Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP)

Abstract

This article explores both the sexual desires and pleasure in the context of HIV pre-exposure prophylaxis (PrEP) use among gays, bisexuals and other men who have sex with men (GBMSM). Our main findings suggest that individuals were assuming notions of natural and unnatural sex, while these categories were linked to condomless sex, acquisitions of sexually transmission infections (STIs) and their perceptions of intimacy. Individuals also believed they could enhance pleasure and desire by acknowledging their inner subjectivity and societal positions associated with PrEP. We argue that the individuals play a positive and conflicting ethic towards sex while on PrEP.

Keywords

Bareback sex HIV/AIDS pre-exposure prophylaxis sexual desire sexual pleasure

Introduction

The AIDS epidemic has given rise to many varied and new social processes (Daniel and Parker, 1993). One of them is the significant impact on the sexuality and sexual practices of the main groups affected by the epidemic, especially gays, bisexuals and other men who have sex with men (GBMSM) (Halkitis, 2014; Parker, 1993). The invention of safe sex during the 1980s, with condoms as an effective form of prevention, affected subsequent forms of pleasure and discourses on sexuality (Brier, 2009; Parker, 1993; Treichler, 1999).

The HIV/AIDS epidemic has historically undergone constant transformation, with fluctuations in infection incidence and occurrence of new cases influencing discourses on prevention and sexuality (Biehl, 2007; Race, 2018). A case in point is the adoption of new methods for risk management in sexual practices where condom use is not consistent. Since there is an increasing incidence of new HIV-acquisition cases, particularly among young GBMSM in a number of western countries (CDC, 2016), prevention strategies have become the focus of global discussions on epidemic control (UNAIDS, 2016). One of the most recent medical-scientific innovations is the HIV pre-exposure prophylaxis (PrEP), which consists of a daily antiretroviral regimen that prevents the HIV acquisition in more than 90% of cases (Grant et al., 2010). This strategy is one choice among several HIV/AIDS chemoprophylaxis methods, which stands as effective as condoms, or even superior (McCormack et al., 2016).

While on PrEP, individuals find new possibilities of managing their sexual practices and ways to transform their experience of pleasure and desire during sexual practices (Grace et al., 2018). This transformation takes place through constructed meanings, in which the technology plays a crucial role in their desires and pleasures (da Silva-Brandao, 2018; Race, 2018). For example, PrEP can facilitate the fulfillment of sexual fantasies such as condomless sex, relieving fears of its users as well as reducing erection difficulty due to condoms. This technology, therefore, combines positive individual, biological, and social traits in the context of the HIV/AIDS epidemic (da Silva-Brandao, 2018).

The range of individual choices stemming from biotechnological innovations is a consequence of previously obtained advancements in pharmaceutical intervention and social technologies (Rose, 2007). The introduction of high-potency antiretroviral drugs for the treatment of people living with HIV/AIDS as early as the 1990s – which is highly effective in controlling the proliferation of viruses – opened many possibilities in patient care and management of the epidemic (Lisk, 2010). Furthermore, there was a decrease in deaths and diseases related to AIDS, allowing for an increase in life expectancy and a reassurance of the hopes of an entire generation, which had already been facing the disease and its terrifying prospects (WHO, 2018). Such advances have led to direct impacts on the perception of the epidemic by subsequent generations (Dean, 2009; Halkitis, 2014).

Our premise is that these successes mark the beginning of a period in which the epidemic becomes recognized by its chronification. On the one hand, it is a disease with an infectious dynamic, sensitive to virus-host relationships and modes of transmission; on the other hand, all biomedical interventions that make use of sophisticated and precise antiretroviral drugs ultimately confer the epidemic a handleability mediated by technique. In other words, nowadays one cannot conceive of an HIV/AIDS epidemic separate from the technical and technological societal spheres. Currently, the virus undetectability in the blood of people living with HIV – due to continuous and prolonged adherence to antiretrovirals – is a UNAIDS global goal, since it prevents virus transmission (CDC, 2017). Thus, in the present epidemiological stage, the exhaustive control of the infection via technical-scientific means has reached its historical peak.

