Remediated sexuality: the meanings of postand pre-exposure prophylaxis for HIVAbstract
This article discusses the sexual character of HIV preand post-exposure prophylaxis (PEP and PrEP, respectively). It derives from a socio-anthropological study on the biomedicalization of responses to HIV that analyzed the offer of these prophylaxes in the metropolitan area of Rio de Janeiro and the experiences of its users in 2019. Based on document analysis, fieldwork observations, and interviews with gay men, we describe how sexuality is addressed in guidelines, clinical protocols, and care forms, and how PEP and PrEP are meant in terms of the sexual concerns of their users. The comparison between these two prophylaxes is one of the methodological resources adopted to recognize the vicissitudes of their sexual character, whether based on the way they are publicly disseminated and offered in health services or on the experience of their users. The analysis suggests that such prophylaxis acts at the intersection between anxieties derived from a biotechnical truth and the search for controllable sexual practices and situations, given their unpredictable nature.
Keywords:
Medicalization; Sexuality; Medical Anthropology; Pre-Exposure Prophylaxis; Post-Exposure Prophylaxis.
Resumo
O artigo discute o caráter sexual das profilaxias pós-exposição (PEP) e pré-exposição (PrEP) ao HIV. Deriva de uma pesquisa socioantropológica sobre biomedicalização das respostas ao HIV que analisou a oferta dessas profilaxias na zona metropolitana do Rio de Janeiro e as experiências de seus usuários em 2019. Fundamentados em análise documental, observações de campo e entrevistas com homens gays, descrevemos como a sexualidade é acionada em guidelines, protocolos clínicos e fichas de atendimento, e como a PEP e a PrEP são significadas em termos das preocupações sexuais de seus usuários. A comparação entre essas duas profilaxias é um dos recursos metodológicos adotados para reconhecer as vicissitudes de seu sentido sexual, a partir do modo como elas são difundidas publicamente e oferecidas nos serviços de saúde e da experiência dos usuários. A análise sugere que essas profilaxias atuam no encontro entre ansiedades derivadas de uma verdade biotécnica e a busca por práticas e situações sexuais controláveis, frente à imprevisibilidade de sua natureza.
Palavras-chave:
Medicalização; Sexualidade; Antropologia da Saúde; Profilaxia Pré-Exposição; Profilaxia Pós-Exposição.
Introduction
The article is set against the backdrop of the intense transformations of responses to the AIDS virus in recent years, mainly resulting from the introduction of the treatment as prevention (TcP) strategy, post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP) to HIV in health policies. Grounded on the use of ARVs for preventive purposes, these technoscientific developments have gained the centrality and hegemony previously assumed by condoms. This is a paradigmatic shift in the field of HIV and AIDS that expresses an integration of prevention with the logic of treatment, observed in efforts to contain the epidemic by expanding the provision of testing to track HIV cases, rapid linkage to antiretroviral therapies, and the provision of drug prophylaxis for people at greater risk of infection. The change also implies a new language, which merges social and biochemical terms to refer to the problem and its solutions.
This work is nested in a broader research interest in the meanings of these biomedical resources and strategies and their social roots. In this particular case, we are interested in analyzing how sexuality is conceived and activated in the presentation and provision of PEP and PrEP and the link between these prophylaxis and their users’ exercise of sexuality. It is important to comprehend how sexuality is an inherent part of its constitution and how they are coupled with social interactions and subjectivity. We consider that science, technology, and medicine are key elements in understanding the contemporary rearrangements of social control and self-government dynamics (Rabinow; Rose, 2006; Haraway, 2018; Preciado, 2008).
Both prophylaxis approaches involve the use of ARVs for preventive and epidemiological control purposes, previously exclusively aimed at caring for people infected with HIV. Strictly speaking, PrEP and PEP are not exactly new technologies, at least not ARVs; the novelty is the objectives that underpin their use and the expanded target audiences (Oscar, 2019). Although they share this foundation, each has particular characteristics and, like other medications, its own “biography” or “social life” (Van Der Geest et al., 1996).
