Between risk and pleasure: reflections on HIV prevention and care in the current context of PrEP use by men who have sex with men

Entre o risco e o prazer: reflexões sobre a prevenção e tratamento do HIV no contexto atual do uso da PrEP por homens que fazem sexo com homens

Entre el riesgo y el placer: reflexiones sobre la prevención del VIH y la atención en salud en el contexto actual del uso de PrEP por hombres que tienen sexo con hombres

Abstracts

This study offers a set of reflections on the relationship between risk and pleasure in the field of HIV prevention and care, as it mediates new biomedical prevention/care technologies, particularly pre-exposure prophylaxis (PrEP), among men who have sex with men (MSM). We begin by investigating some studies about condomless sex between men, more specifically barebacking and PrEP use among young MSM. We base our analysis on the assumption that PrEP, as one of these new actants, has reconfigured the field of HIV prevention/care, especially in relation to the dimensions of risk and pleasure, with the potential to considerably reduce the chances of HIV infection while enabling maximum pleasure and a sense of greater safety and freedom. Despite this progress, we also problematize some of the ambivalences, tensions, and moral conflicts that still exist in the field of prevention, especially the potential for condomless sex. Finally, taking a praxiographic perspective on health care and foregrounding the situated practices of human and non-human actors/actants in interaction, we consider HIV/AIDS prevention as a more fluid, non-linear, erratic phenomenon that involves multiple types of knowledge, feelings, and participations, and is open to different kinds of experimentation. Besides a “logic of choice”, we hold that health care is a permeable, continuous process that is enacted in situated practices and may produce different effects in response to a heterogeneous network of interactions.

Keywords: Risk; Pleasure; Pre-Exposure Prophylaxis; Men Who Have Sex With Men

O artigo fornece um conjunto de reflexões sobre a relação entre risco e prazer no campo da prevenção e tratamento do HIV, além de colocar na agenda a mediação das novas tecnologias biomédicas de prevenção e tratamento, particularmente a profilaxia pré-exposição (PrEP) entre homens que fazem sexo com homens (HSH). Começamos por rever alguns estudos sobre o sexo sem preservativo entre homens, mais especificamente o barebacking e o uso de PrEP por HSH jovens. Baseamos a análise na pressuposição de que a PrEP, enquanto uma das novas tecnologias, reconfigurou o campo da prevenção e tratamento do HIV, especialmente em relação às dimensões de risco e prazer, com o potencial para reduzir consideravelmente o risco de infecção pelo HIV ao mesmo tempo em que permite o prazer máximo e uma sensação de maior segurança e liberdade. Não obstante esses avanços, também problematizamos algumas das ambivalências, tensões e conflitos morais que persistem no campo da prevenção, principalmente o potencial para sexo sem preservativo. Finalmente, a partir de uma perspectiva praxiográfica sobre os cuidados de saúde e destacando as práticas de atores/actantes humanos e não humanos na interação, consideramos a prevenção do HIV/aids como um fenômeno mais fluido, não linear e errático, que envolve múltiplos tipos de conhecimento, sentimentos e participações, e que está aberto a diferentes tipos de experimentação. Além de uma “lógica de escolha”, propomos que os cuidados de saúde constituem um processo permeável e contínuo que é instituído em práticas situadas e que podem produzir efeitos diferentes em resposta a uma rede heterogênea de interações.

Palavras-chave:  Risco; Prazer; Profilaxia Pré-Exposição; Homens que Fazem Sexo com Homens

Este trabajo ofrece un conjunto de reflexiones sobre la relación entre riesgo y placer, en el ámbito de la prevención y tratamiento del VIH, ya que debate el impacto de las nuevas tecnologías de prevención/cuidado biomédicas, particularmente la profilaxis de preexposición (PrEP) entre los hombres que tienen sexo con hombres (HSH). Empezamos investigando algunos estudios sobre el sexo sin condón entre hombres, más específicamente a pelo, y el uso de PrEP por parte de jóvenes HSH. Basamos nuestro análisis en la asunción de que la PrEP, uno de estos nuevos actantes, ha reconfigurado el campo de la prevención y cuidados del VIH, especialmente, en relación con las dimensiones de riesgo y placer, con el potencial de reducir considerablemente las posibilidades de infección por VIH, mientras que permite un máximo placer y sensación de una mayor seguridad y libertad. A pesar de este progreso, también problematizamos algunas de las ambivalencias, tensiones, y conflictos morales que todavía existen en el ámbito de la prevención, especialmente el potencial del sexo sin condón. Finalmente, teniendo en consideración una perspectiva praxiográfica sobre la atención en salud, y destacando las prácticas mencionadas de actores/actantes humanos y no humanos en la interacción, consideramos la prevención de VIH/SIDA como un fenómeno errático más fluido, no lineal, que implica múltiples tipos de conocimiento, sentimientos, y participaciones, y está abierto a diferentes tipos de experimentación. Además de la “lógica de elección”, sostenemos que la atención sanitaria constituye un proceso permeable, continuo que se concreta en las prácticas mencionadas y puede producir diferentes efectos como respuesta a una heterogénea red de interacciones.

