Abstract

In the current context of the HIV epidemic, multiple prevention strategies including biomedical interventions have been presented as alternatives for vulnerable groups. This study investigated homosexuals’ and bisexuals’ perceptions of the risk of HIV infection and their experiences of using HIV post-exposure prophylaxis (PEP). We conducted a qualitative study with 25 men who have sex with men (MSM) in five Brazilian cities using semi-structured interviews. The results showed that the use of condoms was the main HIV prevention strategy employed by the respondents. In addition, condom failure, inconsistent condom use and intentional non-use are the main prompters of risk perception and the consequent decision to seek PEP. The respondent’s perceptions and meanings of the use of PEP were mediated by prior knowledge of PEP. This work broadens the debate on the more subjective aspects of HIV prevention among MSM, especially those related to risk perception and the decision to use PEP in the context of combined prevention.

Key words:
Masculinity; HIV; Sexual and gender minorities; Risk management; Post-Exposure Prophylaxis

Introduction

It is estimated that 37.9 million people are currently living with HIV worldwide¹1 United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS 2019 Data. Geneva: UNAIDS; 2019.. In Brazil, official data show that gay and bisexual men account for more than half (51.3%) of the cases reported to the Ministry of Health²2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. HIV/AIDS. Bol Epidemiol 2019; 9(1):1-58. and that the prevalence of HIV among men who have sex with men (MSM) rose from 12.1% in 2009 to 18.4% in 2016³3 Kerr L, Kendall C, Guimarães MDC, Mota RS, Veras MA, Dourado I, Brito AM, Merchan-Hamann E, Pontes AK, Leal AF, Knauth D, Castro ARCM, Macena RHM, Lima LNC, Oliveira LC, Cavalcante MS, Benzaken AS, Pereira G, Pimenta C, Pascom ARP, Bermudez XPD, Moreira RC, Brígido LFM, Camillo AC, McFarland W, Johnston LG. HIV prevalence among men who have sex with men in Brazil. Medicine (Baltimore) 2018; 97(1S Supl. 1):S9-S15..

The predominant approach adopted in the response to the HIV epidemic in Brazil and the rest of the world is combination prevention⁴4 United Nations Programme on HIV/AIDS (UNAIDS). Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Struct ural Strategies to Reduce New HIV Infections. Geneva: UNAIDS; 2010.

5 Jones A, Cremin I, Abdullah F, Idoko J, Cherutich P, Kilonzo N, Rees H, Hallett T, O'Reilly K, Koechlin F, Schwartlander B, Zalduondo B, Kim S, Jay J, Huh J, Piot P, Dybul M. Transformation of HIV from pandemic to low-endemic levels: A public health approach to combination prevention. Lancet 2014; 384(9939):272-279.

6 Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Structural approaches to HIV prevention. Lancet 2008; 372(9640):764-775.^-77 Grangeiro A, Kuchenbecker R, Veras MA. New HIV prevention methods: recognizing boundaries between individual autonomy and public policies. Rev Bras Epidemiol 2015; 18(Supl. 1):1-4.. In theory, this approach involves the combination of different strategies, such as structural, community-based and biomedical interventions, expanding HIV prevention efforts on different fronts. However, the implementation of this approach has received criticism due to the excessive focus on biomedical and pharmacological interventions over structural and community-based efforts⁷7 Grangeiro A, Kuchenbecker R, Veras MA. New HIV prevention methods: recognizing boundaries between individual autonomy and public policies. Rev Bras Epidemiol 2015; 18(Supl. 1):1-4.

8 Machado LV, Lessa PS. Medicalização da vida: Ética, saúde pública e indústria farmacêutica. Psicol Soc 2012; 24(3):741-743.^-99 Kauss B, Leal AF, Grangeiro A, Couto MT. Reincidentes en el cuidado, pero sin derecho a la prevención: un análisis de la oferta de la profilaxis posexposición sexual al VIH en Porto Alegre, Brasil. Salud Colect 2020; 16:e2463.. It is also worth highlighting that the funding and distribution of biotechnologies has been negatively impacted by the policies of ultra-conservative governments (including the Brazilian government), thus hampering the consolidation of this approach across different levels of health care.

Individual risk perception is an important element of combination prevention. As a sociological concept, risk is understood as a complex mix of historically situated social factors and probabilistic conceptions with a range of actors and forces at play¹⁰10 Beck U. Sociedade de risco: rumo a uma outra modernidade. São Paulo: Editora 34; 2011.

