The Paradoxes of PrEP: Rejection, Reluctancy, and Novel Gay Identities in Biomedical HIV Prevention in Serbia

Zoran Milosavljević

doi:10.51897/interalia/odvi6514

Abstract

This article explores the different ways in which gay men in Serbia perceive PrEP as a novel method of HIV prevention. In the article, I draw on data from my research on PrEP use among thirty gay men in Belgrade. The use of PrEP is still very low amongst gay communities in Serbia due to their rejection of PrEP and due to the stigma around PrEP use. In Serbia, the social significance of PrEP relates to HIV status disclosure on gay social/dating media. Paradoxically, on gay dating sites, the signifier "PrEP" blurs the line between HIV positive gay men – who have achieved undetectable HIV status through a potent ARV therapy – and those HIV negative gay men who use PrEP as a preventative tool against HIV transmission. In the article, I will argue that a new form of gay identity has emerged on gay dating apps in Serbia – "undetectable, on PrEP." This new identity emerges from confusion in HIV risk assessment. The use of PrEP has been seen as a marker to denote someone’s HIV negative status and to protect them from HIV transmission. However, some gay men with an undetectable HIV status would like to be regarded as HIV negative even though they are not, and thus they use the signifier "on PrEP" to highlight their desire to claim an HIV negative status. PrEP has many symbolic valences: from HIV status disclosure to assumed promiscuity. As I will argue, while the health paradigm is of utmost importance for Serbian gay men, internalized stigma additionally drives the low uptake of PrEP amongst gay communities in Serbia, thus contributing to the confusion regarding PrEP use and the overall approach to HIV prevention. This article finds that those respondents who accept PrEP without stigma or confusion regarding their HIV status are also more willing and ready to recommend using PrEP to other gay men.

Highlights

The use of PrEP in Serbia among gay men for HIV prevention is a complex question, best defined through ambivalence and reluctance
There is a high level of confusion among gay men on the role of PrEP, which leads to a certain paradox
This potent preventive tool cannot fulfil its preventive role against HIV transmission because so many in the gay community either reject PrEP outright or are reluctant to use it; and second, in many cases its potency has been “hijacked” by the fear of stigmatization and confusion about for whom PrEP is designed – whether for HIV negative or HIV positive gay men

Summary

Introduction

The use of PrEP in Serbia among gay men for HIV prevention is a complex question, best defined through ambivalence and reluctance. There is a high level of confusion among gay men on the role of PrEP, which leads to a certain paradox This potent preventive tool cannot fulfil its preventive role against HIV transmission because so many in the gay community either reject PrEP outright or are reluctant to use it; and second, in many cases its potency has been “hijacked” by the fear of stigmatization and confusion about for whom PrEP is designed – whether for HIV negative or HIV positive gay men. In this confusion around PrEP and HIV status a new sexual identity – “undetectable, on PrEP” – emerges with further risk assessment implications. The match between objective risk and subjective perception of risk among gay men is frequently a mismatch and it erodes PrEP’s preventive potential. Race (2016) sees PrEP as a signifier to the changing paradigm of HIV prevention and a 34 “reluctant object” to be or not to be used in gay sexual practices

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