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. Author manuscript; available in PMC: 2019 Jul 1.
Published in final edited form as: Med Anthropol. 2018 Jan 19;37(5):387–400. doi: 10.1080/01459740.2017.1416608

BODY/SELVES AND BEYOND: MEN’S NARRATIVES OF SEXUAL BEHAVIOR ON PrEP

Shana D Hughes 1, Nicolas Sheon 1, Erin V W Andrew 2, Stephanie E Cohen 2, Susanne Doblecki-Lewis 3, Albert Y Liu 2
PMCID: PMC6136979  NIHMSID: NIHMS1500618  PMID: 29257911

Abstract

Although pre-exposure prophylaxis (PrEP) has dramatically impacted HIV prevention, deep engagement with PrEP-takers’ own accounts of their sexual behavior is still rare. We report findings from semi-structured interviews with male participants of the US PrEP Demonstration Project. In their narratives, interviewees variously foregrounded their individual selves, interactions with sexual partners, and the biopolitical and historical context of their lives. PrEP served to discursively integrate the multiple selves populating these stories. We argue that medical anthropological notions can help make sense of men’s accounts, and PrEP’s role in them, advancing a holistic conception of personhood that includes but transcends concern with HIV.

Keywords: Pre-exposure prophylaxis (PrEP), MSM, sexual behavior, risk, HIV prevention, US

Pre-exposure prophylaxis (PrEP) has dramatically impacted HIV prevention. In 2012, the US Food and Drug Administration approved daily dosing with Truvada™, a pill that combines the antiretroviral medications (ART) tenofovir and emtricitabine, for HIV PrEP. It is highly effective when taken as prescribed (Baeten et al. 2012; Grant et al. 2010), though breakthrough cases have been documented (Knox et al. 2016). Clinical efficacy, however, is not the only reason for PrEP’s noteworthiness; it has also ignited controversy over potential unintended outcomes. In particular, much interest surrounds the question of whether PrEP use triggers “risk compensation,” or an increase in behaviors that could expose those engaging in them to HIV (Hogben and Liddon 2008; Blumenthal and Haubrich 2014; Curran and Crosby 2013). Findings from research on observed or predicted changes in behavior associated with PrEP have been mixed (Brooks et al. 2012; McCormack et al. 2016; Grov et al. 2015; Marcus et al. 2013; Golub et al. 2010; Liu et al. 2013; Mitchell et al. 2016). Available evidence suggests that, while some behavior change may take place, it is unlikely to be sufficient to counteract the protection PrEP offers against HIV (Carnegie et al. 2015; Volk et al. 2015).

This growing body of work is pioneering and important. However, our current knowledge about the behavior of people taking PrEP is slightly reminiscent of Sobo’s (1997:68) description of the literature on “people with AIDS” from the 1990s; we know “how many [research subjects] do what and with whom and how often. But the complex subjective (and intersubjective) reasons motivating the numbers reported often remain unexamined.” Fortuitously, anthropologists and like-minded scholars had begun by then to examine the interplay of behavior, meaning, and structure that led individuals to acquire HIV (e.g. Farmer 1992; Singer 1994; Glick Schiller, Crystal, and Lewellen 1994; Brummelhuis and Herdt 1995). Over time, such analyses grew in both quantity and nuance, often focusing on how various axes of inequality intersected with (necessarily cultural) notions of identity and belonging (e.g., Biehl 2007; Hirsch et al. 2006; Davis 2008). Prominent threads of this work engage directly with stigmatized behaviors (Davis and Flowers 2011; Carballo-Dieguez et al. 2011; Dowsett et al. 2008; Rhodes et al. 2012; Syvertsen et al. 2015), highlighting that actions posing HIV transmission risk may also serve other social and psychological needs, such as intimacy and pleasure. To paraphrase Wikan, avoiding infection may not be the most compelling concern, even when that risk “looms large in a person’s life” (2000:218). In short, anthropological engagement with the dynamism and polysemy of sexual “risk behavior” long predates PrEP (Moyer 2015).

The burgeoning literature on PrEP, however, comes primarily from public health and has not typically engaged with such perspectives. Prevailing biomedical discourse often constructs “sex on PrEP” primarily in terms of HIV prevention, risk, and individual choice. From within such a frame, attending to intimacy (Gamarel and Golub 2015) and varying meanings of sexual behavior (Golub 2014) can seem groundbreaking, though this may strike anthropologists as obvious.

Ethnographic approaches in multiple contexts have documented widespread lack of awareness of PrEP (DiStefano 2016), and structural and sociocultural barriers to its uptake (e.g., Garcia et al. 2015; Syvertsen et al. 2014; van der Straten et al. 2014). Other forms of qualitative inquiry have documented PrEP-related stigma and uncertainty existing alongside perceptions of valuable potential benefits (Collins, McMahan, and Stekler 2017; Jaspal, Daramilas, and Lee 2016; Schwartz and Grimm 2017; Koester et al. 2017). Still, relatively few studies situate PrEP users’ own narratives of their sexual practice and decision-making within the biographical, social, and historical trajectories in which they are produced.