11 Beck U, Giddens A, Lash S. Modernização Reflexiva. São Paulo: UNESP; 2000.^-1212 Mythen G, Beck U. A critical introduction to the risk society. Londres: Pluto Press; 2004.. From an epidemiological perspective, risk is understood as the probability of an event during a specified period of time¹³13 Rothman K, Greenland S, Lash T. Epidemiologia Moderna. Porto Alegre: Artmed. 2011.. Risk (of getting a disease, for example) is perceived and experienced differently depending on social status, age, race/color, sexual orientation and gender, and social, political and economic context¹⁰10 Beck U. Sociedade de risco: rumo a uma outra modernidade. São Paulo: Editora 34; 2011.

11 Beck U, Giddens A, Lash S. Modernização Reflexiva. São Paulo: UNESP; 2000.^-1212 Mythen G, Beck U. A critical introduction to the risk society. Londres: Pluto Press; 2004..

Within the context of the transformations that characterize today’s society, reflexivity¹⁴14 Giddens A, Sutton PW. Conceitos essenciais da sociologia. São Paulo: SciELO-Editora UNESP; 2017., as a fundamental mechanism of institutional organization and formation of the self, promotes risk expert systems. These systems, made up of policy makers and biomedical and media experts, among others, operate on a basis of trust, propagating valid technical knowledge beyond their immediate field¹⁵15 Perrusi A, Franch M. CARNE COM CARNE Gestão do risco e HIV/Aids em casais sorodiscordantes no Estado da Paraíba. Rev Cien Soc Polit Trab 2012; 2(37):179-200.. The calculation of risk by subjects is therefore a complex relation of individual criticism and acceptance of these systems, involving the confluence of a complex order of beliefs, desires and calculations that underpin how individuals manage risk and behavior. Thus, in the relations of power established between individuals and expert systems, risk awareness¹⁵15 Perrusi A, Franch M. CARNE COM CARNE Gestão do risco e HIV/Aids em casais sorodiscordantes no Estado da Paraíba. Rev Cien Soc Polit Trab 2012; 2(37):179-200. does not always reflect health guidelines.

The idea of risk perception proposed by Wiedemann¹⁶16 Wiedemann PM. Understanding Risk Perception. In: Gray PCR, Stern RM, Biocca M, editores. Communicating about Risks to Environment and Health in Europe. Boston: Springer; 1998. p. 335-353. is consistent with this perspective insofar as it suggests that perception is influenced by imaginary constructions and beliefs developed through experience. From this perspective, the perception of the risk of HIV/AIDS infection influences the capacity to manage the probability of a potentially high-impact event such as HIV infection.

With regard to biomedical prevention technologies, post-exposure prophylaxis (PEP) has been a prominent method for preventing HIV infection since 2010. Available on the SUS (acronym in Portuguese for Sistema Único de Saúde, Brazil’s national health system)¹⁷17 Centers for Disease Control and Prevention (CDC). US Public Health Service. Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR Recomm Rep 1990; 39(RR-1):1-14.

18 Tokars JI, Marcus R, Culver DH, Schable CA, McKibben PS, Bandea CI, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118(12):913-919.^-1919 Gerberding JL. Prophylaxis for occupational exposure to HIV. Ann Intern Med 1996; 125(6):497-501. for consensual sexual exposures, PEP is an emergency prevention alternative that should be started within 72 hours after exposure²⁰20 Brasil. Ministério da Saúde (MS). Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveisdo HIV e das HV. Protocolo clínico e diretrizes terapêuticas para Profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e Hepatites Virais. Brasília: MS; 2018.. Despite being the oldest biomedical prevention method, its distribution is inadequate in some regions, being invariably restricted to sexual health services in large cities⁹9 Kauss B, Leal AF, Grangeiro A, Couto MT. Reincidentes en el cuidado, pero sin derecho a la prevención: un análisis de la oferta de la profilaxis posexposición sexual al VIH en Porto Alegre, Brasil. Salud Colect 2020; 16:e2463.^,2121 Maksud I, Fernandes NMM, Filgueiras SLL. Technologies for HIV prevention and care: challenges for health services. Rev Bras Epidemiol 2015; 18(Supl. 1):104-119.. Studies have confirmed the efficacy of PEP and evidence²²22 Pereira I, Pascom A, Mosimann G, Barros Perini F, Coelho R, Rick F, Benzaken A, Avelino-Silva VI. Post-exposure prophylaxis following consented sexual exposure: impact of national recommendations on user profile, drug regimens and estimates of averted HIV infections. HIV Med 2020; 21(4):240-245. suggests that it may have contributed to preventing HIV transmission in at least 3,138 people between 2009 and 2017.