Palabras-clave:  Riesgo; Placer; Profilaxis Pre-Exposición; Hombres que Hacen Sexo con Hombres

Introduction

In Brazil, the risk of HIV infection remains high among men who have sex with men (MSM) ¹, with new cases occurring primarily among young MSM ². Despite this scenario, there is also optimism in the scientific community, especially in response to recent biomedical findings which indicate that individuals living with HIV and receiving antiretroviral treatment will stop transmitting the virus during sex if they reach an undetectable viral load ^3,4,5,6,7,8. Another biomedical breakthrough is pre-exposure prophylaxis (PrEP), the daily use of a pill composed of two antiretroviral drugs (emtricitabine and tenofovir) by people who are HIV-negative. Randomized clinical trials have shown the effectiveness of PrEP in preventing HIV infection ^9,10,11.

These new technologies represent significant steps forward in the fight against the epidemic. However, it is important to discuss how they have contributed to or reconfigured certain aspects of sexual practices among men, enabling more anxiety-free sexual activities or satisfying them, while also raising new issues for discussion. For example, in the case of an undetectable viral load, this new status could reduce anxiety about sexual intercourse by decreasing concerns about HIV transmission ¹². As for PrEP, it may also enable enhanced sexual satisfaction and intimacy, and an increased sense of security and ease in situations in which condoms are unavailable or it is hard to negotiate their use ^{13,14,15,16,17}.

Yet, notwithstanding these positive effects, conflicts/tensions and ambivalence still permeate this context. For example, despite all the information and discussion on the international scenario about “undetectable = untransmissible” ^7,8, people living with HIV may still see themselves and be seen by others as “high-risk” individuals ¹⁸ - a narrative that still conjures up feelings of guilt and fear due to the infection or the potential to transmit HIV, especially in the context of gay/homosexual men, who tend to be seen as more “excessive” and “promiscuous” or else marginal or wretched ¹⁹. As for PrEP use, despite its benefits and effectiveness in preventing HIV, it has been associated with the negative image of promiscuity attributed to gay men ^20,21,22. These stigmas, including the association with HIV, may produce barriers to the acceptability ^23,24 or even the continued use of PrEP ^21,22.

Considering this ambivalent scenario, in which pleasure may be experienced more freely or with less fear/guilt, at the same time that (moral) barriers are built or reformulated for some of these actors and their pleasure, especially when it comes to condomless sex, it is important to discuss the dimensions of sex/pleasure and risk outside the biomedical domain and the ideas of “control” and “choice” in the context of disease prevention and health care ²⁵, especially ideas of “safe sex”. Here, we will highlight the daily scenarios or practices in which people, partners, technologies, symbols, fantasies, etc. interact, indicating how fluid, multiple, unstable, and unpredictable prevention and care can be.

As such, this essay draws on the literature - particularly on some studies conducted in Brazil - to offer a reflection on the relationship between risk and pleasure in the field of HIV care and prevention, putting into perspective the mediation of these new biomedical prevention and care technologies, especially PrEP. The idea is to show how these new technologies have mediated or reconfigured sex between men insofar as they considerably reduce the chances of HIV infection/transmission. In this sense, we view PrEP-agency as part of a network of relationships, acknowledging its status as an actor/actant with the capacity to produce displacements and movements and influence the actions of other actors ²⁶. Finally, we also problematize some persistent ambivalences and tensions in this field, especially since biomedical breakthroughs enabled the potential for condomless sex.

In so doing, we sustain the argument that while these new technologies may signify a “new gay sexual revolution” ²⁷, assuaging the climate of AIDS-related fear and paranoia and enabling experiences of greater freedom and pleasure, they also prompt a reworking of discourses and practices of body, pleasure, and health care normalization. These are biopolitical processes that enable arousal, but also involve regulation and control ²⁸, including the very routines and procedures inherent in using medications/technologies in the context of global consumption. As such, we stress the importance of thinking about care and prevention in manifold ways, considering the malleability, porosity, and fluidity of the practices involved and even the actors/actants at play.