The aim of this article is to discuss the experiences of individuals on PrEP, especially GBMSM, regarding sexual desire and pleasure, considering biomedical interventions as a means of producing erotic experiences mediated by technical-scientific incorporation. To be precise, we find in PrEP a success of science and technology which, diffused to individual life trajectories, produces new and emerging sexual desires and practices.

Reflection on these issues will be carried out in two ways: first, by counterposing reports of PrEP users and issues related to the production of sexual desires and practices – with and without the mediation of condoms. As an uncontrolled contingent of the AIDS epidemic, the introduction of the condom code had influenced diverse perceptions on sexuality such as fetishizing, glorification and nostalgizing for condomless sex (Mowlabocus et al., 2013; Race, 2018). This was mainly translated into bareback practices, which emerges as an expression of risk conflation and sexual desires in the imminence of the HIV acquisition (Dean, 2009; Race, 2018). In this way, we incorporate into our argument the theoretical contributions Tim Dean (2009, 2015) makes about bareback practices and their relationship with the new HIV chemoprophylaxis strategies. Second, these questions are put into the context of a body of theoretical literature that discusses individual action in the contemporary context, identifying their inner contradictions in respect to broader social transformations. In our view, this approach helps understanding the social production of sexual desires and pleasures arising from an increasingly PrEP use.

Exploring Facebook® data

This study analyzed data collected from interactions of PrEP users and their interlocutors in a Facebook® discussion group on PrEP and HIV/AIDS, which gathered thousands of members, predominantly GBMSM from the USA. The group aims to discuss PrEP facts without judgments on members’ experiences and sexualities. The members seek sharing experiences, reflect on them, and being on the forefront of social advocacy in the HIV/AIDS epidemic. The group was made by PrEP users and shortly after gathered many HIV/AIDS activists. There is no recruitment for the group members, nor any institutional support that funds their activities.

This study is part of a large sociological and public health interdisciplinary study that analyzed contemporary social change and individualization processes in public health. The follow-up period for members’ posts took place during a three-month period in 2017, including a preparatory one-month pilot phase. Data from the pilot phase were used as final data, since there were no significant changes in data collection procedures, or in the previously established data collection script. As ethic-based measures, we have protected group and members’ names as well as any other information that might identify one of the members, including all moderators. We have followed all local ethical guidelines to securely protect and destroy the original reports in our archives. As one of the authors is also an HIV/AIDS activist, we see that a public discussion on these issues is one of the commitments of critical thought that the group shares as a principle.

Based on the method of content analysis with thematic categories (Quivy and van Campenhoud, 2008), we focused our attention on the content of the discussions, checking in which ways individuals presented their personal issues, particularly their routines, conflicts, and successes on PrEP use. We assumed reports on these issues were a rich and adequate material to the purpose of this study. A structured analysis script was developed to capture specific and detailed experiences, which helped us filter all the selected posts. To make this script, we considered recurrent aspects of these experiences, as well as the specificities of PrEP use. We made questions that oriented our post selection, for example how new forms of desire and pleasure were discovered while on PrEP. Further details of the questionnaire are in da Silva-Brandao (2018).

After the post mapping phase, we proceeded to select a set of posts for analysis by considering the following criteria: first, the content of users’ experiences, those which were denser discussions, in longer posts, which acquired greater interactions among group members; second, discussions based on reports of personal experiences by PrEP users; third, the sensitivity of some issues in the context of the group’s general discussion: some topics gathered more individuals to debate sensitive conflicts on PrEP use, for example, discussions on the STI rise among PrEP users, drug efficacy failures, drugs’ side effects, condom use, condomless sex, among others. These topics caused controversy among members, which led us to take a closer look at them.

After post selection, we analyzed whether each post responded to any questions of the structured analysis script. By confronting these two materials, we obtained four thematic sets of posts, totalizing the respective number of posts, and the average number of all comments per post, as follows: Experience of individuals on PrEP (36, 38); production of sexual desires and/or pleasures (26, 32); user individuation and identity expression (21, 26); and, finally, the social context in which this prevention strategy is employed (20, 25). Although this study focuses on posts reporting and discussing the users’ production of sexual desires and/or pleasures, the content is interlinked within all categories. We transcribed, compared, and catalogued the most recurrent contents by similar themes. Details of the post pre-selection process, the employed criteria, and the techniques used to group the contents are available in da Silva-Brandao (2018).

