More than prevention: early adoption of HIV pre-exposure prophylaxis (PrEP) by gay and bisexual men in New Zealand

Abstract

Pre-exposure prophylaxis (PrEP) minimises HIV risk and New Zealand was one of the first countries to publicly fund PrEP in 2018. However, no studies have explored in-depth the experience and meaning of living ‘on PrEP’ among individuals at elevated risk of HIV, such as gay and bisexual men. This qualitative study builds on findings from the NZPrEP demonstration project of early PrEP-adopting gay and bisexual men in Auckland, New Zealand. We interviewed 10 of the 150 NZPrEP participants using an ethnicity equity quota (five European ethnicities and five non-European ethnicities). A phenomenologically-inspired thematic analysis was conducted. We identified three themes. The first, Trusting in the Pill, focuses on the relationship between PrEP and its user, while the second theme, A Liberation of Sorts, details the freedom PrEP offered men, sexually, mentally and socially. The final theme, Reframing Risk, explores the risk perceptions and the conflicting discourses surrounding gay and bisexual men using PrEP. This first qualitative study in New Zealand about the experiences of PrEP early-adopters suggests that the role of PrEP extends well beyond HIV prevention and, for many, involves redefining safe sex even in a country with historically high levels of condom promotion and low HIV incidence.

Keywords:

• New Zealand
• HIV prevention
• gay men
• sexual behaviours

Introduction

Pre-exposure prophylaxis (PrEP) is an antiretroviral medication that minimises the risk of acquiring HIV if taken as prescribed (McCormack et al. 2016; Grant et al. 2010). New Zealand has a low-level, concentrated HIV epidemic, and in 2018 it was one of the first countries to publicly fund PrEP on a targeted basis (Pharmac 2018). Most individuals eligible for subsidised PrEP are gay and bisexual men (Saxton and McAllister 2019). Messaging in New Zealand has emphasised PrEP being part of a broad and comprehensive sexual health programme that involves regular testing and condom use, as PrEP does not protect against other sexually transmitted infections (STIs). Key questions explored in early assessments included acceptability and adherence to PrEP in New Zealand’s multicultural setting, where publicly funded sexual health services are underfunded and often difficult to access (Azariah 2023; Saxton et al. 2018).

Despite these early policy responses, little is known about PrEP implementation in New Zealand since then. Between 2011 and 2019, reported PrEP use rose from 0% to 30% among gay and bisexual men engaging in anal intercourse with casual partners (Saxton et al. 2020). The most robust local data on the experiences of taking PrEP have come from the NZPrEP demonstration study, a prospective cohort of early PrEP adopters recruited from sexual health clinics (Azariah et al. 2019), in which 50% of participants were of non-European ethnicities (e.g. Māori, Pacific, Asian and Middle-Eastern). That quantitative study found that participants were highly motivated to take PrEP and that PrEP was an acceptable form of HIV prevention (Saxton et al. 2019), that STIs were high but did not increase, and that sexual partnering was stable (Saxton et al. 2022). PrEP adherence and self-efficacy were also higher among non-Māori and non-Pacific participants, raising questions about equity.

Qualitative data from New Zealand, however, are scarce (Adams et al. 2019). Open-ended responses from NZPrEP collected at baseline found that motivations to use PrEP included altruism, intimacy and pleasure, and peace of mind and autonomy (Punchihewa, Saxton, and Wiles 2019). Consequently, there is a gap in the literature concerning qualitative experiences of being on PrEP, needed in order to better understand the roles PrEP can play in people’s lives, so as to better target public health messaging.

Elsewhere, PrEP use has been found to reduce anxiety about sex and acquiring HIV (Keen et al. 2020). Pleasure is also becoming more prominent in recent scholarship, as PrEP-users report PrEP playing a major role in sexual freedom (Mabire et al. 2019), particularly from traditional means of HIV prevention for gay and bisexual men such as condom use (Grant and Koester 2016; Starks et al. 2014). Relatedly, however, PrEP has triggered debate around behavioural risk compensation (Holt et al. 2018). Consistent evidence of risk compensation is mixed (Blumenthal and Haubrich 2014), for example, high-risk men eligible for PrEP typically already engage in condomless sex (Ortblad et al. 2019) or use condoms inconsistently (Cohen et al. 2015). How ideas about (and the practice of) risk compensation are manifesting in New Zealand’s own tradition of HIV and sexual health programmes is not known.