While we underline the multiplicity of care, we should also point out a few important considerations. When prevention and care are discussed in the realm of health, is it common for care to be conceived in a way that seems strongly linked to the concept of risk, meaning threat, danger, and negative, undesirable results; i.e., something to be avoided ^29,30. Lupton ²⁹ points out that this focus on risk avoidance is strongly associated with the ideal of a civilized body, a growing desire to control life, to rationalize and regulate the self and the body, and, ultimately, to avoid the “vicissitudes of fate”. While there may be other means of conceiving of health care that consider individual subjects, their intersubjective relations, and the barriers to their “projects for happiness” ³¹, the way care is often conceived seems closer to this prevention-oriented rationale. When viewed from this perspective, the individual, as an information-processing unit, should perceive their vulnerability to risk and the serious consequences thereof, while, at the same time, believing that prevention will be effective, and the benefits will be greater than the costs ²⁹. It is an attitude that leaves little room for comprehending the rationalities present in actual sexual practices. “Care”, when viewed from this perspective, tends to involve actions that revolve mostly around simplified and prescriptive educational offers.

Turning the spotlight on more concrete, lived experiences in situations involving “risk” gives us a chance to see that better or safer options are not always available for individuals in such circumstances. People’s everyday experiences involve myriad tensions, stoked by desires, fears, pleasures, etc., quite apart from the moments in which rational choice is the main driving force. What we attempt to do, then, is to strike some kind of balance between these different values, desires, and pleasures, which is to say that we are intersected by many “modes of ordering”, “styles”, or “logics” and that, in the course of our practices, unexpected things always happen, demanding great creativity on our part ²⁵. This is why the notion of the logic of care proposed by the philosopher and anthropologist Annemarie Mol ²⁵ is so important, as it provides us with the opportunity to comprehend these concrete situations in which people face the need to reconcile tensions between desires, fears, and demands for protection.

Therefore, in the debate proposed here, we understand care as something that is produced in different ways in various sexual interactions, deriving from dissimilar kinds of knowledge, diverse actants, and distinct “meanings” and lived experiences. For that reason, the notion of care developed by Mol ²⁵ offers an important contribution. She shows the limits of individual “choice” when people find themselves in the specific situation (and place) of sickness and care. The discussion shown below about condomless sex shines a light on the fact that knowing what is “appropriate” at each place or in each situation is not a given. People acquire this understanding in dynamics whose coherence is tenuous, localized, and which may appear pertinent but not necessarily obvious to the people involved.

Condomless anal sex between men: a borderland between risk and pleasure

We begin this section with a discussion about the relationship between risk and pleasure in some homoerotic practices, considering the ambivalence inherent to them. Specifically, we start out with some sexual practices regarded as freer, barrier-free, or raw, even if, paradoxically, that may appear improbable, especially at a time when prevention technologies can even be lodged in our own body, as is the case with the use of a chemical substance such as PrEP ³². For this reason, it is important to consider the erotic factors that motivate subjects, as well as the moral dimensions that impose limits on certain practices taken as excessive. One such case is barebacking, which is generally understood to be the conscious, deliberate decision to engage in condomless anal sex in full knowledge of the risks involved ³³.

In a study conducted between 2006 and 2008 to assess some versions of this emerging phenomenon in the mid-2000s in Brazil, Silva ³⁴ found manifold practices and meanings, and contributed to discussions about some of the effects or meanings then in vogue, such as resistance to prevailing health/prevention discourses ^35,36 and to the fear induced by the AIDS epidemic ¹⁶, or even the association with an increased sense of freedom and of individuals’ right to choose ³⁷. Far from homogeneous, fixed or stable, what came to light was a nuanced polysemous practice that had diverse ramifications and formulations, constituting a complex, open, multiple object or phenomenon that shifted and was enacted by practices. Race ³⁸ (p. 161) described a similar phenomenon in reference to the multiple nature of condomless sex: “sometimes it is produced as barebacking. Sometimes it is produced as serosorting, or ‘negotiated safety’. Sometimes it is produced as an erotic transgression of gay community and public health norms”.

Seen in this light, it should therefore be stressed that many gay and other MSM may also use different strategies to reduce or manage their risk of HIV infection or transmission in their sexual activities in ways that are more consistent with their own sexual desires, experiences, and practices ³⁹. They may also prefer to be top or bottom, may seek partners that are seroconcordant for a relationship, try to withdraw before ejaculating or even rely on certain “bodily signs” to assess whether they can “trust” their partner ⁴⁰. In other words, even in condomless sex, there are other forms of care that are brought into play above and beyond the biomedical rationale, mediated by native theory or by knowledge stemming from lived bodily experiences, in which different senses (sight, taste, smell, etc.) can serve as “scientific categories” to identify risks, the quality of encounters, and engagement in different practices ¹³.

