Background
In 2012, the U.S. Food and Drug Administration (FDA) approved a new human immunodeficiency virus (HIV) prevention strategy, pre-exposure prophylaxis (PrEP) [
1]. Although highly effective, PrEP has not been highly accessed by many populations at high risk of HIV infection including gay and other men who have sex with men (collectively GMSM) [
2]. In the U.S., HIV infection rates among GMSM remain higher than those of the rest of the population [
3].
Three prominent areas of PrEP research have focused on PrEP’s medical utility (e.g., side effects and effectiveness), its impact on behaviors such as
risk compensation (e.g., how individuals adjust their behavior in relation to their level of perceived risk), and its rates of utilization and uptake. Data consistently show that PrEP is highly effective [
4‐
6] and that side effects are relatively minor, absent for most, and usually resolve in the first 3 months of treatment [
7].
Data on sexual risk compensation, on the other hand, have been less straightforward. A recent review noted that previous findings indicating no evidence of risk compensation among PrEP users relied on data from blind trials in which participants were not certain whether they were receiving PrEP [
8]. Data from real-world settings, however, indicate that sexually transmitted infection (STI) diagnoses, condomless anal sex (CAS), and other sexual risk behaviors, are higher among PrEP users [
8]. Many researchers contend that the reduction in risk of HIV infection from PrEP use exceeds the increased risk from behavioral changes [
9].
PrEP uptake among some populations at greatest risk of HIV infection, such as young GMSM and GMSM of color, remains low [
2]. Research has focused on describing how PrEP is utilized by GMSM, including what facilitates and hinders PrEP use, hoping to develop interventions that increase uptake [
10] and persistence [
11‐
16]. This research indicates PrEP uptake is significantly affected by awareness of it and its acceptability, cost and healthcare barriers, and PrEP-related stigma [
17,
18].
As early as 2015, researchers began to theorize how the various individual and interactional meanings behind sexual behaviors and intimacy and partnership dynamics might affect PrEP use [
19,
20]. They suggested that further research into these domains held the potential to orient clinicians in their work with GMSM individuals or couples who are considering whether to use PrEP [
19,
20]. Subsequent research has suggested that, for GMSM who use PrEP, relational factors, including intimacy, and pleasure influence engagement in sexual risk behaviors and PrEP uptake [
21‐
23]. Other studies have suggested that HIV-negative GMSM in serodiscordant partnerships might be interested in adopting PrEP in the future to decrease their anxiety about engaging in CAS with a serodiscordant partner, for HIV protection, and to engage in sex using a noncondom HIV prevention method [
24].
Ethnographic studies about PrEP use and research about the subjective and relational factors associated with PrEP use have produced valuable findings while remaining much less developed than research on PrEP’s utility, behavioral effects, and utilization [
25]. There is also a dearth of research that explicitly addresses how partnered consensual non-monogamy (PCNM) affects PrEP and its absence from public health messaging [
26]. We hope our study enriches extant PrEP research through a grounded theory approach [
27] via interviews of gay men who have considered using PrEP, focusing on the beliefs, feelings, and experiences that undergird their sense of the relevance of PrEP use to their lives that then affect whether they are motivated to use it.
Discussion
This study sought to allow participants to discuss how PrEP affected their intimate relationships and what factors determined whether PrEP felt relevant to them and motivated them to use PrEP. The researchers hypothesized that when gay men consider using PrEP, they consider subjective and relational factors over and above their self-perceived risk. Previous studies about facilitators and barriers to PrEP uptake and adherence have identified social stigma, cost, health insurance, healthcare provider awareness, and concern about side effects as factors that allow or impede GMSM from starting PrEP [
14,
31,
32]. As we discuss below, our research supports these findings.
