The Resonance Project

Project summary: Key Findings and Conclusions 

What we heard from gay men and their service providers about:


The prevention landscape is changing, and gay men have been leading the way

There have been rapid advancements in the science of HIV prevention over the last 10 years. One of the biggest factors that will impact Canada’s HIV epidemic over the coming decade will be the extent to which biomedical knowledge of HIV risk, transmission and prevention is integrated into our programs and services, and into individual behaviours.

In the Resonance Project, we wanted to know more about how gay men and other men who have sex with men, and their service providers, understand, perceive and integrate these new prevention approaches. The focus was on gay men because they are the group that accounts for the largest proportion of new HIV infections in Canada, and the largest group of people living with HIV. Also, gay men tend to be early adopters of new information, new technologies, and new trends, and thus they have been among the first to take on new approaches to HIV prevention.

What did we want to find out?

The Resonance Project: Emerging Biomedical Discourses and Decisions within Gay Men’s Knowledge Networks is a community- based research project led by researchers and representatives from four national HIV organizations and three gay men’s health organizations. The Resonance team set out to critically examine:

  • how gay men are taking up biomedical knowledge of HIV;
  • how biomedical knowledge of HIV impacts or influences their everyday lives;
  • the dialogue gay men and their service providers use to make sense of risk, and inform sexual decision-making and practices;
  • the roles and responsibilities of institutions and service providers to shape and respond to these discourses.

Who did we talk to?

We conducted five types of focus groups with 86 participants in Vancouver, Toronto and Montreal, including:

  1. gay men connected to HIV organizations;
  2. gay men in serodiscordant relationships (where one partner is HIV positive and the other is HIV negative);
  3. sexually-active HIV-positive gay men;
  4. HIV-negative gay men at ‘high risk’ for HIV; and,
  5. service providers who provide sexual health, counselling and HIV prevention services to gay men.

We also conducted individual interviews with four gay men, eight nurses and physicians working in a clinic or public health setting, and eight service providers who identify as gay men.

Summary of Key Findings

In what ways do gay men – individually and as communities – make sense of, incorporate into their understanding, and modify their behaviours based on, biomedical knowledge of HIV?

Gay men discussed a wide variety of biomedical aspects of HIV risk and prevention, but here we highlight what they said about pre- exposure prophylaxis (PrEP) and undetectable viral load (UVL).

  • PrEP awareness and concerns. Some men had never heard of PrEP, while others were already using it. Being HIV-positive, knowingly interacting with positive men, or being connected to HIV organizations seemed to increase knowledge and confidence levels in PrEP. HIV-negative participants without these connections tended to have lower levels of knowledge and confidence than others. Concerns included the cost of PrEP in the absence of health insurance coverage, PrEP not being preventive against sexually transmitted infections other than HIV, potential side effects, and the ethics of providing antiretroviral drugs to people who are HIV-negative.
  • PrEP users are responsible/sluts. Judgments about PrEP users were rooted in how the men experienced the HIV crisis, and their experiences around ARVs and condoms. They debated whether PrEP users were sluts, responsible men, or both at the same time—responsible sluts. Some of the participants who were HIV positive could, in retrospect, see how PrEP would have been beneficial in their own situations.
  • Calculating risk with PrEP. For some gay men—both positive and negative—PrEP provided sufficient reassurance to have condomless sex, while others remained committed to condom use regardless of PrEP’s effectiveness. The participants also wondered: Are men on PrEP safer sexual partners than others? Can I trust that a sexual partner is really on PrEP?
  • PrEP and the sex gay men desire. For some participants, PrEP provided a false sense of security in the pursuit of condomless sex, and was helping to precipitate it. For others, PrEP was introduced into a context where gay men were already pursuing the type of sex they desire (by which they meant condomless sex), allowing them to do so with lowered risk of HIV. Especially for men who found condoms an impediment to sexual satisfaction, PrEP promised enhanced sexual pleasure.
  • Undetectable viral load awareness and concerns. As with PrEP, levels of awareness and confidence were highest among those who were living with HIV, knowingly interacting with positive men, or connected to HIV organizations. They noted that UVL was an exciting new concept for HIV prevention, but all members of the gay community did not understand what that meant in the same way.
  • Undetectability and risk calculation. For some gay men, an UVL provided sufficient reassurance to have condomless sex, while for others it did not. Many gay men emphasized that while it might lower the risk, some risk remains. And some gay men wondered: Can I know that a sexual partner really is undetectable?
  • Undetectable as “the new negative”. Many HIV-positive men talked about the idea of undetectability as an identity (as opposed to ‘poz’ or ‘positive’), signifying that they were healthy and posed a lower risk of transmission. They felt this helped reduce stigma. But participants questioned the impact of identifying as undetectable when the concept was not well understood in the community.