That is what we strive to achieve in this article, drawing on data from qualitative exit interviews with participants of the US PrEP Demonstration Project (hereafter, the Demo Project). We focus on men’s narratives of sexual behavior before, during, and after taking PrEP, aiming to engage with the meanings embedded in such stories more deeply than possible through other methods.

METHODS

In this article, we report results from a qualitative sub-study of an open-label multi-site PrEP demonstration project. The parent study included 557 HIV-uninfected men who have sex with men (MSM) and transgender women in San Francisco, CA, Miami, FL, and Washington DC. HIV incidence was low despite high incidence of sexually transmitted infections (STIs); indices of risk behavior declined or remained stable (see Cohen et al. 2015; Liu et al. 2016). The objective of the exit interviews was to understand participants’ experiences and perceptions of the Demo Project, and help develop ways to support PrEP use in real world settings. Participants from the San Francisco (SF) and Miami sites1 who spoke English or Spanish and consented to be contacted were eligible for exit interviews, which took place at least six months after participants’ last study appointment. These sites were selected for the demographic diversity of their participants, which facilitated purposive sampling based on race/ethnicity and reporting PrEP-related social benefits or social harms. We initiated study recruitment for 58 participants, of whom 32 (15 SF, 17 MI) were interviewed.2 Of the remainder, 17 were unresponsive, seven did not complete scheduled interviews, one declined, and one consented but was not interviewed due to the brevity of his Demo Project participation.

We collected data from May 2014-August 2015, through semi-structured, individual, telephone interviews conducted by one of three trained qualitative researchers (EA, SH, NS). Interviewers were not part of Demo Project staff and they made this clear to interviewees. Telephone interviews allowed participants to avoid returning to study sites, which might have influenced their responses. Study information was provided via email and/or telephone, according to participant preference. Participants’ questions were answered prior to obtaining verbal consent. The interview guide covered topics such as Demo Project study visits, sexual behavior and communication with partners before, during and after the Demo Project, and post-Demo Project PrEP use; interviews were audio-recorded. Most interviews were in English; five Miami participants opted to be interviewed in Spanish. Participants received a $50 electronic gift card. The Human Research Protection Programs of the University of California—San Francisco, the Florida Department of Health, and the University of Miami approved our study procedures.

Interviews were transcribed verbatim and imported into a qualitative data analysis software package (Dedoose, version 5.0.11, 2014). Interviewers read early transcripts and discussed important themes with consensus understandings incorporated in an initial codebook, the development of which proceeded in parallel with further data collection and analysis. Subsequently, each transcript was assigned to one of two analysts (EA and SH) who took a modified Grounded Theory (Charmaz 2005) approach to coding and analysis, working both deductively and inductively (Bernard and Ryan 2010). Deductively, we adapted elements from the interview guide into codes (e.g., Adherence, Access to PrEP), applying them as relevant themes surfaced. Other codes emerged inductively, from line-by-line analysis (e.g. Emotional Impact of PrEP, Risk Perception).

After completing the initial round of coding, analysts discussed new codes, refined definitions, and re-examined each transcript to ensure systematic application of all codes. We achieved strong inter-rater reliability for all codes (at least 0.8, following Hruschka et al. 2004) Given widespread interest in potential risk compensation, our preliminary analysis focused on whether PrEP had prompted interviewees to alter their sexual behavior in ways that could entail more frequent exposure to HIV. To gauge this, interviewers had probed regarding condom use, number and type of partners, sexual positioning and serosorting. Accordingly, we examined segments coded with parent codes Risk Behaviors and Sex Life and their subcodes (including Risk Compensation/Behavioral Disinhibition, STIs, Sexual Practice-Change, Sexual Practice-No Change, Intimacy). We found, however, that stratifying interviewees by reported sexual behavior change or maintenance while on PrEP did not reveal patterns in meaning associated with those behaviors. Through a more inductive approach to this group of segments, clusters of narratives emerged. The most cohesive of these foregrounded interviewees’ biological and psychological selves, their interactions with other men over the course of PrEP use, or the historical moment their own lives occupied within the epidemic. Illustrative quotations below are attributed to participants by pseudonym to protect their confidentiality; we also provide their study site (SF or MI), and age for reference.

RESULTS

The 32 interview participants were all MSM, with a mean age of 40 (range: 24–66). Thirteen identified as White, 12 as Hispanic/Latino (10 White, 2 non-White), 5 African American, 1 Asian, and 1 mixed race. Six interviewees (1 SF, 5 MI) mentioned they were born outside of the U.S. (5 in Latin American countries, 1 in Europe). Interviewees reported a range of sexual practices that varied by partner and over time. In addition, their narratives cited multiple, sometimes contradictory influences on behavior. Though PrEP was frequently mentioned, its precise role in shaping overall sexual practice was often impossible to ascertain, given the contextual variation emphasized by many interviewees.

