Othering discourse and stigma amidst the identity formation process among gays, bisexuals and other men who have sex with men on HIV pre-exposure prophylaxis (PrEP).

With the global emergence of the HIV pre-exposure prophylaxis (PrEP), questions have emerged on which ways the social identity formation process among gays, bisexuals and other men who have sex with men on PrEP arise and constitute beyond exclusive sexual orientation expressions. We conducted a content analysis with thematic categories in a PrEP online group guided by group-web affiliation and individualization approaches. Individuals identify themselves as PrEPsters as part of a PrEP club, while dealing with conflicts on serosorting sexual partners and stigmatizing reactions towards people living with HIV/AIDS (PLWH). Self-worth and othering discourses towards PLWH emerged as complex themes in men’s production of identity processes across four overlapping domains: (1) self-worth as a strategy to challenge individual HIV-acqui-sition-related anxiety and fear, (2) group-worth and group empowerment, (3) body control and reclaiming power on sexual health, and (4) othering discourses, HIV/AIDS stigma and criminalization of PLWH. Paradoxically, internal and external discourses to the group constitute and challenge identity differentiation; individuals on PrEP claim to fight against the HIV/AIDS stigma, while this reverberates alongst HIV-related dis-criminatory expressions in their discourses.


Introduction
The United States continues to see growing rates of HIV transmission, with a persistently disproportionate burden of new infections among gay, bisexual, and other men who have sex with men (gbMSM) 1 . To better address the HIV epidemic among gbMSM, there has been increasing use of the HIV pre-exposure prophylaxis (PrEP) as part of a biomedical approach to reduce transmission 1 . PrEP consists of an oral-daily combination of antiretroviral medications that prevents HIV infection. Clinical trials have demonstrated efficacy above 99% for preventing HIV among gbMSM when adherence is 4-7 doses of daily PrEP each week 2,3 .
Scholarly works have increasingly documented the identity formation process (IFP) among gbMSM in the ongoing biomedical prevention landscape. Studies have revealed unequal forms of biomedical self-governance towards people living with HIV/AIDS (PLWH) 4,5 , whose bodies were seen as risky, accompanied by the responsibility to manage it 4 . Additionally, biosocialites among PLWH and those on PrEP point to conflicting views on the use of antiretrovirals for HIV prevention 5,6 . Particularly, negotiations of biosocial identities were linked to HIV serostatuses and managing treatment 7 , revealing perceived PrEP-related stigma 4,8-10 as well as perceptions that PrEP leads to reduced condom use and greater sexual risk behaviour 11,12 . These processes have informed understandings of emerging shifts on sexual practices, with great extension of biopower surveillance 13 , while dismantling previous conceptualizations and practices of bareback sex toward new intimacy codes 14 . Upon this debate, there is a prevalence of the interplay between technoscience, knowledge and sexuality [15][16][17] informing individuals' experiences upon negotiating HIV prevention strategies and sociabilities 4,5,7,18 .
As HIV/AIDS-related stigma and discrimination continue to thrive cross-cultural populations in the HIV chemoprophylaxis era 8,19,20 , these socio-structural problems invariably influence biological IFP. These situations are often articulated through othering discourses, commonly defined as the process in which powerful groups relegate often marginalized/stigmatized subordinate ones into a reductionist way, ascribing problematic and/or stigmatizing characteristics to these subordinate groups 21,22 . An study-sample of gbMSM overwhelmingly expressed reluctance to date or to have sex with PLWH, regularly describing them as sick 19 ; participants perceived PrEP to be offered to others in need, as they did not see themselves at risk for HIV 19 . Othering discourses are linked to negative health outcomes, lower rates of HIV status disclosure, and expression of high-risk behavior among PLWH 19,23 .
However, key relational and social domains about IFP on PrEP have been undiscussed in the literature: (1) while PrEP has been linked to more direct communication about HIV among sexual partners 24 and reduced stigma against HIV-positive partners 25 , it is unknown in which ways individuals on PrEP may contradict and/or benefit from these claims as part of their ongoing IFP; (2) while previous research had clearly identified othering processes linked to HIV/AIDS stigma and to a great self-worth expression of gbMSM who are not on PrEP 19 , there has remained a lack of knowledge on which ways gbMSM on PrEP may articulate stigmatizing othering discourses to differentiate their own biosocial identities; (3) the role HIV/AIDS stigma (and criminalization) of PLWH play on IFP through othering processes among concomitant biosocialities experiences are undiscussed; importantly, (4) studies have not yet explored the consequences of structural individualization, as a societal process rather than granted perceptions of individual choice/ individualism/altruism, on this highly differentiated HIV-prevention landscape.
We here seek to identify and to understand in which ways othering discourses link to identity formation processes of individuals on PrEP in the context of the ongoing biomedical prevention landscape. We present new evidences that point to highly differentiated scenarios of biosocial identities, while we explore the central role of individualization in this process. Social individualization refers to an ever-increasing socialization process in the risk society in which the individual action is the core of contemporary contradictions among individuals, institutions and technological fabrications of post-industrial societies 26,27 . Within this theoretical landmark, we had analysed othering processes and their connections to IFP as discursive processes 22 . We further advanced on discussing how individuals on PrEP produce social differentiation and recognition 28,29 amidst social attachments 30 linked to major societal IFP in contemporary North-Western societies.