Dismantling bareback sex: Natural and unnatural sex

For individuals on PrEP, sexual pleasure retains an individualized meaning, which is intrinsically associated with the use of the drug. This technology adjusts to each one’s sexual meanings and prospects. While on PrEP, individuals express the change in forms of pleasure through terms that value the new sensations arising from being on PrEP; a tension emerges between natural and non-natural types of sexual practices.

The first type corresponds to the search for natural, condomless sex, orienting the imaginary of those who seek sexual interactions closer to the ‘real thing’.¹

The intervention of a condom in the sensation changes the entire feel, and therefore is not as nature created the feeling. The feeling of penile skin on mucosal layer is an inherent motivator for sex, as created by nature. PrEP doesn’t interfere with that, while condoms do.

This ‘real’ dimension of experience relates to the emerging ideals about bareback sex in the early 1990s, in which a subculture of gay men initiated a movement seemingly opposed to the advances of epidemic prevention and control. Gay and bisexual men from the USA started to intentionally assume the risk of unprotected anal sex in the context of the HIV/AIDS epidemic in the early 1990s (Carballo-Diéguez, 2001; Dean, 2009; O’Hara, 1997). The term bareback, which originally describes riding a horse without a saddle, exalted the freedom of unprotected sex as a form of resistance to the produced fear by the AIDS epidemic. These ideas would resonate later, as described by Dean (2009), in alternative subcultures of GBMSM in the USA.

Dean (2009) studied barebacker subcultures in the USA and identified this practice as a cultural and identitary construction following the emergence of antiretrovirals. As he argued, these drugs reopened a space for sexual behaviors, fantasies, and sexual desires – typical of libertarian and communal practices from previous decades – that AIDS had disrupted. In this argument, while antiretrovirals increased the life expectancy of people with HIV/AIDS, they also forged a new social space for sexual practices, with moral implications on sexual intimacy, such as the positivation of condomless sex and semen exchange. These have contributed to an interpretation of these sexual interactions as more affective and intimate, and, at the same time, more masculinized (Berg, 2009; Race, 2018).

In the domain of this early assumption, individuals on PrEP, a few decades later, assert that sex with condoms is ‘non-natural’. They may decide to have sex with a condom though to avoid unwanted effects, for example, the acquisition of STIs other than HIV that may result from condomless sex:

I think condoms still have their place in high risk situations for STIs. As a person living with well controlled HIV, I know I am more susceptible to contracting an STI than I was before so there are still times when condoms are fine for me and do not destroy hot sex.

In the context of PrEP, bareback practices gain other meanings, which arise from the combination of technology and individual practices that no longer have to deal with the risk of HIV acquisition. While bareback practices were roughly defined by the imminent risk of HIV infection in urban areas (Halkitis et al., 2005), the term appears to be bound up to the AIDS epidemic, developing alongside it. The apparent elimination of any significant chances of infection, in the context of PrEP and the undetectability of the virus, leads to a dismantling of the concept and practices of bareback sex into other cultural expressions and terminologies such as natural sex, real sex, and condomless sex; in short, a diversity of terms that do not impose the HIV risk of infection as an immanent characteristic of sexual interaction.

However, the distinction between the two types of sexual practices is often counterposed or tensionated by different, but individual perspectives:

I am not a fan of this use of ‘natural’. … given how often ‘unnatural’ has been used to mean ‘deviant’ in our society (especially against Queer folks), it strikes me as subtly dismissive towards men who choose to use condoms. And if one uses it to include condomless, PrEP-protected sex, then it is putting condoms in the ‘unnatural’ category and PrEP in the ‘natural’ category, which seems imbalanced to me.

As in this case, while HIV is not crucial, individuals struggle to qualify their sexual practices. Also, they take into account all the accumulated knowledge about their sexual prevention and practices over the epidemic as an attempt at mediating new practices. Dean (2015) advanced reflections on this matter, asking whether the term bareback still maintains part of its original meaning in times of chemical prevention and undetectable viral loads, considering that sexual practices also suffer the effects of a normative biopower on bodies. In this sense, one cannot assume that the risk sphere attributed to HIV is exchangeable, at the individual level, for other STIs in the chemoprophylaxis era. These risk spheres belong to different imaginaries of severity and stigma, as well as personal, subjective, and material consequences on the lives of individuals (Treichler, 1999). However, it is also possible to see that bareback practices in the chemoprophylaxis era emphasize its natural sex attribution in the sense of sex without the fear of getting HIV or of sex with direct mucosal contact. This assumption though goes in disagreement with ideological apprehensions of the term, such as those of bareback subcultures that reject any form of biomedical intervention that normalizes sexual desire and pleasure (Morris and Paasonen, 2014; O’Hara, 1997).