Our research query was motivated by research that has targeted “common uncertainties around widespread PrEP implementation” [
8] including risk compensation. Often, this research reduces the benefit of being on PrEP to an “objective” decrease in the risk of HIV infection [
33], i.e., as straightforward and objective. Risk and safety, however, can be considered “thick concepts” [
34] that are rich with idiosyncratic meaning [
35]. Research addressing risk and motivations for use among GMSM who use PrEP suggests, “The meaning of an event or a phenomenon (e.g., HIV disease, [STIs]) may or may not be perceived as threatening, depending on the values held. To consider something as risky implies that something of value is at stake and is under threat” [
35]. In the present study we sought to ask gay men about how risk and other factors affected their motivations about whether to use PrEP, and how risk and PrEP were relevant to their lived experience. Our final aim was to provide qualitative data about the relevance of subjective, relational, and intersubjective factors, i.e., factors beyond “objective” risk of HIV infection, in gay men’s decision to adopt or forgo PrEP. We sought to build upon the scant information we found about psychological correlates of PrEP use [
33], which suggested that subjective factors (affective factors such as fear of HIV and motivational factors like pleasure and intimacy) affect GMSM’s interest in PrEP [
18,
36]. Entering into committed partnerships has been observed to correlate with GMSM’s self-perceived level of risk and their discontinuation (or restarting) of PrEP [
37]. The researchers came across no studies that explored what relationship, if any, PrEP use has on the establishment of committed relationships.
Thirteen gay men shared intimate details of their lives understanding they would not be compensated but that their stories would contribute to a body of research that aims to understand and help GMSM who consider using PrEP. The results of our study indicate that interpersonal factors, including group identification, committed relationships, and sexual partners, as well as changing sexual norms and specific characteristics of taking a biomedical intervention like PrEP, are all relevant to the decision about whether to use PrEP and affect how PrEP use relates to and is experienced in our participants’ lives. These findings are discussed below.
The results of our study indicate that, for the participants of our study, there is a specific sense of “what it’s like to be someone who is on PrEP,” a category described by participants that comprised how social and interpersonal factors, including group identification, committed relationships, and sexual partners, have a significant bearing on the motivations to use PrEP and on the sense of whether PrEP is relevant for individuals.
The notion of the inextricable mutuality between the individual’s identity processes and the relational matrix has been referred to, among other things, as the “holon” (the “whole”) by structuralist systemic thinkers such as Minuchin [
38]. Our participants’ narratives evoked a similar idea when they described how the social environment determined what they thought about using PrEP. PrEP-using participants and some non-users who previously used it stated that talking to friends about PrEP and hearing friends talk about using PrEP allowed them to take PrEP more seriously and to consider using it themselves. Previous findings have identified similar relationships between sexual and social relationships and the likelihood of using PrEP [
39]. Participants talked about how their friends viewed PrEP differently than how they talked about the “gay world’s” attitude toward PrEP. One participant who previously used PrEP stated that being on PrEP is “almost the norm within the gay world” (N4, 20s, open relationship, $85 k). Concern about the gay community motivated participants to use PrEP to be “responsible” by “doing their part” to stop the spread of HIV. Many participants expressed that feeling normal and being part of a community were ideas that were embedded in their experience of PrEP use.
Some participants who considered using PrEP ultimately felt that PrEP was less relevant for them, and the reasons for this varied. Some of these men denied that their friends talked about being on PrEP. Some participants stated that sex stigma affected their decision about PrEP use. Consistent with Grace and his team’s findings that stigma is experienced in multiple ways among PrEP users [
18,
40], the men in our study experienced stigma in many ways, including concern about HIV, negative bias against PrEP use, and negative judgments about casual sex, barebacking, or non-monogamy. The significance of HIV among GMSM has been described in previous research [
41]. Most if not all participants also recognized that HIV stigma, the fear that people living with HIV “are sick” (U1, 30s, single, $10 k) and contagious, continues to be prevalent, if less intense than it was in the past. Some men who felt concerned about their risk of HIV infection and were aware of the stigma against HIV positive men felt motivated to start PrEP. Men in the present study also differentiated HIV from other STIs, describing HIV as something that antibiotics cannot “fix” (U3, 20s, open relationship, $65 k), that is, incurable and permanent, which aligns with previous research findings (e.g., [
42]).
Stigmatizing views about PrEP use influenced how relevant PrEP felt for our individuals and whether they decided to start PrEP. Participants who experienced stigma because they were on PrEP described being stereotyped as being promiscuous and sexually irresponsible, “you must have no value, basically, like a cum rag. .. just pieces of ass or just people to fuck” (U1, 30s, single, $10 k). Previous research has revealed similar findings [
11,
18,
40,
43]. Thomann and colleagues found that stigma against PrEP use appears to be decreasing [
44], which fits our participants’ narrative of PrEP use being increasingly acceptable. However, for our participants, PrEP use continued to carry negative associations when paired with specific behaviors (e.g., barebacking with casual sex partners, bottoming). This mirrors findings in recent research indicating that GMSM have a range of evolving attitudes towards PrEP that may be mediated by attitudes towards specific sex acts [
45‐
47].