Although there is a growing body of literature on this topic, qualitative studies on the use of PEP among MSM²³23 Mathias A, Santos LA, Grangeiro A, Couto MT. Thematic synthesis HIV prevention qualitative studies in men who have sex with men (MSM). Colomb Med 2019; 50(3):201-214. are scarce, particularly those discussing how knowledge of prophylaxis influences the decision to use the method. A recent review²³23 Mathias A, Santos LA, Grangeiro A, Couto MT. Thematic synthesis HIV prevention qualitative studies in men who have sex with men (MSM). Colomb Med 2019; 50(3):201-214. found that the central themes of studies in England²⁴24 Sayer C, Fisher M, Nixon E, Nambiar K, Richardson D, Perry N, Llewellyn C. Will I? Won't I? Why do men who have sex with men present for post-exposure prophylaxis for sexual exposures? Sex Transm Infect 2009; 85(3):206-211. and Australia²⁵25 Körner H, Hendry O, Kippax S. It's not just condoms: Social contexts of unsafe sex in gay men's narratives of post-exposure prophylaxis for HIV. Health Risk Soc 2005; 7(1):47-62.

26 Körner H, Hendry O, Kippax S. Safe sex after post-exposure prophylaxis for HIV: Intentions, challenges and ambivalences in narratives of gay men. AIDS Care 2006; 18(8):879-887.^-2727 Körner H, Hendry O, Kippax S. Negotiating risk and social relations in the context of post-exposure prophylaxis for HIV: Narratives of gay men. Heal Risk Soc 2005; 7(4):349-360. investigating PEP were motivation, type of sexual partner, negotiation, and risk perception. In Brazil, although studies have investigated the PEP use by heterosexual men²⁸28 Santos LA, Couto MT, Mathias A, Grangeiro A. Hombres heterosexualmente activos, masculinidades, prevención de infección por VIH y búsqueda de profilaxis posexposición sexual consentida. Salud Colect 2019; 15:e2144., studies addressing MSM were not found.

The present study investigated MSM’s perceptions of PEP in the context of HIV/AIDS prevention based on their risk perceptions. To this end, we look at the context in which PEP emerged as a viable prevention option, discussing elements that help understand what influences the decision to use the medicine and whether and how its use leads people to reconsider risk perception.

Methodology

We conducted a qualitative study with a sample of 25 MSM using data from semi-structured interviews conducted as part of a broader study²⁹29 Grangeiro A, Couto MT, Peres MF, Luiz O, Zucchi EM, Castilho EA, Estevam DL, Alencar R, Wolffenbüttel K, Escuder MM, Calazans G, Ferraz D, Arruda É, Corrêa MG, Amaral FR, Santos JCV, Alvarez VS, Kietzmann T. Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): Protocol for a pragmatic clinical trial at public healthcare clinics in Brazil. BMJ Open 2015; 5(8):e009021. investigating the effectiveness of PEP in public health services in five Brazilian cities (Porto Alegre-RS, Curitiba-PR, Fortaleza-CE, Ribeirão Preto-SP, and São Paulo-SP) called “The Combine! Study”²⁹29 Grangeiro A, Couto MT, Peres MF, Luiz O, Zucchi EM, Castilho EA, Estevam DL, Alencar R, Wolffenbüttel K, Escuder MM, Calazans G, Ferraz D, Arruda É, Corrêa MG, Amaral FR, Santos JCV, Alvarez VS, Kietzmann T. Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): Protocol for a pragmatic clinical trial at public healthcare clinics in Brazil. BMJ Open 2015; 5(8):e009021..

The interviews were conducted using an interview guide addressing the respondents’ affective-sexual experiences and the relationship between sexual practices and PEP use within the context of their perceptions of the risk of exposure to HIV and what led them to seek PEP.

The interviews were conducted between March and December 2015 by trained researchers and all respondents signed an informed consent form. The interviews were terminated when enough information was gathered to explain the study phenomenon, adopting the saturation criterion³⁰30 Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DG. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad Saude Publica 2011; 27(2):388-394. and the interviews were conducted in a private room in the health facility and recorded and transcribed, respecting colloquial expressions, slang and pauses. Average interview duration was 45 minutes. The organization and thematic categorization of the transcribed interviews was performed using QSR NVivo®.

