Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men
Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52–59 years) and younger (18–25 years) generations endorsed positive views, compared with 32% of men in the middle (34–41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men’s narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men’s sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men.
KeywordsPrEP HIV/AIDS Gay men Public health Sexual culture Sexual orientation
Research reported in this article is part of the Generations Study, supported by the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health under award number R01HD078526. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Generations investigators are: Ilan H. Meyer, Ph.D. (Principal Investigator), David M. Frost, Ph.D., Phillip L. Hammack, Ph.D., Marguerita Lightfoot, Ph.D., Stephen T. Russell, Ph.D., and Bianca D. M. Wilson, Ph.D. (Co-Investigators, listed alphabetically). We acknowledge the research assistance of Jessica Fish, Janae Hubbard, and Evan Krueger. This article was completed while the first author was supported by a fellowship from the Center for Advanced Study in the Behavioral Sciences at Stanford University.
This study was funded by Grant R01HD078526 from the National Institute of Child Health and Human Development of the National Institutes of Health.
Compliance with Ethical Standards
Conflicts of interest
All authors declare that they have no conflicts of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- Adam, B. D. (2009). Emergence of a poz sexual culture: Accounting for “barebacking” among gay men. In P. L. Hammack & B. J. Cohler (Eds.), The story of sexual identity: Narrative perspectives on the gay and lesbian life course (pp. 207–222). New York: Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195326789.003.0009.CrossRefGoogle Scholar
- Brooks, R. A., Landovitz, R. J., Kaplan, R. L., Lieber, E., Lee, S., & Barkley, T. W. (2012). Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: A mixed methods study. AIDS Patient Care and STDs, 26(2), 87–94. https://doi.org/10.1089/apc.2011.0283.CrossRefPubMedPubMedCentralGoogle Scholar
- Cahill, S., Taylor, S. W., Elsesser, S. A., Mena, L., Hickson, D., & Mayer, K. H. (2017). Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in Black compared to white gay and bisexual men in Jackson, Mississippi and Boston,Massachusetts. AIDS Care, 29(11), 1351–1358. https://doi.org/10.1080/09540121.2017.1300633.CrossRefPubMedPubMedCentralGoogle Scholar
- Calabrese, S. K., Underhill, K., Earnshaw, V. A., Hansen, N. B., Kershaw, T. S., Hansen, N. B., & Dovidio, J. F. (2016). Framing HIV pre-exposure prophylaxis (PrEP) for the general public: How inclusive messaging may prevent prejudice from diminishing public support. AIDS and Behavior, 20(7), 1499–1513. https://doi.org/10.1007/s10461-016-1318-9.CrossRefPubMedPubMedCentralGoogle Scholar
- Carter, D. (2004). Stonewall: The riots that sparked the gay revolution. New York: St. Martin’s Press.Google Scholar
- Centers for Disease Control and Prevention. HIV surveillance report, 2016; vol. 28. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published November 2017. Accessed October 13, 2018.
- D’Emilio, J. (1983). Sexual politics, sexual communities: The making of a homosexual minority in the United States, 1940–1970. Chicago: University of Chicago Press.Google Scholar
- Dean, T. (2009). Unlimited intimacy: Reflections on the subculture of barebacking. Chicago: University of Chicago Press. https://doi.org/10.7208/chicago/9780226139401.001.0001.CrossRefGoogle Scholar
- Eaton, L. A., Kalichman, S. C., Price, D., Finneran, S., Allen, A., & Maksut, J. (2017a). Stigma and conspiracy beliefs related to pre-exposure prophylaxis (PrEP) and interest in using PrEP among Black and white men and transgender women who have sex with men. AIDS and Behavior, 21(5), 1236–1246. https://doi.org/10.1007/s10461-017-1690-0.CrossRefPubMedPubMedCentralGoogle Scholar
- Eaton, L. A., Matthews, D. D., Driffin, D. D., Bukowski, L., Wilson, P. A., Stall, R. D., & the POWER Study Team. (2017b). A multi-US city assessment of awareness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among Black men and transgender women who have sex with men. Prevention Science, 18(5), 505–516. https://doi.org/10.1007/s11121-017-0756-6.CrossRefPubMedPubMedCentralGoogle Scholar