As Mol ²⁵ (p. 21) describes, aside from the availability of products (and choices), care is a process that has no clear boundaries, meaning it is “not a transaction in which something is exchanged (a product against a price), but an interaction in which the action goes back and forth (in an ongoing process)”. According to the logic of care, she explains, the unpredictability of bodies and life itself must be noted, as must the particularities and differences and conditions in which people and groups live. And it is according to this unpredictability and viscosity of life - with its many “variables” that are beyond our control ⁴¹ - that care cannot be thought of as a clearly delineated product, but as a semi-open process, in which there will be trial, adjustment, and new attempts, always with the aim of producing a better life or a possible existence ²⁵. This route towards producing a better life is marked by needs for protection, desires, pleasure-seeking, fears, feelings of guilt, and anxiety. They are processes permeated by tensions that cannot be avoided, as they are part of the very fabric of life.

Another key point from Silva’s study ³⁴ is that sometimes the concept of barebacking appears in association with intentionally unprotected sex and with casual partners or strangers, whereas, at other times, it appears in association with more generic condomless sexual activity, irrespective of the relationship with the partner (or lack thereof) or any intentionality implicit in the act ⁴². Considering this more generic definition, it is interesting to draw attention to the following point: some men say they bareback with their boyfriends, distinguishing what might be considered healthy barebacking from other more wild, promiscuous or potentially disease-transmitting barebacking. As such, some accounts attempt to legitimize or recognize the possibility of unprotected sex. This, according to Silva ⁴² (p. 518), may indicate the way or the intensity with which discourse about safe sex “has become intertwined with a general norm of ‘good conduct’ for the healthy functioning of bodies and relationships”.

Two potentially antagonistic or conflicting situations arise from this discussion: unprotected sex with a steady or trusted partner versus casual sex with strangers. In this discursive trajectory about sexual practices, the reference to the promiscuous gay man is often used to bring to mind a hierarchy of sexual values, separating “good” sex from “bad” ⁴³. In this sense, even within homoerotic practices, the image of promiscuity seems to have the function of distinguishing between gay lifestyles and identities, such as between those who are promiscuous and those who have what could be regarded as a healthier, more normal relationship, or one that can be self-regulated; an image that still seems to prevail among young gay men living with HIV as a justification for seroconversion ⁴⁴. It is no wonder that Dean ⁴⁵ highlights barebacking as a way of not being assimilated by a monogamous norm or the ideal of the non-promiscuous gay man.

If we return to the specific practice of barebacking prior to the emergence of PrEP, it is important to stress that this came about in “a borderland of tension between the pleasure of sensory contact and the risk of infection [with HIV]” ⁴⁶ (p. 694). The pleasure of risk did not necessarily mean an intentional or conscious movement towards HIV - the active pursuit of HIV-positive individuals to contract HIV, commonly known as bug-chasing. Even if this may take place, granting erotic satisfaction through the fantasy of deep connection, unlimited intimacy, fraternity, kinship, or permanence through the virus, and thus being more than just a disease ⁴⁵, many other barebackers simply point to the heightened sensorial pleasure to be enjoyed by having condomless sex ^37,47, bringing into focus the excess pleasure enjoyed by violating frontiers or the separation of bodies; and consequently, valuing barrier-free, rubber-free, more intimate, raw, naked, natural, in-the-flesh sex.

Today, stigmatization processes are still in place and still produce vulnerabilities despite the emergence of new actants like PrEP and an undetectable viral load, which remove the risk of HIV infection/transmission or cease to necessarily associate it with condomless sex. Meanwhile, the whole vocabulary surrounding it has been expanded to include “natural sex”, “real sex”, or just “condomless sex”, rather than “barebacking” ^16,32. It is important to remember that these (not so) new uses and meanings were already around before these biotechnologies came into existence, including when barebacking came to be used as a synonym for any kind of condomless sex ⁴², putting the focus on sensorial pleasure at a time when attempts were being made to remove some of its negative associations, such as the desire to contract or pass on HIV ⁴⁸. As these authors note, as time has gone by, what seemed to be an organized movement for freedom of choice (to use or not use a condom) has been gradually replaced by a dispersion of practices and meanings, with more diluted, individualized forms of transgression, and heterogeneous intentions and trajectories.