While interview questions were open-ended, participants were asked about their sexual and affective experiences before, during and (for those who had discontinued) after PrEP use. As they described particular sexual encounters, interviewees in this study connected them to underlying emotional and cognitive processes, and framed their experiences as broadly shaped by social and historical dynamics around PrEP and HIV. Participants presented themselves as beings-in-bodies that existed simultaneously on multiple levels, evoking Scheper-Hughes and Lock’s (1987) classic conceptualization of “three bodies:” the body-self, the body social, and the body politic. PrEP often provided a way to discursively integrate these multiple selves/histories, allowing access to a conception of personhood that transcended concern with HIV. Ultimately, we argue that these ideas help us to understand men’s accounts of their sexual behavior, and PrEP’s role in it. Thus, we draw loosely from Scheper-Hughes and Locke’s framework in presenting the findings in four domains: individual body/selves, social bodies on PrEP, perspectives from the body politic, and integrations.

Individual Body/Selves

One common narrative around men’s experiences of sex on PrEP emphasized the lack of significant changes from previous practices. The pre-PrEP sexual behavior of the men making this assertion varied, ranging from no condom use with some degree of serosorting or seropositioning, to consistent condom use for anal but not oral sex. For example, Jamie (SF, 25) reported not using condoms while on PrEP but clarified, “I’m not one of these people who are now on PrEP and find themselves liberated from condoms. I never really used condoms.” Jermaine (MI, 34) had been an inconsistent condom user, and versatile in terms of sexual positioning, but likewise insisted that PrEP had not changed his practices:

Jermaine: It ain’t like, “Oh, I’m on Truvada™, so I can do this,” you know. I never thought about it.

Interviewer: You didn’t?

Jermaine: Never did. It’s, like, when I had sex, like—it was after, you know? It’s, like, “Oh, damn, maybe...”—that’s when I thought about it. But then I be like, “Okay. I hope that Truvada™ kick in!” You know, like that. (laughs)

PrEP users like these claimed they were “taking the same risks” they did before. Individual history is essential to understanding these explanations because behavior was framed in terms of continuity with the past.

Other interviewees acknowledged changes in their sexual behavior while on PrEP. Some unequivocally attributed this to Truvada™. For example, Hugh (SF, 31) noted, “I would definitely say... I’ve been steadily taking more risks than I normally would have.” Tyson (SF, 66) explained that he was drawn to PrEP so he didn’t have to “stop in the heat of the moment and put on a condom.” Such accounts implicitly associated PrEP with freedom. For other participants, however, PrEP’s meaning and role in behavior change was less clear. For example, Fred (SF, 58) reported “rare” condom use prior to taking PrEP, mainly taking the insertive role sexually (“topping”) as a way to prevent HIV. During the Demo Project he had been receptive (“bottomed”) more frequently but explicitly attributed this to feeling rejected after a work lay-off. The story he told about these encounters prioritizes his “emotional need” at the time:

When this happened there were no drugs, there was no alcohol involved whatsoever. It really comes down to—I know this is going to sound maybe corny, but, you know, there’s a real want to feel loved and needed and, you know, and to feel desired. So, when I’m in that space I have a tendency to let those protective thoughts [about seropositioning] go out the window.

Fred was not the only participant who attributed changes in sexual behavior primarily to affective experiences, with PrEP constructed as a secondary or even peripheral factor. Six interviewees explicitly linked alterations in their sexual practices to either becoming single or beginning a new relationship. Aloysius (SF, 45) provided a poignant example. Like Fred, he reported more receptive anal intercourse while on PrEP; he had not used condoms “for years” prior to the Demo Project. Around the time he enrolled, however, he began a new relationship that would be a watershed. “Before my boyfriend, I wouldn’t let anyone fuck me,” he stated matter-of-factly, later explaining: “I was raped as an altar boy and [that] made it very difficult for me to get fucked.” His new boyfriend was communicative and “very sex-positive,” and helped him overcome psychological scars left by childhood sexual abuse. Thus, in Aloysius’s telling, a supportive relationship made bottoming possible again. When directly asked about Truvada™’s role, he was noncommittal, saying, “I probably wouldn’t have had sex the way I had sex with my boyfriend and with other people if I wasn’t on PrEP ... or maybe I would have.”

Despite varied circumstances, these two accounts construct key linkages between intimate practices and individual psychological needs. In contrast to Hugh and Tyson, Fred and Aloysius downplay PrEP’s role in their sexual behavior change. This should not be taken to suggest, however, that PrEP meant nothing to these men. Indeed, both acknowledged that taking Truvada™ reduced their anxiety around condomless intercourse; hence it may have had an important if indirect influence (as Aloysius’s ambivalent comment suggests). What such stories reveal is that PrEP acquires meaning within a biographical sexual trajectory; it is interpreted as part of a multifactorial etiology of behavior change.