In Brazil, PrEP has been offered by the Unified Health System (SUS) since December 2017. It is the first country in Latin America to offer this resource as a public health strategy (Ministry of Health, 2017). PrEP was implemented based on the continuous use of a daily pill. Its indication involves a health professional assessment regarding users’ understanding and motivation, their sexual practices, frequency, types of partnership, contexts associated with risk of infection, history of sexually transmitted infections (STIs), and potential commitment to adherence to the medication (Ministry of Health, 2018). It was initially prescribed for populations “at higher risk of exposure to HIV”, such as gay men and other men who have sex with men (MSM), trans women, transvestites, sex workers, and members of serodiscordant couples. In the protocol’s revised version, the indication was expanded to “all sexually active adults and adolescents at increased risk of HIV infection” (Ministry of Health, 2022).
PEP is indicated after exposure to HIV and consists of administering ARVs for 28 days. Due to its action principle, it is defined as a medical emergency. It should ideally be offered in health services within the first two hours after sexual contact and a maximum of 72 hours. It was adopted in the country in 1999, initially to address occupational accidents, and later expanded to include sexual violence situations (Ministry of Health, 2017). From around 2013 onwards, it began to be prescribed for cases of consensual sexual exposure and was available to all people, regardless of gender, sexual identity, or exposure type.
In fact, PrEP and PEP, together with TcP, are central to current national epidemiological control policies. The emphasis on these prophylaxis measures, especially PrEP, contrasts with the predominant actions until now, such as encouraging condom use, testing linked to counseling, and reducing vulnerability to HIV. Aligned with other critical reflections in the social sciences, we argue that prophylaxis is part of a global re-medicalization (Nguyen et al., 2011) or biomedicalization of responses to AIDS (Aggleton; Parker, 2015; Kippax; Stephenson, 2016; Kenworthy et al., 2017; Monteiro et al., 2019).
According to Clarke et al. (2003), biomedicalization is an important historical shift regarding events related to societal medicalization. While medicalization indicates the expansion of medicine and its rationality over diverse domains of social life, reconstructing and redefining them, the practices and events related to biomedicalization, by extension, point to the transformations that technoscientific resources operate on medical events, such as diseases, dysfunctions, health, and bodily capacities.
This new configuration concerns increasingly complex, multi-situated, and diffuse medicalization processes that extend and reconstitute themselves in social contexts intensely conditioned by scientific and technological production. The interventions to which they refer promise the treatment of diseases and improved and streamlined physical and cognitive capacities. Based on new knowledge about diagnostic methods and therapeutic resources, medicine has transformed the framework of its practices. Previously determined to restore organic normality altered by pathologies, its action is now supported by technologies and interventions of a molecular nature, pursuing a molecular reengineering of life itself with complex social implications (Rabinow; Rose, 2006).
This reflection is particularly relevant for HIV and AIDS. HIV prevention prophylaxis, like biomedical technologies in general, is intrinsically related to contemporary social life’s architecture. In their proposition and consolidation, ways of understanding life itself, intervening in collective existences, regulating social interactions, and shaping subjectivity compete (Biehl; Coutinho; Outeiro, 2001). Understanding PrEP and PEP implies considering that they are part of a broad network made up of pharmaceutical companies, international agencies, clinical researchers, health professionals, government managers, activists, and funders. In this sense, they can be read within the framework of a political economy of pharmaceutical innovations, whose production, circulation, distribution, and consumption interconnect diverse financial and institutional interests, collective needs, and individual desires in the shape of a complex therapeutic coalition (Biehl, 2007).
PrEP and PEP are not only products of this process but also have an impact on its establishment. One of their main features is their ability to act on specialized conceptions of prevention and paradigms in public health, transforming them. Such prophylaxis also acts on microsocial relationships and self-care. In addition to a notable transformation of the programmatic plan, with a growing hegemony of medical knowledge and clinical logic, we see a reconfiguration of the social position of the stakeholders in this field, whose actions and discourses are often encapsulated by new biomedical concepts. Rapid HIV testing, for example, is now promoted and conducted by community sector stakeholders while we observe a loss of their leading role in determining responses to the epidemic and a transformation of the meanings associated with prevention, health promotion, and rights (Monteiro; Brigeiro, 2024).
