Abstracts

Introduction

In Brazil, the risk of HIV infection remains high among men who have sex with men (MSM) ¹1. Kerr L, Kendall C, Guimarães MDC, Mota RS, Veras MA, Dourado I, et al. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore) 2018; 97(1S Suppl 1):S9-15., with new cases occurring primarily among young MSM ²2. Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico HIV/Aids 2020; (número especial). http://www.aids.gov.br/pt-br/pub/2020/boletim-epidemiologico-hivaids-2020.
http://www.aids.gov.br/pt-br/pub/2020/bo... . Despite this scenario, there is also optimism in the scientific community, especially in response to recent biomedical findings which indicate that individuals living with HIV and receiving antiretroviral treatment will stop transmitting the virus during sex if they reach an undetectable viral load ³3. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316:171-81.^,44. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019; 393:2428-38.^,55. Grulich A, Bavinton BR, Jin F, Prestage G, Zablotska IB, Grinsztejn B, et al. HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. In: 22nd Conference on Retroviruses and Opportunistic Infections. https://www.croiconference.org/abstract/hiv-transmission-male-serodiscordant-couples-australia-thailand-and-brazil/ (accessed on 15/Apr/2021).
https://www.croiconference.org/abstract/... ^,66. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016; 375:830-9.^,77. The Lancet HIV. U=U taking off in 2017. Lancet HIV 2017; 4:e475.^,88. Programa Conjunto das Nações Unidas sobre HIV/AIDS. Indetectável = intransmissível. Saúde pública e supressão da carga viral do HIV. https://unaids.org.br/wp-content/uploads/2018/07/Indetect%C3%A1vel-intransmiss%C3%ADvel_pt2.pdf (accessed on 15/Apr/2021).
https://unaids.org.br/wp-content/uploads... . Another biomedical breakthrough is pre-exposure prophylaxis (PrEP), the daily use of a pill composed of two antiretroviral drugs (emtricitabine and tenofovir) by people who are HIV-negative. Randomized clinical trials have shown the effectiveness of PrEP in preventing HIV infection ⁹9. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010; 363:2587-99.^,1010. Molina JM, Charreau I, Spire B, Cotte L, Pialoux G, Capitant C, et al. On demand PrEP with oral TDF/FTC in the open-label phase of the ANRS IPERGAY Trial. In: 22nd Conference on Retroviruses and Opportunistic Infections. https://2jg4quetidw2blbbq2ixwziw-wpengine.netdna-ssl.com/wp-content/uploads/sites/2/posters/2016/886.pdf (accessed on 15/Apr/2021).
https://2jg4quetidw2blbbq2ixwziw-wpengin... ^,1111. McCormack S, Dunn D. Pragmatic open-label randomised trial of preexposure prophylaxis: the PROUD study. In: 22nd Conference on Retroviruses and Opportunistic Infections. https://www.croiconference.org/abstract/pragmatic-open-label-randomised-trial-preexposure-prophylaxis-proud-study/ (accessed on 15/Apr/2021).
https://www.croiconference.org/abstract/... .

These new technologies represent significant steps forward in the fight against the epidemic. However, it is important to discuss how they have contributed to or reconfigured certain aspects of sexual practices among men, enabling more anxiety-free sexual activities or satisfying them, while also raising new issues for discussion. For example, in the case of an undetectable viral load, this new status could reduce anxiety about sexual intercourse by decreasing concerns about HIV transmission ¹²12. Grace D, Chown SA, Kwag M, Steinberg M, Lim E, Gilbert M. Becoming “undetectable”: longitudinal narratives of gay men’s sex lives after a recent HIV diagnosis. AIDS Educ Prev 2015; 27:333-49.. As for PrEP, it may also enable enhanced sexual satisfaction and intimacy, and an increased sense of security and ease in situations in which condoms are unavailable or it is hard to negotiate their use ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217.^,1414. Gamarel KE, Golub SA. Intimacy motivations and pre-exposure prophylaxis (PrEP) adoption intentions among HIV-negative men who have sex with men (MSM) in romantic relationships. Ann Behav Med 2015; 49:177-86.^,1515. Mabire X, Puppo C, Morel S, Mora M, Castro DR, Chas J, et al. Pleasure and PrEP: pleasure-seeking plays a role in prevention choices and could lead to PrEP initiation. Am J Mens Health 2019; 13:1557988319827396.^,1616. Silva-Brandao RR, Ianni AMZ. Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP). Sexualities 2020; 23:1400-16.^,1717. Zimmermann HML, Postma LR, Achterbergh RCA, Reyniers T, van der Loeff MFS, Prins M, et al. The impact of pre‐exposure prophylaxis on sexual well‐being among men who have sex with men. Arch Sex Behav 2021; 50:1829-41..