The data was analyzed using meaning interpretation, which draws on hermeneutical and dialectical principles to interpret context and the reasons and logic behind speech, actions and interrelations³¹31 Gomes R, Souza ER, Minayo MCS, Malaquias JV, Silva CFR. Organização, processamento, análise e interpretação de dados: o desafio da triangulação. In: Minayo MCS, Assis SG, Souza ER, organizadoras. Avaliação por triangulação de métodos: abordagem de programas sociais. Rio de Janeiro: Editora Fiocruz; 2005. p. 179-220.. Data analysis and interpretation comprised the following stages: (a) in-depth reading to gain an overview and capture the particularities of the transcribed interviews; (b) identification and naming of themes; (c) identification and problematization of explicit and implicit ideas; (d) identification of underlying sociocultural meanings; (e) contextualization of the problematized ideas in relation to existing literature; and (f) construction of an interpretative synthesis³¹31 Gomes R, Souza ER, Minayo MCS, Malaquias JV, Silva CFR. Organização, processamento, análise e interpretação de dados: o desafio da triangulação. In: Minayo MCS, Assis SG, Souza ER, organizadoras. Avaliação por triangulação de métodos: abordagem de programas sociais. Rio de Janeiro: Editora Fiocruz; 2005. p. 179-220..

The presentation of the results uses fictional names in order to guarantee the anonymity of the respondents. The study was approved by the University of São Paulo Faculty of Medicine Ethics Committee and the National Research Ethics Committee.

Results

The age of the respondents differed, with eight being aged between 19 and 23 years and 17 aged between 26 and 40 years. Most of the sample were white (14/25) and homosexual (20/25). Only six of the respondents sought PEP because they had sex with partners in a stable relationship, five of whom knew they were HIV positive. Of those who had had sex with a casual sexual partner (19/25), most (15/19) did not know the partner’s HIV status. Chart 1 shows the characteristics of the respondents.

The transcribed interviews were divided into three subgroups according to the respondents’ use and knowledge of PEP: those who had previously used PEP (3/25); those who had never used PEP and with limited prior knowledge of the method (7/25); and those who had never used PEP and without prior knowledge of the treatment (15/25). The analysis compares the respondents’ perceptions of the risk of HIV infection, the reasons behind the decision to use PEP, and the meaning of the use of PEP across these subgroups.

In the subgroup who had previously used PEP (3/25), prior use influenced the respondents’ perceptions of the risk of HIV infection, the time taken to decide to seek PEP, and the ease of access to PEP services. The implications of using PEP reported by this subgroup were positive and the strategy was seen as a valid prevention method, being incorporated into the respondents’ prevention repertoire (3/25). The following statement from Noel, who was exposed in another country, clearly shows that he was sure about how to act and what actions to take in seeking medical help:

The respondents in the subgroup who had never used PEP and with limited prior knowledge of the method (7/25) reported inaccurate information, including not knowing for sure the name of the treatment, use prerequisites, or where to find the medication. The respondents mentioned the mainstream media (newspapers and television), with the internet being the main source of information, notably government sites, such as the Ministry of Health and state and municipal health departments, and videos from public figures:

Forms of prevention without aids (condoms, gel, oral fluid rapid test, etc..) appear in three of the interviews (3/7), while routine HIV testing was only mentioned by one respondent. The perception that the risk of HIV infection is high was practically unanimous (6/7) in this subgroup. The stigma of AIDS, and the anticipation of the stigma by the fear of being infected, are commonly recurring themes:

Negative perceptions are commonly recurring implications and meanings of use (4/7), not only in relation to side effects, but also feelings of guilt and shame.

As expected, the lapse of time between the moment of exposure, recognition of the risk of infection, and seeking specialist help was greater in the subgroup who had never used PEP and without prior knowledge of the treatment (15/25). The main source of information on HIV prevention methods and strategies in this subgroup were friends and the internet.

The majority of respondents in this subgroup arrived at the health service with limited information on PEP (13/15). Two of the respondents (2/15) visited the service seeking HIV testing and were indicated PEP by health professionals during counselling:

With regard to prevention methods and strategies, the respondents in the subgroup who had never used PEP and without prior knowledge of the treatment reported that they used, almost solely, condoms (9/15), albeit not always on a consistent basis. Little mention was made of HIV testing, which was not referred to as prevention method by the respondents, suggesting that HIV testing is used as a negotiation resource. The use of behavioral strategies, such as preference for a specific sex position (active, passive) or avoiding ejaculating directly onto the partner were mentioned by few respondents. Alexandre explains that the importance of the use of condoms may be downplayed depending on the moment:

With regard to risk perception, the following account from Miqueias shows that, despite dating someone who was HIV positive, he was not aware of PEP as a prevention option, and only perceived the high risk of infection at the time of exposure:

The risk of HIV infection was perceived as high by two-thirds of the respondents in this subgroup (10/15). Associated with the self-assessment of risk, other responses revealed negative meanings, such as HIV and homosexual stigma and guilt.

