(Laugh)

Q: And PrEP. (Laugh) R: 253 out of 300! (HIV-negative MSM) Although the participant in this extract was joking about adding up the numbers, the interpretation of efficacy rates in relation to other prevention options posed a potential source of confusion or misinformation for participants. Managing adherence Given the evidence concerning the enzyme inhibitor patterning of efficacy by adherence,2 maintaining regular adherence to medication was identified as a potential barrier to effective PrEP use. Some participants described how they might forget to take tablets or their routine might be disrupted because of non-regular working patterns, and were therefore concerned about how effective PrEP would be if they did not take the drugs regularly: “Sometimes I forget. Because I don’t have a regular sleeping pattern, so sometimes I’ll fall asleep at four in the afternoon and I usually take my pills [for an existing health condition] after dinner” (HIV-negative MSM). Establishing and maintaining a routine to take PrEP was also affected by the perception of social stigma attached

to HIV medication. This meant maintaining daily adherence would be difficult if there was limited privacy (eg, the presence of roommates) or if there was a change in environment. One participant reported concerns about his family potentially finding the tablets: If I was on those medications for a year and if I went home…or anything like that I’d find it very difficult to be able to take my medications or I would find it a bit of a barrier that if my family knew about it they’d investigate why are you on these pills. And again that would probably put some doubt in their head and then they’d probably then think the worst—that I was

HIV positive. (HIV-negative MSM) In addition to being unable to establish or maintain a regular routine to facilitate good adherence, most participants expressed concerns about the physical effects of the drugs themselves, and how the side-effects might inhibit taking them. Some participants described disliking taking tablets and that this would be a barrier to daily PrEP use: “I don’t really like pills so I don’t think I would take any pills every day” (HIV-negative African man). Many viewed the potential for side-effects, such as nausea and diarrhoea, as too great a trade-off for increased HIV prevention, in spite of being informed that trials Carfilzomib had reported high tolerance of the drugs: But, could I put up wi’ side-effects all the time as well, like taking a pill, and going tae a nightclub, and ended up wi’ diarrhoea? You know, you’ve gotta think of things like that, am I [going to] take this? Am I [going to] stand tired, have a headache in a club just at the fact that I might at the end of it get a shag…(HIV-negative MSM) Other participants felt the side-effects would interfere with sexual practice itself: “Nausea, an’ diarrhoea an’—you’ll be shittin’ all over his [penis].