For the men in our study, using PrEP felt relevant to their sexual relationships both within casual sexual encounters and in the context of committed partnerships, and the effect of using PrEP on these relationships varied considerably. Some men expressed a decreased need to trust their sexual partners. Many participants expressed uncertainty about whether using PrEP felt “right” in monogamous relationships because they felt a tension between trusting their partners, and wanting to communicate this to them, while wanting personal peace of mind from taking care of their own health. This was a novel finding, as previous research has predominantly focused on the discontinuation and reinitiating of PrEP when individuals form or dissolve monogamous relationship contracts, respectively, and has usually attributed these phenomena to changes in individuals’ self-perceived level of risk [
37]. Some PrEP non-users in our study described experiences reminiscent of Carlo Hojilla’s team’s findings. For other participants, using PrEP within closed relationships involved considering what their partner’s perception would be if they chose to stay on PrEP. Participants’ views about PrEP use within open relationships was more consistent. Participants whose relationship agreements incorporated the use of PrEP believed both couple members were taking measures to protect each other’s health. Some men in our sample also expressed differing views on whether using PrEP influenced their interest in establishing committed partnerships. Our participants surmised that PrEP might decrease the desire to be in a committed partnership by enabling some participants to feel comfortable having more sex or barebacking, both of which might have been incentives to be in monogamous relationships previously. For many participants, PrEP use created an opportunity to negotiate their desire for sexual intimacy with their desire for self-preservation consciously. These findings support recent findings about the multitude of ways in which PrEP use can be facilitated or complicated within primary sexual relationships [
28,
48‐
52].
Participants spoke specifically about changing sexual norms in their communities.
Participants in this study described an evolving social and sexual environment in which safe sex fatigue, experienced as dissatisfaction with the norm and frustration with the constraints placed by condom use, was punctuated by PrEP’s development and widespread uptake.
Many participants expressed dissatisfaction with condoms because of their unreliability, the physical and psychological strictures of having to put on a condom, and the decreased sensation and loss of pleasure from their use. Dissatisfaction with condoms has appeared in the extant literature as a possible factor associated with PrEP adoption [
33]. Some participants acknowledged that using PrEP felt relevant because of the general decrease in the prevalence of condom use. Our participants reported that their sexual partners often did not use condoms and that they experienced pressure to engage in CAS. Previous literature has suggested that there are greater rates of CAS among GMSM in the past two decades [
28]. In partial contrast with previous findings, the men in our study denied that wanting to bareback more themselves was a reason for starting PrEP. They did say, however, that they wanted to start PrEP in part because others wanted to bareback more.
Some participants said that PrEP allowed them to have more spontaneous and pleasurable sexual experiences. For them, sex became liberating and comfortable, and they were no longer beset by worry about possible HIV infection. Previous research has described similar experiences about decrease in anxiety and worry about HIV infection among individuals who use PrEP [
33,
37]. Participants conveyed a greater sense of satisfaction in their sexual encounters. This is surprising given that previous research about the effect of PrEP on sexual satisfaction did not find evidence of a relationship between PrEP use and sexual satisfaction [
33]. Whitfield and his team found that being in a relationship and having more CAS experiences were associated with greater sexual satisfaction, but PrEP use itself was not predictive of this increase. Whitfield’s team conjectured that, “Taken together with the decrease in sexual anxiety, it is possible that sexual satisfaction for these participants is linked not simply to a fear of HIV acquisition but to a deeper sense of contentment not predicted by PrEP use” [
33].
Participants’ narratives seemed to reveal a dynamic process of compromise between risk and sexual satisfaction. Some participants who used PrEP considered themselves at high risk of HIV infection prior to starting PrEP. Most PrEP users related engaging in sexual risk behaviors and associated changes in their sexual behavior to being on PrEP. Some PrEP users had riskier sex by barebacking, bottoming, or having group sex, while others reported having more sex or more sexual partners. Our findings are consistent with previous research indicating that some GMSM who start using PrEP report engaging in more sexual risk behaviors as a result [
8]. The idea of risk compensation was perceived as liberating and also as scary, potentially dangerous, and reckless by some of our participants. Some PrEP non-users wanted to avoid using PrEP out of fear that they might start to engage in riskier behavior. Such experiences of fearing one’s own disinhibition as a reason for forgoing PrEP use was not one the researchers came across in their review of the literature. Previous studies about PrEP have suggested that some GMSM anticipate that they would engage in more CAS on PrEP [
35]. However, in these studies anticipated sexual disinhibition was not a reason for not taking PrEP, as was the case in the current study. Some PrEP users in our study talked about being less cautious and putting themselves at risk without thinking about it, an idea also raised by PrEP non-users. For some participants, it became difficult to draw the line about what was too risky when barebacking was considered to be safe.