To analyze common features that form risk perception across the subgroups, we categorized the responses into risk perceived as high, for respondents who showed greater concern during or straight after exposure (14/25), and risk perceived as low, for those who were less worried about HIV infection during or immediately after exposure (4/25).

Érico, who perceived the risk to be high, refers to “stealthing” (non-consensual condom removal during sexual intercourse). The decision to seek medical help was influenced by the fact that he had casual sex not knowing his partner’s HIV status. The consumption of alcohol was an important factor that prompted self-reflection and the decision to seek PEP or other methods of prevention and diagnosis:

Influenced by questions such as pleasure and drug use. Juliano perceived the risk to be low. Despite knowing his partner was HIV positive, prevention was not a priority:

With regard to the HIV prevention methods and strategies reported by the groups, the condom was understood as being the safest method and was almost always present in the respondents sexual practices (25/25).

Intermittent condom use, a commonly recurring theme in the responses, appeared in two different forms: the beginning of sex takes place without a condom, with the condom being used only when an erection occurs or close to ejaculation; the condom is used at the beginning of sex and later removed for a variety of reasons, such as loss of erection and/or discomfort (loss of sensation, tightness).

The responses show that condom use is influenced by stereotypes and stigmas linked to the sexual partner. For example, the responses of a bisexual respondent show that the choice to use a condom was driven by gender stereotypes and sexual stigma, whereby condom use is dispensable in sex with women and indispensable in sex with men. This may be because he considers the risk of infection to be greater with MSM because the prevalence of HIV and sexually transmitted infections (STIs) is higher in this group than in women.

In short, the respondents’ risk perception and the consequent decision to use PEP stem from the following situations: 1- The recognition that not using a condom is a deliberate choice (14/25); 2- The perception that contextual questions such as affective characteristics or the use of alcohol and other drugs interfere with negotiation and remembering to use a condom (9/25); and 3- The association between condom use and awareness of, or remembering, the partner’s HIV status (2/25). Four of the 25 respondents mentioned situations that fall into the above situations, demonstrating the interconnections between pleasure/desire and prevention and negotiation and power relations in sexual contexts.

Age appeared to have a marked influence on prior knowledge of PEP. Most of the respondents aged over 24 years (17/25) had more comprehensive and consistent prior knowledge about prophylaxis (13/17) and mentioned the internet and/or support networks as sources of information, while most of those aged up to 24 years (5/8) mentioned the internet as a source of information, with only one person referring to support networks (1/8).

The meanings and implications of PEP use were predominantly negative across the three subgroups (14/25), expressed through sentiments such as fear, guilt and shame. The anticipation of stigma related to the fear of being confused with being HIV positive because of the use of antiretroviral drugs was evident in the responses of almost half of the respondents who had not previously used PEP. Positive meanings related to the experience of using PEP were predominant among the respondents who had previously taken the medication.

Discussion

The condom and HIV testing were the most commonly cited prevention methods. A number of quantitative and qualitative studies also reported that the most commonly cited prevention method by men in general was the condom²⁵25 Körner H, Hendry O, Kippax S. It's not just condoms: Social contexts of unsafe sex in gay men's narratives of post-exposure prophylaxis for HIV. Health Risk Soc 2005; 7(1):47-62.^,2828 Santos LA, Couto MT, Mathias A, Grangeiro A. Hombres heterosexualmente activos, masculinidades, prevención de infección por VIH y búsqueda de profilaxis posexposición sexual consentida. Salud Colect 2019; 15:e2144.^,3232 Dourado I, MacCarthy S, Reddy M, Calazans G, Gruskin S. Revisiting the use of condoms in Brazil. Rev Bras Epidemiol 2015; 18(Supl. 1):63-88.^,3333 Martinez O, Wu E, Frasca T, Shultz AZ, Fernandez MI, López Rios J, Ovejero H, Moya E, Baray SC, Capote J, Manusov J, Anyamele CO, López Matos J, Page JSH, Carballo-Diéguez A, Sandfort TGM. Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City. Am J Mens Health 2017; 11(2):181-195.. Despite their widespread use, condom failure, inconsistent use (for various reasons) and intentional non-use were the main prompters of risk perception and the consequent decision to seek specialist help or PEP³²32 Dourado I, MacCarthy S, Reddy M, Calazans G, Gruskin S. Revisiting the use of condoms in Brazil. Rev Bras Epidemiol 2015; 18(Supl. 1):63-88.^,3434 Barreto VHS. Risco, Prazer e Cuidado: técnicas de si nos limites da sexualidade. Ava Rev Antropol 2017; 31:119-142.^,3535 Grangeiro A, Ferraz D, Calazans G, Zucchi EM, Díaz-Bermúdez XP. The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review. Rev Bras Epidemiol 2015; 18(Supl. 1):43-62..

