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Notwithstanding predictions from theories of risk compensation, diminished fear of HIV has not been associated with increases in risky behavior 1 — 446 — In general, sexual practices remain unchanged or tend to become safer during PrEP use, both in the context of clinical trials and demonstration projects. These days it is possible to sit through entire conferences apparently devoted to HIV prevention in which the issue of sexual practice is barely mentioned…. Such interactions lead to increased sensitivity to HIV issues, and greater inclusion of HIV positive people in social networks that were ly exclusionary 50 Among HIV seronegative people, such preference for sexual partners who are also seronegative, or serosorting, is not known to be effective The social harms of serosorting have included its fostering HIV stigma, by excluding HIV positive people from social networks.
Given that growing families are appropriately risk adverse, such safer conception technologies are often used in combination Assisted conception services are not available in all places, and can be expensive. These highly desired collateral benefits of PrEP could be undermined, or eliminated, if PrEP is implemented in ways that are coercive or that foment fear of sexual risk compensation, drug resistance, toxicity, or moral judgment.
Present-bias is the tendency of people to respond to short-term temptations at the expense of long-term benefits. People want prevention strategies that can be adapted to situations when HIV risk is most present and salient. Examples relevant to PrEP are the low level of knowledge of PrEP among general practitioners saliencehesitancy to invest now to avoid paying more for the HIV epidemic later present-biasand fear of sex affect. I still want to be with my wife. Kane Race, cultural studies scholar, observed that PrEP has created opportunities to consider pleasures and perils of sexual practices more fully….
Couples had the highest level of adherence to PrEP during the peri-conception period Safer conception technologies for serodiscordant couples in which the man is HIV positive include use of sperm donations, sperm washing with in vitro or in utero insemination, suppressive antiretroviral therapy, and PrEP. The antagonism associated with sex and HIV prevention may be considered a form of stigma. It would remove that month long hangover of psychological anguish after sex, worrying about whether or not I might have put Women wants hot sex Douglas Alabama at risk of HIV and looking for the slightest.
Loewenstein characterizes hot and cold affective states that differ in how decisions are made Sexual intercourse, and the period leading to it, are affectively hot states during which plans for condom use, serodisclosure, or non-penetrative sex may be forgotten.
As such, PrEP is one of the only prevention interventions that is controlled by the receptive partners. There was confusion and misunderstanding about how to interpret the quantitative messages. Knowledge and use of PrEP remained low for several years after the publication of research findings demonstrating safety and efficacy 1 — 4. As indicated by the quotes, fear of acquiring HIV infection has been a preoccupation for many gay men.
Rather than serving as a wedge between people infected and uninfected with HIV, PrEP facilitates greater interaction between HIV negative and positive people, including the possibility of safer sexual interactions. Sexual pleasure may have multiple dimensions including bonding 31intimacy 32 — 34spontaneity 24and adventure 23all of which are potentially enhanced by PrEP. I found myself negative when she is positive.
There is some evidence that assisted reproductive services are not always desired 55 nor is it always available or affordable.
PrEP is prefentially being taken up by people who are not using condoms consistently 10 PrEP has created a space for users to voice the deeply felt fears associated with becoming infected with HIV 42 and for many PrEP has been an antidote to those fears. People move in and out of seasons of risk Seasons of risk can begin with the breakup of a long-term relationship, with substance use, migration to a new city, or coming out as a gay man. More effective management of ambiguity aversion could also increase uptake of HIV treatment. Some PrEP users reporting feeling empowered Empowerment also comes from planning for sex and safety in calm or cold moments, which allows more proactive consideration of sexual and partnership goals.
This benefit is best expressed by PrEP users themselves in the following quotes:. PrEP provides a way to further stabilize couples in serodiscordant relationships.
Prior knowledge of PrEP was associated with about 1. Belief in PrEP efficacy is an important motivator of adherence Indeed, the tipping point in demand for PrEP in the U. Perhaps more importantly, PrEP demonstration projects were well underway providing salient, present, and affective anecdotes from PrEP users who were having sex and avoiding HIV infection 10 The gist messages were preferred and motivating for adherence.