In addition, the scope of individual choice is modified by the emergence of PrEP; while during the early 1990s, the possible choices were to negotiate between risks – that could potentially lead to death – and sexual practices, nowadays this confrontation takes place under more refined scientific and technological bases, allowing for the massification of a sexual practice previously seen as marginal or inconsequential (Holmes et al., 2008; Dean, 2009). In this sense, many PrEP users choose their sexual practices backed by scientific knowledge, a departure from times when prevention technologies were much more restricted. As one PrEP user wrote: ‘I know all the statistics’.

In this sense, PrEP as a chemoprophylaxis confers bareback sex a status of consequence and responsibility, previously non-existent in sexual practices that flirted directly with risk (Krüsi et al., 2017). Today, on the contrary, increasing barriers against infection by the virus, and an expansion of the sphere of biomedicalization, promote the capillarity of this practice among segments that wish to meliorate their sexual experience (Young et al., 2019) in what could be called an advance in the processes of sexual performance improvement.

In this context, sexual practices assume new meanings, with questions asked by researchers shifting their focus from the so-called deviants to the issue of an individuality normalized by medical practices. If, according to Dean (2009), the original definition of this term referred to a population of political and identitary outlaws, biomedicalizing practices, like PrEP, spread its use in a sense related to the capacity of individuals to consume. This allows individuals themselves to become agents of their own lives, by claiming for themselves the exercise of medical knowledge and risk management methods, producing and experiencing their sexual desires and practices under the aegis of scientific evidence. As Nicolas Rose has long discussed (2007), this is a contemporary process that intercepts bodies with science, chemicals and medical power, allowing individuals to navigate through biomedical identities with the sense they are free though highly regulated by advanced biopower technologies.

This attitude of choosing between, or adopting an economy that weighs the risk of virus exposure against the possible gains of condomless sex, finds in hot sex the horizon of pleasure in sexual intercourse. It is a contraposition among perceptions of sexual intercourse – natural and non-natural, more pleasurable and less pleasurable, healthier and less healthy, with or without condoms – that gives new ambiguities to sexual relations, beyond mere arousal. In other words, the idea of pleasurable sex is not limited to decreased risk of exposure thanks to PrEP, or even to erection itself:

I just find it more natural to have sex with a man with no latex in between our skins. Better. More spontaneous. Less stressful. You name it.

Hot sex, as in this case, also stems from a greater or lesser approximation with the sexual partner. Although the ‘natural’ and ‘non-natural’ categories may presuppose a moral dichotomy between good and bad, adjustment and non-adjustment to normality, they justify this based on mucosal/physical contact and its pleasurable effects:

… the point being the physical feel of natural sex, as I call it, is the same whether PrEP is in the bloodstream or not.

As in these cases, the subjective content of condomless sexual practices in times of PrEP diffusion are framed by enhancing PrEP positivity effects on individuals. It does not appear to us that condomless sex has a self-destructive connotation as the psychoanalytical approaches first observed (Bersani, 2008, 2009). Individuals on PrEP refer to their practices as something positive in which they perform their pleasure and desires without previous constraints, a fact that Young, Davis, Flowers and McDaid (2019) have also found while discussing HIV citizenship in the treatment as prevention era. Interestingly, in the two foregoing quotations, one of them highlights how stressful it was having sex with condoms, while the other disregards the fact that PrEP is not a natural intervention. For the latter, the feeling itself seems to play a major role in his perception of what natural is.