As mentioned, a distinctive aspect of current biomedical strategies for responding to HIV is erasing distinctions between treatment and prevention. HIV prevention actions are reorganized under principles, resources, and clinical treatment spaces. In this new framework, the focus of prevention strategies would no longer be on changing sexual behavior but rather on using disciplinary measures to develop surveillance over the implications of sexual practices. Verifying HIV serology through rapid testing becomes a central resource for biomedical prevention to achieve the goals of the Treatment as a Prevention strategy and as a mediating biotechnological resource for access to PEP and PrEP. The goal is to develop health behavior through drugs or medical interventions (Giami; Perrey, 2012) and surveillance of another nature, which focuses on the inside of the body, biomolecular and organic, to control serological status (Preciado, 2015; Mora; Brigeiro; Monteiro, 2018).
We started from the hypothesis that preventive interventions based on medication imply a shift in the approach to sexuality in prevention work. Thus, we aimed to explore the biomedical discourse surrounding their use. From their users’ perspective, we were interested in identifying the meanings of these technologies and the motivations for their use. Our attention was directed to the convergences and tensions between biotechnical truths, self-care, and the circumstances of sexual encounters. In short, this article aimed to analyze the interrelationships between sexuality and biomedical technologies for HIV prevention, particularly PEP and PrEP. To this end, we started from the understanding in social studies of science that there is no autonomy or externality of these technologies regarding social life.
Furthermore, we aimed to avoid simplistic clashes between a position of uncritical affiliation with the announced benefits of these technologies and another that views them with suspicion (Manica; Ramírez-Galvez, 2015). Our questions aimed to identify the social strength of PEP and PrEP through what is said by their users, including considering the possibilities of resistance and diverse incorporations of their potential.
Methodological procedures
The research is nested in a broader project on the implementation of PrEP and PEP in the metropolitan region of Rio de Janeiro and the experience of gay users, trans/transvestite women, and sex workers.
The methodological procedures involved documentary analysis and bibliographic review of indexed literature on PrEP and PEP; observations in PEP and PrEP services and in-depth interviews with managers, health professionals and community leaders in municipalities in the Metropolitan Region of Rio de Janeiro (Rio, Duque de Caxias, São João de Meriti, Belford Roxo, Niterói, and São Gonçalo); in-depth interviews with 10 gay men, 11 trans/transvestite women and 15 sex workers about discrimination, knowledge, access, and use of PrEP and PEP, experiences with health services and sexual practices; survey of campaigns and educational materials on PrEP and PEP published by governmental and non-governmental organizations.
The Research Ethics Committee approved the study, and fieldwork was conducted from January 2019 to February 2020, before the COVID-19 pandemic and at the initial stage of PrEP provision in Brazil. Health service professionals and the team’s network of contacts mediated access to the respondents. The interviews were held after authorization for recording and signing of the TCLE and were later transcribed. The project was supported by the institutional call for proposals (Inova Fiocruz Knowledge Generation Program) and resulted in publications (Murray; Brigeiro; Monteiro, 2022; Silva Júnior; Monteiro; Brigeiro, 2022; Mora, Nelvo; Monteiro, 2022; Silva Júnior; Brigeiro; Monteiro, 2023; Brigeiro; Monteiro, 2023).
In this article, we used the following sources: guidelines (documents from international agencies such as UNAIDS and WHO that provide data on the promotion of these prophylaxis measures within the framework of a global health policy); protocols and service forms that guide the provision of prophylaxis and management at the local level; interviews with ten gay men, who constitute the vast majority of users of PrEP services; in contrast to the lower demand from transvestites, trans women, and sex workers. Through their testimonies, we aimed to analyze their experiences with prophylaxis measures and the meanings associated with them. The profile of the respondents is described in Table 1. The names indicated are pseudonyms, in order to preserve the anonymity of the interviewees.