Another consistent narrative of sexual decision-making and behavior emerged around “performance issues,” linking condom use to erectile dysfunction (ED). As Matthew (SF, 55) noted, “Getting an erection just in and of itself is such a performance-related issue that when you throw a condom on...it almost kills the sex.” This was particularly problematic for interviewees who reported normally topping, like Joe (SF, 53): “I’m completely, totally a top guy. So, if my dick goes limp, it’s a problem. And so I don’t wear a condom.” This handful of interviewees tended to be older, and reported having taken medication for ED, which did not eliminate what they saw as a barrier to fulfilling sexual practice. Some had dispensed with condoms prior to PrEP use; for others, the order was reversed. All agreed, however, that PrEP increased their comfort level with condomless sex.

Other risk reduction strategies used in conjunction with PrEP appeared to augment this sense of comfort. For instance, Henry (MI, 60) and his primary partner were both on PrEP and still used condoms with new partners, resorting to ED medication to make this possible. However, within the small sexual network of men they had known for about a decade, the couple’s condom use had declined while taking PrEP. This had triggered a further change in sexual practice: avoiding ejaculation inside a partner. Henry explained, “Not that we did that a lot before, but we did when we had condoms. But now it’s like we don’t...go all the way.”

To summarize this section, some interviewees acknowledged sexual behavior change while taking PrEP; others did not. Likewise, descriptions of sexual practices prior to PrEP use varied. Most narratives, however, notably resist exclusive focus on PrEP, instead sharing a common framing through what, following Scheper-Hughes and Locke (1987:7), we call interviewees’ “lived experience of the body-self.” Whether this was primarily biographical (e.g., continuation of pre-PrEP patterns in sexual practice), psychological (e.g. overcoming a history of abuse), or biological (e.g. ED), individual past experiences proved necessary to understand these men’s accounts of PrEP, and the sex they had while taking it. The perceived protection offered by PrEP also freed interviewees to continue their sexual lives in fulfilling ways while addressing their emotional and psychological needs.

Social Bodies on PrEP

The role of sexual partners and experience with PrEP were also as catalysts of change in interviewees’ sexual decision-making and behavior. Again, sexual practice before, during and, for men who discontinued, after PrEP use varied; and participants framed their accounts in terms of “bodies social”—that is, bodies in social interaction and/or relationships.

Participants understood that PrEP did not guarantee they would remain HIV-negative. As Joe explained, “PrEP was never designed as a catch-all, end-all, miracle drug that would protect in 100% of the situations.” Participants specifically noted Truvada™ did not protect against other STIs, a message reinforced by counseling sessions during study visits. Even so, some men shared accounts of sexual risk taking and subsequent regret, which prompted them to reconsider their behavior. Sexual practice was thus a social process. Marco (MI, 40), for example, was in a 20-year relationship with an older, HIV-negative partner. He lamented that, due to his partner’s diminishing interest, they rarely had sex. Though the relationship was ostensibly monogamous, Marco occasionally sought outside partners. He insisted several times that his sexual behavior had not changed while he was on PrEP, and described the risk reduction strategies he typically employed:

Marco: In general, when I’m’Makin mischief’ I don’t go further than oral. And if there has to be penetration, I try to make sure it’s not of me. I try to do the penetration because I trust my condoms, I know where they’ve been. I don’t know where other people’s condoms were...

Interviewer: So it’s a conscious thing, about protection.

Marco: Yes, because it’s.. .like I said to [a Demo Project staff member], “Outside of me, everyone else is infected.”

Eventually, though, Marco revealed that during the Demo Project he had condomless intercourse outside his relationship. He emphasized that this occurred “after a few drinks,” and was influenced by his confidence in PrEP, which he’d felt was the “protection of the century.”3 As he told it, “I had a moment of craziness and I took the consequences,” including a gonorrhea diagnosis. This reinforced his resolve to use condoms, he said; remaining HIV-negative and STI-free was important, given the clandestine nature of the sexual contacts that posed these risks: “The responsibility is still mine,’ he concluded, “not the medicine’s.”

David (SF, 35) shared a similar story. Though his condom use increased during the Demo Project, he did not forego condomless sex. He saw PrEP as a tool that enabled him to engage in this practice “judiciously and, you know, not wantonly.” Even so, he was diagnosed with multiple STIs after an encounter with a partner who was also on PrEP. The partner was “allergic to condoms” and his sexual activity had spiked after initiating Truvada™. David called this incident “a correction on my judgment,” and reflected:

The reason I had unprotected sex with him was because he was on PrEP. And I felt more safe. But, then I’m like, wait a minute... inquire a little further, you know. And, figure out why they’ve been using PrEP... if they’re using it just to have unprotected sex all the time, then the risks of me, you know, getting a bacterial infection are a little bit greater.