The researchers wonder whether participants’ process of figuring out their limits might be related to other phenomena they described. Participants expressed that PrEP opened them up to new experiences, allowed them to work through issues, and enabled them more fully to explore their sexuality and become more confident, both sexually and as a whole. Some described increased ability to make their own decisions about how they engage sexually, from choosing whether to ask about HIV status or whether to wear a condom. For participants who described starting PrEP or considering starting PrEP because of a health scare, taking PrEP represents self-care. PrEP’s effect on sexual esteem, or the “positive feelings they have about their sexual activity and ability to deal effectively with the sexual aspects of themselves” [
33] has not yet been well studied [
33].
Some participants’ attitudes about PrEP itself evolved as they integrated PrEP into their lives and taking it became the new normal. The researchers are unaware of previous studies that have investigated how PrEP users’ attitudes about PrEP change over time.
Moreover, participants also discussed the relevance of different characteristics of using a biomedical intervention like PrEP on their motivations to use PrEP and on their sense of whether PrEP was relevant to them. Participants frequently mentioned the importance of education and awareness about PrEP. Many participants stated that it was important to them that physicians be aware of PrEP and that they have experience prescribing it. There is ample evidence that many GMSM continue to feel stigmatized within the context of their relationship with their primary care providers [
53]. Additionally, physicians appear to have implicit biases against individuals who engage in sexual risk behaviors, which compromises doctors’ willingness to prescribe PrEP [
54]. Participants in our study often attributed their own willingness or resistance to being on PrEP to familiarity with PrEP or lack thereof. Ads about PrEP, which numerous users and non-users reported having seen, increased PrEP visibility and made these men consider PrEP more relevant for them. Participants’ views ranged from “It’s almost the norm to use PrEP in the gay world” (N4, 20s, open relationship, $85 k) to “I think people just don’t know it’s there” (U3, 20s, open relationship, $65 k). This may suggest that some participants in this and previous studies identify with being privileged and having more knowledge than some of their peers. Indeed, as one PrEP-using participant observed, “I say all these things coming from what I recognize is a position of extreme relative privilege. .. I’m a cis-gender white male living in [the heart of a big city with] health insurance, a job that affords me that health insurance, and I can, barring some catastrophe, usually afford to pay my medical bills, which is not necessarily the case for this entire community, um, you know, particularly our trans brothers and sisters, people of any color” (U3, 20s, open relationship, $65 k).
Most participants identified logistical factors such as cost, health insurance, and accessibility as important, and they considered these factors when deciding whether to start PrEP. This trend has been robustly observed in previous research [
17].
Some participants who knew more about PrEP declared that PrEP felt more relevant for them. These participants appeared to be less deterred by concerns such as resistance to taking a medication, worry about side effects or the effort of adhering to a drug regimen. Trust in medical research and health professionals also influenced participants’ interest in PrEP. Participants who knew less about PrEP or felt less certain about the data on PrEP were less certain that PrEP was relevant for them. This, too, has been supported in previous literature in which participants’ skepticism of medical professionals is a reason why they do not seek talk to their providers about PrEP [
55].
Some men in our study conjectured that increasing campaigns to promote PrEP education, particularly ones not only targeting gay men, might help increase uptake. The researchers of this study agree. Participants speculated that insufficient education about PrEP likely results in lack of awareness about PrEP and contributes to PrEP’s low uptake. This conjecture is only partially borne out by the data, as rates of PrEP awareness are close to 90% [
2], and it is worth revisiting to clarify why even relatively privileged and well educated GMSM continue to believe that awareness is low among their communities.