Understanding the cultural aspects of PrEP uptake requires researchers to listen to PrEP-users’ experiences. Focusing research purely on risk-driven sexual behaviours can neglect the social and mental wellbeing factors that can increase vulnerability to HIV, which might suppress uptake among GBM who could benefit from PrEP (Calabrese, Krakower, and Mayer 2017). The NZPrEP study provided a pool of potential participants for a qualitative exploration of nuanced issues surrounding the taking of PrEP. Minority ethnic gay and bisexual men in New Zealand continue to acquire HIV but appear to be under-represented in PrEP uptake (Saxton et al. 2020), meaning their experiences should be intentionally included. The aim of this article, therefore, was to understand the experiences of being on PrEP by early adopting gay and bisexual men in Auckland.

Methods

This research built on the earlier NZPrEP demonstration study that recruited 150 participants (Azariah et al. 2019). All those participants were at elevated risk for HIV, identified as gay or bisexual, and lived in Auckland. The design and quantitative findings of NZPrEP are reported elsewhere (Azariah et al. 2019; Saxton et al. 2019; Saxton et al. 2022). Our current study began at the conclusion of NZPrEP with the goal of exploring qualitative issues in greater depth.

Participant eligibility and recruitment

Ethics approval was granted by the Health and Disability Ethics Committee in 2016 (16/NTA/112) for one-on-one face-to-face interviews with a subset of NZPrEP respondents who consented to be contacted, invited randomly to participate until an equity quota of 10 participants (five of European ethnicities and five of non-European ethnicities) was achieved. The small sample size was deliberate and aligns with the in-depth methodology we aimed to use.

Participants were selected by splitting the NZPrEP survey respondents anonymised ID numbers into two groups (European ethnicity and non-European ethnicity). Randomised lists of clinic IDs were generated; participants were eligible for inclusion if they were Auckland-based (where the interviewer (TMP) was located); and the first 10 individuals on each list were sent an invitation to be interviewed, including participant information and informed consent paperwork.

If no response was received in two weeks, the person with the next ID number was contacted. Participants opted in by contacting the interviewer by email, confirming they understood the purpose of the research, giving informed consent, and stating they had participated in the NZPrEP study. They did not need to have completed that study nor still be taking daily PrEP.

The selection of participants was on a ‘first come, first served’ basis, with this processing being repeated three times until the equity quota and sample size were met. A shopping-centre gift voucher was given to participants in recognition of their time and participation.

Data collection

Recruitment and interviews occurred between October 2019 and January 2020. A semi-structured interview was used to facilitate reciprocity between interviewer and participant, allowing the interviewer to improvise with follow-up questions, and providing participants with space for verbal expression (Galletta 2013; Kallio et al. 2016). Topics included checking demographic data, PrEP status, and general experiences of PrEP; exploring high-risk behaviour/perceptions and PrEP (including anxiety, mental health, wellbeing and pleasure); and comments on disclosing PrEP to sexual partners (exploring communication, stigma and roles within intimacy). Interviews lasted 40–120 min.

Data analysis

Interviews were audio-recorded and transcribed verbatim by TMP. Participants could request a copy of their interview transcript to remove or amend responses before analysis. Six requested their transcriptions; none requested changes. This step validated the transcripts, preserved research ethics, and empowered the interviewees by allowing them some control over what was used for analysis (Mero-Jaffe 2011). In presenting the data, confidential or participant-sensitive information are withheld (McLellan, MacQueen, and Neidig 2003). We refer to individual participants using a pseudonym (e.g. ‘Manaia’) and their self-identified ethnicity category (e.g. ‘European’, and ‘Pacific’).

