PrEP paradox: Prevention & empowerment face off against sex shaming
A common theme in stories from those who use PrEP is how this biomedical prevention tool has decreased HIV-related stigma and lessened the divide between HIV-negative and HIV-positive people. Qualitative research conducted in Canada reports some PrEP users experience a different kind of stigma based on assumptions about how and why people use PrEP.
“What is most exciting about PrEP, and treatment as prevention, is that I think we’re tearing down walls between HIV-positive and HIV-negative men in the community…You see many more guys online saying they’re poz-friendly. You see more guys being open about being undetectable,” said PrEP advocate Jake Sobo, on BETA.
New qualitative research, by Daniel Grace, PhD and colleagues in Toronto, Canada, shows that men who have sex with men taking PrEP are aware of the ways that PrEP has challenged HIV stigma, for themselves and others. Yet at the same time, men seem to be experiencing a different kind of stigma—related to their PrEP use and the assumptions it can elicit about sexuality and partner choice.
“We have elucidated a paradox in participants’ accounts: Men said that PrEP use led them to experience stigmatizing reactions within their social and sexual networks while also being described as helping to remove stigma, shame, and fear related to HIV, sexuality, and sex with gay men living with HIV,” said Grace and colleagues.
Some of the PrEP users who were interviewed as part of the study described an assumption that “PrEP use [is] equated with having bareback or condomless sex.” And, that they in turn had to manage assumptions about their own condom use and the number of partners they had because they were on PrEP.
“There were several instances in which I had to calm people down once I told them that I was on PrEP because they assumed that my whole lifestyle changed,” said one participant. “One of the regulars that I had previous to going on PrEP decided to stop doing me because he assumed that I would instantly become like a receptacle for… every gay plague known to man.”
Are you in the PrEP closet?
Other PrEP users talked about how PrEP-related stigma or judgment stopped them from telling friends, family and potential partners that they were taking PrEP.
“I hardly told anybody, just because I know my friends would be judgmental—gay or straight,” said one participant.
“I was prepared for a kind of cursedness like, ‘Oh, you’re on PrEP,” I’m not going to sleep with you, because you’re clearly a slut,’ and I’m like, ‘you don’t even understand what it’s about,’” said another participant.
Overall, PrEP users are proud and feel more “free”
Although these narratives shed light on stigma against PrEP and gay sexuality, the researchers emphasized that the PrEP users they interviewed were not overburdened by stigma or shame.
“Many participants discussed being ‘proud’ and ‘liberated’ because of their PrEP use. This was not a ‘spoiled identity’ in need of stigma management, but rather an innovation to celebrate and, for some, a return to normalcy—normal, exciting, pleasurable sex that many deemed as no longer reliant on condom use,” they said.
“Frankly, it’s been one of the greatest things of my life,” said one participant. “I have absolutely loved it. I have a lot of sex, and I go to the bathhouses a lot, despite my advanced age. I can tell you, sex has never been better. For the first time in my lifetime, it’s taken away the fear from having sex. Sex isn’t something you’re ashamed of or fearful of. It’s meant to be enjoyable and PrEP has made sex enjoyable for me, which is fantastic.”
Details of the study
To learn about the lived experiences of people using PrEP, Grace and colleagues recruited PrEP users in Toronto, Canada who were participating in the PREPARATORY-5 study and had been taking PrEP for a year or longer. The study was conducted between November 2014 and June 2016.
A total of 16 men who have sex with men, who were HIV-negative and at high risk for HIV infection, completed qualitative interviews in small groups or individually. Interviewers asked participants about the reasons they started PrEP, their experiences accessing PrEP, their sex lives and sexual decision making, challenges to using PrEP, and recommendations related to PrEP use and access.
What changes when people start taking pre-exposure prophylaxis (PrEP) to prevent HIV? Read more from cultural anthropologist Kim Koester about what people experience when they start PrEP—like feeling more secure, decreased anxiety, and a deep sense of relief and freedom. Hear from Pierre-Cedric Crouch, PhD, ANP-BC, nursing director at San Francisco AIDS Foundation, about why it’s important for all health care providers to be sharing information about PrEP with their patients, and reaching communities of color with PrEP information and services.
Learn more about PrEP & find PrEP services
San Francisco AIDS Foundation offers free PrEP services at Strut (470 Castro Street in San Francisco) and at their main office (1035 Market Street in San Francisco). Find more information and make an appointment online.
PleasePrEPme.org is a website linking people seeking PrEP services to PrEP providers across the U.S. The site includes a searchable directory (by state, zip code or street address) for users to find PrEP clinics and PrEP clinicians with hours, contact information and health insurances accepted for each listing.
San Francisco City Clinic offers free and low-cost sexual health care to people in the Bay Area regardless of immigration or insurance status. They offer same-day PrEP enrollment during drop-in hours:
Monday, Wednesday, Friday: 8 am – 3 pm Tuesday: 1 pm – 5 pm
For trans people, San Francisco City Clinic offers PrEP services by appointment Thursdays from 8 am – 11 am or during the drop-in hours.
The CDC offers more info about PrEP and videos about this HIV prevention option.
Prepfacts.org provides FAQs about PrEP and other PrEP info.
Grace, D. and colleagues. The pre-exposure prophylaxis-stigma paradox: Learning from Canada’s first wave of PrEP users. AIDS Patient Care and STDs. January, 2018.
Share your PrEP story
Do you use PrEP and want to share your story? If so, email Emily at firstname.lastname@example.org.