The use of the internet as a source of information on HIV prevention, especially after sexual exposure, was frequently reported by the respondents, corroborating the findings of other studies on prevention focusing on PEP²⁸28 Santos LA, Couto MT, Mathias A, Grangeiro A. Hombres heterosexualmente activos, masculinidades, prevención de infección por VIH y búsqueda de profilaxis posexposición sexual consentida. Salud Colect 2019; 15:e2144.^,3636 Card KG, Lachowsky NJ, Gislason MG, Hogg RS, Roth EA. A Narrative Review of Internet Use, Interpersonal Connectedness, and Sexual Behaviour Among Gay, Bisexual and Other Men Who Have Sex With Men. J Homosex 2020; 67(2):265-283.

37 Chiasson MA, Hirshfield S, Rietmeijer C. HIV Prevention and Care in the Digital Age. J Acquir Immune Defic Syndr 2010; 55(Supl. 2):S94-S97.^-3838 Yang Z, Zhang S, Dong Z, Jin M, Han J. Prevalence of unprotected anal intercourse in men who have sex with men recruited online versus offline: a meta-analysis. BMC Public Health 2014; 14(1):508.. These studies confirm that the potential of this tool for positively impacting HIV response strategies. However, attention and investment are needed to ensure the reliability of the internet as an information source³⁷37 Chiasson MA, Hirshfield S, Rietmeijer C. HIV Prevention and Care in the Digital Age. J Acquir Immune Defic Syndr 2010; 55(Supl. 2):S94-S97..

Our findings also show that the respondents, especially those aged over 24 years, access support networks of friends, through which respondents were indicated PEP services and follow-up. Friends and support networks are key to exposure-related risk perception. Very often, self-reflection prompted by support networks ensures that participants seek specialist help or PEP. In this regard, the literature highlights the beneficial effect of support networks on the prevention of HIV and other STIs, especially among MSM³³33 Martinez O, Wu E, Frasca T, Shultz AZ, Fernandez MI, López Rios J, Ovejero H, Moya E, Baray SC, Capote J, Manusov J, Anyamele CO, López Matos J, Page JSH, Carballo-Diéguez A, Sandfort TGM. Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City. Am J Mens Health 2017; 11(2):181-195.^,3939 Grace D, Chown SA, Jollimore J, Parry R, Kwag M, Steinberg M, Trussler T, Rekart M, Gilbert M. HIV-negative gay men's accounts of using context-dependent sero-adaptive strategies. Cult Health Sex 2014; 16(3):316-330.^,4040 Medline A, Daniels J, Marlin R, Young S, Wilson G, Huang E, Klausner JD. HIV Testing Preferences Among MSM Members of an LGBT Community Organization in Los Angeles. J Assoc Nurses AIDS Care 2017; 28(3):363-371..

The use of alcohol and other drugs appeared in various interviews, showing that this factor has an important influence on risk perception and assessment. Likewise, affective characteristics emerged as complicating factors for the process of managing the risk of infection. In a similar vein, Chakrapani et al.⁴¹41 Chakrapani V, Boyce P, Newman PA, Kavi AR. Contextual influences on condom use among men who have sex with men in India: subjectivities, practices and risks. Cult Heal Sex 2013; 15(8):938-951. reported that affectivity was a contextual factor that negatively affects condom use among Indian MSM. Our findings show that these factors were strongly related to inconsistent condom use, ultimately leading respondents to seek PEP. These findings confirm prevention challenges such as strengthening support networks⁴²42 Andrade GRB, Vaitsman J. Apoio social e redes: conectando solidariedade e saúde. Cien Saude Colet 2002; 7(4):925-934.^,4343 Juliano MCC, Yunes MAM. Reflexões sobre rede de apoio social como mecanismo de proteção e promoção de resiliência. Ambient Soc 2014; 17(3):135-154. and damage reduction programs⁴⁴44 Silva LAV. Redução de riscos na perspectiva dos praticantes de barebacking: Possibilidades e desafios. Psicol Soc 2012; 24(2):327-336.^,4545 Machado LVV, Boarini MLL. Políticas sobre drogas no Brasil: a estratégia de redução de danos. Psicol Cien Prof 2013; 33(3):580-595..