- Franks, J., Hirsch-Moverman, Y., Loquere, A. S., Amico, K. R., Grant, R. M., Dye, B. J., & Mannheimer, S. B. (2018). Sex, PrEP, and stigma: Experiences with HIV pre-exposure prophylaxis among New York City MSM participating in the HPTN 067/Adapt Study. AIDS and Behavior, 22, 1139–1149. https://doi.org/10.1007/s10461-017-1964-6.CrossRefPubMedGoogle Scholar
- Goedel, W. C., Halkitis, P. N., Greene, R. E., & Duncan, D. T. (2016). Correlates of awareness of and willingness to use pre-exposure prophylaxis (PrEP) in gay, bisexual, and other men who have sex with men who use geosocial-networking smartphone applications in New York City. AIDS and Behavior, 20(7), 1435–1442. https://doi.org/10.1007/s10461-016-1353-6.CrossRefPubMedGoogle Scholar
- Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L., & Glidden, D. V. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587–2599. https://doi.org/10.1056/NEJMoa1011205.CrossRefPubMedPubMedCentralGoogle Scholar
- Green, J., Willis, K., Hughes, E., Small, R., Welch, N., Gibbs, L., & Daly, J. (2007). Generating best evidence from qualitative research: The role of data analysis. Australian and New Zealand Journal of Public Health, 31(6), 545–550. https://doi.org/10.1111/j.1753-6405.2007.00141.x.CrossRefPubMedGoogle Scholar
- Grov, C., Rendina, H. J., Whitfield, T. H. F., Ventuneac, A., & Parsons, J. T. (2016). Changes in familiarity with and willingness to take preexposure prophylaxis in a longitudinal study of highly sexually active gay and bisexual men. LGBT Health, 3(4), 252–257. https://doi.org/10.1089/lgbt.2015.0123.CrossRefPubMedPubMedCentralGoogle Scholar
- Halkitis, P. N. (2014). The AIDS generation: Stories of survival and resilience. New York: Oxford University Press.Google Scholar
- Hammack, P. L., & Cohler, B. J. (2009). Narrative engagement and sexual identity: An interdisciplinary approach to the study of sexual lives. In P. L. Hammack & B. J. Cohler (Eds.), The story of sexual identity: Narrative perspectives on the gay and lesbian life course (pp. 3–22). New York: Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195326789.003.0001.CrossRefGoogle Scholar
- Hammack, P. L., Meyer, I. H., Krueger, E. A., Lightfoot, M., & Frost, D. M. (2018b). HIV testing and pre-exposure prophylaxis (PrEP) use, familiarity, and attitudes among gay and bisexual men in the United States: A national probability sample of three birth cohorts. PLoS ONE, 13, e0202806. https://doi.org/10.1371/journal.pone.0202806.CrossRefPubMedPubMedCentralGoogle Scholar
- Hannaford, A., Lipshie-Williams, M., Starrels, J. L., Arnsten, J. H., Rizzuto, J., Cohen, P., & Patel, V. V. (2018). The use of online posts to identify barriers to and facilitators of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men: A comparison to a systematic review of the peer-reviewed literature. AIDS and Behavior, 22, 1080–1095. https://doi.org/10.1007/s10461-017-2011-3.CrossRefPubMedPubMedCentralGoogle Scholar
- Hoff, C. C., Chakravarty, D., Bircher, A. E., Campbell, C. K., Grisham, K., Neilands, T. B., & Dworkin, S. (2015). Attitudes towards PrEP and anticipated condom use among concordant HIV-negative and HIV-discordant male couples. AIDS Patient Care and STDs, 29(7), 408–417. https://doi.org/10.1089/apc.2014.0315.CrossRefPubMedPubMedCentralGoogle Scholar
- Hojilla, J. C., Koester, K. A., Cohen, S. E., Buchbinder, S., Ladzekpo, D., Matheson, T., & Liu, A. Y. (2016). Sexual behavior, risk compensation, and HIV prevention strategies among participants in the San Francisco PrEP demonstration project: A qualitative analysis of counseling notes. AIDS and Behavior, 20(7), 1461–1469. https://doi.org/10.1007/s10461-015-1055-5.CrossRefPubMedCentralGoogle Scholar
- Hubach, R. D., Currin, J. M., Sanders, C. A., Durham, A. R., Kavanagh, K. E., Wheeler, D. L., & Croff, J. M. (2017). Barriers to access and adoption of pre-exposure prophylaxis for the prevention of HIV among men who have sex with men (MSM) in a relatively rural state. AIDS Education and Prevention, 29(4), 315–329. https://doi.org/10.1521/aeap.2017.29.4.315.CrossRefPubMedGoogle Scholar
- Klevens, R. M., Martin, B. M., Doherty, R., Fukuda, H. D., Cranston, K., & DeMaria, A. (2018). Factors associated with pre-exposure prophylaxis in a highly insured population of urban men who have sex with men, 2014. AIDS and Behavior, 22, 1201–1208. https://doi.org/10.1007/s10461-017-1879-2.CrossRefPubMedGoogle Scholar
- Kuhns, L. M., Hotton, A. L., Schneider, J., Garofalo, R., & Fujimoto, K. (2017). Use of pre-exposure prophylaxis (PrEP) in young men who have sex with men is associated with race, sexual risk behavior and peer network size. AIDS and Behavior, 21(5), 1376–1382. https://doi.org/10.1007/s10461-017-1739-0.CrossRefPubMedPubMedCentralGoogle Scholar