Risk society and social individualization: entangling the identity formation process
Risk society refers to a phase of the modernization process in which post-industrial societies radically confronts its successes and setbacks in the historical sense, producing more risks, uncertainty and new social forms 26 . In this new social order, risks structure the material and social contradictions of late modernization processes mainly due to the increasingly scientific knowledge production amid uncertain challenges in contemporary society. This process overwhelmingly leads individuals to make decisions based on risk calculations and, very often, make them confused and without much direction.
The risk society produces at its core the societal individualization process 26,27 . This means that individuals become the core of social contradictions like-an-spiral into the structural domains of society -having to confront themselves with modern social institutions and all of their consequences and risks. While the distribution of risks differentiates societies themselves broadly, the individual is in charge of constructing their own (auto)biographical paths like never before. This sets ambiguity as a major societal contingent; while making decisions of their own, individuals deal with their consequences as they too produce more risks and uncertainties as products of their social action 27 .
Finally, as the individualization process also structures society, its consequences on IFP is immanent and overspread 27 . As individuals seek more solutions or recognition for their livesor to which they stand for -this is precisely the relational arena of choices, discourses and risks, particularly in health interventions like the use of PrEP. Within this biomedical landscape, issues like alterity, which is the capacity individuals have to make choices of their own and deal with the overseeing consequences 22 , is even more in charge amid the lenses of the other discourses and the risks as part of their lives. In this sense, discourses are understood as socio-political production that also orients and constitute relational IFP 21,22 .
Within this analytical framework, the othering processes and their connections to IFP are entangled in risk society and the individualization process. In this study, the interplay between IFP -as a relational and discursive process -, risk and individualization is theoretically beneficial to understand the ongoing IFP in the HIV prevention biomedical landscape.

methods
This study is part of a large sociological and public health interdisciplinary study that analyzed contemporary social change and individualization processes in public health. Based on the method of content analysis with thematic categories 31,32 , this study analyzed data collected from interactions of individuals on PrEP and their interlocutors in a Facebook® discussion group on PrEP and HIV/AIDS, which has thousands of members, predominantly gbMSM from the US. The group aims to discuss PrEP facts free from judgments on members' experiences and sexualities. Members seek sharing experiences, reflecting on them, and being on the forefront of social advocacy in the HIV/AIDS epidemic. There is no recruitment for the group members, nor any funding backing their activities. This group was selected due to high and diverse number of members, and more importantly, intense posting and interacting between members on daily basis.
This study benefited from observational and community studies practices 33 , as one of the authors is also an HIV/AIDS activist and long member of the group. Although there were no direct interaction with profiles in the scope of this study, nor any researcher's interference upon the analyzed posts, we see that a public discussion on these issues is one of the commitments of critical thought that the group shares as a principle, which had been well accepted as a group practice throughout the years.
We have followed all local ethical guidelines regarding proceedings with non-human interaction under observational social-media research (OSR). Following international ethical principles -aligned with local guidelines on conducting research on social science and health-related areas 34 -, we ensured highly consolidated practices on OSR [35][36][37] , particularly regarding contextual integrity of the group 38 in order to build up our research protocol upon questions of consent, privacy and managing sensitive information; as such, group and profiles' names were removed as any other information that might identify any of the members of the group, including all moderators under Facebook-site best OSR ethics orientation on privacy [35][36][37] . By acknowledging legal and contextual integrity of privacy 35 , we have followed all recommendations to securely protect and destroy the original reports in our archives, extending measures to protect identifiable content shared in all phases of the writing and publishing processes; due to the level of sensitive in-formation shared within this group 36 , all profiles' direct quotes were edited and summarized within all thematic categories to prevent any remote chances of members' identification under special conditions through site and engine searches 36,37 . Our institutional Ethical Board can be reached regarding further queries about all the ethical measures we adopted in this study.