A phenomenologically-inspired thematic analysis was conducted, via an iterative process between data generation and analysis (Kiger and Varpio 2020; Pope, Ziebland, and Mays 2000). Prior to coding, a summary profile of each participant’s PrEP journey was created incorporating their own words (Seidman 2006), in an effort to keep each participant’s data ‘whole’ (in line with phenomenological approaches) (Van Manen 2017), before looking for patterns across the data in coding (Maxwell and Chmiel 2014). The rigorous and iterative process of data analysis involved several rounds of coding (continuously defined, refined and interrogated by the research team), then developed into categories (using in-vivo terms from the data and concepts from literature) and finally clustered into themes (Braun and Clarke 2006; Braun and Clarke 2021).

With respect to reflexivity, the interviewer was a heterosexual woman sexual health educator. Such outsider status to the minoritised community of gay men can be both a strength and a challenge (Breen 2007; Merriam et al. 2001; Dwyer and Buckle 2009). Participants are more likely to share if there is an assumption of shared distinctiveness; however, outsider status ensured data generation and analysis were divorced from individual experiences. The article’s co-authors participated in interview guide development, data analysis and article write-up, and brought expertise from the gay, HIV and qualitative research communities, respectively. 

Results

All participants were aged over 30 and most identified as gay. Half were of non-European ethnicities and two had stopped taking PrEP at the time of the interview (Table 1).

Table 1. Participant characteristics.

Participant (pseudonym)	Age^a	Ethnicity	Sexual identity	Currently taking PrEP^b
Tyrone	30s	Non-European	Gay	Yes
Joshua	40s	European^c	Gay	No
Manaia	30s	NZ Māori	Gay	Yes
Daniel	40s	European	Gay	Yes
Noa	40s	Pacific	Gay	Yes
Levi	50s	Non-European	Bisexual/gay	No
Jordan	40s	European	Gay	Yes
Ben	30s	European	Gay	Yes
Rawiri	30s	NZ Māori and Pacific	Gay	Yes
Thomas	30s	European	Gay	Yes

aParticipant ages are presented in decades for ethical reasons and to protect their privacy.

^bCurrently taking PrEP means participant was taking PrEP at the time of the interview.

^cThe ethnicity ‘European’ refers to both Pākehā (NZ European) and migrant European participants; however, is presented as simply European to maintain anonymity and consistency with previous NZPrEP literature (Azariah et al. 2019).

Three themes were developed through thematic analysis: Trusting in the Pill; A Liberation of Sorts; and Reframing Risk.

Trusting in the pill

For interviewees, PrEP acceptability was linked to the notion of trust. Tyrone (non-European) expressed how he ‘can never trust someone 100%’. Others believed they would not stop taking PrEP even if they were in a monogamous relationship:

Even as much as I trust, I couldn’t trust that person. Could I trust them, 100%? Probably not, because I’ve been one of those who actually was unfaithful. (Ben, European)

Thomas (European) also drew on his own experiences and behaviours in coming to this decision, ‘Knowing gays, I wouldn’t still trust my partner’. When these participants suggest they find trusting their sexual partners challenging, they did not necessarily believe partners were intentionally dishonest, but rather that partners may not be aware of their current HIV status.

Being in an HIV serodiscordant relationship was Tyrone’s (non-European) main motivation for PrEP, despite his partner having an undetectable viral load and there being ‘virtually zero’ chance of transmission. In addition, being in an open relationship, Tyrone wanted ‘to worry less’ when engaging in condomless intercourse with other partners, as he believed ‘sex with condoms is not the same thing’.

The decision to continue to take PrEP regardless of one’s relationship status was commonly seen across GBM, both in open and monogamous relationships. When asked for what reason participants would stop taking PrEP, four out of the eight who were taking PrEP at the time of the interview could not see themselves stopping. For Tyrone, this was because he wanted ‘complete peace of mind’. For such men, the balance of power had shifted from being dependent on a sexual partner for safety to instead maintaining control over their own sexual wellbeing, by being able to ‘trust’ in the pill. This reduced anxiety:

I’ve only known him for a couple of weeks, and to take him at his word that he’s HIV negative - there’s a certain amount of anxiety around that. (Joshua, European)

In this way, PrEP provided certainty and control over one’s HIV status and might be one of the reasons why participants felt it was easier to trust in the pill (rather than their sexual partner), especially if doing so helped manage their anxiety:

[PrEP gives me] confidence that I am not going to be infected if there is HIV… and if there was a mistake or an accident that happened, I wouldn’t feel so worried, I wouldn’t have anxiety about it, and I am a lot more positive about going to get tested with the idea that I am likely not going to be infected with HIV. (Rawiri, Māori and Pacific)

Responses by participants suggest PrEP played a wider role in improving mental health and wellbeing and could consequently influence behaviour. Testing is vital to HIV and STI control, so Rawiri’s sense of feeling more ‘confident’ about testing regularly is important. It was shared by Jordan (European), who also reflected on accepting the community he belonged to, while valuing being able to trust in PrEP:

I kind of came to terms with the fact that this is the community I live in… and this is how I practise safe sex. I’m fine with it in a mental health point of view…. You expect [a test] to be negative, but maybe it won’t be….[PrEP] removes any sort of niggling thing about HIV, you trust the drug … and the kind of evidence that’s out there. (Jordan, European)

The role of PrEP in encouraging a positive orientation towards HIV screening is an important feature of the medication which suggests that, with the appropriate public health messaging, it can make people more assured of their current HIV status. In contrast, Noa (Pacific) questioned the trust some people placed in PrEP, feeling there was still risk and that it could lead to a ‘false sense of protection’ if sexual partners indicated they were PrEP when they were not:

People can use this option even though they are not actually on PrEP. So, there’s no kind of, um, what’s the word? Certainty. (Noa, Pacific)

These comments highlight the complexity involved in ‘trusting the pill’ and reminds us that, behind the pill, is a person responsible for taking it.

A liberation of sorts

PrEP was seen by participants as playing a pivotal role in liberating sex for gay and bisexual men, as opposed to the traditional ‘culture bundled with stigma and fear’, where ‘men and women have sex [to] create life… where[as when] a man and man have sex, you create death’ (Manaia, Māori). While HIV is no longer a fatal disease if diagnosed and treated early, the lack of a cure and the history of stigma still have profound impacts on gay and bisexual men today (Golub 2018). This theme uncovers the many faces of PrEP by unpacking the various ways in which it frees up its users.

Participants described a liberation of sorts in that PrEP had provided a means of freedom to engage in sex without fear and anxiety. Tyrone shared how he had ‘lots of anxiety before PrEP’, especially when he lived overseas, yet ‘with PrEP, I feel free, I don’t worry anymore. It’s much better’ (Tyrone, non-European). Similarly, for Rawiri (Māori and Pacific), PrEP removed the ‘anxiety of not knowing’ his partner’s HIV status. For Thomas, liberation meant moving from thinking, ‘I don’t want anything to do with you’ when meeting someone HIV-positive, to feeling:

[I’ve] opened up to people more, and am not afraid to have sex with even HIV positive people … to me, it’s a mind-blowing exercise. (Thomas, European)

PrEP provided liberation to safely engage in condomless sex, without the risk of HIV. Noa (Pacific) described PrEP as ‘a condom in the form of a pill’, suggesting PrEP provided a level of protection against HIV comparable to condoms, with the difference being it allowed for condomless sex. Similarly, Ben (European) felt condoms could be relegated for use with ‘people who are not on PrEP’.

A key reason for this was that PrEP was also liberating in terms of sexually pleasurable activities, such as being able to engage in bareback, ‘skin-to-skin’ sex (Tyrone):

Since starting on PrEP, 99% of my sexual experiences have been bareback … I’ve had a lot more sex, and a lot more sexual partners. Most guys increase their sexual activity with PrEP. (Tyrone, non-European)

Similarly, Daniel (European) described having more pleasurable sensations, explaining he has ‘always been a bottom’ but since being on PrEP, ‘I have found that I do top more … because of the sensation’ (referring to being the insertive partner).

Another liberating aspect of PrEP was its capacity to act as a gateway to international events and parties, described as ‘the world that I wanted to be part of’ (Daniel) and allowing ‘me to be me’:

Melbourne Trough Party or parties in Mardi Gras or in Berlin… having watched videos of [them] and that’s what I’ve always liked. And then I can finally do it. So, it’s played a role in me kind of being me. (Daniel, European)

These international settings were important drivers in the demand for and the growing culture around PrEP use, as PrEP was seen to have become the ‘status quo’ (Daniel, European) in these events.