The idea of having natural sex beyond the fact that it is not natural – in the ultimate sense of the term – reveals a profound subjective perception that collapses natural into chemical, nature into culture and vice versa, which is part of a large contemporary anthropological phenomenon (Cadena, 2019; Latour, 1993). As part of the foundations of contemporary societies, individuals are cultural-biological constructs in which subjectivity and rationale collapses into undetermined social expressions (Latour, 1993) and risks (Beck, 1992). Most of these processes occur via science and technology innovations (Latour, 1993; Beck, 1992), as well as power relations dynamics on controlling and manipulating the body (Comaroff and Comaroff, 1992; Rose, 2007). As such, the subject critique loses its modern alterity strength due to the lack of reflection and signalization of themselves in this social network (Han, 2015; Latour, 1994). In this case, individuals see a strong chemoprophylaxis as part of the constituency of themselves, which nurtures their inner fantasies towards sex. In this situation, there is no distinction between the artifact and the subject (Cadena, 2019) and, most importantly, both cooperate in the production of cultural practices – fantasies and sexual practices – and of the individuals, as they become bioculturally enhanced bodies that the virus cannot enter. As a result, individuals weaken their capacity to distinguish the concrete – PrEP is a non-natural remedy – from bodily-subjective productions – sex on PrEP is natural because there are no condoms.

Although bareback practices have being profoundly changed over the last decades, particularly with the emerging HIV chemoprophylaxis (Race, 2018; Dean, 2015), some of its core concepts are still present in individual sexual narratives. The bareback breakdown into diverse social expressions still conflates with risk though in different levels of severity and significance to both individuals and society. In the following section, we argue the STIs play the HIV role as a minor character in the GBMSM sexual contemporary imaginary, while subjectivity continues to amalgamate nature and culture, bodies and chemicals as only a self-construct.

Negotiating STIs, tensioning sexual pleasure

Besides the natural versus non-natural dichotomy, STIs mediate sexual interaction as individuals consider them to decide in which ways they have sex. Some PrEP users view condoms as a risk-reduction tool to be deployed strategically, as this contributor:

I mostly stopped using them after starting PrEP, but after encountering STIs a good deal more frequently than previously, I reverted to using them again sometimes.

In this situation, STIs act as an intermediate factor that tension individuals to decide whether to have natural or non-natural, or even a different sexual practice in this spectrum. If some recognize the need for condoms as a form of protection against other STIs, others deny or downplay the importance of these other STIs in calculating whether or not to wear condoms, alluding to an emerging political economy of sexual pleasure:

HIV is the only significant STI

And the poster proceeds:

… only HIV has killed millions in the modern era. When was the last funeral you went to for chlamydia? … as for Herpes: ‘oh my god’, it is a nothing disease.

Individuals tend to have low perceptions in relation to STIs, including the HIV/AIDS epidemic; the varying perceptions amongst them relate to the clinical severity and the social perceptions of these illnesses or infections, which includes cultural experiences of stigma and discrimination (Reuter et al., 2018). Interestingly, however, despite the STIs' relative low severity to individuals, they gain higher importance to individuals on PrEP in order to decide whether or not they have sex with condoms. The findings that suggest people on PrEP have lower STIs incidence due to continuing STI/HIV screening (Mayer et al., 2016) has been continuously questioned in the literature, showing that individuals do more of condomless sex while on PrEP (Holt et al., 2018; Montaño et al., 2019). At a first glance, these findings may suggest that individuals are deliberating abandoning the long-term condom code that predominated in public health discourses. Instead, it seems individuals negotiate the STIs prevention by putting their fears in balance – due to high frequency of STIs, for example – and their sexual interests towards pleasure, which enriches the idea of a sexual pleasure economy while doing condomless sex.

Although some experience of having STIs ‘can actually be emotionally devastating’, as one contributor has said, the dichotomy moves between negative personal impacts of STIs, and individual interest into more pleasurable forms of sexual intercourse. Within this individualized political economy, lies a mediation towards opting for sex with or without a condom. This shows that the imaginary of STIs presents itself with greater or lesser tension in each person’s choice of sexual practice, either being neglected or taken as a starting point for this choice. Through their experiences, individuals have noticed that ‘there are men that are beginning to reject sex just because condoms are brought up’. One PrEP user stated that he had stopped using condoms long before PrEP and ‘refused to have sex with condoms, no matter the [HIV] status of the guys’ he was sleeping with. Aligned with these perceptions, one adds that his preventive choices do not make him a TruvadaWhore, referring to the commercial PrEP drugs, as ‘I am sick of the stigma around folks and their method of preventing HIV/STI transmission and the fear of being SexPositive’.

