(1) “One-a-day”–easy, convenient, effective.

At the outset of each interview, most participants indicated that they did not know very much about PrEP or how it works. Thus, each interview began with us providing a standardized and brief overview of PrEP and how it functions. Initially, many participants likened PrEP to female birth control (“the pill”), frequently referring to the ease and convenience of being able to take a daily dose and be assured of protection. For example, one 22-year-old gay man who reported multiple concurrent sexual partners described:

It’s just like girls can get birth control, you know what I mean? Like, if I can go and just say, like, “Don’t wanna get HIV” and like [the doctor could say] ‘Here you go. Here’s your “one-a-day”‘. (#023)

Most respondents indicated that PrEP was not for everyone, explaining that it would be best suited for use by ‘high-risk’ groups (e.g., sexually “promiscuous” people). Some respondents positioned PrEP use by ‘high-risk’ people as being an act of taking on responsibility for both personal and public health reasons. For example, a 23-year-old straight man explained his view that PrEP would be appropriate for gay men to use:

I think that’s a great approach if they want to take it, by all means, they should be protecting themselves and potentially future partners that they have. (#029)

Like this young man, many participants who did not perceive themselves to be at ‘high risk’ for HIV positively viewed PrEP’s convenient, ‘once-a-day’ approach and acknowledged its potential as an effective risk-reduction strategy for those ‘others’ who were at ‘high risk’.

(2) ‘Bullet-proof’–exacerbating risky practices.

Some participants described how the introduction of PrEP might affect perceived HIV risk. For instance, one 20-year-old straight man who was engaged in sex work at the time of our interview worried that the expansion of PrEP as a risk-reduction strategy could result in a ‘shift’ in how ‘high-risk’ individuals understand HIV risk and, thus, exacerbate the likelihood that they would choose to engage in risky practices:

I wouldn’t just hand PrEP out over the counter, like Advil.™ […] It’s not like it’s a cure. Remember, it’s a treatment. ‘If it [PrEP] was given out like Skittles, everyone is going to think it’s a cure’ (#041).

Although clinical guidelines indicate that those who initiate PrEP are to be clinically monitored and tested for HIV and other STIs at recommended intervals, some participants were concerned that PrEP could inadvertently reduce some men’s engagement with HIV testing. As one 22-year-old bisexual man worried:

I wonder how frequently they would still test. Because I think that frequent testing would actually be a more positive way of making sure that people are safe and cared for than treating somebody for a disease they don’t have. (#017)

These kinds of statements reflect an overall conception of PrEP as the provision and consumption of a medication. In our sample, few people focused on the fact that PrEP approaches also involve ongoing clinical monitoring and engagement with care providers and PrEP was therefore generally characterized quite simplistically as ‘taking a pill’.

Others suggested that young men who decide to initiate PrEP might be more likely to engage in condomless sex, promiscuity, or other ‘high-risk’ behaviour. For example, one 20-year-old gay man who described himself as being ‘low-risk’ for HIV described how PrEP could unintentionally result in increased sexual activity among some individuals:

If they know that ‘Okay, I’m on treatment. And because ‘I’m on treatment, I’m like, you know, I’m bulletproof. I could be even crazier!’ I don’t think it’s a good idea. (#024)

Similarly, a sub-set of participants who had previous experiences with illicit drug injecting worried that those who choose to initiate PrEP may be less likely to seek out and use sterile syringes, as one 20-year-old straight man who was living on the streets at the time of our interview explained:

They’d probably think that ‘Oh, I take this pill, so I’m not going to catch anything.’ And then they’re just gonna share needles. (#034)

The participants in our study included people who could be characterized as ‘low risk’ (e.g., those who had not been sexually active for several months) as well as those who could be considered at ‘high risk’ for acquiring HIV (e.g., those who report frequent experiences of sharing syringes or who avoid the use of condoms). However, both ‘low’ and ‘high’ risk participants articulated the assertion that PrEP could exacerbate risk practices amongst so-called ‘high-risk’ individuals.

(3) ‘High-risk lifestyles’–stigma and individualized practices.