In these accounts, interviewees described embodied interaction as changing their conception of the risks of sex on PrEP. Specifically, the aftermath of some “risky” sexual encounters became an experiential resource, helping participants determine what they felt was the “right” way to have sex on PrEP. Participants frequently used terms like “took the consequences,” “responsibility,” and “judiciously/wantonly,” suggesting that such determinations involve more than correctness in a merely practical sense (e.g. avoiding STIs or discovery of clandestine sexual encounters). These terms reveal interviewees’ navigation of the moral and ethical dimensions of sexual decision-making when using PrEP.

These narratives highlight the social dimensions of biobehavioral HIV prevention technology. PrEP use is portrayed as a catalyst for behavior change, with subsequent interaction with PrEP users and other partners prompting further adjustments. Thus, interviewees describe a feedback loop in which initial assumptions and consequences of early behavioral modifications while on PrEP ultimately exert their own effects. Sexual decision-making is therefore not an “all-or-nothing,” irreversible outcome; instead, it is described as an ongoing social process, always subject to revision and concerned with both practical and ethical question

Perspectives from the Body Politic

In contrast to narratives framed in terms of body-selves or social bodies, participants sometimes positioned themselves within much broader trajectories that, while not of their own making, nonetheless impacted their lives in intimate ways. Meanings attributed to PrEP—and the sex men had while taking it—were inflected with interviewees’ lifetime experiences with HIV, which had been heavily influenced by the epidemic’s evolution as a whole. Although interviewees reported varied sexual behavior, they shared an implicit conception that they were subject to biopolitical regimes. Biopower - “making live and letting die” (or, in this case, “letting seroconvert”) exercised by states (Foucault 2003)—is made concrete in these narratives through antiretroviral medication. These are stories told from the perspective of members of a body politic.

These narratives could be emotionally charged. While all participants welcomed the preventive promise of daily Truvada™, those who had lost friends and lovers to AIDS also experienced other emotions. Sal (MI, 55), for example, found PrEP’s advent “bittersweet... because we didn’t have the tool to fight against the virus ... before all those people died.” There was clear recognition that the epidemic had changed over time, and PrEP was changing this further. But their survival had left some participants with indelible marks. As Fred explained:

I still carry some of that same terror that I had in my 20s now. I don’t really know if the folks in their 20s today have that same, you know, level of terror. It seems like not.... I can’t speak for them, but I can speak for me: the PrEP program... felt like a huge weight lifted off of me as far as fear and terror was concerned.

Aloyisius put the association starkly

“Sex has always meant the possibility of dying for me.” For him, PrEP had “made it a little easier to breathe.” The high emotion in such narratives was not limited to fear, but was reflected in the intensity of relief PrEP triggered. Echoing Fred and Aloyisius’s sentiments, Brad (MI, 42) described how Truvada™ reduced the dread he felt in conjunction with sex: “I had never known that level of non-anxiety. You always go to bed with anxiety, right? You want to be with somebody, it’s like, it’s the third partner who’s always there. [laugh] That’s the anxiety.”

Men in their mid-30s and older often cited earlier periods of ,he epidemic—sometimes decades earlier—as still influencing what HIV meant to them at the time of the interview. This, in turn, influenced their feelings about PrEP. These participants often speculated, as Fred did (above), that younger gay men did not harbor the same fear; men “in their 20s” had had a different experience of HIV. Russ (MI, 36) elaborated:

They don’t have the same understanding of risk as I do. I came of age in the ‘90s, which is when they developed the cocktail for people that, you know, stopped [HIV] from being a death sentence. For people who only know of it as a chronic illness, maybe they just don’t see it as being that serious.

The narratives of younger men, in contrast, revealed a variety of orientations toward risk and the epidemic more generally. Some invoked fear of HIV, though not typically in terms as dramatic or indissolubly linked to sex as older men. Nonetheless, three participants did talk about HIV and fear in ways similar to older interviewees. For example, Jorge (MI, 31) said: “When [clinic personnel] talked to me about the pill I thought it was marvelous that, wow, they found the salvation so that your ever-present fear of becoming infected diminishes.” These three men had all immigrated from Latin America, where they described more pervasive homophobia and discrimination against MSM, reduced availability of ART, and less political will to fight the virus. This contrasted with the epidemic referenced by US-raised interviewees; different biopolitical regimes shape people’s experiences of HIV.

In general, younger participants did not construct HIV as something they needed “salvation” from. Andrew (SF, 29) and Gordon (SF, 28) both told stories of anxiety after specific possible sexual exposures to HIV, but they did not suggest PrEP had been life-altering. When asked about the emotional impact of being on PrEP, for example, Andrew said, “I guess I just didn’t really think about it that much.” This may reflect the fact that these interviewees (all, to our knowledge, born and raised in the US) had watched friends be “made to live” with HIV through ART, not allowed to die from AIDS. As Jody (MI, 29) said, “I had a couple of buddies in the past that were HIV-positive and they had to take pills.” Though he noted he had “heard the stories” about changes in living with HIV, there was no palpable sense that his friends had eluded a death sentence.