By taking these experiences into a broad spectrum, individuals are looking for great positivity in sex and, by doing so, they attribute greater positivity to the practice itself; in other words, to keep doing it in order to improve sexual experience in terms of pleasure. This consecutive and permanent state of doing can end in harmful effects, such as personal exhaustion, which extends to both physical and subjective exposition to others (Han, 2018). At the same time, individuals have to live with other STIs and fatigue of functional biological mechanisms, which in an everyday basis can potentially be followed by low perceptions of the self that are implicated in negative mental health outcomes (Resneir et al., 2010). In short, these are consequences that flirt with the idea of self-exploitation on concrete analytical bases, which differ from the psychoanalysis and pathological take on early bareback practices (Bersani, 2008, 2009). In the context of this study, the medical normalization does not depress sexual pleasures and desires; on the contrary, these interventions potentiate the sphere of sexual desires and practices, even considering that technical-scientific discourses are oriented to preventing new infections (WHO, 2018).

Over the course of the epidemic, unprotected sex continues to be at the core of scientific and technological production that target the individual, assuming that conjugating unidirectional processes, such as treatment as prevention and PrEP, could single-handedly overcome the epidemic -- despite all of its socio-historical inequalities and contradictions (Seffner and Parker, 2016). Dean (2015), operating within the Foucauldian theoretical framework, asserts that this occurs because sexuality is the precise point in which societal regulation and discipline takes place, a well-articulated meeting for the normalization of both body and population. In the context of PrEP, however, these punctual encounters have other implications for the individual action. The present dilemma no longer revolves around irresponsible outlaws that must be disciplined by medical knowledge, but disciplined patients who request for themselves a disciplined status on behalf of freedom. The individual disintegrates perceived biopower framings into liberating forms of sexualities despite being highly disciplined. Likewise, it is no longer simply a question of self-destruction instilled in the psychic memory of each individual: sexual interaction is an objective process that can take place on a self-exploitative basis, given the suffering resulting from infections by other STIs.

In this sense, the fear of contracting other STIs mediates the choice whether to wear a condom or not, which is similar to what the fear of contracting HIV used to be in the past generations. However, the death contingent that past generations had to deal with (Halkitis, 2014) is not objectively in place for these individuals. They point out though that ‘no matter how well I know the statistics concerning my chances of getting HIV while under PrEP, still, I guess years and years of fear take their time before leaving our minds’, alluding to the fact that the death fear still has subjectively a burden in their imaginary. Throughout their experiences, STIs play a minor character on individuals’ perceptions. In this complex web of choices, fears and risks, the medical action assumes the role of propelling technological adoption, contributing to the dissemination of all of its effects, whether positive or not (Illich, 1975). Within this context, the biomedical technology goes alongside personal interests and the combination of both, as well as the health consequences, are mutually and socially fabricated to the same extent as they are chemically dependent.

Individualizing conflicts and sexual performance

Upon the experiences of individuals, we see that the realization of sexual pleasures occurs through a negotiation involving the possibilities offered by available prevention technologies, so as to increase sexual pleasure according to particular desires, minimizing the possibility of harmful effects, as one contributor sums up:

If your personal experience with PrEP is having more condomless sex and correlated STI, then adjusting your strategy might make great sense. It’s never a bad idea to take our own temperature on these matters.

This negotiation is invariably accompanied by conflicts concerning risk management, particularly implying risk reduction strategies. STIs, on the other hand, are a regulating factor of sexual practices, and influence the adoption of preventive methods to allow sexual pleasure to be reached in the most individualized way possible. For example, one PrEP user said he also takes

Doxycycline [potent antibiotic] daily as protection for other STIs and, while I know that is not 100% foolproof, I have not had an STI for 2 years. … I also see no shame or issue with having an STI as I recognize that this is a possibility—just as when people play sports such as football for enjoyment, cuts, bruises, concussions and other; which do not deter them from having their enjoyment.

Another user adds that all preventive methods, including bacterial prophylaxis, are important to preventing HIV so ‘that each of us has to decide what works for us’.

