Although not strictly a sexual practice, men’s discussion of biomedical
approaches to HIV prevention helps highlight the importance of knowledge of HIV status in men’s assessments of whether sex with a partner was perceived as more or less safe. Around a quarter of the men in the sample spontaneously raised the topic of biomedical HIV prevention such as Post Exposure Prophylaxis (PEP/PEPSE), Pre-Exposure Prophylaxis (PrEP), Treatment as Prevention (TasP), and/or the role of viral load/count in the transmission of HIV.
Six men described having some knowledge of PEP in terms of HIV prevention, however, none of the men reported having accessed or taken PEP themselves.
These men were all aware that PEP (or PEPSE) was available in their area and knew that it could potentially prevent, or reduce, the likelihood of HIV
seroconversion. The men’s accounts suggested that they considered taking PEP to be appropriate after an episode of unprotected sex which fell outside typical (or ‘normal’) safer sex practices, perhaps after a “lapse in judgement” (Kyle,
26). Three of the men reported personally knowing someone who had taken PEP after an episode of UAI. Nicky described PEP as “useful to have”, but took a strong moral stance, arguing that it cannot be considered a valid form of HIV prevention, and does not constitute ‘safe sex’. He suggested that some men use PEP as a way of ‘justifying’ not using condoms for anal sex.
Harry was the only participant to report personally considering accessing PEP after an episode of UAI with a friend. Although Harry recognised that UAI in this context was potentially risky, he reasoned that as this partner was ‘known’ to him as a friend, and that he had some knowledge of the person’s sexual history, this partner did not pose a high risk. On this basis, he decided against using PEP.
This again foregrounds the interplay between (potentially) ‘risky’ practices and people, emphasising that a sexual encounter may be considered less risky if a partner is seen as ‘safe’.
Four men discussed the role of antiretroviral drugs (ARVs) and treatment (ART) in HIV prevention. Tiernan and Max highlighted their reasons for interest in the topic; Max had been diagnosed with HIV, and Tiernan was in a serodiscordant relationship with an HIV positive partner. Both men talked about treatment with ARVs, and were conversant with the concept of viral load in assessing risk of HIV transmission. For example, Max explained that he and recent ex-partner (on his PC map) had gone to seek advice on the best way to reduce risk of HIV
transmission during sex. This was primarily in response to his HIV negative partner’s lack of knowledge around sex in the context of a serodiscordant relationship. Although they had chosen to continue using condoms together, he explained that based on his increasing knowledge around viral load and
transmission risk, he might approach sex differently in future relationships:
“So if I was to go into another relationship, then I would, you know, I would feel very confident about talking about a whole range of things and about obviously condom use is really important but as time goes on, if that becomes an issue, then if you’re in a monogamous
relationship and the rest of it, there’s lots of things that, other things like viral load and PrEP and all the rest of it that you can know about and be aware of and it becomes something that’s got very little effect.” (Max, 25)
Similarly, Tiernan explained that he had sought advice from health professionals to allay his concern around the risk of HIV transmission between him and his
partner. Although he knew that his partner had a low viral load, and as such there was little risk of transmission of the virus, they had agreed that they would continue to use condoms for anal sex.
Finlay reported having some existing knowledge about PEP, and noted that hearing about research around biomedical HIV prevention18 had prompted him to engage in further research around PrEP. Finlay stressed that the possibility of using ART as a prevention strategy was unlikely to influence his future sexual practice, reasoning that he saw the use of drugs as an “added extra”, but not an alternative to using condoms. Eamon was the only other participant to discuss the role of ART as a factor in HIV transmission. He explained that he had developed knowledge of the role of drug treatments and viral load through his university studies, and also by volunteering with a service encouraging testing among men in his area. Although he was aware that the likelihood of
transmission from someone on treatment was low, he questioned how he could know and trust whether a person was on treatment and had a low viral load:
“But I suppose how would you know if the other person is on
retrovirals and got a low viral count; how would you know?” (Eamon, 24)
Eamon seemed to question whether treatment in and of itself would be enough for him to stop using condoms, but went on to describe how condoms could be used in conjunction with ART to prevent transmission.
Although these men all reported different viewpoints on the use of PrEP and TasP, a common theme across their accounts was the need for knowledge of HIV status in order to be able to access HIV treatment and use ARVs for prevention purposes, thus emphasising the importance of HIV testing.
How though, did men develop knowledge around safer sex and sexual health, and what resources did they draw on to inform the meanings they ascribed to it?
The section that follows introduces the varieties of ways the men discussed this.
18 Two of the men (Tiernan and Max) heard about my research as a result of participating in a project exploring biomedical HIV prevention which was recruiting for participants at the same time as my own research (conducted by one of my colleagues). Finlay had heard about the project, but had not participated in it.