Gay men in our focus groups revealed the many ways that they were grappling with new and evolving HIV prevention information:

  • Frustration with, distrust and sometimes avoidance of, inconsistent information. Many gay men noted the inconsistency of information around HIV prevention in the public domain (e.g., social media, mainstream media, HIV organizations’ messages, gay media, public health messages, hook-up apps or websites). Some described the information as overwhelming, sensationalist, inaccessible, and/or contradictory. As a result, some gay men felt that they might as well just wait for the confusion around new biomedical prevention options to pass, and actively avoided any new information on HIV prevention as they found it unhelpful. Several gay men expressed considerable distrust of the pharmaceutical industry and of the biomedical research establishment, often linked to profit motives. Trusted sources were healthcare professionals or people working in the HIV field.
  • Feeling like information was withheld. Some gay men expressed frustration at the lack of evolution in HIV prevention messages, with its persistent emphasis on condom use. They acknowledged that messages around condom use were simpler, but felt that information about risk reduction strategies other than condoms was being withheld from them, considered taboo, or forbidden by public health.
  • Synthesizing a personal strategy. Even when facing a vast and complex array of information sources and opinions, many gay men described making their own autonomous decisions after reviewing information that they could understand and deemed credible. Some of the gay men stated that they refused to pay attention to new information, relying instead on what they already knew.

For gay men, questions around trust and responsibility were important factors in calculating risk, in addition to the biomedical information that they had to consider:

  • Trust and deception. Gay men discussed whether or not they could trust other gay men around sexual encounters, particularly in regards to claims about serostatus (especially HIV-negative or undetectable), testing frequency and test results, use of condoms, use of PrEP, and being monogamous. They also wondered whether some gay men deliberately lied or sought to deceive, particularly in the online dating scene.
  • Responsibility and good citizenship. Gay men discussed the burden placed on the gay community for HIV prevention, and how biomedical strategies both entrench and change norms around risk reduction. They described what they thought constituted responsible and irresponsible behaviours for “good gay citizens”, and discussed the tension between the idea of shared responsibility for prevention and that everyone should look after their own health.

How are community-based organizations and service providers succeeding and struggling in integrating new biomedical knowledge of HIV within their existing HIV prevention efforts?

Not surprisingly, service providers identified several challenges in managing new HIV prevention information:

  • Staying on top of it all. Finding the time to read, interpret and distil research findings, and translate them into simple lay terms in ways that clients understand was a challenge. Some service providers noted the high expectation from clients and colleagues to have ‘all the answers’ despite their own knowledge limitations.
  • Consensus versus multiple interpretations. Service providers expressed a contradiction in their risk counselling: on  one hand wanting to have consensus and to be able to provide a definitive statement about a particular biomedical intervention, while on the other hand wanting to be able to provide a variety of viewpoints and interpretations of the science. The lack of consensus led to conflicting interpretations, messages and advice between service providers and organizations.
  • Erring on the side of caution. Some service providers tended to give the most conservative messages possible, such as condom use only, but also acknowledged that being overly simplistic, overly complex or too conservative in HIV prevention messages could frustrate or alienate clients who knew of risk reduction options other than condoms.
  • Heterogeneity of the gay community. Service providers noted the wide range of awareness and openness to new prevention strategies in the gay community. Some gay men were perceived as having very basic knowledge and not being ready for, or open to, the complexities of biomedical aspects of HIV prevention. At the other end of the spectrum, service providers said they encountered gay men with sophisticated knowledge of HIV prevention, challenging service providers to keep up with the community.
  • The service provision context. The risk reduction messages that service providers gave to their clients depended on the setting, duration and frequency of their contact with gay men. If they only saw a client in a brief one-time encounter such as in a bathhouse, or only had a brief exchange through online outreach on a cruising app, then some service providers erred on the side of caution in their risk reduction message, whereas if they were able to have repeated contact with a client over time, the messages could be more nuanced.
  • Correcting partial information. Service providers found it challenging to help gay men correct and make sense of brief and often sensationalized snippets of information. Some service providers had the impression that gay men approached them to confirm information gleaned from sources such as news headlines, awareness campaigns or social media posts.
  • Finding the right fit. Service providers discussed the scientific complexity of the multiple prevention options now available, the resulting complexity of prevention messages, their concerns with keeping up with the science, and the underlying value systems that often guided prevention messaging. They discussed the challenge of identifying who would benefit most from diff prevention options.
  • Avoiding paternalism. While some clients wanted clear directives, others resisted paternalistic messages and didn’t want to be told what to do. Some service providers avoided overwhelming clients with too much information. Other service providers pointed out that many gay men had been adopting different non-condom strategies for a long time, sometimes in reaction to conventional prevention messaging.
  • Acknowledging the role of (dis)trust. Service providers acknowledged the challenges gay men face when trying to decide whether or not they should trust other gay men, particularly what they said around sexual encounters (e.g., claims of a negative or undetectable serostatus, testing frequency and test results, use of condoms, use of PrEP, being monogamous). As a result, some of the service providers said that they often actively encouraged their clients to be distrustful.

What are the implications for service providers?

Service providers described the many roles that they played and strategies they used in helping gay men navigate new HIV prevention information:

  • Equip clients to assess their own risk tolerance. An important part of service providers’ risk counselling process is helping the client decide what level of risk they are comfortable with, as well as helping them think through risk reduction or management strategies. A key role played by service providers was equipping a client with enough information to make a judgment call for himself, balancing what he knows about HIV risk, transmission and prevention, with what he desires and values.
  • Help gay men navigate information. Community discourse is building around the role of biomedical information as an integral part of a comprehensive approach to HIV prevention, sometimes without adequate input or guidance from service providers. These are the very service providers who are most trusted when it comes to HIV prevention information. An important role for service providers is to communicate in clear, sex-positive and user-friendly ways the key messages of what we now know works for HIV risk reduction.
  • Support and nurture leaders in the gay community. Some gay men are acting as peer educators, albeit sometimes reluctantly. In general, we found that gay men who had connections to the HIV sector, who were in serodiscordant relationships, and/or were living with HIV, were the most knowledgeable about PrEP and undetectable viral load. PrEP users and gay men who have an UVL are often acting as key opinion leaders, shifting the conversations, one hook-up profile or chat conversation at a time. As service providers, we can support key opinion leaders and (sometimes reluctant) peer educators by getting easily accessible information into the very (virtual or physical) venues in which gay men are meeting and interacting.
  • Don’t forget about the bigger picture. Too often, prevention approaches such as PrEP and undetectability are framed as stand- alone biomedical tools without recognizing their broader influences and impacts. Biomedical prevention strategies such as PrEP and undetectable viral load are having some important benefits in terms of reducing HIV-related fear and stigma, breaking down serodivides (the divisions between people who are HIV-negative and HIV-positive), allowing gay men and serodiscordant couples to have the kind of sex they desire, and generating renewed conversations around HIV prevention in gay communities.
  • Start where he’s at. Whether an individual chooses to rely on one or more prevention strategies will depend on not only his understanding, but also his preferred sexual practices, his relationship with his sexual partners, his values around what it means to be a responsible person, and the extent to which he feels he can trust his sexual partners. For service providers, an important part of risk counselling and prevention education is to quickly gauge the knowledge levels, values, and types of sexual relationships of their clients, and customize the messages accordingly.
  • Ground HIV prevention in the lived realities of gay men. In all risk counselling interactions with gay men, focus on situations, relationships, and encounters that gay men are likely to experience in their lives and in their community. In our focus groups, we used mock hook-up and dating profiles, and dating and relationship scenarios to trigger discussions about biomedical approaches to prevention.