Data analysis
The follow-up period for members' posts occurred within a three-month period in 2017, including a preparatory one-month pilot phase. Data from the pilot phase were used as final data, since there were no significant changes in the data collection procedures, or in the previously established data collection script. We focused on the discussions content rather than on individual social location/status, checking in which ways individuals presented their personal issues, particularly their routines, conflicts, and successes on PrEP. Sociological theory upon conflict and the web of group-affiliation 28 and on the social individualization process 26,27 were utilized to ground the original methods in an online group and all data analysis proceedings. Further details are available at Silva-Brandao 39 and briefly schematized in Figure 1.

Results
We identified four overlapping themes across individuals' discourses on PrEP referring to selfworth as a strategy to defy HIV-acquisition-related anxiety and fear, group-worth amidst their social expression and group empowerment, body control and power-dynamics on sexual health and othering discourses linked to stigma and criminalization of PLWH.

self-worth: defying anxiety and fear
Individuals revealed anxiety traits while questioning themselves whether they would be HIV-positive being off PrEP. For many years, though, the question was not whether or not one would seroconvert, but rather the resigned curiosity of "when" the inevitable seroconversion would come. One contributor stated that before every test he was convinced he had seroconverted. As such, PrEP is viewed as a turning point to a better sexual life as individuals start to truly have the "best sex" of their lives.
To the same extent, they justify and encourage others to be on PrEP; the reduction or loss of anxiety and fear of acquiring HIV takes time and occurs differently for each individual. For some, it took a few months to embrace the freedom of no fear, while others believe that being "PrEPsters" has to do with having "faith" in it, implying that it will take longer to feel at ease. Contributors also show how much they have learnt to let go of the fear/anxiety that one may have hammered into oneself through years of scare HIV/ AIDS campaigns. There is an idea that being on PrEP is like the sexual liberalization of the 1970's again, where one can play with others at almost anytime, anywhere and enjoy the excitement of the spontaneity and adventure being shared with others. It is, for one of them, a "miracle really".

shared worth: social expression and empowerment
Individuals found these shifts on sexuality "revolutionary" and felt "empowered" both as individuals and as a group by being on PrEP. As one contributor said, losing the "PrEP virginity" feels really good and empowering. Freedom and liberation are also associated with being PrEP empowered. In this sense, being on PrEP has not only freed them from fear and shame, it has opened up a new world of intimacy and sexual self-expression that one had only hoped would be possible.
Empowerment is often linked to a common understanding of a group, community or movement of PrEP users. To some of the PrEP users, it feels great to take action and stand against the HIV crisis as they advocate for the "PrEP movement", calling all the guys to protect themselves and others. Interestingly, one said he was proud to be HIV negative, and a proud user of Truvada. Many contributors are keen to use the word "club" to refer to their sociability and, for most of them, it has been a wonderful and life changing experience. Being on PrEP and embracing it is seen as an ongoing process and the emotional benefits were somehow unexpected for some of them.

"It's about taking control"
Empowerment is conceived as a retaining power process to oneself, which freed up individuals from fear, shame and anxiety. As one summed up, being strong and independent means being smart about his health and body as it affects their lives and partners. Ultimately, PrEP is about taking back one's inner power and taking ownership over their bodies. PrEP is about taking control of their sexual health.
Individuals believe PrEP offers greater safety, especially in cases whereby control over sexual health may be lost, such as in the use of recreational drugs. Men have found their ways to harder drugs because the anxiety that kept them away from the chemsex scene was based on a fear of "losing control". As one contributor said, PrEP helps when you are "too trashed" to make informed decisions. PrEP, in this case, will not protect people from other consequences of being trashed but it will preserve them from that "cruel and unusual punishment". This process is seen as a form of emancipation of a group; one contributor stated that if anyone tries to shame people for being on PrEP, he questions whether they say the same thing to women on birth control.