- Lachowsky, N. J., Lin, S. Y., Hull, M. W., Cui, Z., Sereda, P., Jollimore, J., & Moore, D. M. (2016). Pre-exposure prophylaxis awareness among gay and other men who have sex with men in Vancouver, British Columbia, Canada. AIDS and Behavior, 20(7), 1408–1422. https://doi.org/10.1007/s10461-016-1319-8.CrossRefPubMedPubMedCentralGoogle Scholar
- Merchant, R. C., Corner, D., Garza, E., Guan, W., Mayer, K. H., Brown, L., & Chan, P. A. (2016). Preferences for HIV pre-exposure prophylaxis (PrEP) information among men who have sex with men (MSM) at community outreach settings. Journal of Gay & Lesbian Mental Health, 20(1), 21–33. https://doi.org/10.1080/19359705.2015.1105115.CrossRefGoogle Scholar
- Minton, H. L. (2001). Departing from deviance: A history of homosexual rights and emancipatory science in America. Chicago: University of Chicago Press. https://doi.org/10.7208/chicago/9780226304458.001.0001.CrossRefGoogle Scholar
- Mosley, T., Khaketla, M., Armstrong, H. L., Cui, Z., Sereda, P., Lachowsky, N. J., & Moore, D. M. (2018). Trends in awareness and use of HIV PrEP among gay, bisexual, and other men who have sex with men in Vancouver, Canada 2012–2016. AIDS and Behavior, 22, 3550–3565. https://doi.org/10.1007/s10461-018-2026-4.CrossRefPubMedGoogle Scholar
- Oldenburg, C. E., Mitty, J. A., Biello, K. B., Closson, E. F., Safren, S. A., Mayer, K. H., & Mimiaga, M. J. (2016). Differences in attitudes about HIV pre-exposure prophylaxis use among stimulant versus alcohol using men who have sex with men. AIDS and Behavior, 20(7), 1451–1460. https://doi.org/10.1007/s10461-015-1226-4.CrossRefPubMedPubMedCentralGoogle Scholar
- Parsons, J. T., Rendina, H. J., Lassiter, J. M., Whitfield, T. H. F., Starks, T. J., & Grov, C. (2017). Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. Journal of Acquired Immune Deficiency Syndromes, 74(3), 285–292. https://doi.org/10.1097/QAI.0000000000001251.CrossRefPubMedGoogle Scholar
- Parsons, J. T., Rendina, H. J., Whitfield, T. H., & Grov, C. (2016). Familiarity with and preferences for oral and long-acting injectable HIV pre-exposure prophylaxis (PrEP) in a national sample of gay and bisexual men in the U.S. AIDS and Behavior, 20(7), 1390–1399. https://doi.org/10.1007/s10461-016-1370-5.CrossRefPubMedPubMedCentralGoogle Scholar
- Pérez-Figueroa, R. E., Kapadia, F., Barton, S. C., Eddy, J. A., & Halkitis, P. N. (2015). Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: The P18 Study. AIDS Education and Prevention, 27(2), 112–125. https://doi.org/10.1521/aeap.2015.27.2.112.CrossRefPubMedPubMedCentralGoogle Scholar
- Rendina, H. J., Whitfield, T. H. F., Grov, C., Starks, T. J., & Parsons, J. T. (2017). Distinguishing hypothetical willingness from behavioral intentions to initiate HIV pre-exposure prophylaxis (PrEP): Findings from a large cohort of gay and bisexual men in the U.S. Social Science and Medicine, 172, 115–123. https://doi.org/10.1016/j.socscimed.2016.10.030.CrossRefPubMedGoogle Scholar
- Rofes, E. (1998). Dry bones breathe: Gay men creating post-AIDS identities and cultures. New York: Harrington Park Press.Google Scholar
- Shapiro, L. (2014). The most celebrated, mistrusted little pill in the world. Huffington Post. Retrieved from https://www.huffingtonpost.co.uk/entry/prep-hiv-truvada_n_6185028?guccounter=1.
- Storholm, E. D., Volk, J. E., Marcus, J. L., Silverberg, M. J., & Satre, D. D. (2017). Risk perception, sexual behaviors, and PrEP adherence among substance-using men who have sex with men: A qualitative study. Prevention Science, 18(6), 737–747. https://doi.org/10.1007/s11121-017-0799-8.CrossRefPubMedPubMedCentralGoogle Scholar
- Strauss, B. B., Greene, G. J., Phillips, G., Bhatia, R., Madkins, K., Parsons, J. T., & Mustanski, B. (2017). Exploring patterns of awareness and use of HIV pre-exposure prophylaxis among young men who have sex with men. AIDS and Behavior, 21(5), 1288–1298. https://doi.org/10.1007/s10461-016-1480-0.CrossRefPubMedPubMedCentralGoogle Scholar
- Tappan, M. B. (1997). Interpretive psychology: Stories, circles, and understanding lived experience. Journal of Social Issues, 53(4), 645–656. https://doi.org/10.1111/j.1540-4560.1997.tb02453.x.CrossRefGoogle Scholar
- Whitfield, T. H. F., John, S. A., Rendina, H. J., Grov, C., & Parsons, J. T. (2018). Why I quit pre-exposure prophylaxis (PrEP)? A mixed-method study exploring reasons for PrEP discontinuation and potential re-initiation among gay and bisexual men. AIDS and Behavior, 22, 3566–3575. https://doi.org/10.1007/s10461-018-2045-1.CrossRefPubMedGoogle Scholar