Jody was explicit that other STIs could be “as bad or worse than HIV ... it’s just that HIV is the poster boy for the ‘bad’ STD.” Such normalization also surfaced in Jamie’s reflection on aspects of Demo Project participation. As one of several benefits, he mentioned, “getting rid of the anxiety and the worry around, like, getting a lifelong disease” (emphasis added). Older participants, even as they remarked that HIV-positive individuals now survive for decades with access to treatment, never described the virus this way. Taken together, statements made by these younger, US-raised participants constructed their relationship to the virus as less inflected by past suffering, less traumatic overall. As a consequence, PrEP, as a way to prevent HIV, meant something different as well.

These stories remind us that what sex, risk, and HIV prevention mean to individuals is highly contingent. Interviewees who tethered their narratives to the suffering of the pre-combination therapy period contrasted with those who, free of such trauma, related to HIV as a chronic disease. As already suggested, this division mainly manifested between older and younger participants, suggesting it was a product of the way age intersected with the evolution of the epidemic as a whole, especially the availability of treatment for HIV. However, the existence of a counter narrative among younger interviewees raised outside the US complicates the picture. Their stories highlight the importance of geo-political factors in addition to individual biography/history as structuring dynamics in their lived experience. Whether men take the “making live” associated with ART as a matter of course, or carry within them the tragedy of “letting die” is partially a reflection of their membership in a particular body politic. That biopolitical context is linked to whether PrEP is seen as “salvation” or a way to avoid “getting a lifelong disease.”

Integrations: Sexuality and Self

As is evident, there were many bodies, selves, histories, and politics in interviewees’ stories of their sexual behavior before, while, and (for some) after taking PrEP. Virtually all of these men positioned themselves at multiple levels individually, socially and politically. At times, the various framings could raise conflicting expectations about behavior. For instance, Jermaine emphasized his desire to avoid HIV and other STIs, describing a previous diagnosis as “heartbreaking.” But he also told stories of “risqué” and enjoyable condomless encounters with men he knew did not use condoms with other partners. Likewise, Fred reported a “terror connection” between HIV and sex, but sometimes satisfied his need to feel desired through bottoming without a condom. Often, PrEP was constructed as a way to reconcile these conflicting priorities, helping participants narrate their lives as integrated wholes.

As Fred explained, the PrEP-induced reduction of fear around bottoming had follow-on effects: “It allowed me to be more evolved sexually, and I think that’s a good thing... Who wants to be intimate with somebody and be in a state of terror? You know? You’re not giving your all.” Here, being fully present (“giving your all”) in a sexual experience is a positive sign of personal development—even though it coincides with behavior typically seen as “high risk.” Sal (MI, 55) also addressed this apparent contradiction when he acknowledged some men might “throw caution to the wind,” with PrEP making them feel less afraid during sex. In contrast to those who worry over risk compensation, however, his assessment of this potential behavior change was positive: “To me, if that’s the impact of it, I think, awesome, because you know what? Then they can enjoy sex. They can... express all of who they are, sexually and everything else.” Many older participants portrayed PrEP not just as a form of sexual liberation, but a means of self-actualization more generally.

As mentioned above, younger participants generally did not voice a need for “salvation” or liberation. Still, HIV prevention did figure as a challenge, an exercise in guessing how and with whom it was safe to satisfy certain needs. In discussing their reasons for PrEP use, much like older interviewees, they commonly invoked notions of holism or integrality. Jamie explained: “I’m trying to take advantage of the things that are out there that work for me as part of, you know, the whole complex of my sexual health, which is part of the complex of my entire health.” Gordon likewise chose an expansive frame to describe his sexual decision-making, connecting this to a larger trend of changes in his life: “It’s not just sexual, it’s more of life decision-making.”

In their contemplation of the three bodies, Scheper-Hughes and Locke (1987:28–29) see emotions as constituting a “‘missing link’ capable of bridging mind and body, individual, society, and body politic.” For these interviewees, however, PrEP often integrated the multiple bodies populating their stories, producing a newly intelligible subject. This calls to mind Holt’s (2015:429) observation, made with reference to PrEP, that “knowledge, materials and actors (both human and non-human) interact with and change each other.” Brisson and Nguyen (2017:4) put this idea slightly differently when they assert that, “the practice of HIV prevention produces both subjects and technologies together.” These insights may offer the key to understanding PrEP’s power to discursively integrate the multiple body/selves that figure in these narratives. Further research, particularly ethnographic studies, should examine the relationship between PrEP use, sexual practice, emotion, and subjectivity, and attend to the ways this novel assemblage may represent an “epistemological continuity” (Moyer 2015) with previous scholarly work on both HIV and new technologies. What is clear from our data is that the PrEP-mediated integration of multiple discursive bodies was effected by interviewees in service of a notion of personhood that encompassed much more than merely HIV prevention.