Yet, notwithstanding these positive effects, conflicts/tensions and ambivalence still permeate this context. For example, despite all the information and discussion on the international scenario about “undetectable = untransmissible” ⁷7. The Lancet HIV. U=U taking off in 2017. Lancet HIV 2017; 4:e475.^,88. Programa Conjunto das Nações Unidas sobre HIV/AIDS. Indetectável = intransmissível. Saúde pública e supressão da carga viral do HIV. https://unaids.org.br/wp-content/uploads/2018/07/Indetect%C3%A1vel-intransmiss%C3%ADvel_pt2.pdf (accessed on 15/Apr/2021).
https://unaids.org.br/wp-content/uploads... , people living with HIV may still see themselves and be seen by others as “high-risk” individuals ¹⁸18. Silva LAV, Duarte FM, Lima M. “Eu acho que a química entrou em reprovação”: relações afetivo-sexuais de homens jovens vivendo com HIV/aids e com carga viral indetectável. Sex Salud Soc 2020; (34):25-45. - a narrative that still conjures up feelings of guilt and fear due to the infection or the potential to transmit HIV, especially in the context of gay/homosexual men, who tend to be seen as more “excessive” and “promiscuous” or else marginal or wretched ¹⁹19. Miskolci R. “Discreto e fora do meio”: notas sobre a visibilidade sexual contemporânea. Cadernos Pagu 2015; (44):61-90.. As for PrEP use, despite its benefits and effectiveness in preventing HIV, it has been associated with the negative image of promiscuity attributed to gay men ²⁰20. Dubov A, Galbo Jr. P, Altice FL, Fraenkel L. Stigma and shame experiences by MSM who take PrEP for HIV prevention: a qualitative study. Am J Mens Health 2018; 12:1832-43.^,2121. Wong CS, Kumar PA, Wong CM, Choong BCH, Lim OZ, Chan YY, et al. Acceptability of HIV pre-exposure prophylaxis (PrEP) and opinions on PrEP service delivery among men who have sex with men in Singapore: a qualitative study. AIDS Educ Prev 2019; 31:152-62.^,2222. Pillay D, Stankevitz K, Lanham M, Ridgeway K, Murire M, Briedenhann E, et al. Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa. PLoS One 2020; 15:e0228620.. These stigmas, including the association with HIV, may produce barriers to the acceptability ²³23. Race K. Reluctant objects: sexual pleasure as a problem for HIV biomedical prevention. GLQ 2015; 22:1-31.^,2424. Magno L, Dourado I, Coats CS, Wilhite D, Silva LAV, Oni-Orisan O, et al. Knowledge and willingness to use pre-exposure prophylaxis among men who have sex with men in Northeastern Brazil. Glob Public Health 2019; 14:1098-111. or even the continued use of PrEP ²¹21. Wong CS, Kumar PA, Wong CM, Choong BCH, Lim OZ, Chan YY, et al. Acceptability of HIV pre-exposure prophylaxis (PrEP) and opinions on PrEP service delivery among men who have sex with men in Singapore: a qualitative study. AIDS Educ Prev 2019; 31:152-62.^,2222. Pillay D, Stankevitz K, Lanham M, Ridgeway K, Murire M, Briedenhann E, et al. Factors influencing uptake, continuation, and discontinuation of oral PrEP among clients at sex worker and MSM facilities in South Africa. PLoS One 2020; 15:e0228620..

Considering this ambivalent scenario, in which pleasure may be experienced more freely or with less fear/guilt, at the same time that (moral) barriers are built or reformulated for some of these actors and their pleasure, especially when it comes to condomless sex, it is important to discuss the dimensions of sex/pleasure and risk outside the biomedical domain and the ideas of “control” and “choice” in the context of disease prevention and health care ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008., especially ideas of “safe sex”. Here, we will highlight the daily scenarios or practices in which people, partners, technologies, symbols, fantasies, etc. interact, indicating how fluid, multiple, unstable, and unpredictable prevention and care can be.

As such, this essay draws on the literature - particularly on some studies conducted in Brazil - to offer a reflection on the relationship between risk and pleasure in the field of HIV care and prevention, putting into perspective the mediation of these new biomedical prevention and care technologies, especially PrEP. The idea is to show how these new technologies have mediated or reconfigured sex between men insofar as they considerably reduce the chances of HIV infection/transmission. In this sense, we view PrEP-agency as part of a network of relationships, acknowledging its status as an actor/actant with the capacity to produce displacements and movements and influence the actions of other actors ²⁶26. Latour B. Reagregando o social: uma introdução à teoria do ator-rede. Salvador: EDUFBA/Bauru: EDUSC; 2012.. Finally, we also problematize some persistent ambivalences and tensions in this field, especially since biomedical breakthroughs enabled the potential for condomless sex.

In so doing, we sustain the argument that while these new technologies may signify a “new gay sexual revolution” ²⁷27. González OR. HIV pre-exposure prophylaxis (PrEP), the “truvada whore” and the new gay sexual revolution. In: Varghese R, editor. Raw: PrEP, pedagogy, and the politics of barebacking. Regina: University of Regina Press; 2019. p. 47-70., assuaging the climate of AIDS-related fear and paranoia and enabling experiences of greater freedom and pleasure, they also prompt a reworking of discourses and practices of body, pleasure, and health care normalization. These are biopolitical processes that enable arousal, but also involve regulation and control ²⁸28. Preciado P. Texto junkie: sexo, drogas e biopolítica na era farmacopornográfica. São Paulo: N-1 Edições; 2018., including the very routines and procedures inherent in using medications/technologies in the context of global consumption. As such, we stress the importance of thinking about care and prevention in manifold ways, considering the malleability, porosity, and fluidity of the practices involved and even the actors/actants at play.

While we underline the multiplicity of care, we should also point out a few important considerations. When prevention and care are discussed in the realm of health, is it common for care to be conceived in a way that seems strongly linked to the concept of risk, meaning threat, danger, and negative, undesirable results; i.e., something to be avoided ²⁹29. Lupton D. Risk. London/New York: Routledge; 1999.^,3030. Lupton D, Tulloch J. ‘Risk is part of your life’: risk epistemologies among a group of Australians. Sociology 2002; 36:317-34.. Lupton ²⁹29. Lupton D. Risk. London/New York: Routledge; 1999. points out that this focus on risk avoidance is strongly associated with the ideal of a civilized body, a growing desire to control life, to rationalize and regulate the self and the body, and, ultimately, to avoid the “vicissitudes of fate”. While there may be other means of conceiving of health care that consider individual subjects, their intersubjective relations, and the barriers to their “projects for happiness” ³¹31. Ayres JRCM. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde Soc 2004; 13:16-29., the way care is often conceived seems closer to this prevention-oriented rationale. When viewed from this perspective, the individual, as an information-processing unit, should perceive their vulnerability to risk and the serious consequences thereof, while, at the same time, believing that prevention will be effective, and the benefits will be greater than the costs ²⁹29. Lupton D. Risk. London/New York: Routledge; 1999.. It is an attitude that leaves little room for comprehending the rationalities present in actual sexual practices. “Care”, when viewed from this perspective, tends to involve actions that revolve mostly around simplified and prescriptive educational offers.

Turning the spotlight on more concrete, lived experiences in situations involving “risk” gives us a chance to see that better or safer options are not always available for individuals in such circumstances. People’s everyday experiences involve myriad tensions, stoked by desires, fears, pleasures, etc., quite apart from the moments in which rational choice is the main driving force. What we attempt to do, then, is to strike some kind of balance between these different values, desires, and pleasures, which is to say that we are intersected by many “modes of ordering”, “styles”, or “logics” and that, in the course of our practices, unexpected things always happen, demanding great creativity on our part ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008.. This is why the notion of the logic of care proposed by the philosopher and anthropologist Annemarie Mol ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008. is so important, as it provides us with the opportunity to comprehend these concrete situations in which people face the need to reconcile tensions between desires, fears, and demands for protection.