Othering discourses, HIV/AIDs stigma and criminalization
HIV/AIDS stigma is sometimes outlined in a simplistic way, leading more people to consider figure 1. Flow diagram for data-selection and analysis from a PrEP Facebook group.
Note: PrEP: oral HIV pre-exposure prophylaxis. a Experience, sexual desire and pleasure and individuation and identity are overlapping themes of the overall study on individualization and health; albeit interlinked, this study explores only Individuation and Identity data; individuation refers to the individualization dimension, which accounts for personalization, uniqueness and individual emancipation 26 . b A question-oriented survey was utilized to filter relevant discussion associated with PrEP; it consisted of a 20-question filter that covered all three overlapping themes. c Exclusion criteria included discussions on how to access PrEP, health insurances offers, clinical trials recruitment, videos/series on PrEP. Inclusion criteria included posts with denser discussions, personal experience reports and conflicting and sensitive/hot-topics to the group. d Denser discussions consisted of posts with many "likes" and individual comments, longer texts and that were active for more than two days. e Conflicts refer to sensitive/hot-topics to the group that often consisted of controversial topics such as condomless sex/bareback and STIs, recreational drug use, sex shame to be on PrEP and cases of PrEP inefficacy. f Personal experiences reported by individuals on PrEP, such as drug side-effects, positive and negative consequences of being on PrEP. g The material was typed and the most recurrent statements were transcribed into the result section. We used a grounded theoretical approach to code and to interpret the qualitative data 27  PrEP a way to overcome this social-cultural phenomena. As one contributor stated, since removing stigma is a long cultural process, bypassing it by simply restyling the chemical cocktail contained in Truvada® in order to make it look as if it were specifically meant for prevention/PrEP was brought up to discussion. Othering PLWH is recurrent as one HIV-positive member on medication shares his experience of hunting a guy on PrEP is harder than it should be. He saw a hookup app profile of a guy on PrEP and, as soon as he disclosed being HIV-positive, the guy blocked him. He concluded saying that even the guys who do not have to worry about HIV still block him due to his HIV status. While discussing a case of a man that rejected condomless sex with an undetectable HIV-positive person prior to being on PrEP, someone explains this due to the fact that being PrEP people are "in control" of the prophylaxis because they take the pill -alluding to the fact the HIV-positive persons are subject of discrimination despite being undetectable and, thus, not offering risks of HIV transmission.
Questioning individuals' adherence to medication also appeared over a seroconversion case of an individual on proper use of PrEP. Over the discussion, one contributor suspected that the guy was not telling the truth -"he is lying" -as he asserted the risk of contracting HIV when on PrEP is very small. He finally concludes by saying it is sad that HIV and sex itself still carry such a stigma and people feel they need to make up stories that will somehow "exonerate" them.
Diverse discourses arise when the issue of HIV/AIDS criminalization emerges. When discussing a case of a man living with HIV/AIDS, imprisoned in Toronto, Canada, for apparently infecting his sexual partners on purpose, individual's perceptions on stigma arise objectively: (i) If people decriminalize these actions, there would be more instances of men lying about their status because there is no second thought of getting in trouble for their actions.
(ii) Criminalizing HIV exposure does next to nothing to slow the epidemic. Would be far better by making testing and treatment easily accessible, and fighting the stigma that prevents people from getting tested.
(iii) Individuals should take control over their own protection because they can never totally entrust their health to another person, whether a stranger or a boyfriend. As one contributor alerted, they can be HIV-positive with uncontrolled viral load.
(iv) Disclosing HIV-status to hook-ups seems to be easy, at least until their hate and rumor mills start to swirl.
In this context, PrEP appears to many of its users as a strategy that, apparently, would resolve a great part of these conflicts. For one, this is why PrEP needs to be more widespread, and easily accessible. Amid discussing the given case of HIV criminalization, one contributor concludes by saying that if those two young guys were on PrEP, they would still be HIV-negative.