The respondents’ perceptions of risk are similar in many ways to Perrusi and Franch’s¹⁵15 Perrusi A, Franch M. CARNE COM CARNE Gestão do risco e HIV/Aids em casais sorodiscordantes no Estado da Paraíba. Rev Cien Soc Polit Trab 2012; 2(37):179-200. propositions regarding the multiple features of risk, including subjective dimensions. Some studies specifically addressing HIV-related risk suggest that subjective questions have a major impact on the formation of the idea of risk¹⁵15 Perrusi A, Franch M. CARNE COM CARNE Gestão do risco e HIV/Aids em casais sorodiscordantes no Estado da Paraíba. Rev Cien Soc Polit Trab 2012; 2(37):179-200.^,4646 Filgueiras SL, Maksud I. Da política à prática da profilaxia pós-exposição sexual ao HIV no SUS: sobre risco, comportamentos e vulnerabilidades. Sex Salud Soc 2018; 30:282-304.. Thus, improving access to quality information, ensuring services are prepared to embrace subjective questions related to prevention, and strengthening support networks, such as NGOs and groups, are options for improving the implementation of PEP and other combination prevention methods and strategies.

Questions related to risk and masculinities echo throughout the responses given by the bisexual respondents, both in relation to risk perception and prevention strategies. Like Santos et al.²⁸28 Santos LA, Couto MT, Mathias A, Grangeiro A. Hombres heterosexualmente activos, masculinidades, prevención de infección por VIH y búsqueda de profilaxis posexposición sexual consentida. Salud Colect 2019; 15:e2144., we observed that respondents perceived that the risks involved in heterosexual relationships are lower. The notion of male “invulnerability” to HIV, underpinned by hegemonic masculinity, has been reported in studies of PEP seeking behaviors among heterosexuals²⁸28 Santos LA, Couto MT, Mathias A, Grangeiro A. Hombres heterosexualmente activos, masculinidades, prevención de infección por VIH y búsqueda de profilaxis posexposición sexual consentida. Salud Colect 2019; 15:e2144.. In a study with MSM who practice bareback sex, Barreto³⁴34 Barreto VHS. Risco, Prazer e Cuidado: técnicas de si nos limites da sexualidade. Ava Rev Antropol 2017; 31:119-142. reports that risk exposure is viewed as an acceptable performance of masculinity. We did not find this type of argument in the exposures among our homosexual respondents, but we did find reports of not using condoms for the sake of pleasure.

With regard to perceptions of meanings of the use of PEP, the findings suggest that prior knowledge of the method, albeit sometimes limited and inaccurate, has an influence on the decision to seek PEP, especially bearing in mind that time is a key factor in the success of PEP as a prevention method⁴⁷47 Liu AY, Kittredge PV, Vittinghoff E, Raymond HF, Ahrens K, Matheson T, Hecht J, Klausner JD, Buchbinder SP. Limited knowledge and use of HIV post- and pre-exposure prophylaxis among gay and bisexual men. J Acquir Immune Defic Syndr 2008; 47(2):241-247.^,4848 Nodin N, Carballo-Diéguez A, Ventuneac AM, Balan IC, Remien R. Knowledge and acceptability of alternative HIV prevention bio-medical products among MSM who bareback. AIDS Care 2008; 20(1):106-115..