As we will discuss below in our consideration of the latest biomedical breakthroughs, which could curb or even prevent new cases of HIV infection or transmission, we should also consider how the relationships between pleasure, risk, and erotic fantasy that mobilize different sexual practices - including direct contact with another man’s sperm - have come about or been reconfigured, even when the risk of other sexually transmitted infections (STIs) continues to be an issue. What we want to argue here is that despite changes, these tensions between pleasure and risk/danger are still present, mobilizing or coproducing subjects and practices.

The relationship between risk and pleasure in the context of biomedical progress

“It happened.

I went to [name of establishment]. There was this guy there that I call a hunk and a half. Really big, long-haired, with a big cock. What a wet dream. I kept on brushing past him. I went to that darker part where there’s a fence and he went after me. I stayed there behind the fence watching what was going on and he came up behind me, rubbing himself against me. He pulled out that big wet cock and began to rub it on my tight little butt. I get shivers down my spine just thinking of it. His cock was already wet, and he quickly managed to get it in. That’s when I remembered about the condom, but by then it was too late to get it. He told me to lean over, and he held onto the fence while he pushed into me. It was so hot. He fucked me really hard and fast. There was already a bunch of guys standing round, masturbating and watching.

I began to grab, masturbate, and suck different ones that were nearby until one came in my mouth. I had to wash it out and I think that’s why that hunk and a half didn’t come in my ass. Just as well. If he had I would have been really worried, but it was really good. God, I just love whoring around [laughs]” ⁴² (p. 521-2).

“Except one day I... I have protected sex, but it happened, drinking, it happened, the same thing, that I ended up having sex without a condom twice, but I didn’t worry anyway because I use PrEP. Because I know it’ll stop me from getting HIV, but not anything else (...) ‘Cos there’s no cure for HIV but there’s treatment for the rest, so I didn’t worry. Not that I want [wanted] to catch something, but I felt OK, you know? (...) ‘cos I know the person. I did it again afterwards [and] nothing happened. I just did the test and nothing. That was a relief. I’m not going to go out and have sex without a condom, but I was relieved” (account given by a 19-year-old participant as part of the PrEP1519 project, Brazil, 2019).

“They [family] asked what the medicine was and I explained it was PrEP. Then, they understood that it was a medicine to prevent HIV and all that, and then they asked why I was doing that treatment, and I said ‘Look, guys, you know what a busy life I have’ [laughs], and that’s how it was (...) I think I’m (...), you know, to be able to be using PrEP in a high-risk situation, because I get together with all sorts of people and sometimes I don’t even know if the person’s being safe or not” (account given by a 19-year-old participant as part of the PrEP 1519 project, Brazil, 2019).

These accounts were produced at different times vis a vis the introduction of PrEP. They are narratives that serve as examples or vignettes for us to think about the interplay between risk and pleasure, and may be guided by the signs of “excess” or “controlled permissiveness”. Thus, the need to protect oneself using whatever technologies are available coexists in tension both with a body that appears more open, unstable, and somewhat unpredictable, and also with different prevention norms and discourses, including the prevention of other STIs. At the same time, if new prevention technologies like PrEP can enhance feelings of safety and freedom, as at bareback orgy parties ¹³, it should be noted that different prevention strategies or methods may be brought into play (including a condom) depending on the contingencies and actors involved in the sexual encounter.

In any attempt to problematize the relationship between risk and pleasure, especially in the situations of condomless sex discussed here, it would be quite wrong to say that people fail to take care of themselves or that they are absolutely free to do whatever they want. In group sex, for instance, there are also “norms” or principles that regulate or impose certain limits, like the idea of consent, even if they may be breached or modified or there may be fissures in what may have been agreed, foreseen or imagined beforehand ¹³.

Complementing the data that point to reduced condom use among PrEP users ^49,50,51,52, we would like to focus on this complex relationship between risk and pleasure, or, as Silva ⁴⁰ (p. 334) puts it, this “complex network of negotiated losses and gains” that takes place in the diverse reality of sexual encounters, in which interests, emotions, bodies, partners, fantasies, values, prevention strategies, medications, and diverse actants interplay. As Silva-Brandao & Ianni ¹⁶ note, also taking the risk of STIs into account, people may negotiate condom use, weighing up their fears and sexual interests in the pursuit of pleasure or even testing out or using drugs like antibiotics as prevention methods ^13,16,53. Meanwhile, in this negotiation between losses and gains or this offsetting of fear and pleasure, the risk inherent to acquiring an STI may be viewed as lower in view of the prospect of treatment and cure ¹³.