Discussion
Our findings suggest individuals' discourses and group-affiliation dynamics are increasingly intertwined with IFP on PrEP. Individuals frequently described themselves as having higher levels of self-worth and shared great empowerment among group members. PrEP is perceived to be a tool that promotes sexual freedom by diminishing anxiety and fear for those who are not HIV-positive. We argue individuals articulated high levels of self-worth and empowerment partly because they belong to a group in which they can share common experiences by assimilating a sense of being between equals 28,29 , expressing their subjective attachments to it 30 . Self-worth among gbMSM on PrEP is well-documented 19,40 though individual self-worth expression leading to a great group-empowerment is an emerging process we first identified in a PrEP online-group. This process may offer a number of individual benefits, such as gains in meanings of the intimacy 8,13,14,25 , the sense of not coping with anxiety associated with sex 25,41 and an eventual seroconversion that was deeply rooted in their imaginaries 14 . Interestingly, individuals see themselves as part of a club that allows them to overcome perceptions of sexual ostracism linked to rooted sexual restrains over fear/anxiety of acquiring HIV; conversely, the group exacerbates an ideal of individuals being part of a revolutionary process, alluding to structural shifts in the epidemic, seeking to dismantle the long condom-code via condomless sex idealization 14,42 , particularly fostering their perceptions from the sex scene before AIDS.
Individualization is central for those on PrEP, while group-affiliation mediates sociability and recognition from one's self. Individualization greatly accounts for power and control of the one's self, which are two interchangeable concepts in group-members' discourses; as individ-uals exert power to control their own HIV status, they produce a personal agency 43 that, apparently, is not regulated by external forces or negatively impacted by circumstances of uncontrolled recreational substance use. This contradicts classic-to-contemporary theoretical approaches that sustain the controlling dimension of the medical power via medicalization over the individual body in public health interventions 44,45 . As such, individuals partly produce the individualization process by conflicting personal interests, i.e. condomless sex, drug-use, pleasure and intimacy, to given biomedical technologies 27 through their own HIV prevention practices. As the individual action regulates the core of the HIV prevention, which is framed by great subjective dimensions, such as power, control, fear, this constitutes enormous barriers to find the other as proximal being, rather distant and, sometimes, derogatorily differentiated from the self 30 . "It is the varieties of 'self-other' talk which emerge as the critical ingredient" in contemporary IFP 43 .
While individuals relate to seemingly proximal biosocilities of PLWH, power-disputing discourse within and outside the group constitute a fundamental element of their IFP. Noting Truvada could be used both for HIV prevention and treatment, members feared being characterized and stigmatized in the same manner as PLWH. Similarly, noting PLWH could be potentially infectious despite of being HIV-undetectable, individuals reported rejecting sex with them 4,5,19,46 , amid expressing being proud to be HIV-negative. Such othering discourses affirm the legitimacy and superiority of the powerful self and condition identity differentiation among the subordinate -the other 22,47 . However, within these seemingly dichotomic-polarizing discourses, the subaltern tends to be voiceless, restraining further relational exploration over IFP on contemporary societies 29,[48][49][50] ; contradicting postcolonial understandings on the othering process 22,47 , our findings point to political and discursive disputes/ tensions between individuals over HIV/AIDS stigma and criminalization.
Parker and Anggleton 51 had extended foundational concepts of stigma pointing out power-disputing and social inequities as core relational domains of stigma, which is a structural societal phenomenon. In this sense, stigma is more than a significantly discrediting attribute, rather, it is an intimately phenomenon linked to the reproduction of social difference that burdens those in positions of less power and recognition in society. In this framework, stigma is also presented in discourse and health policies across different levels of power dynamics. In our study, this inner conflicting process primarily accounts for structuring each party itself 28,29 and, paradoxically and simultaneously, questions the group differentiation by its pretense superiority over PLWH. While PLWH have expressed PrEP-related stigma 6,52 , others have indicated PrEP shortens HIV-serology distances 17 . These paradoxical power-disputing relations within and outside the group constitute necessary elements of IFP on contemporary societies 29,53 . Despite the undefined identity, PrEPsters encompass relational process related to agency-identity formation 43 in search for recognition and differentiation from other HIV/AIDS groups 30 . Upon this context, stigma assembles political discourses and power dynamics altogether with IFP in an increasingly context of social individualization.
Individuals on PrEP share common codes with PLWH, which challenges an IFP's analysis solely on othering processes. This points to an ever-increasing ambivalence over IFP in highly individualized societies 27,29 . The theory of IFP via othering process assumes that subordinate people are offered, while being relegated to, subject positions as others in discourse/society. Arguably, these processes do not involve ambivalence, structural conflicts or the exoticism of the colonial gaze 22,54 . As we have shown, individuals confront these assumptions as they share common codes with the subaltern, such as the Truvada use, and perhaps social marginalization statuses 55 . Importantly, individuals' differentiation lies on a progressive discourse to end AIDS as they consider themselves to be advocates fighting for ending HIV/AIDS. Both individuals on PrEP and PLWH may share the inequities to access Health Care facilities in their regions. Moreover, antiretroviral drugs to prevent and treat HIV/AIDS are not adequately available to all in need, where marginalized communities of gbMSM of color are disproportionately affected by lack of resources and health care, particularly in the United States 18 . Thus, othering discourses might only be beneficial/opportune to individuals on PrEP as they sell themselves out of the AIDS stigma and criminalization PLWH are subject to, while utilizing the other as a beneficial artifact of social differentiation. As Parker 56 more recently pointed out, the dynamics of stigma are rooted in societal violence, in which the production and reproduction of inequities nurtures discrimination that, ultimately, aggregates to HIV/AIDS-related stigma. This process challenges modern-polar and non-ambivalent identity processes, as individual construct their autobiographical paths immersed in this conflicting arena 27,53 . This draws attention to the levels at which individuals negotiate/mediate their self-expression and societal locations amidst diverse biosocialities 40 , while being highly integrated into current biomedical approaches 7 .
These social dynamics help to shed light on broader consequences upon individualization and IFP in the context of the ongoing biomedical prevention landscape. The subpolitics 27 individuals perform mostly refers to individuating processes -which accounts for personalization, uniqueness and the ideal of individual emancipation 26,27 -, in conflation with biomedical productions and proximal biosocialities. Simultaneously, the identity subpolitics differentiates by aggregating groups as individuals respond to common patterns of consume that health providers and health systems offer as suitable prevention strategies; as Beck and Beck-Gernsheim claim 27 , the health sector plays a major role in producing the IFP within the individualization process, while very often dismisses the ways in which societal and negative outcomes, such as stigma and discrimination towards PLWH, ought to be addressed towards protecting marginalized populations 20 .