The findings in relation to age are consistent with those of epidemiological studies reporting high HIV transmission rates among young people²2 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. HIV/AIDS. Bol Epidemiol 2019; 9(1):1-58.^,33 Kerr L, Kendall C, Guimarães MDC, Mota RS, Veras MA, Dourado I, Brito AM, Merchan-Hamann E, Pontes AK, Leal AF, Knauth D, Castro ARCM, Macena RHM, Lima LNC, Oliveira LC, Cavalcante MS, Benzaken AS, Pereira G, Pimenta C, Pascom ARP, Bermudez XPD, Moreira RC, Brígido LFM, Camillo AC, McFarland W, Johnston LG. HIV prevalence among men who have sex with men in Brazil. Medicine (Baltimore) 2018; 97(1S Supl. 1):S9-S15.^,4848 Nodin N, Carballo-Diéguez A, Ventuneac AM, Balan IC, Remien R. Knowledge and acceptability of alternative HIV prevention bio-medical products among MSM who bareback. AIDS Care 2008; 20(1):106-115.. This group use a smaller variety of information sources, restricting themselves almost exclusively to the internet, while in the 24 years and over group support networks are important sources of information in addition to the internet. These differences are associated with aspects of a generational gay culture³⁵35 Grangeiro A, Ferraz D, Calazans G, Zucchi EM, Díaz-Bermúdez XP. The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review. Rev Bras Epidemiol 2015; 18(Supl. 1):43-62.^,4949 Paiva V, Pupo LR, Barboza R. O direito à prevenção e os desafios da redução da vulnerabilidade ao HIV no Brasil. Rev Saude Publica 2006; 40(Supl.):109-119.^,5050 Taquette SR, Souza LMBM. HIV-AIDS prevention in the conception of HIV-positive young people. Rev Saude Publica 2019; 53:80., which establishes and maintains networks of belonging, solidarity, and pursuit of recognition.

Many of the respondents only became aware of PEP when they sought HIV testing or through support networks. These findings reinforce the importance of disseminating quality information in addition to ensuring the availability of PEP services with sufficient resources to meet demand.

The stigma of AIDS and anticipation of this stigma were evident in the respondents’ perceptions of the meanings and implications of the use of PEP. In the same vein, Ferraz et al.⁵¹51 Ferraz D, Couto MT, Zucchi EM, Calazans GJ, Santos LA, Mathias A, Grangeiro A. AIDS- and sexuality-related stigmas underlying the use of post-exposure prophylaxis for HIV in Brazil: findings from a multicentric study. Sex Reprod Heal Matters 2019; 27(3):1650587. highlight the impact of this stigma across different groups of PEP users. The findings of both studies reinforce the need for a more in-depth investigation of the reproduction of this stigma, despite the growing popularity of drug-based HIV prevention strategies.

It is important to remember that the fact that the interviews were conducted in health services may have influenced the responses. An example is the frequent mention of condoms, with respondents possibly repeating the recommendations in the health guidelines produced over recent decades³²32 Dourado I, MacCarthy S, Reddy M, Calazans G, Gruskin S. Revisiting the use of condoms in Brazil. Rev Bras Epidemiol 2015; 18(Supl. 1):63-88..

Final considerations

This is first study in Brazil to investigate perceptions of risk of HIV infection among MSM who sought and had access to PEP, providing a window to understanding more subjective aspects of HIV prevention among MSM, especially those related to risk perception and the decision to use PEP in the context of combination prevention.

The promotion of male condoms in the narratives of HIV prevention among MSM and condom failure, shown to be the main reason for seeking PEP among our respondents, demonstrate the complexity of the relationship between risk and pleasure, which has been highlighted as a theme to be explored in gender and sexuality studies in the field of HIV/AIDS. Extrinsic contextual factors (unplanned sex or sex under the influence of drugs or alcohol, for example), more specifically the type of affective bond with the sexual partner (the pursuit of pleasure), warrant highlighting as key elements to be taken into consideration in HIV prevention actions directed at MSM. These elements suggest the need for further research to investigate the complex relation between the exercise of masculinities, risk perceptions and HIV prevention strategies among MSM, in the same vein as the work of Luis and Spink⁵²52 Luiz GM, Spink MJ. O gerenciamento dos riscos no cenário da aids: estratégias adotadas por homens que fazem sexo com homens em parceria casual. Athenea Digit 2013; 13(3):39-56..

Consistent prior knowledge, not only of PEP, but also other prevention strategies and methods, stood out as an important factor that helps subjects to make decisions with greater certainty and less anguish and suffering and that result in successful outcomes.

Support networks were clearly evident among the study group, with the respondents confirming the numerous findings in the literature. In this regard, it is important to highlight the role of the state and civil society organizations in the ongoing dissemination of consistent information and overcoming conservatism in the design and language used in published material in order to access the groups that most need this information, including MSM.

Our findings indicate that, in addition to access to biomedical methods such as PEP, to be successful, HIV/STIs/AIDS prevention actions tailored towards MSM need to consider the complexities involved in the formation of risk perceptions and decision-making among this group and ensure access to a range of prevention strategies and methods without sacrificing sexual-affective satisfaction and health care needs.

References

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