Notably, in the state of Rio de Janeiro, 81% of PrEP users were gay men in 2023. Furthermore, 71% of all users had a high schooling level. Although offered to different populations, these data indicate the profile of users who have resorted to this type of prevention resource (Ministry of Health, 2024).
Results and discussion
Comparing PrEP and PEP was one of the methodological resources adopted to recognize the vicissitudes of their sexual nature, whether from how they are publicly disseminated and offered in health services or from the user’s experience. By sexual nature, we understand here the sexual content that defines and gives meaning to these technologies. Thus, the results were organized into two topics. The first addresses the associations of each prophylaxis with sexuality, discussing the sexual aspects found in the discourses of the documentary sources. The second highlights the meanings users attributed to PrEP and PEP, describing their viewpoints on prevention, the moralities involved in their access and use, and
PrEP e PEP sexual nature
In HIV prevention, sexual PEP and PrEP are consolidated technologies whose indication is related to the forms of sexual exposure to HIV. Inquiring about their sexual nature may seem tautological. However, the analysis of what was “sexual” in the discursive plot of official documents and clinical protocols that gave them social existence aimed to identify whether the apparent redundancy could provide inputs for understanding them. Since the clinical trial phase, PrEP has been officially presented by international agencies as an alternative prevention measure for national contexts and population groups most affected by HIV, for whom, according to epidemiological monitoring, a set of existing methods did not appear to be sufficient. As indicated in a WHO guideline on the use of PrEP in clinical trials, even with the availability of internal and external condoms, voluntary male circumcision, prevention of vertical HIV transmission, and harm reduction strategies for injecting drug users, the dynamics of the epidemic remained strong in some countries and among specific populations. The need for additional safe and effective preventive approaches was justified. The populations participating in the clinical trials mentioned in the guideline were organized into two types: 1. MSM and trans women; 2. serodiscordant heterosexual couples. In addition to this identification, the sexual practice type (anal and vaginal) was also important in the design of the studies, as the aim was to understand its effectiveness by type of sexual transmission (WHO, 2012). In other words, since its formulation, PrEP has been referring to the sexuality of its potential users.
The idea of it being an alternative method has spread and become consolidated. In 2016, after it was approved for use in countries such as France, Kenya, the United States, and South Africa, the justifications for the importance of PrEP due to the insufficiency or failure of other methods started to emphasize the individual dimension further. A 2016 UNAIDS guideline affirms that PrEP is an option for those who cannot consistently use condoms or choose their partners freely. The idea of individual control is highlighted as an advantage of PrEP, given that its use promises individuals a power not achieved by previous methods; in other words, control over themselves and over what escapes them in their sexual lives. Another aspect highlighted concerns the fact that this technology is invisible during sex, and the decision to take it would somehow be separate from the sexual act, hidden in the body, and imperceptible to partners during sex. It would even remedy structural problems and could be provided to populations with limited access to health services (UNAIDS, 2016).
PrEP is formulated based on its ability to overcome inconveniences in the sexual scene or in the partner that are beyond the individuals’ control, thus compromising prevention. In this sense, this pharmacological resource presupposes a reflexivity on the possibility of HIV infection and the vicissitudes of sexuality, besides previous preparation that does not depend on negotiations. We find here a similarity with the “empowerment policy” promoted in the defense of microbicides as a “feminine” preventive resource capable of restoring women’s control over their bodies and sexuality (Montgomery, 2012). Indeed, the discourses of international agencies on PrEP do not point to a particular subordinate social condition of its potential users. However, they point out several conditions of lack of control over the exercise of sexuality which was effectively captured and managed as a medical problem and an opportunity for the pharmaceutical market.
Again, on the subject of sexuality, the provision of PrEP in health services requires an initial assessment of individuals’ sexual lives. To prescribe it, the professional is guided by a form, which we had access to during fieldwork. This form records sexual orientation, gender identity, sexual practices for material gain, use of alcohol and other drugs, sexual intercourse frequency, gender identity of partners, and condom use. In the documents, PrEP talks and makes people talk about sexual habits and their risky nature.