Returning to the narratives we showed above, the first scene, posted in an online community which discussed experiences of condomless sex ⁴², shows some of the situations in which heightened sexual arousal seems to outweigh all other considerations, specifically those involving another individual whose appearance is perceived as irresistible (the “hunk and a half”) and a body that appears more open, seamless, and permeable to the world and to another. Certainly, it is impossible not to notice here how an image or sign of masculinity (penis size) galvanizes the other man’s fantasy. This indicates that erotic practices, despite their transgressive potential, with the power to produce profound feelings of “inseparability” between beings and thus, violation and excess ⁵⁴ or even “transcendence” ⁵⁵, occur in dialogue (and tension) with social norms, including those relating to gender and sexuality.

In this sense, risk appears as an important element of erotic practices, especially when it is associated with the transgression of social norms and conventions, with the power, as Gregori ⁵⁶ points out, to jeopardize gender and sexuality conventions, making it impossible to retain complete control or the assurance that abuse and violence will be avoided. In this perspective, for us to better understand the situations in which condomless sex takes place, it is important to bring to the forefront of the analysis these threshold situations of tension between pleasure and risk/danger or, as Gregori ⁵⁷ (p. 3) insists, these “limits of sexuality”, understood as a “borderline zone where norm and transgression, consent and abuse, pleasure and pain coexist”.

It is worth noting here that the “shivers down the spine” reported in the first account show a certain ambivalence in the face of the risk of losing oneself in the other. As seen in other situations that are apparently more excessive or transgressive, the act of transgressing, interfering with or destabilizing boundaries (of identities, morals or social mores) seems to be an important element of pleasure that is present in many sexual encounters and practices, such as direct, intense contact with another man’s semen (spunk or cum), which may signify sharing, communion, partner mixing, and an “interchange” of masculinities ⁴⁶ or even augmented masculinity ⁵⁸. As Lupton ²⁹ points out, beyond the negative (probabilistic) dimension, transgressing (cultural and corporal) boundaries may well prompt fear and anxiety, but also fascination, arousal, ecstasy, or be a source of pleasure. In other words, transgression is a high-risk activity because it confronts the given or set conceptual (and bodily) boundaries. Following this line of thinking, feelings of ecstasy, losing one’s head, or losing oneself in another ⁵⁶ when engaging in erotic practices may be risky because they challenge our Western ideas of self-determination, self-regulation, order, and self-containment or even control of our bodies, while at the same time they may produce a sense of anxiety around the relaxation and loss of control of the boundaries of the body/self ⁵⁹.

When we stress the tensions of sexual practices with respect to pleasure and risk, even if we consider that, in some situations (barebacking), participants may know in advance that no condom will be used, with consent being an important and triggering element of the practice ¹³, there are also fissures that should be acknowledged. Activities may reach a level of “intensity that may not have been foreseen or anticipated”, potentially leading to the breach of the “pact made with the other and with the self” ⁶⁰ (p. 4). Just as intention may be “enacted” by gestures and movements, being relational and performative ⁴⁸, so authorization with regard to another (what you can do or what I want to do) also may be indicated by gestures and body language ¹³, and may be unclear in practice, such as when there is a loss of control over the “limits of the interaction” ¹³. As we saw in the first account, crossing limits or boundaries - when the other man seems to appear out of nowhere, penetrating him without a condom, or especially if someone comes inside him - can also elicit ambivalent feelings and emotions, in which pleasure is mixed with worry, anxiety, fear, and guilt.

In a context in which new preventive technologies like PrEP are emerging, it is possible that feelings like these are attenuated or that users feel encouraged to explore other sexual practices, even if they still experience moral conflicts. Such is the case of the second account, given as part of our qualitative research with young MSM and transgender women aged 15 to 19 in the city of Salvador (Brazil), as part of a demonstration project of PrEP use among these key populations in Salvador, Belo Horizonte, and São Paulo (PrEP1519 study).

PrEP1519 is the first cohort study in Latin America of the use of PrEP by MSM and transgender women aged 15 to 19 years. A variety of strategies (peer educators, social media platforms, hook-up apps, word-of-mouth, and a chatbot called Amanda Selfie) were employed to reach out to the target audience, resulting in the enrollment of 383 adolescents and youth for PrEP use and 101 for the non-PrEP-use branch of the program by April 2020 ⁶¹. Between July 2019 and June 2020, the research team carried out 20 semi-structured interviews with adolescent and young MSM taking part in the PrEP1519 program in Salvador, covering topics related to their PrEP experience and the relationship between their PrEP use and the different dimensions of their life: sexual/love and family relationships, work, etc. The interviews were conducted in private rooms at the project headquarters by members of the research group who were specialized in qualitative approaches. Before their interviews, all participants read and signed an informed consent form or an informed assent form (for those under 18 years of age) and consented to having their interviews recorded (audio). The research was approved by the research ethics committees of the World Health Organization (WHO), the Faculty of Medicine of the University of São Paulo, and the Institute of Collective Health of the Federal University of Bahia (n. 3,224,384), and was conducted in compliance with Brazilian legislation (Brazilian National Health Council resolutions n. 466/2021 and n. 510/2016). As highlighted earlier, although this text takes the form of an essay, we have introduced the two scenes produced as part of the PrEP1519 study as a “pragmatic” means of illustrating and supporting our line of argument.