Use of PrEP was often portrayed as being problematic because it was viewed as an ‘excuse’ from adherence to other risk-reduction practices and, therefore, it was also often viewed as contributing to ‘high-risk’ lifestyles. The language use and tone of these portrayals were highly individualizing and accusatory, as the following example from a 19-year-old straight man illustrates: Just because you are on the most amazing treatments in the world, I don’t think it excuses not having safe sex (#002). In expressing their concerns about PrEP, participants, including many who identified as gay, bisexual, or MSM, frequently drew on stereotypes that link promiscuity and condomless sex with a ‘gay lifestyle’ and used those prejudices to underpin their negative opinions about PrEP. For example, one 20-year-old gay participant who was involved with multiple concurrent sexual partners at the time of our interview described PrEP’s potential impact on gay men’s sex lives in nihilistic terms:

I think it’s [PrEP] ridiculous. I think it’s this kind of idea that the drugs will fix it instead of being a little bit more safe […] It seems a little bit like a kind of a “Rolls Royce” kind of condom to me–it seems a little bit extreme. […] If people are paying thousands of dollars out of pocket so they can be having bareback sex, I think that’s a little bit insane. […] I think that if you’re offloading kind of the responsibility for safe sex onto a pill […] it has this kind of fatalism for me that I don’t appreciate. (#014)

Participants’ concerns about PrEP, promiscuity, and condomless sex, especially amongst people who identify as gay, bi-sexual and MSM, were often juxtaposed against more conventional approaches to HIV prevention (condom use; limiting numbers of sex partners). As one 20-year-old gay participant who described himself as being ‘low-risk’ for HIV explained:

I think the fine line is this: the people who are [already] promiscuous are going to be even more sexually active than they were before, and that defeats the purpose of having the antivirals. Either way, they’re probably gonna get it [HIV]. (#024)

In contrast to these somewhat fatalistic perspectives, participants also described scenarios under which they thought PrEP would be an acceptable risk-reduction strategy. A frequent example of a condition under which PrEP would be viewed to be acceptable was among HIV serodiscordant couples. For example, one 21-year-old straight man (who himself reported having multiple concurrent sex partners) described how he thought PrEP would be highly acceptable and helpful for ‘faithful’ serodiscordant couples, while highly unacceptable for ‘promiscuous’, single people:

In [the situation of serodiscordant couples], I’d be like “Okay, cool.” Cause, they’re in a committed relationship, they’re being faithful. So, obviously they’re not gonna run around and be all promiscuous or running all over town, right? So that would make sense, cause you’re helping someone in a committed relationship to stay healthy. Whereas, on the flip side, you’re helping someone that’s promiscuous to keep being promiscuous. (#009)

Thus, a complex and sometimes conflicting narrative emerged in which PrEP was described both as a ‘responsible’, safety-enhancing strategy (when used by monogamous serodiscordant couples) or a highly ‘irresponsible’ approach that excused people from engaging in other, more conventional risk-reduction practices. A 22-year-old straight participant who had previously engaged in same-sex sexual behaviour and reported a history of injection drug use went as far to say that he feared that being on PrEP could serve as a proxy for one’s stigmatized social status:

It would almost turn into an insult. People would be like ‘Oh well he’s on the preventative treatment. That’s the sort of person he is.’ Or, ‘You’re such a slut! You should be on preventative treatment’. And that would be a huge insult if such were the case. (#007)

A strong theme emerged across the interviews whereby participants suggested that rather than choosing to initiate PrEP, individuals at high risk of HIV should focus their efforts on reducing or eliminating their risk through other practices (e.g., use condoms; stop sharing syringes). Clearly, these narratives position risk, risky behaviour and risk groups in highly contentious ways–and the absence of recognition of structural risk or other contextually based factors that contribute to risk of HIV was remarkable. The strong ways in which individualization of responsibility for reducing HIV risk is succinctly summarized in the following quote from one 24-year-old straight man that was not sexually active at the time of our interview, as he said:

Instead of continuing these risky behaviours and using HIV medication, maybe people should just stop the behaviour, right? (#020).

Furthermore, several participants felt that those who choose to engage in “high-risk lifestyles” while using PrEP should be required to pay for the treatment themselves, rather than have government subsidies cover the costs. For example, one 21-year-old straight man that reported multiple concurrent sexual partners explained:

Someone that’s living a–what would be classified a “high-risk lifestyle", then obviously they need to deal with the consequences and take precautionary measures. I can’t say it’s wrong, I mean, they can do whatever the hell they wanna do. It’s their life. But with regards to providing treatment? They should, in my opinion, pay for it. Because they’re putting themselves in high-risk positions. (#009)