Conversations between gay couples have also seen a liberation of sorts. In the summary of his PrEP journey, Daniel shared how his partner was initially resistant when he first suggested they take PrEP. However, since going on PrEP, Daniel feels more confident knowing both primary partners are safe in their open relationship:

There is no longer any concern about the activities the other one could be doing. We always had a disclosure thing that we would always tell what each other did. But beforehand … I would be worried, like ‘Well, what will you do? What happened?’ Or, ‘Did you potentially do something and not report it back to me that could put me at risk?’ Which now is completely gone. I think it’s liberated the sexual part of the relationship. (Daniel, European)

PrEP was therefore a catalyst for some participants to engage in challenging conversations with their sexual partners on how to better protect their sexual health.

Interlinked with these notions of pleasure and condomless sex, liberation could also mean having more ‘unsafe’ sex, as Joshua explained. The purpose of PrEP is ‘to allow me to engage in unsafe sex… there’s a certain amount of freedom in that. It’s wonderfully free’ (Joshua, European). For participants such as Joshua, PrEP was a means of freedom from having to compromise sexual pleasure for protection. It reflected a sense of empowerment as the result of having more prevention options.

While all 10 participants acknowledged that PrEP allowed them to engage in condomless sex ‘more freely’ (Manaia, Māori), they still demonstrated a high level of awareness of other STIs. Having to manage the risk of HIV and STIs has long been imperative but, because of stigma associated with STIs, has also resulted in some gay and bisexual men developing a fraught relationship to sex. Jordan (European) and Rawiri (Māori and Pacific) reflected on how the dating landscape had changed since the arrival of PrEP. PrEP has become part of the wider context in which sexual negotiation takes place, such as online or through geo-spatial dating apps like Grindr. Rawiri (Māori and Pacific) described how HIV and PrEP status are the two most common questions asked within this context, which makes negotiation easier and more transparent. However, it still requires investing a high level of trust that a sexual partner is indeed on PrEP. This poses an interesting question around what is now considered to be ‘unsafe sex’ in this new PrEP-driven milieu:

It’s so funny we use these words ‘unsafe sex’, you know, it’s the reality in this day. [PrEP] enabled me to have the ability, if I chose to have unprotected sex with someone I just met and be assured I wasn’t going to get HIV. (Joshua, European)

Reframing risk

A frequent issue participants raised was how they perceived their decision to engage in condomless sex while on PrEP. In these discussions, we identify two conflicting discourses; the first framing the PrEP-user as a good citizen educating others about sex, HIV, STIs and PrEP; and the other, as someone ‘spreading disease’ (Tyrone, non-European). This dichotomy reflects tensions firmly rooted in the history of the AIDS epidemic and which continue to be associated with HIV.

Interestingly, most participants believed ‘STIs should be treated differently’ to HIV (Thomas, European). For example, Daniel (European) believed there was a ‘fundamental difference’ between them, in the sense that HIV was ‘far more high-risk’ than other STIs. Daniel’s view was largely due to his perception that most STIs can be cured, unlike HIV. For Daniel, their ‘treatability’ reduced their seriousness.

Sexual pleasure was a key reason for Levi (non-European) and Ben (European) deciding to engage in condomless sex despite PrEP not protecting against STIs:

Let’s put it this way, if there’s no HIV, I don’t think gay people would like to use condoms. (Levi, non-European)

The pleasure you get without a condom is much higher and more intense. (Ben, European)

These responses highlighted the importance of sexual pleasure. When weighed against the risk of STIs, participants demonstrated a trade-off towards enjoyment. They also challenged what it means to have ‘safe sex’. Especially when the risk of HIV is minimised by using PrEP, sexual pleasure takes precedence for some men over the risk of acquiring other STIs.