PEP, in turn, did not originate as a sexually oriented technology. Its original indication was related to accidents involving potentially risky biological material. A guideline from the Rio de Janeiro Municipal Health Secretariat affirms that the term “Sexual PEP” refers to a differentiation from that indicated for accidents with biological material. When it receives the qualifier “sexual”, the aim is to highlight “sexual exposure to HIV”, whether consensual or not (SMS, 2016). It is a prophylaxis that seeks to remedy situations of a sexual scene that escaped the control of the individuals, although this aspect is implicit in its definition.
Prescribing sexual PEP involves a particularity. As indicated by clinical guidelines and protocols, its indication does not require an assessment of the user’s sexual profile or the consistent use of condoms or other preventive resources. It mainly aims to identify whether sexual interaction can be considered an “exposure to HIV” (Ministry of Health, 2017; WHO, 2024). To dispense the medication, the professional must assess the demand and complete the medication request form. The identification data, similar to the PrEP first aid form, seeks an “assessment of HIV transmission risk” by asking about sexual orientation, gender identity, circumstances of sexual exposure (consensual or sexual violence) when it occurred, whether there was anal or vaginal sex, insertive or receptive, and condom use, and whether the sexual intercourse was in exchange for some benefit. PEP refers, above all, to a particular sexual scene and whether it is possible to identify it as an exposure to HIV.
In short, the documents relating to the promotion of PEP and PrEP by international agencies and their provision at the local level suggest that controlling the spread of HIV through intervention in sexual practices is limited. Thus, one of the significant advantages of the biomedical preventive response would be the possibility of rational (self)control over sexual interactions, as opposed to other methods, such as condoms. In other words, ARV use would circumvent possible complications and inconveniences involving sexual practices and situations, an inextricable aspect of the definition and provision of these biomedical technologies. As we show below, the interview data reiterate, to a certain extent, this potential HIV prevention prophylaxis.
PrEP and PEP in contrast: user experiences
Well, I had to tell the details, ‘I had sex without a condom’, but that wasn’t enough; I had to say, ‘- I’m gay, I had sex without a condom, and the person has HIV’. I had to tell all the details and ‘Did he cum inside?’ I had to say that he did because just saying that the condom broke, I was afraid that wouldn’t be enough. It wasn’t enough, you know, the things I was saying weren’t enough. So, in this case, I didn’t say that the condom broke. I said that it was without a condom. Because I said I had had sex without a condom, and it didn’t work for the first person. So, I had to give more details.
Silvio is a 24-year-old white man who identifies as “homosexual,” studying architecture and living in Niterói. He sought PEP at an emergency service several years ago when it was initially being expanded to include all sexual exposure cases. His experience shows how hard it was to obtain the medication and that he was aware that the prescription depended on a detailed description of the sexual event capable of attesting to its risk. His report points to embarrassment in admitting to a health professional a situation of deliberate exposure to HIV and the fear of moral judgments about her sexuality and self-care. The experience of fear was compounded by the fact that, at that time, the care protocol was barely known by the professionals themselves:
Well, since it’s an emergency room, most people there didn’t know much about the subject... ‘What is PEP?’ So, I had to explain... There was a professional who said, ‘PEP? What do you mean you’re talking about PEP? That’s for doctors... So, I had to explain: ‘No, the protocol has changed. Now, people who aren’t doctors or in the health sector can also take it.
Besides misinformation, Silvio and other respondents’ reports indicate that the experience of obtaining PEP was marked by resistance from emergency service professionals. The inclusion of sexuality in emergency services was not exactly new since the routine of treating sexual violence cases with the prescription of prophylaxis was consolidated. The new concept, which required time to assimilate and political efforts, was the change from the interpretation of a risk of harm resulting from imposition or violence to exposure due to consensual sexual acts, a deliberate “exposure”. Furthermore, some hospitals did not adhere to the proposal at the beginning due to the lack of training of the teams to address the sexual PEP protocol in the emergency room and users’ demand, and the difficulty in prioritizing such care in contrast to the others.
