates, highlighting the ways in which PrEP can easily be integrated into one’s daily habits may be necessary (Pantalone et al., 2020; Pinto et al., 2019). Our theme of Committed relationship tensions however, indicates that PrEP stigma is still a major concern. These tensions may serve as a particularly difficult barrier to overcome as it is largely interpersonal. If one’s partner is the main barrier to PrEP, then PrEP uptake is likely to be low. Taken together, although PrEP acceptability, uptake, and adherence have all improved over time, these are all still areas of concern and targets for interventions (Holt et al., 2019; Pantalone et al., 2020).

Despite the strengths of this study, there are some limitations to consider. To begin, the focus of the interviews was initially designed to inform an intervention study. Thus, the interview did not explicitly target ways in which PrEP use and sexuality intersect in participants’ daily lives. We acknowledge that there may be other narratives of PrEP use that are not represented in this study. Our sample was also restricted in a number of ways. This sample consisted of individuals regardless of PrEP use status, reported not living with HIV, and were in the Southeastern U.S. Restricting samples to only include those who are living with HIV or only PrEP users may provide a greater understanding how BSMM perceive HIV and PrEP. Further, these findings may not be representative of others who live in the Southeastern U.S. particularly as they relate to the diversity of attitudes toward PrEP among BSMM.

Conclusion

This study highlighted five distinct thematic experiences among BSMM related to their beliefs about or use of PrEP, which contributes to the current literature on PrEP research in several ways. These findings indicate a need to differentiate between aspects of freedom of choice and self-efficacy as it pertains to sexual health. Further, this work indicates potential contradictions between quantitative and qualitative research that should be further investigated (e.g., Whitfield et al., 2019). The developed themes also provide information on the unanticipated benefits of PrEP that BSMM experience. Finally, these findings pinpoint areas of relationship tensions, or ruptures, that may occur among SMM who are considering the potential costs (e.g., tensions within relationships) and benefits (e.g., HIV risk reduction) of PrEP use. These considerations could be important areas for strengths-based interventions (e.g., PrEP use makes a relationship stronger; Quinn et al., 2020) and encourage greater PrEP use. These contributions to the scientific literature further our understanding of PrEP as well as an ongoing cultural movement toward greater sex positivity and empowerment among BSMM.