It is possible to note that prevention strategies follow a particular logic, with the purpose of improving sexual performance. These forms of performance enhancement become more complex as they are influenced by other drugs that mediate self-produced sexual pleasure. In one case, an individual experiencing mental illness (depression) used to have condomless sex before being on PrEP due to his medication, which decreased his sexual pleasure experience; wearing a condom in that condition was even worse for pleasure because he could not afford Viagra®. While on PrEP, he had a way better sexual experience. In addition to these practices, individuals feel that PrEP has finally allowed them ‘to be responsible and to have the sex we each like to have … We are doing our part, by protecting ourselves, so that one day, hopefully soon, sex = pleasure’, alluding to the fact that before sex = risk.

Individuals also have to live with the uncertainties of problems eventually arising from the use of drugs for prophylaxis and from the acquisition of other diseases. As in one case: while he regularly tests for STIs/HIV, he is worried about the possibility about antibiotic resistance and the chances of acquiring Hepatitis C; ‘it can be a serious and expensive infection that is worth taking into consideration’, while having condomless sex.

Individual prevention choices, although influenced by available technologies, at a certain point impose a negotiation, involving the fearful imaginary of contagion or doubt regarding the consequences of combining viral and bacterial prophylaxis. This combination contradicts the imaginary of certainty, while increasing the responsibility of the individual in risk reduction, as well as everything that comes from their choices. As one contributor describes his experience saying that he met a guy who did not seem honest about his HIV status:

I just had a gut feeling for the first time that I did not feel for a while. I had condomless sex with the notion of letting go of my fear. However I still felt uneasy for some reason and I was the one that initiated it. I wanted to hear other people’s responses. How it feels to just constantly have condomless sex and only condomless sex?

And the response:

We, being PrEPsters, have to have faith in it. It will, for some [of us], take longer to feel at ease and have Faith in PrEP, and I am one. However, each day my anxiety is easing and this makes sex more enjoyable, knowing we are protected to 99.9%.

Another member of the group appeals to the experiences of the others in order to find reassurance from his fear of contracting the virus as ‘I know the statistics but it’s more reassuring to hear from real people’. Another user interjects by saying ‘There is no clinical evidence anywhere that demonstrates the effectiveness of thoughts and feelings to prevent an STI’.

These empirical experiences all show, at different levels, the strategies individuals adopt for reaching pleasurable sexual relations. In this search, PrEP is used as an artifact to relax from the fear of contracting the virus and to remain protected, also others consider using prophylactic antibiotics and other substances that stimulate sexual function. The search for condomless sex is based primarily on the pleasure of the experience, with the goal of obtaining greater gains in the intimacy. These choices, which are triggered by an idea of continuous gain – and never of loss – intrinsically relate to the drug consumption in a way that sets the individual action closer to an ethic of positivity. This positivity (Han, 2015, 2018) consists of the dominance of a social pattern that inhibits denial and deep reflection on the life paths and individual attitude. This process leads individuals to self-exploitation (Han, 2015), in detriment to the ability to exert a force of alterity able to reverse the cascade of un-reflected production and consumption (Han, 2015, 2018). This positivity is due to the idea of negativity being increasingly impossible, which expresses the reflexive force of modern individuals. In this sense, contemporary western individuals are losing the reflective capacity in favor of forms of reacting to the concept of experience, to the image and to the ephemeral nature of pleasure. Han (2015, 2017) works with those categories as one side of individual potency, that is, there are no dichotomies of values between one such idea and another, but intrinsic ambiguities and contradictions that emerge from them within the social context.

This contemporary pattern of sociability (Han, 2015, 2018) in which, for example, individuals themselves define which chemical combinations best suit their inner interests, lead them to exploit themselves without being subjected to any kind of extraneous constraint. The excess of positivity, as a societal production, and the search for individual success make the exploiter the exploited (Han, 2015), reinforcing an individualized political economy. Likewise, this self-referentiality generates a paradoxical freedom that, because of the coercive societal structures inherent to them, becomes violence (Han, 2015: 30). This sense of freedom, in which individuals express themselves through the individual choices and through feelings of pleasure and intimacy free from the threat of death, is paradoxical; it frees individuals from previous forms of suffering while, at the same time, restores their dependence on medicalization and consumption, which implies a living under a preventive health model eminently ruled by fear and risk (Beck, 1992; Lipovestky and Serroy, 2013).