The second account brings up precisely some of these effects produced in the context of a situation in which the interlocutor seeks to justify a certain momentary loss of control with regard to condom use. Alcohol and the presence of a known partner emerge as important actors/actants (not so unpredictable, but not entirely predictable) in this situation, with the power to modify the course of action (condom use). However, PrEP also appears as a key actor/actant in this network of relationships that brings into play and enables the “condomless sex” scenario, coproducing the young man’s feelings in that situation: “I felt OK”. PrEP, therefore, appears here as an actant or differential, another line of protection in a context in which there may not always be a condom at hand. This management of condom use in the context of PrEP emergence does not necessarily mean a rejection of the condom, known for its importance for STI prevention.

Meanwhile, as we can see in the third account from the PrEP1519 study, the introduction of this technology to the young man’s life makes an important difference to the experimentation, contingency, and unpredictability of his sexual encounters: “you know what a busy life I have” and “I get together with all sorts of people and sometimes I don’t even know if the person’s being safe or not”. Thus, PrEP actualizes certain lifestyles, preferences, encounters or ways of experiencing sexuality. As an actant, PrEP also seems to shape or produce new ways of expressing oneself, one’s body, and one’s relationships, enabling more engaged, affirmative postures towards pleasure ⁶², even if in a sense of controlled permissiveness.

As a new addition to the prevention strategy toolkit, PrEP has raised new questions that extend the limits of the biomedical/pharmacological field. Even if its use is intersected with challenges, such as the need to generate adherence based on the regular ingestion of a pill every day at the right time, plus the possibility of side-effects, PrEP repositions or reconfigures certain “images” of prevention, blurring the boundaries between safe sex and risky/unprotected sex. Insofar as it is not a traditional barrier method (as is the latex of a condom), it enables its users to experience a different level of intimacy without the presence of a physical barrier, but with something new: diminished concerns about HIV. It could therefore enhance the feeling of safety in situations which do not feature condoms, enacting effects of sexual well-being ¹⁷.

Nevertheless, it should be noted that there are also conflicts or tensions in the daily use of PrEP, especially because it is in interactions and practices, in concrete, lived experiences that PrEP is enacted, takes place, or comes into existence, with the capacity to produce multiple effects as it interacts with other actors/actants. As our field research shows, sexual interactions may sometimes be tinged by doubts, worries, guilt, and fear because of slip-ups in the use of the medication. It is also important to stress that PrEP can be adjusted or reconfigured according to types of partnership, frequency of sexual activity, and patterns of sex/love life and may be suspended in situations where partners jointly weigh up the risk/pleasure ratio, which implies considering the existence of differences around ideas of stability, trust, risk, and even the need to use such a technology. It is also important to remember that this technology enters the real life of young people who have their own particular histories, families, relationships, and experiences. They exist in situations or practices in which different tensions occur, such as between the desire to more freely experience pleasure/sexuality and the ways they position themselves or are positioned in their interaction networks. Therefore, PrEP involves conflicts and ambiguities that actualize polarities, like control and freedom, disciplined and undisciplined body, threat and protection, at the same time that other logics and modes of care shift or come into play.

We cannot forget that taking up PrEP may (re)produce stigmas in relation to its users, resulting in them being labelled as “Truvada whores” ^63,64 or being seen, often mistakenly, as pathologically promiscuous or inclined to be careless ²⁰, presupposing that they no longer use condoms. These are moral conflicts that continue to exist and cause tension in sexual interactions and practices, when gay/homosexual men continue to be regarded as excessive, promiscuous or risk-prone ^18,23.