Therefore, in the debate proposed here, we understand care as something that is produced in different ways in various sexual interactions, deriving from dissimilar kinds of knowledge, diverse actants, and distinct “meanings” and lived experiences. For that reason, the notion of care developed by Mol ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008. offers an important contribution. She shows the limits of individual “choice” when people find themselves in the specific situation (and place) of sickness and care. The discussion shown below about condomless sex shines a light on the fact that knowing what is “appropriate” at each place or in each situation is not a given. People acquire this understanding in dynamics whose coherence is tenuous, localized, and which may appear pertinent but not necessarily obvious to the people involved.

Condomless anal sex between men: a borderland between risk and pleasure

We begin this section with a discussion about the relationship between risk and pleasure in some homoerotic practices, considering the ambivalence inherent to them. Specifically, we start out with some sexual practices regarded as freer, barrier-free, or raw, even if, paradoxically, that may appear improbable, especially at a time when prevention technologies can even be lodged in our own body, as is the case with the use of a chemical substance such as PrEP ³²32. Dean T. Mediated intimacies: raw sex, truvada, and the biopolitics of chemoprophylaxis. Sexualities 2015; 18:224-46.. For this reason, it is important to consider the erotic factors that motivate subjects, as well as the moral dimensions that impose limits on certain practices taken as excessive. One such case is barebacking, which is generally understood to be the conscious, deliberate decision to engage in condomless anal sex in full knowledge of the risks involved ³³33. Suarez T, Miller J. Negotiating risks in context: a perspective on unprotected anal intercourse and barebacking among men who have sex with men - where do we go from here? Arch Sex Behav 2001; 30:287-300..

In a study conducted between 2006 and 2008 to assess some versions of this emerging phenomenon in the mid-2000s in Brazil, Silva ³⁴34. Silva LAV. Desejo à flor da tel@: a relação entre risco e prazer nas práticas de barebacking [Doctoral Dissertation]. Salvador: Instituto de Saúde Coletiva, Universidade Federal da Bahia; 2008. found manifold practices and meanings, and contributed to discussions about some of the effects or meanings then in vogue, such as resistance to prevailing health/prevention discourses ³⁵35. Crossley ML. Making sense of “barebacking”: gay men’s narratives, unsafe sex and the “resistance habitus”. Br J Soc Psychol 2004; 43:225-44.^,3636. Rofes E. Desires as defiance: gay male sexual subjectivities and resistance to sexual health promotion. Health Educ J 2002; 61:125-37. and to the fear induced by the AIDS epidemic ¹⁶16. Silva-Brandao RR, Ianni AMZ. Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP). Sexualities 2020; 23:1400-16., or even the association with an increased sense of freedom and of individuals’ right to choose ³⁷37. Silva LAV. Barebacking e a possibilidade de soroconversão. Cad Saúde Pública 2009; 25:1381-9.. Far from homogeneous, fixed or stable, what came to light was a nuanced polysemous practice that had diverse ramifications and formulations, constituting a complex, open, multiple object or phenomenon that shifted and was enacted by practices. Race ³⁸38. Race K. Engaging in a culture of barebacking: gay men and the risk of HIV prevention. In: Davis M, Squire C, editors. HIV treatment and prevention technologies in international perspective. London: Palgrave Macmillan; 2010. p. 144-66. (p. 161) described a similar phenomenon in reference to the multiple nature of condomless sex: “sometimes it is produced as barebacking. Sometimes it is produced as serosorting, or ‘negotiated safety’. Sometimes it is produced as an erotic transgression of gay community and public health norms”.

Seen in this light, it should therefore be stressed that many gay and other MSM may also use different strategies to reduce or manage their risk of HIV infection or transmission in their sexual activities in ways that are more consistent with their own sexual desires, experiences, and practices ³⁹39. Terto Jr. V. Diferentes prevenções geram diferentes escolhas? Reflexões para a prevenção de HIV/AIDS em homens que fazem sexo com homens e outras populações vulneráveis. Rev Bras Epidemiol 2015; 18 Suppl 1:156-68.. They may also prefer to be top or bottom, may seek partners that are seroconcordant for a relationship, try to withdraw before ejaculating or even rely on certain “bodily signs” to assess whether they can “trust” their partner ⁴⁰40. Silva LAV. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafios. Psicol Soc 2012; 24:327-36.. In other words, even in condomless sex, there are other forms of care that are brought into play above and beyond the biomedical rationale, mediated by native theory or by knowledge stemming from lived bodily experiences, in which different senses (sight, taste, smell, etc.) can serve as “scientific categories” to identify risks, the quality of encounters, and engagement in different practices ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217..

As Mol ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008. (p. 21) describes, aside from the availability of products (and choices), care is a process that has no clear boundaries, meaning it is “not a transaction in which something is exchanged (a product against a price), but an interaction in which the action goes back and forth (in an ongoing process)”. According to the logic of care, she explains, the unpredictability of bodies and life itself must be noted, as must the particularities and differences and conditions in which people and groups live. And it is according to this unpredictability and viscosity of life - with its many “variables” that are beyond our control ⁴¹41. Spink MJP. Clientes, cidadãos, pacientes: reflexões sobre as múltiplas lógicas de cuidado na atenção à saúde. Saúde Soc 2015; 24 Suppl 1:115-23. - that care cannot be thought of as a clearly delineated product, but as a semi-open process, in which there will be trial, adjustment, and new attempts, always with the aim of producing a better life or a possible existence ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008.. This route towards producing a better life is marked by needs for protection, desires, pleasure-seeking, fears, feelings of guilt, and anxiety. They are processes permeated by tensions that cannot be avoided, as they are part of the very fabric of life.