Even when PEP was requested in specialized services, where addressing sexuality was commonplace, fear was frequently mentioned by respondents. The fears associated with the demand for this prophylaxis are analogous to what Biehl, Coutinho, and Outeiro (2001) called “technoneurosis” when studying the relationship of users of a Testing and Counseling Center (CTA) with testing practice. In the early 2000s, when the exceptionality of testing governed preventive logic, the authors did not consider repeat testing as a failure of counseling to incorporate protected sexual practices. It was, rather, an effect, an amalgam of biotechnical truths with the concerns of users. Thus, they argue that the CTA played a decisive role in the production of an “imaginary AIDS”, responsible for the intense concern with HIV and the biotechnical truths about themselves and their bodies.
Gilberto is a 27-year-old gay, brown man with a college degree. He describes taking PEP in Curitiba at a specialized service. He says the reason that led him to request prophylaxis was not entirely justified. He was terrified and insecure about whether the sexual situation he experienced could really be “considered an exposure to HIV”. His considerations were imbued with medical concepts and terms, articulated with his anxiety about sexual intercourse with an HIV-positive partner. Even though he considered the odds of HIV infection in that sexual relationship to be minimal, he decided to take PEP. Aware of the criteria and technical procedures for obtaining it, he adjusted the description of the sexual situation to be considered eligible for prophylaxis. During the consultation, he described that the sexual intercourse was unprotected, as he had used a condom during anal sex. The incorporation of technical information mentioned by Gilberto appears similarly in the report of Lucas, a 39-year-old gay, brown lawyer resident of Ipanema:
So, it was a specific situation, and I thought it was best to do it, even though I didn’t think I was. I thought it was best to do it… [it was during] a sexual intercourse. I thought I was exposed and said, ‘Just in case’. I’m very methodical and annoying. Just in case, ‘I’m going to do PEP’. However, it’s powerful! I took the medication and was very well attended to, there at the Lourenço Jorge hospital. I took medication right away; they explained it very well and gave me all the necessary assistance. The medication is powerful. You feel all the symptoms. Among them, the worst of them were intestinal problems, which was desperate. […]. PEP is not very well known, but I already knew about the situation. I had heard about it. I said, ‘Well, I’m going to find out more’. I went to find out where it worked and where to get it. I went to the Lourenço Jorge Hospital [in the emergency room]. I already had information because I looked for much information and because I dated a foreigner, and he was HIV-positive. So, also because of that relationship that was five years ago.
The great fear of HIV infection sometimes leads to dangerous practices, such as that reported by André, a 60-year-old black nursing technician and civil servant:
There was a rupture, rupture with ejaculation, you know? I sought PEP the next day […], but I was so paranoid that at the time, I did an anal wash, even with hypochlorite.
In addition to the healthcare service, taking PEP was a distressing and exhausting experience for most of the respondents. Guilt regarding sexual contact, distress, uncertainty about their “serostatus”, and unpleasant side effects persisted throughout the 28 days that the medication lasted. Such situations are usually experienced in isolation and accompanied by a period of withdrawal from affective-sexual interactions. Wallace, a 54-year-old psychoanalyst, had to use PEP after a condom broke during sexual intercourse about three decades ago when he was participating in a clinical study at the Hospital São Francisco de Assis. This fact affected his sexuality:
How was my sex life while taking PEP? Nothing happened. I was fasting, and even after PEP, I was concerned. As I said, I was still starting my sex life with several issues; everything also becomes a reason for us to sometimes retreat in the face of something that is causing anxiety. However, then I started to work on it in my head. It took me a long time to return to…
For Wallace, PEP is not a preventive measure in the strict sense of the term but some remediation. André, a 60-year-old nursing technician who has had different experiences with sexual PEP and after an accident with biological material, also associates it with the remediation of imponderables.