Limitations
Recruitment was challenging. This difficulty may have arisen due to the topic, which required that subjects describe their sexual behaviors and discuss their consideration of PrEP or due to a lack of established relationships between the researchers and local community centers. The participants in this study were largely a homogenous group primarily consisting of young, White, affluent, highly educated, gay-identifying HIV-negative cisgender men. Participants were only asked if they were “sexually active” generally, and they were not asked to state more clearly what recent sexual activity or sexual risk behaviors were. These data were elicited over the course of the interview for many but not all participants. None of the men were in serodiscordant relationships. Although we reached saturation, our sample size was more homogeneous than was initially our goal. Considering the difficulty recruiting a random sample of participants and with the inherent bias in qualitative research (namely, that of the researchers’ own biases), the main limitation to this study is the generalizability of the findings.
Additionally, despite the study’s inclusion of a comparable number of PrEP users and non-users, a limitation of these findings was that the number of individuals included who were not and had never been on PrEP was small. We could have approached recruitment and the research questions differently to incorporate the views of men who had never used PrEP. Thus, the researchers note that in this study we mostly saw why GMSM might use PrEP but not so much why they do not or would not use it. It is also possible that reasons for not using PrEP are, in fact, largely due to external constraints on access to PrEP.
Future research
The results of this study have inspired us, the researchers, to consider areas of future study that might enrich and clarify the current literature. First, and foremost, future researchers investigating PrEP use might diversify and expand the sample of participants involved. Ideally, the sample recruited would include participants of varying age, level of education, SES, race, and geographic regions. The researchers of this study believe that future research about the casual and committed sexual partners of individuals on PrEP might also proffer valuable insights that complement the experience of PrEP users themselves. Finally, we also believe that trans women and substance using GMSM represent two additional vulnerable populations in the U.S. burdened by high HIV rates, and their experiences should also be targeted by future PrEP research.
Comparing the experiences of GMSM of different backgrounds would shed light on their views of related phenomena, such as barebacking, PCNM, HIV, casual sex, Grindr and/or other location-based hookup and dating apps.
Additionally, given that PrEP is a biomedical intervention, future research might consider the experiences of both physicians and mental health practitioners working with GMSM for whom PrEP might be useful. For physicians, education about various reasons why GMSM might seek PrEP might serve to mitigate their bias against patients whom they see as sensation-seeking or high risk. More education about the diverse experiences that could benefit from PrEP use might allow physicians to recommend PrEP for people who do not fit the “standard” PrEP user profile (e.g., single, sexually active GMSM). Fuller awareness about the experiences of GMSM who have considered PrEP might help mental health workers suggest PrEP to patients they think will benefit from it and to help them anticipate difficulties and benefits that are more relevant to them. Greater sensitivity to differences among PrEP users might reduce sex-negative bias and enhance clinicians’ ability to empathize with patients whose behavior they consider risky.
Finally, should our findings be found to generalize to larger samples, they may inform future PrEP advertisements and help them appeal to a more diverse population with a wider array of experiences. Better ads might allude to experiences that appeal to higher risk groups (such as young GMSM or GMSM of color). We lacked such participants, but if our findings apply to those populations, advertising might shift to emphasizing that taking PrEP is socially responsible. Future ads might try to normalize PrEP use (rather than merely highlighting its risk-reducing effectiveness) such that even its use within committed partnerships is seen as responsible preventive healthcare. Future attempts to increase uptake should also incorporate education about HIV and other STIs in a way that is not stigmatizing but nonetheless conveys their seriousness.
The feasibility of adopting these and other measures, however, depends on the availability of relevant, current research. We, the researchers of this study, firmly believe in the power of education and information, and hope that, by giving greater attention to the experiences of GMSM and their use of PrEP, future research will be poised to help deliver meaningful messages to others that safely enrich their individual lives and their relationships.
Conclusions
In this study, the researchers spoke with 13 GMSM who shared their experiences of PrEP, how they gauged its relevance to them, and how their lives have changed since this decision. To address gaps in the literature and develop greater insight about PrEP’s meaning in the cultural context of gay men specifically, we asked both gay men who used PrEP and those who contemplated PrEP but did not initiate it about what factors were relevant when they decided whether to use and to the experiences undergirding these decisions. We anticipated many of our findings, and were surprised and intrigued by others.
Many of the phenomena described by these men have been identified in previous research: self-perceived risk [
56], PrEP acceptability [
17,
24], access and affordability of PrEP and LGBT-aware healthcare [
17], dissatisfaction with condoms [
33], concern about taking medication and its side effects [
17], risk compensation [
8], decreased anxiety about HIV infection during sex [
26], and HIV- and PrEP-related stigma [
18,
40]. It is both heartening and perplexing to see that many of our findings have been observed in previous research, as described above, given the shortcomings in reaching at-risk GMSM and increasing PrEP uptake [
2].