Another key point from Silva’s study ³⁴34. Silva LAV. Desejo à flor da tel@: a relação entre risco e prazer nas práticas de barebacking [Doctoral Dissertation]. Salvador: Instituto de Saúde Coletiva, Universidade Federal da Bahia; 2008. is that sometimes the concept of barebacking appears in association with intentionally unprotected sex and with casual partners or strangers, whereas, at other times, it appears in association with more generic condomless sexual activity, irrespective of the relationship with the partner (or lack thereof) or any intentionality implicit in the act ⁴²42. Silva LAV. A cibersexualidade e a pesquisa online: algumas reflexões sobre o conceito de barebacking. Interface (Botucatu) 2010; 14:513-28.. Considering this more generic definition, it is interesting to draw attention to the following point: some men say they bareback with their boyfriends, distinguishing what might be considered healthy barebacking from other more wild, promiscuous or potentially disease-transmitting barebacking. As such, some accounts attempt to legitimize or recognize the possibility of unprotected sex. This, according to Silva ⁴²42. Silva LAV. A cibersexualidade e a pesquisa online: algumas reflexões sobre o conceito de barebacking. Interface (Botucatu) 2010; 14:513-28. (p. 518), may indicate the way or the intensity with which discourse about safe sex “has become intertwined with a general norm of ‘good conduct’ for the healthy functioning of bodies and relationships”.

Two potentially antagonistic or conflicting situations arise from this discussion: unprotected sex with a steady or trusted partner versus casual sex with strangers. In this discursive trajectory about sexual practices, the reference to the promiscuous gay man is often used to bring to mind a hierarchy of sexual values, separating “good” sex from “bad” ⁴³43. Rubin G. Thinking sex: notes for a radical theory of the politics of sexuality. In: Vance CS, editor. Pleasure and danger: exploring female sexuality. Boston: Routledge & Kegan Paul; 1984. p. 267-319.. In this sense, even within homoerotic practices, the image of promiscuity seems to have the function of distinguishing between gay lifestyles and identities, such as between those who are promiscuous and those who have what could be regarded as a healthier, more normal relationship, or one that can be self-regulated; an image that still seems to prevail among young gay men living with HIV as a justification for seroconversion ⁴⁴44. Silva LAV, Duarte FM, Magno L, Dourado I, Squire C. Moral barriers to HIV prevention and care for gay and bissexual men: challenges in times of conservatism in Brazil. Sociol Health Illn 2021; 43:424-40.. It is no wonder that Dean ⁴⁵45. Dean T. Unlimited intimacy: reflections on the subcultures of barebacking. Chicago: The University of Chicago Press; 2009. highlights barebacking as a way of not being assimilated by a monogamous norm or the ideal of the non-promiscuous gay man.

If we return to the specific practice of barebacking prior to the emergence of PrEP, it is important to stress that this came about in “a borderland of tension between the pleasure of sensory contact and the risk of infection [with HIV]” ⁴⁶46. Silva LAV. Masculinidades transgressivas em práticas de barebacking. Revista Estudos Feministas 2009; 17:675-99. (p. 694). The pleasure of risk did not necessarily mean an intentional or conscious movement towards HIV - the active pursuit of HIV-positive individuals to contract HIV, commonly known as bug-chasing. Even if this may take place, granting erotic satisfaction through the fantasy of deep connection, unlimited intimacy, fraternity, kinship, or permanence through the virus, and thus being more than just a disease ⁴⁵45. Dean T. Unlimited intimacy: reflections on the subcultures of barebacking. Chicago: The University of Chicago Press; 2009., many other barebackers simply point to the heightened sensorial pleasure to be enjoyed by having condomless sex ³⁷37. Silva LAV. Barebacking e a possibilidade de soroconversão. Cad Saúde Pública 2009; 25:1381-9.^,4747. Silva LAV. Prazer sem camisinha: novos posicionamentos em redes de interação online. Cadernos Pagu 2010; (35):241-77., bringing into focus the excess pleasure enjoyed by violating frontiers or the separation of bodies; and consequently, valuing barrier-free, rubber-free, more intimate, raw, naked, natural, in-the-flesh sex.

Today, stigmatization processes are still in place and still produce vulnerabilities despite the emergence of new actants like PrEP and an undetectable viral load, which remove the risk of HIV infection/transmission or cease to necessarily associate it with condomless sex. Meanwhile, the whole vocabulary surrounding it has been expanded to include “natural sex”, “real sex”, or just “condomless sex”, rather than “barebacking” ¹⁶16. Silva-Brandao RR, Ianni AMZ. Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP). Sexualities 2020; 23:1400-16.^,3232. Dean T. Mediated intimacies: raw sex, truvada, and the biopolitics of chemoprophylaxis. Sexualities 2015; 18:224-46.. It is important to remember that these (not so) new uses and meanings were already around before these biotechnologies came into existence, including when barebacking came to be used as a synonym for any kind of condomless sex ⁴²42. Silva LAV. A cibersexualidade e a pesquisa online: algumas reflexões sobre o conceito de barebacking. Interface (Botucatu) 2010; 14:513-28., putting the focus on sensorial pleasure at a time when attempts were being made to remove some of its negative associations, such as the desire to contract or pass on HIV ⁴⁸48. Silva LAV, Iriart JAB. The meanings and practices of barebacking among Brazilian internet users. Sociol Health Illn 2012; 34:651-64.. As these authors note, as time has gone by, what seemed to be an organized movement for freedom of choice (to use or not use a condom) has been gradually replaced by a dispersion of practices and meanings, with more diluted, individualized forms of transgression, and heterogeneous intentions and trajectories.

As we will discuss below in our consideration of the latest biomedical breakthroughs, which could curb or even prevent new cases of HIV infection or transmission, we should also consider how the relationships between pleasure, risk, and erotic fantasy that mobilize different sexual practices - including direct contact with another man’s sperm - have come about or been reconfigured, even when the risk of other sexually transmitted infections (STIs) continues to be an issue. What we want to argue here is that despite changes, these tensions between pleasure and risk/danger are still present, mobilizing or coproducing subjects and practices.

The relationship between risk and pleasure in the context of biomedical progress

“It happened.

