Redefining negotiated safety: Gay, bisexual and queer men adapting to HIV pre-exposure prophylaxis in intimate relationships

HIV pre-exposure prophylaxis (PrEP) is a recent, yet significant, development in HIV prevention. This mixed-methods research followed PrEP’s introduction in Australia, and examined how gay, bisexual and queer (GBQ) men in relationships have adapted to and incorporated PrEP in their sex practices, relationships, and everyday lives. As PrEP raises the prospect of having condomless sex both within and outside primary relationships without risking HIV infection, this research revisited the concept of negotiated safety (Kippax et al., 1997) to explore how HIV-negative GBQ men practice and negotiate safe sex in the era of biomedical HIV prevention. Quantitative data were collected in two national cross-sectional survey projects, The Gay Community Periodic Surveys (GCPS; 2013–2018) and the PrEPARE Project (2013–2021). The GCPS analysis showed a rapid shift away from relationship agreements in which condomless sex is only sanctioned between regular partners. The PrEPARE Project analysis found that men in relationships who used PrEP were more likely to have spoken and non-monogamous agreements, and to have partners that also used PrEP, compared to men in relationships who did not use PrEP. Qualitative data were generated using semi-structured, in-depth interviews conducted between January and August 2019 with 26 GBQ men in Sydney, Melbourne and Perth. Thematic analysis of these data identified new shared meanings and social practices that were enabled or mediated by PrEP, with an analytic focus on complexity, situatedness, contingency and relationality. Participant accounts illustrated diverse sexual practices and views about risk, but most participants adopted PrEP due to perceived HIV risk from casual sex rather than sex with their primary partners. PrEP complicated views about what counted as ‘safe sex’ and revealed changing understandings and practices of intimacy, pleasure, trust and risk. There was, however, an enduring narrative of individual responsibility to practice effective HIV prevention. Participants diverged in how they discussed and disclosed sexual practices with their primary and casual partners, revealing tensions about what disclosures were believed to be necessary or expected. Together, these quantitative and qualitative data collected as PrEP use became more common refocus attention on the practicality and complexity of relationship agreements among GBQ men