final remarks
We aimed to identify and to understand in which ways othering discourses link to identity formation processes of individuals on PrEP in the context of the ongoing biomedical prevention landscape. We discussed the ways this process occurs by leading high self-worth individuals to differentiated scenarios of biosocial identities, in which they negotiate their inner interests upon conflicting discourses of stigma and discrimination towards PLWH.
In being highly interactive, contributors may have shown greater awareness to PrEP, reported an optimistic or positive outlook on PrEP as these were found on members of the LGBT identity Facebook groups 57 . Our approach emphasized in which ways individuals' discourses tension both self-expression and group-differentiation amidst othering discourse and IFP, while it lacks the ethnic, socio-economic status and comprehensive cultural backgrounds of the group members, which may inform their positionality in discourse/society. Further research with gbMSM on PrEP across diverse realities and locations should advance understandings on IFP and experiences of stigma directed to PLWH. Considering the experiences and perspectives of gbMSM living with HIV 6,17 it is also important to acknowledge that the given stigma and discrimination articulated through an othering process that mostly HIV-negative members expressed out, which have direct implications for awareness of health care providers, health policies and community education programs aiming at eliminating the HIV/AIDS stigma and criminalization amidst increasing biomedical approaches to HIV/AIDS prevention.

Collaborations
RR Silva-Brandao worked on the study conception and design, literature review, data collection, database construction and review, analysis and discussion of results, text writing and approval of the version to be published. AMZ Ianni worked on the study conception, analysis and interpretation of results, critical review of the text and approval of the version to be published. stage as first author's Master of Science Graduate Committee Members. Additional thanks to all anonymous peer-reviewers and to Felipe Oliva for their valuable and constructive contributions to this article.

funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Agency; Fundação de Amparo à Pesquisa do Estado de São Paulo (Fapesp) under Grant 2015/16218-0.