On the other hand, the 3-monthly check-ups required as part of the PrEP programme also helped gay and bisexual men to feel more confident to take risks:

PrEP also helps with the regular checks. Part of the culture is, I guess a lot of people don’t go and check themselves until they have some sort of symptom. I think it’s a good routine… that PrEP does for you, so not just taking pills and thinking about your sexual health, but also actually taking those regular checks and blood tests. (Ben, European)

Being on PrEP for Thomas has meant more awareness and testing, as well as trust:

Pretty much less condoms, because you trust more people and because you get checked every 3 months, you get treated if there is something. You are more cautious about your health, and you know more about yourself, your health, your status, not just on HIV but other sexually transmitted infections. So yeah, it’s more clean now, I’d say. (Thomas, European)

When juxtaposed against the narrative that PrEP-users are ‘spreading disease’, these findings suggest the more frequent testing meant gay and bisexual men felt they were now taking better care of their health. Having said this, participants reflected on potentially being seen as vectors for infection when using PrEP, but not condoms:

I think there’s a little stigma. I don’t use condoms, and some people say that you are spreading disease and stuff. People say, you can catch other stuff if you’re not. But you can get the same stuff you know, with oral sex. And I ask, ‘Do you have oral sex with condoms?’ And I ask the guys, they say, ‘Yeah, yeah, I don’t.’ So, I accept the risks I have with not using condoms. (Tyrone, non-European)

Participants also referred to a culture of shame among gay and bisexual men, which often stemmed from misinformation. They argued that these problematic framings could dissuade men from taking PrEP.

Beginning of the [NZPrEP] study, it was not easy because not many people knew what PrEP is. The name Truvada was freaking the hell out of guys. Because everyone knows Truvada is used to treat HIV, so if you even say Truvada, everyone thinks, ‘OMG, he’s probably HIV positive.’ Another perception of people when I say I’m on PrEP was you are having a lot of partners and you don’t care what you do and you’re a slut. (Thomas, European)

Taking PrEP means, not means, but in my own mind it means you are potentially a promiscuous gay man who engages in unsafe sex with multiple partners. (Joshua, European)

Joshua associated taking PrEP with being a ‘promiscuous man’ with many sexual partners. These perceptions are closely interlinked with stigma around condomless sex and lack of knowledge about STI transmission, with participants finding they needed to educate others:

Educate some of the younger guys as well, because they think having safe sex, or safe penetrative sex means they won’t get STIs. That’s not how it works, it can be living in someone’s throat, it can be living in someone’s dick … So, don’t think that by having a condom you’re not going to contract STIs. (Jordan, European)

Some participants enjoyed adopting an educator role as they saw it facilitating a cultural change and more open conversation around sex and HIV:

Now it’s like heavily integrated into gay culture, and at least mostly in a positive light. And like with all the names that are coming out about it or the emoji stickers that are coming out about it… I don’t want to say cool, but it kind of is, like it’s kinda cool to be on at the same time… like it’s part of the gay culture now. (Daniel, European)

By adopting an educator role, participants become advocates for PrEP, paralleling historical movements in AIDS activism by gay and bisexual men. The normalisation of PrEP into ‘gay culture’ has allowed for candid conversations and a strong sense of connection for some men in this study.

Discussion

This is the first in-depth qualitative study about PrEP in New Zealand, a country with a low HIV prevalence, a historically strong condom culture, and an early PrEP policy response. Even in this setting, PrEP has changed the face of HIV prevention. The experiences of early PrEP-adopters in this study also indicate that the role of PrEP extends well beyond HIV prevention. For many gay and bisexual men in New Zealand, PrEP is redefining safe sex and providing new freedoms sexually, mentally and socially.

Participants reported experiences similar to those found in other countries. Much of PrEP’s acceptability among New Zealand users related to trusting in the pill, giving peace of mind and not having to trust sexual partners. In the current study, motivation for taking PrEP was also highest among those who reported condomless sex with both their primary and other partners. These findings echo previous research from the United States (Bosco et al. 2021; Gamarel and Golub 2015). Participants in this New Zealand study also saw PrEP as shifting the power balance, whereby gay and bisexual men at elevated risk of HIV regained control over their own sexual wellbeing by taking PrEP, similar to an Australian study (Philpot et al. 2020).

We found sexual anxiety was common among participants engaging in condomless sex. However, in this study PrEP use helped gay and bisexual men manage and reduce their sexual anxiety, as found in Australian research (Keen et al. 2020). According to some men in the current study, PrEP was seen as playing a pivotal role in liberating sex from fear of disease, providing more HIV prevention choices, improving sexual pleasure and thereby enhancing important aspects of quality of life. These findings echo previous research from Australia (Philpot et al. 2020) and the USA (Malone et al. 2018).