Upon Han’s topology of violence (2018), we point out the mechanics of action of these individuals, which appears self-exploitative in a sociological sense. Individuals are increasingly producing self-violences resulting from continued positivity – bodily manipulation, for gains in the spheres of desire, pleasure and intimacy. One of them may be the experience of contracting an STI, another is the feeling of fear that seems to drive consumption of PrEP and other pharmacological prophylaxis. Although both coexist in individual experience, they become secondary to the experience of pleasure and sexual performance. This stems from a direct contradiction of contemporaneous successes in the domain of sexual freedom mediated by technological consumption that well adjusts to individual life-event-momentum (Beck and Beck-Gersheim, 2002). On the one hand, there is much appreciation of individuals as self-entrepreneurs, regulating and managing their prevention strategies, pleasure, and subjectivity through skillful patterns of consumption. Conversely, historical problems that are associated with the epidemic, such as the HIV/AIDS stigma and discrimination bound to sexual practices continue to persist, while the type of dependence on biomedical practices/power and fear of HIV-acquisition seem to have been shaken off upon emergence of PrEP.

Final remarks

This study aimed to articulate perceptions of individuals on PrEP on sexual desire and pleasure by considering the biomedical interventions as a means of producing erotic experiences. This type of effort, as Dean (2015) warns, remains distant from public debate on chemoprophylactic strategies. Qualifying the public debate means developing further theoretical insights on the interdisciplinary and hybrid web of drugs, sex, bodies, medicine, sociability in social networks, individuals, and society, which reveal new social-cultural expressions like the natural and unnatural sex in the domain of contemporary society.

The meaning of PrEP, a technology initially developed with the goal of preventing HIV acquisition, transformed itself throughout the social process of its use and consumption, influencing sexual pleasures and desires upon emergence and radicalization of an individualized socialization. This medical strategy allows individuals to manage risks and pleasures; whether or not clinical studies have a dominant discourse on PrEP by measuring risks associated with sexual practices, yet, the production of pleasure guards a still unknown, perhaps immensurable logical order. It is certain, in any case, that the use of the technology produces forms of living that were not rationally designed or conceived together with the drug itself.

In times of chemical prevention, sexual desires and pleasures continue to be increasingly mediated by science and technology, leading individuals to conflicting choices. Individuals are expected to manage the risk of contracting other STIs, to the same extent they regulate the pleasure of sexual interactions by creating and renewing sexual concepts and practices, such as bareback sex, which has conceptually shifted through levels of the individual action and sanitary control over mens' bodies and sexual practices. These individuals inhabit an ambiguous place, insofar as their alterity loses a great power of self-determination partially because of the continuous PrEP use. Their capacity for reflection and agency over the sexual act is very particular, with the focus becoming the demand for pleasure, while intimacy is reduced to physical contact. The logic of contemporary societies, mediated by the positivity of actions, encourages this cycle on the basis of consumption and the appeal of the immaterial, in appreciation of the inebriating sensations that consumption and the manipulation of the body can entail.

Footnotes

Acknowledgements

We would like to thank Professor Rebecca Sullivan (University of Calgary) for providing space to develop initial research questions that led to this study. Special thanks to Richard Guy Parker (Columbia University) and Myriam Mitjavila (UFSC) for reading the paper and providing suggestions at its early stage. Additional thanks to all anonymous peer-reviewers and to Sharif Mowlabocus, Guest Editor of this special issue, for their valuable and constructive contributions to this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the CAPES Agency; Fapesp under Grant 2015/16218-0.

ORCID iD

Roberto Rubem da Silva-Brandao

Note

Roberto Rubem da Silva-Brandao is a Social Scientist and PhD candidate in Public Health at the University of Sao Paulo, Brazil. He works with critical theory, contemporary social changes and health. His research interests focus on studying the interplay between sociology and health, particularly in the following areas: science and technology, social individualization, health expropriation and HIV/AIDS.

Aurea Ianni is Professor at the School of Public Health of the University of São Paulo, Brazil, and coordinator of the CNPq Research Group Contemporary Social Changes and Health. She is Scientific editor of Saúde e Sociedade (Health and Society Journal) and works on the sociological approach of health in the following fields: social contemporary changes and health and social thought in health.

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