Clinical exigencies, psychosocial realities: negotiating HIV pre‐exposure prophylaxis beyond the cascade among gay, bisexual and other men who have sex with men in Canada

Notwithstanding the efficacy of oral pre‐exposure prophylaxis (Pr EP ) in clinical trials, a number of obstacles exist to achieving population‐level impact among gay, bisexual and other men who have sex with men ( GBM ). However, few studies have explored the subjective experiences of GBM Pr EP users and non‐users in the community, outside of clinical trials. The objectives of this study were to explore GBM 's experiences of considering, accessing and using (or not using) Pr EP , and to understand emerging sexual health, social and community issues among GBM in the Pr EP era. Methods From October 2015 to March 2016, we purposively sampled Pr EP ‐naïve and Pr EP ‐experienced GBM from community organizations and health centres in Toronto, Canada. In‐depth, 45‐ to 90‐minute semi‐structured interviews explored Pr EP perspectives and decision‐making, access, initiation, use over time, sexual practices and psychosocial considerations. Interviews were recorded, transcribed verbatim, uploaded into NVIVO , reviewed using thematic analysis and then contrasted with the Pr EP cascade. Results Participants included Pr EP users (n = 15) and non‐users (n = 14) (mean age = 36.7 years; SD  = 8.2), largely gay‐identified (86.2%), cisgender male (89.7%) and white (79.3%). Themes indicate not only correspondences, but also limitations of the Pr EP cascade by complicating a user/non‐user binary and challenging the unilateral presupposition that HIV risk perception leads to Pr EP acceptance. Findings further call into question assumptions of a linear stage progression and retention in care as a universal endpoint, instead revealing alternate trajectories of seasonal or intermittent Pr EP use and, for some, an end goal of terminating Pr EP . GBM 's narratives also revealed potent psychological/affective experiences of untethering sex from HIV anxiety; multifaceted Pr EP stigma; and challenges to sexual norms and practices that complicate existing behavioural prevention strategies and sexual and social relationships. Conclusions An expanded Pr EP cascade should consider alternate trajectories of use based on dynamic relationships and behavioural risks that may call for seasonal or intermittent use; systemic barriers in access to and sustaining Pr EP ; and multiple end goals including Pr EP maintenance and discontinuation. Incorporating GBM 's lived experiences, evolving preferences, and psychosocial and community‐level challenges into Pr EP implementation models, rather than a circumscribed biomedical approach, may more effectively support HIV prevention and GBM 's broader sexual and psychological health.