Our participants also elaborated on themes that have not been researched in depth and that may serve as areas for future research. Participants identified health scares as potential catalysts for starting PrEP, and many identified as sexually and socially responsible individuals who want to help stop the spread of HIV. For many participants sex became riskier. Some experienced the changes as liberating; they described feeling more sexually comfortable and able to engage in sex more freely. Others, in contrast, were taken aback by their disinhibition. They described that they feared losing control of their sexual agency and going wild—a new idea that emerged from our participants’ narratives. Some participants shared ways PrEP use may affect them, including promoting greater agency, allowing them to become more sexually open, and enabling them to develop confidence and work through issues. We speculate that satisfaction may increase when one’s sexual way of life feels increasingly less singled out as having greater health and stigma cost than that of the ways of others. PrEP is not only a pill that GMSM are told they need, but also a method of self-care, freedom, agency, and contentment.
Moreover, many of these men described their experiences not as single, independent agents but rather as members of committed partnerships. Some participants felt PrEP affected their interest in committed relationships. Some grappled with whether PrEP use was right within their committed relationship, whether open or closed, and about the protection and trust it conferred on them as individuals and as a couple. Some spoke of conflict deciding whether to use PrEP in monogamous relationships due to what this could signify to their partners, fearing it might foster distrust. Some men also shared that they and their partners were in ongoing dialogue about their sexual contracts about whether to incorporate PrEP, given their combined level of risk. These ideas have not been deeply explored in prior research. We suggest that researchers, in failing to “ask about issues of love, commitment, and affiliation, and, instead, focusing on sexual aspects of these relationships” [
57], have largely ignored consequential ways in which PrEP use is a part of GMSM’s lived experiences. Large scale, future research might test the generalizability of these ideas.
A grounded theory narrative, not to be overgeneralized to anyone beyond our sample, might be as follows: GMSM who consider using PrEP have many points of entry into its use and of decision making. If and when their culture is one where friends, doctors, and romantic partners, as well as public advertisements seem to support PrEP’s use, the men may go ahead and try to get an affordable prescription. If, however, any one of those influences is negative, mistrusting, or shaming, that influence may be felt strongly enough to dissuade choosing to use PrEP. Another choice point can come when the men are exposed to health scares, either in themselves, in friends or in partners. The scares may trigger a sense of needing to take better care of themselves. Some men, however, will not take PrEP because they believe that they will have worse problems on which to focus their energies or that they will get into more health risk situations if they were to take PrEP. This bias is an implicit leaning shared by some health care workers who hold back prescribing PrEP. The participants may simply not want to entrust themselves to PrEP when they cannot trust the science. Commitments, either to one’s partner or to the gay culture as a whole, also affect men’s choices. Some go one way, feeling that all will be safer if they use PrEP, and some the opposite, that is, they fear they will be mistrusted for any commitment promises made in relationships. The men who decided not to use PrEP know it is always out there. Some men who decided to use PrEP seem to feel an added sense of belonging and peace of mind. Others felt more sexually satisfied and more secure about being able to take care of themselves and those they care about, from their partners to their community. It is notable that the men had many dissatisfactions with condoms as a prophylactic; however, the men who used PrEP did not base their decisions about using PrEP solely on their dissatisfactions with condoms. Our participants expressed that interpersonal and social factors, the primary romantic relationship issues around the perception of trustworthiness and the group norms, the sense of acceptance in society (e.g., ads and clinics) also greatly shaped their attitudes towards PrEP and their experiences of it.
Our participants feel a social responsibility to themselves and to the community at large. They seem predominantly to welcome the increased pleasure and peace of mind and perhaps even feel less stigmatized since they may take their sexual pleasures with greater ease than before PrEP. They respect both monogamous relationships and consensual non-monogamous ones; the current authors hope that others may return their respectful attitudes to them. We hope that our conclusions aid that wish’s fulfillment. Some of these men may appear to outside observers to have become careless about their health in risking HIV infection. However, they seem to have made thought-through choices given the treatable nature of those illnesses. Finally, we think the persistent difficulties these men have in finding educated health practitioners requires a major focus among health care educators and the curricula they provide.