The public health concept of ‘risk compensation’ with its claims that the benefits of novel interventions can be counteracted by unintended behavioural consequences has been critiqued as both outdated and negative (Collins, McMahan, and Stekler 2017; Koester et al. 2017), as it neglects to capture PrEP-users’ experiences. Data from participants in this study showed PrEP’s impact to be emotional, not simply behavioural, as men reflected on how their fear of HIV had changed, some feeling freer since the advent of PrEP. In the New Zealand setting, repeat surveys suggest that while condom use has declined since 2011, PrEP use has risen, resulting in relatively stable rates of net HIV prevention coverage (Saxton et al. 2020). Some PrEP users also continue to use condoms (Saxton et al. 2020). Reasons why gay and bisexual men may choose to use or forgo condoms are therefore complex.

Nevertheless, it is important to consider STI concerns. Interviewees in this study had a high awareness of STIs, and treatability of STIs informed their decision-making about not using condoms. Participants’ regular STI check-ups were an important wellbeing contribution of PrEP, given many were concerned about contracting an STI prior to starting PrEP (Saxton et al. 2019). Feeling more ‘confident’ about being tested and receiving results was also important, since anxiety surrounding test results is a barrier to both STI and HIV testing.

The PrEP-user as a good public health citizen is frequently framed as taking active and moral responsibility for their own and others’ sexual health, through adhering to PrEP, regular testing and sometimes condoms. In contrast, the PrEP-user as an individual who ‘spreads disease’ is framed as irresponsible and ‘dirty’, often criticised most severely from within the gay community (Dubov et al. 2018). These ideas are rooted in the earlier history of the AIDS epidemic (Spieldenner 2016). Responses by participants suggest that, for gay and bisexual men, ‘safe sex’ now includes relying on PrEP despite its inability to protect against STIs. HIV prevention messaging should engage with these values that are continually evolving in key affected communities.

Strengths and limitations

The strengths of this study include randomly sampling participants from within two arms of an equity quota, ensuring that the perspectives of gay and bisexual men from minoritised ethnicities are included in PrEP implementation research. We also included the experiences of some individuals who had stopped taking PrEP. New Zealand is in the unusual position of having had an early PrEP policy response that pre-dated relevant behavioural and social research; our study helps close this gap. This study also has its limitations, and we need to understand more about PrEP use among later adopters, younger men, those living outside of urban centres, and gay and bisexual men who only take event-based PrEP. The equity quota in this study was designed to be inclusive of non-European ethnicities rather than understand if there were differences in PrEP experiences between gay and bisexual men of European and non-European ethnicities. Future qualitative research could aim to explore differential experience (ideally using collaborative methodologies and led by members of ethnically minoritised communities) (Bal and Divakalala 2022).

Conclusion

In conclusion, understanding the complex roles PrEP plays in the lives of gay and bisexual men and keeping this central to how PrEP is promoted and provided will help New Zealand achieve its goal to eliminate HIV transmission by 2030 (Ministry of Health 2023). This first qualitative study in New Zealand highlights how the successful adoption of PrEP relies on understanding the wider culture within which it is grounded. After all, the goal is not just one of ending HIV, but also celebrating the emotional, sexual and physical liberation that comes with it.

Acknowledgements

The authors thank the interview participants for sharing their experiences. We thank Ruth Allen for her help developing this manuscript. We also thank investigators of the NZPrEP study for permission to approach participants, especially Sunita Azariah the Principal Investigator.

Disclosure statement

The authors have no conflicts of interest to declare.

Data availability

The qualitative data reported in this article are not available for public access because it is not possible to maintain participant confidentiality in interview transcripts, even when deidentified.

Additional information

Funding

This work draws on participants from a prior study, the NZPrEP demonstration project. The New Zealand AIDS Foundation (now Burnett Foundation Aotearoa) and Pharmac funded Peter Saxton to conduct the behavioural research arm for NZPrEP. Gilead funded the clinical arm of NZPrEP and provided the study medication, but had no role in the behavioural arm. T. Minu Punchihewa conducted this research while completing a Master’s degree in Health Sciences. No specific funding supported the current research.