As Race ²³ points out, some of the types of “resistance” to PrEP use have to do with concerns about risk. The image of “unbridled homosexuality” seems to cause concern or even fear that, with PrEP, what once seemed like an exception could become the rule, meaning “no-holds-barred” sex between men. We therefore want to draw attention to the fact that besides the risks of other STIs, condomless sex is still present as a moral issue in the everyday lives of gay and other MSM, and may be particularly associated to some deviation, difficulty or health problem, such as low self-esteem, depression or drug abuse ⁶³; discourses that end up framing behaviors in pathological and medical terms, failing to consider the complexities of sexual practices and the meanings implied in (condomless) sex ⁴⁵.

As such, the pharmaceuticalization of sexual risk ⁶⁵ enabled by PrEP also implies multiple processes. In the case of HIV/AIDS, PrEP would appear to have the effect of “liberalizing” “safe” sexual pleasure and practices, which might be expected to weaken the stigma operated by the notion of risk behaviors associated with a particular group. However, we have seen that “old” and “new” signs are triggered as they are recommended and used, even tending to reinforce stigmas. But mostly what we have seen is that this “liberalization” of pleasure is counterbalanced by a domestication of sex/sexuality represented by PrEP as a sign of “controlled permissiveness”.

Concluding remarks

In this article, we have attempted to problematize the tensions that exist between risk and pleasure in sexual practices, especially between men, thinking of the changes and conflicts/ambiguities that still exist in the current-day context of new prevention technologies. By highlighting a set of sexual practices deemed high-risk and recognizing that realities (ontologies) are multiple, open, and political insofar as they are enacted in practice ⁶⁶, we have proposed thinking of HIV/STI prevention from the perspective of the logic of care ²⁵, and thus, as a process that is not linear, but dynamic, open, fluid, and erratic with multiple interactions and effects.

The need to protect oneself by using the available technologies goes hand in hand with the tension inherent to having a body that is open, unstable and, to some extent, unpredictable, prompting us to find ways to be “kind” to our bodies and their desires, allowing them to exist and be appreciated. While we may attempt to improve our lives, the ideas of good (living) or (caring) are not static or given, either; what could be “good” or self-evident in one situation may not be in another, insofar as situated practices are involved ^41,67. And that means engaging in endless trials and experimentations.

One point worth stressing here is the “limit” imposed by our own body, always in relation to other bodies. Certainly, human corporality is never experienced “raw”, but is always culturally mediated. Meanwhile, the body (materiality) is also recalcitrant - disobedient, rebellious, resistant, and uncontainable, with a frightening “will of its own” ⁶⁸. Similarly, we may think of the body as a “complex configuration” ⁶⁹, “semi-permeable”, full of tensions that cannot be avoided, but with which we must deal, such as when we are faced with the “limitations” of a disease or the “need” for prevention, not to mention our own desires.

In our attempt to articulate the dimensions of risk, pleasure, and care in the context of new biotechnologies, we remember that there are many ways of doing or enacting prevention/care. Meanwhile, these new technologies interact with other actors/actants - both human and non-human ²⁶ - yielding multiple effects and transformations. In these new scenarios of co-produced subjects, technologies, and other entities, including the sex “event” itself ²³, neither subjects nor technologies are the same. In sexual encounters, irrespective of intentionality and prior, condoms may enter or exit the scene (as may PrEP itself, given its different modalities, interests, and modes of use), insofar as there are many ways of managing or reducing risk ^13,39,40,53. Ultimately, in concrete, lived situations, things happen that were unplanned or unforeseen, mediated by a “swarm” of actors/actants ²⁶ that come in our direction, prompting us to respond or constitute ourselves via these interactions.

It is, therefore, important for us to consider, expand on, and make the different potential resources (material, symbolic, and political) available in the world of disease prevention and health care, and also to problematize and act via people’s actual living conditions. We must also consider the vulnerabilities unequally experienced by different people and groups, and the many barriers that prevent the equitable negotiation of safer sex, the experience of one’s own desires, and access to prevention technologies. The type of vulnerability that brings to mind the bodies or lives of apparently lesser value. As Butler ⁷⁰ (p. 40) asks, “Who counts as a human? Whose lives count as lives?”. That means forming cooperation networks between collectives (of professionals, scientists, activists, and a host of other actors) to enable possible existences. Ultimately, it means recognizing the limits that are imposed in daily interactivity, specifically in the field of HIV/AIDS prevention and care, which also emerge as dynamic, unstable, open (and complex), with their own peculiarities, viscosities, and processes of experimentation.

Acknowledgments

We thank all the professionals, participants, and coordinators of the PrEP1519 study who made this essay possible.

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Publication Dates

• Publication in this collection
  27 Mar 2023
• Date of issue
  2023

History

• Received
  05 June 2021
• Reviewed
  17 Sept 2021
• Accepted
  11 Nov 2021