I went to [name of establishment]. There was this guy there that I call a hunk and a half. Really big, long-haired, with a big cock. What a wet dream. I kept on brushing past him. I went to that darker part where there’s a fence and he went after me. I stayed there behind the fence watching what was going on and he came up behind me, rubbing himself against me. He pulled out that big wet cock and began to rub it on my tight little butt. I get shivers down my spine just thinking of it. His cock was already wet, and he quickly managed to get it in. That’s when I remembered about the condom, but by then it was too late to get it. He told me to lean over, and he held onto the fence while he pushed into me. It was so hot. He fucked me really hard and fast. There was already a bunch of guys standing round, masturbating and watching.

I began to grab, masturbate, and suck different ones that were nearby until one came in my mouth. I had to wash it out and I think that’s why that hunk and a half didn’t come in my ass. Just as well. If he had I would have been really worried, but it was really good. God, I just love whoring around [laughs]” ⁴²42. Silva LAV. A cibersexualidade e a pesquisa online: algumas reflexões sobre o conceito de barebacking. Interface (Botucatu) 2010; 14:513-28. (p. 521-2).

“Except one day I... I have protected sex, but it happened, drinking, it happened, the same thing, that I ended up having sex without a condom twice, but I didn’t worry anyway because I use PrEP. Because I know it’ll stop me from getting HIV, but not anything else (...) ‘Cos there’s no cure for HIV but there’s treatment for the rest, so I didn’t worry. Not that I want [wanted] to catch something, but I felt OK, you know? (...) ‘cos I know the person. I did it again afterwards [and] nothing happened. I just did the test and nothing. That was a relief. I’m not going to go out and have sex without a condom, but I was relieved” (account given by a 19-year-old participant as part of the PrEP1519 project, Brazil, 2019).

“They [family] asked what the medicine was and I explained it was PrEP. Then, they understood that it was a medicine to prevent HIV and all that, and then they asked why I was doing that treatment, and I said ‘Look, guys, you know what a busy life I have’ [laughs], and that’s how it was (...) I think I’m (...), you know, to be able to be using PrEP in a high-risk situation, because I get together with all sorts of people and sometimes I don’t even know if the person’s being safe or not” (account given by a 19-year-old participant as part of the PrEP 1519 project, Brazil, 2019).

These accounts were produced at different times vis a vis the introduction of PrEP. They are narratives that serve as examples or vignettes for us to think about the interplay between risk and pleasure, and may be guided by the signs of “excess” or “controlled permissiveness”. Thus, the need to protect oneself using whatever technologies are available coexists in tension both with a body that appears more open, unstable, and somewhat unpredictable, and also with different prevention norms and discourses, including the prevention of other STIs. At the same time, if new prevention technologies like PrEP can enhance feelings of safety and freedom, as at bareback orgy parties ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217., it should be noted that different prevention strategies or methods may be brought into play (including a condom) depending on the contingencies and actors involved in the sexual encounter.

In any attempt to problematize the relationship between risk and pleasure, especially in the situations of condomless sex discussed here, it would be quite wrong to say that people fail to take care of themselves or that they are absolutely free to do whatever they want. In group sex, for instance, there are also “norms” or principles that regulate or impose certain limits, like the idea of consent, even if they may be breached or modified or there may be fissures in what may have been agreed, foreseen or imagined beforehand ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217..

Complementing the data that point to reduced condom use among PrEP users ⁴⁹49. Gombe MM, Cakouros BE, Ncube G, Zwangobani N, Mareke P, Mkwamba A, et al. Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: qualitative perspectives of general population clients at high risk for HIV. PLoS One 2020; 15:e0227632.^,5050. Holt M, Lea T, Mao L, Kolstee J, Zablotska I, Duck T, et al. Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013-17. Lancet HIV 2018; 5:e448-56.^,5151. Hoornenborg E, Coyer L, van Laarhoven A, Achterbergh E, de Vries H, Prins M, et al. Change in sexual risk behaviour after 6 months of pre-exposure prophylaxis use: results from the Amsterdam pre-exposure prophylaxis demonstration project. AIDS 2018; 32:1527-32.^,5252. Montaño MA, Dombrowski JC, Dasgupta S, Golden MR, Duerr A, Manhart LE, et al. Changes in sexual behavior and STI diagnoses among MSM initiating PrEP in a clinic setting. AIDS Behav 2019; 23:548-55., we would like to focus on this complex relationship between risk and pleasure, or, as Silva ⁴⁰40. Silva LAV. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafios. Psicol Soc 2012; 24:327-36. (p. 334) puts it, this “complex network of negotiated losses and gains” that takes place in the diverse reality of sexual encounters, in which interests, emotions, bodies, partners, fantasies, values, prevention strategies, medications, and diverse actants interplay. As Silva-Brandao & Ianni ¹⁶16. Silva-Brandao RR, Ianni AMZ. Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP). Sexualities 2020; 23:1400-16. note, also taking the risk of STIs into account, people may negotiate condom use, weighing up their fears and sexual interests in the pursuit of pleasure or even testing out or using drugs like antibiotics as prevention methods ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217.^,1616. Silva-Brandao RR, Ianni AMZ. Sexual desire and pleasure in the context of the HIV pre-exposure prophylaxis (PrEP). Sexualities 2020; 23:1400-16.^,5353. Barreto VHS. Risco, prazer e cuidado: técnicas de si nos limites da sexualidade. Avá - Revista de Antropologia 2017; 31:119-42.. Meanwhile, in this negotiation between losses and gains or this offsetting of fear and pleasure, the risk inherent to acquiring an STI may be viewed as lower in view of the prospect of treatment and cure ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217..

Returning to the narratives we showed above, the first scene, posted in an online community which discussed experiences of condomless sex ⁴²42. Silva LAV. A cibersexualidade e a pesquisa online: algumas reflexões sobre o conceito de barebacking. Interface (Botucatu) 2010; 14:513-28., shows some of the situations in which heightened sexual arousal seems to outweigh all other considerations, specifically those involving another individual whose appearance is perceived as irresistible (the “hunk and a half”) and a body that appears more open, seamless, and permeable to the world and to another. Certainly, it is impossible not to notice here how an image or sign of masculinity (penis size) galvanizes the other man’s fantasy. This indicates that erotic practices, despite their transgressive potential, with the power to produce profound feelings of “inseparability” between beings and thus, violation and excess ⁵⁴54. Bataille G. O erotismo. São Paulo: Arx; 2004. or even “transcendence” ⁵⁵55. Martin JI. Transcendence among gay men: implications for HIV prevention. Sexualities 2006; 9:214-35., occur in dialogue (and tension) with social norms, including those relating to gender and sexuality.