Our Overall Reflections

Gay men and their service providers are at the forefront of adopting new biomedical HIV prevention knowledge that expanded the range of available prevention tools beyond condoms. In the Resonance Project, we observed a wide range of responses to the emergence of new biomedical knowledge and tools.

Resonance among gay men

Among gay men levels of awareness about PrEP and undetectable viral load, and levels of confidence in their efficacy for reducing HIV risk, varied greatly. The ways in which gay men made sense of and took up biomedical concepts of HIV prevention depended greatly on contextual factors, including:

  • their HIV status;
  • their generational and personal experience of the HIV epidemic;
  • their experience with condoms as a long-established prevention option;
  • their geographical location and the types of information and attitudes circulating within their social networks;
  • their relationship with, and levels of trust in, their sexual partners;
  • where and how they met their sexual partners;
  • their self-efficacy and the degree to which they actively sought out new information;
  • their sense of what constituted responsible behaviours for “good gay citizens”; and,
  • their level of trust in biomedical research, “big pharma”, media, community-based HIV/AIDS organizations, and healthcare professionals.

Resonance among service providers

We saw that service providers brought their own personal perceptions, knowledge and attitudes towards biomedical prevention technologies. Their own value systems were very evident throughout the focus groups and interviews, and it was easy to recognize the ways in which their interpretations and perceptions shaped the information they provided to gay community members. Not surprisingly, sharing information about biomedical approaches to prevention did not happen in a vacuum. For service providers, it was not a straightforward transmission of facts, but rather a constantly shifting exchange between individuals, institutions, cultures, and structures, all of which was affected by a range of factors, including:

  • social and legal contextual factors of stigma and criminalization, and the desire of service providers to mitigate their impact in the community;
  • socioeconomic considerations of access and affordability;
  • alliance with or contradiction to conventional condom use messages;
  • where interventions took place and for how long;
  • assessments of individual and community levels of knowledge, values and anxiety around HIV and biomedical prevention options;
  • the degree to which formal guidance was in place and consensus existed among peers working in HIV prevention and gay men’s health; and,
  • the level of organizational support for the integration of new and emerging biomedical HIV prevention information.

Resonance among gay service providers

Service providers who were themselves gay men recognized the growing dissonance between the conventional HIV prevention messages they conveyed to clients through their work and the newer biomedical HIV prevention information they incorporated in their own personal decision-making. In a context where the ground was shifting and in the absence of consensus or formal guidance, gay service providers were some of the earliest and most visible adopters of new HIV prevention information.

Resonance in the HIV prevention field

The Resonance Project has shown us the many complex ways  in which biomedical approaches to prevention were introduced and incorporated into gay men’s lives. Biomedical concepts and tools – such as PrEP and undetectable viral load – exist within a social, political, economic and cultural context. These biomedical approaches are laid on top of dynamics that already have a lot of influence on the HIV response: health systems; community understandings of safe sex; HIV stigma, homophobia and moralism about sexual behaviour; and health literacy disparities.

In the time since the data was collected for the Resonance Project, the science has become more definitive (regarding the preventive efficacy of PrEP, for example), and the consensus in the sector is stronger, making it easier for service providers to be clear in our messaging. These data capture a transitional time when the science was changing and a consensus had not yet developed within the sector about what can be confidently said about the new prevention strategies.

We hope that the outcomes of this research project will help HIV prevention stakeholders to identify how they could be integrating recent and emerging biomedical knowledge of HIV into current prevention programs and policies in Canada in ways that are best supported by,  and supportive of, communities of people most at risk for HIV. By focusing on gay men as early adopters of biomedical information, we have gained an understanding about knowledge exchange and uptake, and the effect of biomedical information on sexual practices and understandings of risk. Hopefully, this understanding can also provide guidance for effective prevention messages and program planning with other vulnerable populations in the Canadian context.

Patten S, LeBlanc MA, Jackson E, Adam B (2016). The Resonance Project Community Report: Emerging biomedical discourses on HIV among gay men and their service providers.