PEP is very different from PrEP. PEP is when something already happened. It’s like trying to remediate the loss or trying to put the padlock back after the door is broken down... I can’t see prevention in that. PEP is treatment, not prevention. PrEP is prevention. Something you do before it happens that’s the idea of prevention... (Wallace)
Even if you’re not exposed to risk, sometimes we expose ourselves. What happened before I came here for PrEP? I had a condom break, so I did PEP. Dolutegravir gives me a headache, you know? I resist, but it isn’t very good. Then I did the follow-up, and I had another intercourse with a person who was known to be HIV-positive. He said he was HIV-positive, and what happened? There was penetration, and he said, ‘I’m not going to ejaculate during penetration,’ and then he started masturbating next to me. When he ejaculated, his sperm came onto my face. That’s why I’m telling you. Sometimes, we expose ourselves; we’re exposed. Then it dripped into my mouth, it dripped into my eye, there’s the issue of the mucous membra
In turn, PrEP is seen by these users as a practical preventive resource, given that its use presupposes a rational decision to anticipate a possible “transmission risk” and is associated with self-care. At the same time, it is often perceived as a resource that allows for greater exploration of sexuality, an expansion of pleasure, and freedom from fears, regardless of the practices adopted or what may occur during the sexual encounter.
Advantages of PrEP? Many. Again, the issue of your sexuality, being able to exercise it freely... and I think that you need to think about all the other prevention methods, right? For the process, you have a condom, you put it on, take the condom off, then the arousal decreases, then it comes back, that whole thing. Now, it’s like, ‘Go on, man, feel free, go do it’. I think that creates another reality of sexuality, too. (Lucas)
The use of each of these technologies suggests different degrees of addressing the biotechnical demands of self-care and the fears they shape. Seen as medicine, PEP would have a blocking function in the face of something that has already escaped control. At the same time, PrEP seems to mimic an organic immune action and more effectively performs a sexual exercise without the burden of considerations about viruses, fluids, mucous membranes, serological status, condoms, accidents, or unconscious acts. By acting within the body, they produce protection and remediation within it. While PEP mobilizes guilt and judgment about care practices related to sexuality that were not anticipated or properly mobilized, PrEP refers to the idea of sexual freedom in the face of HIV infection, felt as a present and imminent threat. However, the remediation of fear is a common feature of prophylaxis. As Bruno, a 29-year-old psychology student, and Gilberto point out:
What are the advantages of PrEP? You become immune to HIV, remembering to use the medication correctly without giving up on the condom. It’s magnificent, wonderful. As I said at the beginning, I couldn’t have sex anymore because I was afraid and worried about the condom bursting. All that neurosis. Today, I can allow myself more. It’s improved a lot [my sex life], 100%... in terms of taking care of and preventing myself. I’ve managed to have a more active sex life now, which I wasn’t having because of fear and apprehension. (Bruno)
When I looked for it... I expected to be calm, that’s all, not to have any worries, you know? Because I had already taken PEP. I already knew what it was like. I had already had sex without a condom. So, I didn’t want to go through that again. Since I knew that the person was HIV-positive, there was no reason for me to worry. Then something happens: the condom would break, and I would be scared. So, I said, ‘No, I’m going to take this right away because then I won’t be scared’. I don’t want to worry about that; I want sex to be pleasurable and at peace. That’s why I took it. (Gilberto)
The habitual use of PrEP implies a particular form of fusion with the bodies and sexuality of its users. Maurício, a 32-year-old production engineer, reports that he “got used to the prophylaxis” and effectively got used to “not being afraid anymore, this paranoia about having sex”. If he had to stop taking it due to its effects on the liver, he would lose the safety he had gained from the medication. José Roberto, a 38-year-old psychiatrist, says he was afraid that the prophylaxis would change his behavior, encouraging him to engage in “risky” sexual practices, which did not happen. He continued to use condoms alternately with PrEP.
The remediation offered by PEP and PrEP simultaneously points to the molecular level of the mechanisms involved in the infection of a virus in an organism and a set of circumstances that are beyond the control of individuals in the exercise of sexuality.