Uptake was high regardless of whether or not the person had prior experience in a PrEP trial, whether the person was in the United States or Africa, or whether the person was a man or a woman. What happened, happened. I want to have sex. PrEP use has been associated with feeling safe during sex, usually in contrast to ruminations related to fear of HIV or intimate partner violence or control. Behavioral economics is a field that arose from psychology and economics to understand what drives human behavior 14 Lineemayr identifies three common themes from behavioral economics that are likely drive the use, or non-use, of biomedical prevention strategies: salience, present-bias, and affect Salience is the tendency for people to act on information that first comes to mind rather than making use of all available knowledge.
So, in general, the anxiety, the HIV anxiety, is gone.
The double bind
Reasons for safer behavior may arise from testing and counseling services that are provided as part of PrEP services, although such testing and counseling of HIV negative people was not highly effective when offered as stand alone services But relationships can be a challenge as HIV can be a big barrier between me and guys I date.
The growing demand for PrEP in the United States is consistent with the high proportion of participants in open-label demonstration projects who elect to start PrEP when it is offered. These comparisons are less helpful when diverse interventions are compatible with each other, such as condoms, treatment, and PrEP.
Planning for sexual and social goals in calm moments is also empowering. PrEP is adaptable in that the tablet can be taken any time during the day, with or without food, and started and stopped as needed. PrEP demand has reached a tipping point in the United States and is increasing rapidly.
Even when I was being safe it scared me. Race pushes us to recognize that HIV prevention research has become arguably divorced from sex, or worse, is antagonistic towards sex. These collateral benefits of PrEP have salience, affect, and are experienced in the present, which are compelling drivers of human behavior. Qualitative research identified that love in the relationship was a major driver of adherence and PrEP uptake Serodiscordant status threatens these relationships creating a dilemma about whether to stay in the relationship despite the threat of HIV transmission.
Current PrEP implementation provides direct and indirect benefits that are highly desired. Stigma of this nature is too often reinforced by medical providers who serve as gatekeepers to biomedical interventions and may subtly convey stigmatizing messages about sexual behavior rather than adopting a sexual wellness approach.
Aversion to ambiguity, another concept from behavioral economics, is known to undermine action This bias is strong when choices that appear to have certain benefits are compared with choices having possibly greater but less certain benefits; If choices are made one at a time, ambiguity aversion is less important If so, the science practice of quantitatively comparing efficacy between prevention interventions creates a quagmire that undermines the will to adopt any intervention at any level.
We review emerging literature on the everyday experiences of PrEP users, which emphasizes the importance of benefits that are salient, experienced in the present, and have strong affect. While the primary benefit of pre-exposure prophylaxis use is biological, to reduce risk of HIV infection, PrEP users often express an alternative set of social and emotional benefits that are provided by PrEP. PrEP has a role to play in safer conception. People want to stop PrEP if they find other ways to protect themselves.
As demand for pre-exposure prophylaxis increases, we are learning more about what people want from sex and PrEP.
The most common reasons for refusing PrEP when offered include fear of side effects and Women wants hot sex Douglas Alabama Other reasons are fear of stigma arising from perceptions of promiscuity, sexual orientation, or HIV status.
So when the doctor told us about this study, I saw it as an opportunity. You never know, it might work! Perhaps more importantly, PrEP is shaping users relationship to sex in meaningful ways 40 thus creating an opportunity to expand our depth of understanding of sexual practices. According to this limited database, persons had been dispensed PrEP.
If we had PrEP it would take that fear away. PrEP was perceived as a solution to this serodiscordant dilemma. I love my wife. PrEP is attractive to some people because it allows for sexual intercourse without a condom with less risk of HIV. Qualitative research has consistently shown that serodiscordant couples prioritize relationship factors i. When condoms are perceived to interfere with intimacy, they are less likely to be used PrEP has created opportunities to recognize ly unarticulated concerns about condoms including decreases sensation, interference with erectile function, and disruption of spontaneity.
Feeling safe during sex is a present-oriented benefit that has strong affective value, and is salient readily perceived. PrEP can be used anytime during the day and without the knowledge of sexual partners. This may not be unusual given how few sex positive messages are available in the cultural milieu. Present concerns about social connections, staying in school, avoiding violence, finding housing and employment often eclipse concerns about HIV, which becomes a threat over the long term Affect is when the decisions people make are impacted by their emotional state.
PrEP provides an opportunity to plan for how sex often disrupts expectations and plans Importantly, the processes elucidated in behavioral economics commonly influence all decision-making, including decisions made by political leaders, organizations, scientists, health care providers, community advocates, and patients.