In this sense, risk appears as an important element of erotic practices, especially when it is associated with the transgression of social norms and conventions, with the power, as Gregori ⁵⁶56. Gregori MF. Risco e êxtase nas práticas eróticas. Cadernos Pagu 2016; (47):e164716. points out, to jeopardize gender and sexuality conventions, making it impossible to retain complete control or the assurance that abuse and violence will be avoided. In this perspective, for us to better understand the situations in which condomless sex takes place, it is important to bring to the forefront of the analysis these threshold situations of tension between pleasure and risk/danger or, as Gregori ⁵⁷57. Gregori MF. Prazeres perigosos: erotismo, gênero e limites da sexualidade [Associate Professorship Dissertation]. Campinas: Universidade Estadual de Campinas; 2010. (p. 3) insists, these “limits of sexuality”, understood as a “borderline zone where norm and transgression, consent and abuse, pleasure and pain coexist”.

It is worth noting here that the “shivers down the spine” reported in the first account show a certain ambivalence in the face of the risk of losing oneself in the other. As seen in other situations that are apparently more excessive or transgressive, the act of transgressing, interfering with or destabilizing boundaries (of identities, morals or social mores) seems to be an important element of pleasure that is present in many sexual encounters and practices, such as direct, intense contact with another man’s semen (spunk or cum), which may signify sharing, communion, partner mixing, and an “interchange” of masculinities ⁴⁶46. Silva LAV. Masculinidades transgressivas em práticas de barebacking. Revista Estudos Feministas 2009; 17:675-99. or even augmented masculinity ⁵⁸58. Ridge DT. ‘It was an incredible thrill’: the social meanings and dynamics of younger gay men’s experiences of barebacking in Melbourne. Sexualities 2004; 7:259-79.. As Lupton ²⁹29. Lupton D. Risk. London/New York: Routledge; 1999. points out, beyond the negative (probabilistic) dimension, transgressing (cultural and corporal) boundaries may well prompt fear and anxiety, but also fascination, arousal, ecstasy, or be a source of pleasure. In other words, transgression is a high-risk activity because it confronts the given or set conceptual (and bodily) boundaries. Following this line of thinking, feelings of ecstasy, losing one’s head, or losing oneself in another ⁵⁶56. Gregori MF. Risco e êxtase nas práticas eróticas. Cadernos Pagu 2016; (47):e164716. when engaging in erotic practices may be risky because they challenge our Western ideas of self-determination, self-regulation, order, and self-containment or even control of our bodies, while at the same time they may produce a sense of anxiety around the relaxation and loss of control of the boundaries of the body/self ⁵⁹59. Lupton D. The emotional self: a sociocultural exploration. London: SAGE Publications; 1998..

When we stress the tensions of sexual practices with respect to pleasure and risk, even if we consider that, in some situations (barebacking), participants may know in advance that no condom will be used, with consent being an important and triggering element of the practice ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217., there are also fissures that should be acknowledged. Activities may reach a level of “intensity that may not have been foreseen or anticipated”, potentially leading to the breach of the “pact made with the other and with the self” ⁶⁰60. Díaz-Benítez ME. O espetáculo da humilhação, fissuras e limites da sexualidade. Mana 2015; 21:65-90. (p. 4). Just as intention may be “enacted” by gestures and movements, being relational and performative ⁴⁸48. Silva LAV, Iriart JAB. The meanings and practices of barebacking among Brazilian internet users. Sociol Health Illn 2012; 34:651-64., so authorization with regard to another (what you can do or what I want to do) also may be indicated by gestures and body language ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217., and may be unclear in practice, such as when there is a loss of control over the “limits of the interaction” ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217.. As we saw in the first account, crossing limits or boundaries - when the other man seems to appear out of nowhere, penetrating him without a condom, or especially if someone comes inside him - can also elicit ambivalent feelings and emotions, in which pleasure is mixed with worry, anxiety, fear, and guilt.

In a context in which new preventive technologies like PrEP are emerging, it is possible that feelings like these are attenuated or that users feel encouraged to explore other sexual practices, even if they still experience moral conflicts. Such is the case of the second account, given as part of our qualitative research with young MSM and transgender women aged 15 to 19 in the city of Salvador (Brazil), as part of a demonstration project of PrEP use among these key populations in Salvador, Belo Horizonte, and São Paulo (PrEP1519 study).

PrEP1519 is the first cohort study in Latin America of the use of PrEP by MSM and transgender women aged 15 to 19 years. A variety of strategies (peer educators, social media platforms, hook-up apps, word-of-mouth, and a chatbot called Amanda Selfie) were employed to reach out to the target audience, resulting in the enrollment of 383 adolescents and youth for PrEP use and 101 for the non-PrEP-use branch of the program by April 2020 ⁶¹61. Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 pandemic: continuing HIV prevention services for adolescents through telemonitoring, Brazil. AIDS Behav 2020; 24:1994-9.. Between July 2019 and June 2020, the research team carried out 20 semi-structured interviews with adolescent and young MSM taking part in the PrEP1519 program in Salvador, covering topics related to their PrEP experience and the relationship between their PrEP use and the different dimensions of their life: sexual/love and family relationships, work, etc. The interviews were conducted in private rooms at the project headquarters by members of the research group who were specialized in qualitative approaches. Before their interviews, all participants read and signed an informed consent form or an informed assent form (for those under 18 years of age) and consented to having their interviews recorded (audio). The research was approved by the research ethics committees of the World Health Organization (WHO), the Faculty of Medicine of the University of São Paulo, and the Institute of Collective Health of the Federal University of Bahia (n. 3,224,384), and was conducted in compliance with Brazilian legislation (Brazilian National Health Council resolutions n. 466/2021 and n. 510/2016). As highlighted earlier, although this text takes the form of an essay, we have introduced the two scenes produced as part of the PrEP1519 study as a “pragmatic” means of illustrating and supporting our line of argument.