[…] I think that’s it. Human behavior, there’s no way to say it. We think one thing, feel another and do something completely different from what we thought. We are divided, so the issue of information is a very relativized thing: what I say is not what you hear; what you hear is not what I’m saying. There’s always a mismatch in this story, so information in itself is one of the possibilities for prevention. However, it’s not because we are not rational creatures with common sense and measure. We are of excess; there is an excess there. I think that PrEP comes to address precisely this without abolishing the more conventional forms of prevention. However, it ends up encompassing this excess that makes us, and that doesn’t have to be moralized. It doesn’t have to be pathologized in any way. You don’t want to use a condom, you didn’t remember, you didn’t care… I think that PrEP comes, in some way, to take care of our underpinning unpredictability.” (Wallace)
[…] the advantage of PrEP is that, like, you… how can I explain it to you?… I don’t know; I think that your body has protection… In the case of the condom that you’re going to use at that time. It may or may not work, and you run a risk, […] I can’t guarantee that the condom will be 100% safe. So, I’m using it, but I use it with fear because something could happen. If I’m not careful, it’s happened to me that my partner put it on the wrong way. I don’t see it. He put it on the wrong way, and then it broke at the tip. So, like, many things can happen, and it gives you security. I’m telling you because you feel protected. I’m not doubting the condom, but it can fail. […] It seems that I enjoy having sex more, without fear, guilt, and panic… If the condom breaks like it happened before or if the person ejaculates on my face, the sperm comes out on my face, I won’t get paranoid. I mean paranoia; I mean having that worry and ghost in my head. […] Because you know, I am passive, exclusively passive, so I run the risk of getting sperm in my mucous membranes. Something could happen: a rupture or something else. You feel that insecurity; PrEP gives me security. (André, 60)
In short, such prophylaxis speaks of some imponderables in the exercise of sexuality and the desire of these men to exercise control over themselves and what happens in their bodies. At the same time that they remedy the technoneurosis derived from the technical considerations about a viral infection, prophylaxis fosters this same biotechnical system.
Final considerations
HIV prevention prophylaxis is an essential mediator of affective and sexual experience in contexts guided by global health policies and marked by intense access to biomedical technologies. Its promotion, supply, and use reveal how, in such contexts, sexual practices, pleasures, and self-care are inseparable from technoscientific artifacts. Understanding that techniques and technologies share the fact that their implementation is always related to people’s social lives, such prophylaxis means the possibility of preventing and remediating HIV and a resource to remedy the fears, fantasies, and imponderables in sexual interactions resulting from accidents, unprotected sexual intercourse, and ambiguities inherent to sexual practice and desire. They thus articulate anxieties of a responsible health morality with the claim to control over events and sexual interactions of an unpredictable nature.
The strength of PrEP and PEP derives precisely from the encounter between the search for pleasure and an exercise in reflexivity that mediates the vicissitudes of sexual events and their organic and biochemical implications. HIV infection and such imponderables of sexual events (of oneself, of the other, and this interaction) are inseparable threats against which PEP and PrEP operate as a remedy. These are resources that mediate the idea of self-care, pleasure, and fears of what eventually escape control. They materialize the expectation of control over the body and a pure sexual encounter (Giddens, 1993) without mediations (at least visible ones) that impede pleasure.
However, as Oscar (2019) argues in his analysis of the notion of the subject underlying narratives around PrEP, transformations in HIV prevention are anchored in a heightened contemporary individualism. PrEP, like other guidelines in the field of sexual health, mediates the attempt to eradicate diseases through health self-surveillance mechanisms and the promotion of well-being and sexual pleasure, contributing to a rationalization of eroticism (Davis, 2009). Considering the political economy of these biomedical technologies, we should reflect on the future developments of the epidemic in contexts in which such health rationalization and the pharmacological mediation of sexuality are not hegemonic, given that biomedical controls of the epidemic have less scope in these sociocultural contexts.
Data Availability Statement
The research data are available within the main text of the article.
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Editors:
Ivia Maksud
