Mediating PrEP – Introduction to Special Section

PrEP – pre-exposure prophylaxis – has been hailed as a game-changer when it comes to HIV prevention. In the same way female oral contraception is popularly understood to have revolutionised women’s sexual agency in the 1960s, pre-exposure prophylaxis offers a new method of prevention for HIV negative people at risk of contracting the virus. While the history of HIV prevention work is littered with an array of harm reduction measures (sero-sorting, non-penetrative sex, external ejaculation, voluntary male medical circumcision), PrEP is only rivalled by the condom in its potential to radically alter the trajectory of the global HIV pandemic. Since 2012, a host of countries have recommended using a combination of emtricitabine and tenofovir disoproxil fumarate as a preventative treatment. This treatment has typically been targeted at population groups deemed most at risk of HIV infection. These groups (the boundaries of which are not impervious) include men who have sex with men (MSM) with a history of condomless sex, those in a relationship with an HIV positive partner, sex workers, ex-prisoners who have a history of sex with men, IV drug users, and (in some parts of the world) adolescent girls and young women. The potential of PrEP to reduce HIV transmission rates cannot be overstated. When taken daily, PrEP has a 99% efficacy rate (Anderson et al., 2012) and even when taken just four times per week, the treatment can be up to 72% effective (Cairns, 2012). These figures alone suggest that, while PrEP does little to protect users from contracting other STIs, it nevertheless carries the potential for a new ‘sexual revolution’.

Of course, such revolutions are as much a product of discourse as scientific discovery. Likewise, and in common with other medical technologies, PrEP is just as much the product of discourse as it is of biomedical science. That is to say, the public understanding of PrEP, the decisions not/to make it available, and the attitudes of policymakers, clinicians, health professionals, government ministers and individuals towards the treatment have all been shaped by discursive practices. Gilead, the makers of Truvada, have played a key role in shaping the ‘narrative’ of PrEP in the USA. Alongside prescription refund campaigns and billboard advertising, the makers of the ‘little blue pill’ have had a significant presence at queer cultural events, investing in Pride parades and sponsoring LGBGTQ film festivals.

Outside of the USA, a range of organisations have been involved in shaping understandings and opinions about this new treatment regime, most notably the World Health Organization. In the same year that the US FDA licensed Truvada for use as PrEP (2012), the WHO began listing PrEP as a prophylactic treatment for HIV, and the active ingredients in Truvada are now listed on the organisation’s list of essential medicines and treatments. Global actors such as the WHO rely on other agencies (local NGOs, government health departments, doctors, health promotion experts, peer educators) to act as discursive capillaries, disseminating but also framing information about PrEP within specific communities, and ultimately down to the level of the individual subject. Of course, such actors should be understood as mediators, rather than intermediaries (in the Latourian sense). Meanwhile, qua Foucault, we must acknowledge that such mediation through discourse (like all forms of power) is mobile, fluid and subject to change and resistance.

Alongside the official discourse of government agencies and pharmaceutical companies, the media have played a key role in shaping the public understandings of PrEP. The role of the mass media in shaping public understandings of HIV has been discussed extensively over the last 30 years (see Bertrand and Anhang, 2006; Keating et al., 2006; Miller and Williams, 1993; Owen, 2018; Pickle et al., 2002; Sood et al., 2006; Watney, 1997; Williams, 1999; Wu, 2006) and these discussions have recently extended to the way in which mainstream media outlets have framed understandings of pre-exposure prophylaxis (Hackl and Newman, 2016; Jaspal and Nerlich, 2017). Murphy (2015: 25), for instance, suggests that ‘the media as well as research literature often frames gay men’s interest in antiretrovirals for prevention’ but the media arguably go further than this, acting as a key mediator between research literature and the public; one that selectively reports and carefully frames research in ways that fit the ideology of individual news organisation and their assumed audience.

Indeed, the very development and trialling of PrEP has been shaped by media discourses. Mack et al. (2010) cite negative media coverage as a contributing factor in the premature closure of a PrEP trial in Cameroon in 2004–2005. In particular, the authors identify the role that pre-existing discourses concerning global exploitation and western imperialism played in the national media’s framing of the trial. The authors conclude that negative coverage of PrEP, which summoned up the historical spectre of colonised bodies being used to test new medicines, was one of several interlinking factors that led to the demise of the trial (see also Mills et al., 2005). Such findings point to the fact that, while PrEP is a new treatment, public understandings of that treatment rely on pre-existing discourses, which might on the surface appear to have little to do with HIV prevention.