DISCUSSION

Our initial analytical objective, in reporting on the US PrEP demonstration project, was to identify patterns in accounts of participants’ sexual behavior maintenance and change while on PrEP. However, reported behaviors did not map neatly onto ways that participants spoke about underlying cognitive and emotional processes, or what HIV, risk, or PrEP meant to them. Rather, when allowed to elaborate about their sexual lives, interviewees often mentioned influences other than PrEP, and spoke of their sexual practices as contingent and evolving. Though labels like risk compensation could be applied to some of the behavior change reported by participants, doing so entailed the loss of much of the richness of these data. We therefore focused on the human experiences that rendered behavior and decision-making meaningful for interviewees.

Closely attending to participants’ narratives about sex on PrEP made visible the multiple and sometimes contradictory ways they talked about themselves as beings-in-bodies. Drawing on Scheper-Hughes and Locke’s (1987) tripartite “mindful body,” we saw individual body-selves with both psychological and biological dimensions jostling with social bodies that learned through and negotiated the ethics of sexual interaction with other men. These bodies, and the emotions they experienced, were subsumed within a third body—the body politic—that provided a backdrop influencing meanings attributed to sex, risk, and HIV prevention. Ultimately, PrEP often served to integrate these bodies, enabling a holistic portrayal of the self.

While interviewees’ stories featured specific sexual acts and partners, the narrative frame was virtually always much wider. This helps us understand that PrEP was not the only factor, for example, in Aloyisius’s resumption of receptive anal sex; rather, there was also a supportive partner helping him come to terms with sexual abuse. Likewise, Henry and his partner, both on PrEP, dispensed more often with condoms, but this was partly because advancing age made maintaining an erection more difficult. Condomless sex occurred primarily with an established group of partners for this couple, who also compensated by adopting external ejaculation.

Further, many participants reported revising sexual practices in light of the feedback loop of their lived experience on PrEP—for example, both Marco and David saw STI diagnoses after condomless sex as a “correction on [their] judgment.” Amongst members of our sample who came of age without widespread access to ART (whether because of age or location), PrEP provided a way to decouple the terror of HIV from the enjoyment of sex. Overall, within these narratives, sexual behavior appeared as contingent, multifactorial, and inherently social, situated within the trajectory of an individual’s life and unfolding at a given location and point in the history of the HIV epidemic. HIV, however, was by no means the only or most important element.

This contrasts with biomedical models that still presume that HIV prevention is, or should be, the top priority in sexual decision-making. In the context of sex on PrEP, such an assumption prompts the evaluation of sexual behavior primarily in terms of its potential to expose the PrEP-taker to HIV, which in turn leads to the de facto conceptualization of individuals as the sum of the sexual acts they take. This is not how research participants described their sexual practices or themselves. Above, Sal implicitly posits enjoyment and self-realization as the goal of sexual behavior. Following this reasoning, sexual practice cannot be meaningfully evaluated solely in terms of risk. Though HIV prevention is a consideration (after all, he was talking about people who went to the trouble of obtaining and taking PrEP), Sal’s statement that sexual behavior is a way for individuals to “express all of who they are, sexually and everything else” shifts the frame of reference. It crystalizes a model in which motivations for sexual behavior are rooted in a far more holistic notion of personhood, one that expands beyond HIV and even biomedical notions of “health” more generally.

In virtually every story in which PrEP could be associated with altered sexual behavior, participants explicitly noted benefits beyond HIV prevention (see Grant and Koester 2016): pleasure, intimacy, reduced anxiety around sex, and lessened HIV stigma. These benefits were always valued, and sometimes reported to be life-changing. We therefore concur with Brisson and Nguyen (2017:4) that understanding these dynamics “requires an approach that is attentive to how prevention technologies can shift power relations” and create new subjectivities. Future research should explore ways PrEP and its users are mutually constituted.

This article is among the first to deeply explore men’s narratives about sexual behavior and decision-making on PrEP outside of clinical trials. Even so, interviewees had participated in the Demo Project, and receiving HIV prevention counseling and services may have influenced the way they talked about their behavior and perceptions. Although we employed purposive sampling to recruit a diverse pool of interviewees, and there is notable consistency between our findings and that of other qualitative research on PrEP and US MSM (Collins et al. 2017; Koester et al. 2017), we do not claim our results are exhaustive or represent patterns found across all PrEP users. Unfortunately, we were unable to interview any transgender participants; their experiences may well be different.

Further, one-time telephone interviews are no substitute for the depth of understanding to be gained through ethnography. However, such extended engagement with participants would have thwarted the Demo Project’s objective: to study PrEP use under conditions more closely resembling clinical care than clinical trials. A feasible goal for us was to elicit rich narratives and allow interviewees to contextualize their behavior in ways that were meaningful to them.