The second account brings up precisely some of these effects produced in the context of a situation in which the interlocutor seeks to justify a certain momentary loss of control with regard to condom use. Alcohol and the presence of a known partner emerge as important actors/actants (not so unpredictable, but not entirely predictable) in this situation, with the power to modify the course of action (condom use). However, PrEP also appears as a key actor/actant in this network of relationships that brings into play and enables the “condomless sex” scenario, coproducing the young man’s feelings in that situation: “I felt OK”. PrEP, therefore, appears here as an actant or differential, another line of protection in a context in which there may not always be a condom at hand. This management of condom use in the context of PrEP emergence does not necessarily mean a rejection of the condom, known for its importance for STI prevention.

Meanwhile, as we can see in the third account from the PrEP1519 study, the introduction of this technology to the young man’s life makes an important difference to the experimentation, contingency, and unpredictability of his sexual encounters: “you know what a busy life I have” and “I get together with all sorts of people and sometimes I don’t even know if the person’s being safe or not”. Thus, PrEP actualizes certain lifestyles, preferences, encounters or ways of experiencing sexuality. As an actant, PrEP also seems to shape or produce new ways of expressing oneself, one’s body, and one’s relationships, enabling more engaged, affirmative postures towards pleasure ⁶²62. O’Rourke S, Hartmann M, Myers L, Lawrence N, Gill K, Morton JF, et al. The PrEP journey: understanding how internal drivers and external circumstances impact the PrEP trajectory of adolescent girls and young women in Cape Town, South Africa. AIDS Behav 2021; 25:2154-65., even if in a sense of controlled permissiveness.

As a new addition to the prevention strategy toolkit, PrEP has raised new questions that extend the limits of the biomedical/pharmacological field. Even if its use is intersected with challenges, such as the need to generate adherence based on the regular ingestion of a pill every day at the right time, plus the possibility of side-effects, PrEP repositions or reconfigures certain “images” of prevention, blurring the boundaries between safe sex and risky/unprotected sex. Insofar as it is not a traditional barrier method (as is the latex of a condom), it enables its users to experience a different level of intimacy without the presence of a physical barrier, but with something new: diminished concerns about HIV. It could therefore enhance the feeling of safety in situations which do not feature condoms, enacting effects of sexual well-being ¹⁷17. Zimmermann HML, Postma LR, Achterbergh RCA, Reyniers T, van der Loeff MFS, Prins M, et al. The impact of pre‐exposure prophylaxis on sexual well‐being among men who have sex with men. Arch Sex Behav 2021; 50:1829-41..

Nevertheless, it should be noted that there are also conflicts or tensions in the daily use of PrEP, especially because it is in interactions and practices, in concrete, lived experiences that PrEP is enacted, takes place, or comes into existence, with the capacity to produce multiple effects as it interacts with other actors/actants. As our field research shows, sexual interactions may sometimes be tinged by doubts, worries, guilt, and fear because of slip-ups in the use of the medication. It is also important to stress that PrEP can be adjusted or reconfigured according to types of partnership, frequency of sexual activity, and patterns of sex/love life and may be suspended in situations where partners jointly weigh up the risk/pleasure ratio, which implies considering the existence of differences around ideas of stability, trust, risk, and even the need to use such a technology. It is also important to remember that this technology enters the real life of young people who have their own particular histories, families, relationships, and experiences. They exist in situations or practices in which different tensions occur, such as between the desire to more freely experience pleasure/sexuality and the ways they position themselves or are positioned in their interaction networks. Therefore, PrEP involves conflicts and ambiguities that actualize polarities, like control and freedom, disciplined and undisciplined body, threat and protection, at the same time that other logics and modes of care shift or come into play.

We cannot forget that taking up PrEP may (re)produce stigmas in relation to its users, resulting in them being labelled as “Truvada whores” ⁶³63. Brisson J. Reflections on the history of bareback sex through ethnography: the works of subjectivity and PrEP. Anthropol Med 2019; 26:345-59.^,6464. Calabrese SK, Underhill JD. How stigma surrounding the use of HIV preexposure prophylaxis undermines prevention and pleasure: a call to destigmatize “Truvada Whores”. Am J Public Health 2015; 105:1960-4. or being seen, often mistakenly, as pathologically promiscuous or inclined to be careless ²⁰20. Dubov A, Galbo Jr. P, Altice FL, Fraenkel L. Stigma and shame experiences by MSM who take PrEP for HIV prevention: a qualitative study. Am J Mens Health 2018; 12:1832-43., presupposing that they no longer use condoms. These are moral conflicts that continue to exist and cause tension in sexual interactions and practices, when gay/homosexual men continue to be regarded as excessive, promiscuous or risk-prone ¹⁸18. Silva LAV, Duarte FM, Lima M. “Eu acho que a química entrou em reprovação”: relações afetivo-sexuais de homens jovens vivendo com HIV/aids e com carga viral indetectável. Sex Salud Soc 2020; (34):25-45.^,2323. Race K. Reluctant objects: sexual pleasure as a problem for HIV biomedical prevention. GLQ 2015; 22:1-31..

As Race ²³23. Race K. Reluctant objects: sexual pleasure as a problem for HIV biomedical prevention. GLQ 2015; 22:1-31. points out, some of the types of “resistance” to PrEP use have to do with concerns about risk. The image of “unbridled homosexuality” seems to cause concern or even fear that, with PrEP, what once seemed like an exception could become the rule, meaning “no-holds-barred” sex between men. We therefore want to draw attention to the fact that besides the risks of other STIs, condomless sex is still present as a moral issue in the everyday lives of gay and other MSM, and may be particularly associated to some deviation, difficulty or health problem, such as low self-esteem, depression or drug abuse ⁶³63. Brisson J. Reflections on the history of bareback sex through ethnography: the works of subjectivity and PrEP. Anthropol Med 2019; 26:345-59.; discourses that end up framing behaviors in pathological and medical terms, failing to consider the complexities of sexual practices and the meanings implied in (condomless) sex ⁴⁵45. Dean T. Unlimited intimacy: reflections on the subcultures of barebacking. Chicago: The University of Chicago Press; 2009..