Alongside mainstream national media institutions, social media and ‘hook-up’ apps have been cited as networked spaces in which information about PrEP can be disseminated, debated and discussed (see Adrover et al., 2015; An et al., 2014; Kirby and Thornber-Dunwell, 2014; Schwartz and Grimm, 2017). As with other media channels, digitally mediated environments have also provided a space where resistance to the treatment can be mobilised. In 2012, a PrEP specific variant of ‘slut shaming’ discourse began to be disseminated online. Popularised by David Duran (2012) in a blog post written for the Huffington Post, the term ‘Truvada Whore’ quickly gained traction in western gay male online communities. Illustrating the role that morality plays in public and professional attitudes towards sexual prophylactics (see Myers and Sepkowitz, 2013), the Truvada Whore initially symbolised the ‘bad’ or ‘immoral’ gay man who refused to limit his sexual activities, and who wilfully ignored conventional safer-sex advice in pursuit of sexual freedom. The Truvada Whore discourse worked to frame PrEP as a ‘lifestyle’ or ‘party’ drug that promoted and supported promiscuity.

Of course, the ‘Truvada Whore’ almost immediately became an identity that spoke back to its critics, embodying Foucault’s (1990) concept of the reverse discourse. Thus, while initially deployed as a means of denigrating PrEP users, the Truvada Whore was quickly reclaimed as a sex-positive symbol, a label to be worn with pride (often literally, printed on T-shirts worn by PrEP advocates). Such repurposing and appropriation echoes the use of the biohazard symbol by HIV positive people, who adopted this marker of life-threatening danger to resist the demonising of people infected with the virus (see Spieldenner, 2016). In different ways, and to different extents, the articles that make up this special section acknowledge the ongoing role that media (networked, mass, interpersonal) play in framing public understandings of HIV/AIDS, prevention strategies and treatments, and the constituencies most affected by the virus. They also acknowledge the fact that this ‘public’ is far from homogenous. Indeed, there are arguably as many (if not more) publics constituted by media as there are media outlets.

The articles in this special section of Sexualities therefore focus on mapping specific contexts in which PrEP has been framed, discussed, mediated, promoted and critiqued. For a variety of reasons these foci draw from research sites located in Europe and the USA. There is a great deal more work to be undertaken exploring how PrEP has been framed in non-western contexts. It is hoped that some of the research currently being developed in sites such as Taiwan, Ghana and Brazil will be available in the future. For now, what the contributors to this section offer are a series of critical interventions that examine the various ways in which PrEP has been mediated, and who those mediating agents are. Leading this section, Emily Nicholls and Marsha Rosengarten draw on data from a pan-European study to identify the mediating role that health practitioners play in understandings and uptake of PrEP. The authors discuss how this treatment reshapes understandings of HIV and HIV prevention within the context of the clinic. Drawing on interviews with health professionals, Nicholls and Rosengarten explore the possibilities and challenges that PrEP poses for those tasked with promoting and administering the treatment, and in what manner these professionals are mediating the transformation of sexual cultures.

Focusing specifically on the British context, the next two articles examine the coverage of an influential High Court ruling regarding who has the ‘right’ to fund PrEP. Sharif Mowlabocus explores the discussion of PrEP in the British news media and considers how a politics of homonormativity underpinned the media’s response to calls for the treatment to be made available on the National Health Service. His analysis reveals the conditions under which gay men are accepted in contemporary Britain. Meanwhile, Alexander Maine draws directly on the voices of interview participants to examine the mediating role the British legal system played in legislating more expansive non-normative understandings of gay male sexuality. His analysis identifies the paradoxical position PrEP currently occupies in the lives of gay men in the UK: a biomedical intermediary that ‘liberates’ sexuality and intimacy.

Greg Niedt explores the multiple ways in which both mainstream and ‘gaystream’ media have discussed PrEP in the USA. Drawing upon Kantian notions of the sublime via the work of Kover (1998), Niedt utilises discourse analysis to generate a framework for interpreting these public discussions. He identifies three discourses that underpin news reporting of PrEP, which in turn frame queerness, PrEP and sex in particular ways. He concludes by arguing that the concept of the ‘terrifying sublime’ might in fact be a productive method for disaggregating ‘the threat of HIV from the subjects who are at risk of contracting it’, allowing journalists to frame PrEP in ways that are both more accurate and devoid of the moralising that has hitherto accompanied discussions of this treatment.

Finally, Roberto Ruben Da Silva Brandao and Aurea Ianni offer a compelling analysis of how PrEP has become a mediating factor in gay and bisexual mens' experiences of pleasure. Their analysis identifies how technology and the history of HIV/AIDS have shaped the desires and fantasies of gay and bisexual men. This shaping has resulted in the creation of boundaries regarding what is and isn't safe: what is and isn't permissible. From this perspective, PrEP enters the lives of MSM and offers a challenge to these 'historic' boundaries. It mediates between established conventions around safer sex and the fantasies of transgression that such conventions inevitably produce. PrEP thus becomes a mediating force, in and of itself, offering gay and bisexual men an opportunity to (re)negotiate sexual practices after almost forty years of the ‘condom code'.

As with all medical technologies, understandings of PrEP are never fixed and will continue to evolve. Likewise, those understandings say as much about the social, legal, political and cultural context in which they are formed as they do about this prophylactic treatment. This special section aims to develop a multi-faceted discussion regarding the methods and mechanisms by which PrEP is (and in some cases, is not) being rendered intelligible, acceptable and legitimate.