CONCLUSION

Heretofore, much of the scholarly interest in PrEP has narrowly focused on individual sexual behaviors at discrete moments in time. However, when given the chance to speak at length about their experiences with PrEP, interviewees explicitly positioned themselves at biographical, social, and historical crossroads that were simultaneously personal and collective. They cited multiple influences on their sexual practice, which was portrayed as resulting from fluid but situated processes. While their stories sometimes constructed PrEP as catalyzing behavior change, the medication was just one component of an overall risk reduction strategy, mobilized in pursuit of a fulfillment that was more than simply sexual. Interviewees discursively deployed various “bodies”—individual, social, and biopolitical—to explain this, with PrEP often playing an integrative role in these narratives, allowing access to a holistic notion of personhood.

While not necessarily generalizable to “PrEP users,” our findings nonetheless raise interesting considerations as PrEP becomes more widely prescribed and used. Currently, those who design public health policy and services often know what people do sexually without understanding why. The “what” is important, but only part of the picture. Our work highlights a mismatch between much public health/biomedical discourse, which assumes a PrEP-seeker’s overriding concern is preventing HIV, and men’s explanations of their sexual decision-making, in which other goals and benefits of PrEP may be equally important. Finding a way to reconcile these perspectives may increase the effectiveness of HIV risk-reduction interventions.

ACKNOWLEGEMENTS

We thank the research participants who shared their stories, as well as Demo Project investigators and staff. We are grateful to the Sex and Sexuality Writing Group at CAPS, the anonymous reviewers, and Lenore Manderson for providing constructive feedback in the editing process.

FUNDING

This research was supported by the following grants: R01MH095628 (National Institute for Mental Health); UM1AI069496 (National Institute for Allergies and Infectious Diseases); P30AI073961 (National Institutes of Health and Miami Center for AIDS Research).

Biographies

SHANA D. HUGHES is a Specialist at the Center for AIDS Prevention Studies at the University of California San Francisco. Her research on HIV and HIV prevention conceives of sexual practices and notions of risk as biocultural phenomena, framed by personal, social, and structural factors. She is the co-editor, with Dr. Asha Persson, of Cross-Cultural Perspectives on Couples with Mixed HIV Status: Beyond Positive/Negative. Address correspondence to: Shana Hughes, UCSF Center for AIDS Prevention Studies (CAPS), 550 16th St., 3rd Fl., San Francisco, CA 94158. Email: Shana.Hughes@ucsf.edu

NICOLAS SHEON is an Assistant Professor at the Center for AIDS Prevention Studies at the University of California San Francisco. Dr. Sheon has a Ph.D. in medical anthropology from UC Berkeley and has conducted research on HIV prevention since 1993. Dr. Sheon’s research focuses on HIV and cancer risk counseling, clinical trial recruitment, and addiction. Email: Nicolas.Sheon@ucsf.edu

ERIN V. W. ANDREW (MPhil, University of Cambridge, 2008) has served as project manager and qualitative researcher in multiple research projects. She has investigated end-of-life care in Belgium, malaria prevention during pregnancy in Papua New Guinea, and uptake of and adherence to PrEP among MSM in the United States. Ms. Andrew is currently pursuing a career as a Certified Nurse Midwife at the University of Pennsylvania and continues to be involved in research. Email: erinvwandrew@gmail.com

STEPHANIE E. COHEN, MD, MPH is an infectious disease physician and the medical director of San Francisco City Clinic. She was a protocol co-chair and site co-principle investigator of the PrEP Demo Project. Her research focuses on PrEP implementation and STD prevention in the biomedical HIV prevention era. Email: stephanie.cohen@sfdph.org

SUZANNE DOBLECKI-LEWIS, M.D. is an Associate Professor of Clinical Medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine. She served as a co-investigator and medical director for the Miami site of the PrEP Demo Project. Her research and clinical practice focuses on PrEP implementation in Miami. Email: sdoblecki@med.miami.edu

ALBERT Y. LIU is the Clinical Research Director at Bridge HIV at the San Francisco Department of Public Health. Over the past decade, he has conducted research on the safety and effectiveness of PrEP, strategies to monitor and support PrEP adherence, and how to best implement PrEP in real-world settings. He served as protocol chair of the PrEP Demo Project and is now leading a PrEP demonstration project among transgender populations in the San Francisco Bay Area. Email: albert.liu@sfdph.org

NOTES

1

Participants at the Washington, DC site were not sampled for interviews.

2

Telephone connection with one Miami participant was lost mid-interview and we were unable to re-establish contact. The partial interview was transcribed and analyzed to the degree possible.

3

In his telling of this encounter, Marco’s confidence in PrEP’s efficacy influenced his behavior.However, during the interview he also ruefully mentioned the “many times” past sexual “missteps” had left him “running to get tested.” Hence, condomless sex with outside partners was not novel for him and should not be attributed exclusively to PrEP. Nonetheless, the role PrEP played as one of several factors contributing to this behavior in this instance highlights the contingent, processual nature of these interactions.

Media Teaser: What do men taking PrEP to prevent HIV in the US have to say about their sexual behavior and PrEP’s role in it? What light can this shed on how we might expect this novel technology to impact both users and HIV prevention more generally?

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