As such, the pharmaceuticalization of sexual risk ⁶⁵65. Mamo L, Epstein S. The pharmaceuticalization of sexual risk: vaccine development and the new politics of cancer prevention. Soc Sci Med 2014; 101:155-65. enabled by PrEP also implies multiple processes. In the case of HIV/AIDS, PrEP would appear to have the effect of “liberalizing” “safe” sexual pleasure and practices, which might be expected to weaken the stigma operated by the notion of risk behaviors associated with a particular group. However, we have seen that “old” and “new” signs are triggered as they are recommended and used, even tending to reinforce stigmas. But mostly what we have seen is that this “liberalization” of pleasure is counterbalanced by a domestication of sex/sexuality represented by PrEP as a sign of “controlled permissiveness”.

Concluding remarks

In this article, we have attempted to problematize the tensions that exist between risk and pleasure in sexual practices, especially between men, thinking of the changes and conflicts/ambiguities that still exist in the current-day context of new prevention technologies. By highlighting a set of sexual practices deemed high-risk and recognizing that realities (ontologies) are multiple, open, and political insofar as they are enacted in practice ⁶⁶66. Mol A. Ontological politics. A word and some questions. In: Law J, Hassard J, editors. Actor network theory and after. Oxford: Blackwell; 1999. p. 74-89., we have proposed thinking of HIV/STI prevention from the perspective of the logic of care ²⁵25. Mol A. The logic of care: health and the problem of patient choice. London/New York: Routledge; 2008., and thus, as a process that is not linear, but dynamic, open, fluid, and erratic with multiple interactions and effects.

The need to protect oneself by using the available technologies goes hand in hand with the tension inherent to having a body that is open, unstable and, to some extent, unpredictable, prompting us to find ways to be “kind” to our bodies and their desires, allowing them to exist and be appreciated. While we may attempt to improve our lives, the ideas of good (living) or (caring) are not static or given, either; what could be “good” or self-evident in one situation may not be in another, insofar as situated practices are involved ⁴¹41. Spink MJP. Clientes, cidadãos, pacientes: reflexões sobre as múltiplas lógicas de cuidado na atenção à saúde. Saúde Soc 2015; 24 Suppl 1:115-23.^,6767. Mol A. The body multiple: ontology in medical practice. Durhan: Duke University Press; 2002.. And that means engaging in endless trials and experimentations.

One point worth stressing here is the “limit” imposed by our own body, always in relation to other bodies. Certainly, human corporality is never experienced “raw”, but is always culturally mediated. Meanwhile, the body (materiality) is also recalcitrant - disobedient, rebellious, resistant, and uncontainable, with a frightening “will of its own” ⁶⁸68. Williams SJ, Bendelow GA. ‘Recalcitrant bodies’? Children, cancer and the transgression of corporeal boundaries. Health 2000; 4:51-71.. Similarly, we may think of the body as a “complex configuration” ⁶⁹69. Mol A, Law J. Embodied action, enacted bodies: the example of hypoglycaemia. Body Soc 2004; 10:43-62., “semi-permeable”, full of tensions that cannot be avoided, but with which we must deal, such as when we are faced with the “limitations” of a disease or the “need” for prevention, not to mention our own desires.

In our attempt to articulate the dimensions of risk, pleasure, and care in the context of new biotechnologies, we remember that there are many ways of doing or enacting prevention/care. Meanwhile, these new technologies interact with other actors/actants - both human and non-human ²⁶26. Latour B. Reagregando o social: uma introdução à teoria do ator-rede. Salvador: EDUFBA/Bauru: EDUSC; 2012. - yielding multiple effects and transformations. In these new scenarios of co-produced subjects, technologies, and other entities, including the sex “event” itself ²³23. Race K. Reluctant objects: sexual pleasure as a problem for HIV biomedical prevention. GLQ 2015; 22:1-31., neither subjects nor technologies are the same. In sexual encounters, irrespective of intentionality and prior, condoms may enter or exit the scene (as may PrEP itself, given its different modalities, interests, and modes of use), insofar as there are many ways of managing or reducing risk ¹³13. Barreto VHS. Responsabilidade, consentimento e cuidado. Ética e moral nos limites da sexualidade. Sex Salud Soc 2020; (35):194-217.^,3939. Terto Jr. V. Diferentes prevenções geram diferentes escolhas? Reflexões para a prevenção de HIV/AIDS em homens que fazem sexo com homens e outras populações vulneráveis. Rev Bras Epidemiol 2015; 18 Suppl 1:156-68.^,4040. Silva LAV. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafios. Psicol Soc 2012; 24:327-36.^,5353. Barreto VHS. Risco, prazer e cuidado: técnicas de si nos limites da sexualidade. Avá - Revista de Antropologia 2017; 31:119-42.. Ultimately, in concrete, lived situations, things happen that were unplanned or unforeseen, mediated by a “swarm” of actors/actants ²⁶26. Latour B. Reagregando o social: uma introdução à teoria do ator-rede. Salvador: EDUFBA/Bauru: EDUSC; 2012. that come in our direction, prompting us to respond or constitute ourselves via these interactions.

It is, therefore, important for us to consider, expand on, and make the different potential resources (material, symbolic, and political) available in the world of disease prevention and health care, and also to problematize and act via people’s actual living conditions. We must also consider the vulnerabilities unequally experienced by different people and groups, and the many barriers that prevent the equitable negotiation of safer sex, the experience of one’s own desires, and access to prevention technologies. The type of vulnerability that brings to mind the bodies or lives of apparently lesser value. As Butler ⁷⁰70. Butler J. Relatar a si mesmo: crítica da violência ética. Belo Horizonte: Autêntica Editora; 2015. (p. 40) asks, “Who counts as a human? Whose lives count as lives?”. That means forming cooperation networks between collectives (of professionals, scientists, activists, and a host of other actors) to enable possible existences. Ultimately, it means recognizing the limits that are imposed in daily interactivity, specifically in the field of HIV/AIDS prevention and care, which also emerge as dynamic, unstable, open (and complex), with their own peculiarities, viscosities, and processes of experimentation.

Acknowledgments

We thank all the professionals, participants, and coordinators of the PrEP1519 study who made this essay possible.

References

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