Downloaded from https://journals.lww.com/jaids by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3lO0fy3QXco99iitDufcVfSug2R0pu3ACGW4mECaszgk= on 10/24/2018 SUPPLEMENT ARTICLE Targeting Fallible Men: Communication Strategies and Moral Issues in a Pre-exposure Prophylaxis Trial Mathieu Trachman, PhD* and Gabriel Girard, PhD† Abstract: Based on the analysis of a French pre-exposure pro- phylaxis trial (Ipergay), and focusing on the communication strategies used to recruit volunteers, this article explores the figure who serves to justify the trial and who shapes the way in which populations concerned by this prevention tool are targeted. We show that this figure is that of the fallible man, a classic in moral philosophy: while aware of what is good or right for him, he is unable to put this knowledge into practice. The targeting of fallible men makes sense in the context of a resurgence of high-risk behaviors objectified in the late 1990s: qualifying gays who take risks as fallible individuals create a distance with respect to the “barebacker” who risks his life deliberately and has no intention of changing his behavior. Recognizing that certain gays are vulnerable to risk also provides justification for a preventive strategy that acknowledges the inadequacy of behavioral prevention, without giving up on prevention altogether. All in all, this analysis shows that the technological and epidemiological realism often highlighted in pre-exposure prophylaxis interventions is not without a moral dimension, attentive to individuals’ contradictions and singularities, doubts and uncertainties, and to the risk of stigmatization inherent to the acknowledgement of risk-taking. Key Words: pre-exposure prophylaxis trial, communication strate- gies, HIV, gay men, France (J Acquir Immune Defic Syndr 2018;79:S13–S19) T he objective observation of less cautious attitudes among gay men beginning in the late 1990s has gradually led public health bodies and organizations to promote new intervention and prevention strategies. These changes are inextricably linked to the development of research projects on measuring changes in behavior and assessing new tools for reducing risks. The French National Agency for Research on AIDS, ANRS, plays a key role in prevention research in terms of survey funding and consultation, as demonstrated by the Ipergay pre-exposure prophylaxis (PrEP) trial in which seronegative gay men with at-risk practices were offered an antiretroviral drug to avoid contamination. Performed between 2012 and 2016, the Ipergay trial reflects a broader interest on the part of players in the fight against AIDS in “treatment as prevention” approaches. Numerous sociological issues are at stake in PrEP, 1 but our purpose here is to examine the way in which this trial targets particular subjects. The AIDS literature established very early on how representations of sexuality, and in particular of male homosexual sexuality, on the part of academics and laypeople alike, contributed to shaping preventive approaches by centering around gender or race relations and by contrasting “good” versus “bad” sexual subjects 6,16 (chap. 6). By addressing gay men who take risks, but without aiming primarily to reform their behavior, Ipergay occupies a partic- ular place in this saga, a fact that explains in part the controversy surrounding the trial. Rather than highlighting the exemplary nature of gay men who protect themselves, the trial sheds light on the fragility of those who fail to do so, as well as the need to adapt prevention policies to their situation. Although this image aims to identify the profile of homo- sexuals who take risks, it gives rise to the singular figure of an individual concurrently incapable of protecting himself yet capable of following a complex treatment plan and of rationalizing his sexuality, and thus likely to be receptive to new prevention strategies: the fallible man. The concept of the fallible man has a dual Aristotelian and Christian tradition that sheds light on its contemporary usages (on the persistence of philosophical schemas in contemporary conceptualizations, we were inspired by Bol- tanski 2 ). In the first case, that of weakness and will, the main question is the place of rationality in practical reasoning, that is, identifying situations in which people who know what is good for them nonetheless choose to make the wrong choices 14 (chap. 1). The second case concerns the question of evil, whereby man, as an individual who has an idea of totality and of the infinite but whose existence is governed by contingency, is always free to do evil. 15 Although the aim of both the Aristotelian and Christian approaches is to identify a poor choice without reducing it to ignorance, the first connects fallibility to the limits of experience, whereas the second turns fallibility into a capacity, that of affirming evil. By considering the fallible man as a figure, our objective is not to assess that figure’s descriptive or normative relevance but to show how it informs, in its various guises, prevention policies for male homosexuals. This article is based on materials from participation, as sociologists, in the Ipergay trial: interviews with people involved in the trial [participants, promoters, employees of From the *Institut National d’études Démographiques, Paris, France; and †Ecole de Santé Publique, Université de Montréal, Montréal, QC, Canada. M.T. and G.G. have received a grant from ANRS for a research project on the biomedicalization of HIV prevention (2012–2014). The authors have no funding or conflicts of interest to disclose. Correspondence to: Mathieu Trachman, PhD, Institut national d’études démographiques, 133 Boulevard Davout, 75020 Paris, France (e-mail: mathieutrachman@ined.fr). Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. J Acquir Immune Defic Syndr  Volume 79, Supplement 1, October 1, 2018 www.jaids.com | S13 Copyright Ó 201 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 8