We identified the significance of how the effectiveness of PrEP as a risk-reduction intervention is communicated to and understood by potential candidates. Our research suggests the importance of HIV risk perception and found that, for many participants, PrEP was not immediately seen as a trusted and/or beneficial addition product information to their repertoire of existing risk-reduction practices. Our findings

also highlight how existing risk management strategies in relation to PrEP encompass broad concerns relating to sexual health, relationships, social factors and communities. Understanding how to interpret PrEP efficacy rates, on their own and in combination with other prevention strategies, proved a stumbling block for the participants and poses a considerable challenge to how health providers support the concept of combination prevention in the context of PrEP. Liu et al23 identify accurate consumer knowledge as key to PrEP implementation, in addition to addressing other factors such as stigma, adherence and risk reduction. While we agree with Liu, our findings suggest that the form

and delivery of this consumer knowledge, including how health providers understand and communicate this information, needs further attention to support effective PrEP use. Communicating PrEP effectiveness in real world settings will be a two-way process that demands clarity on the part of providers and potential users. In addition to supporting providers, negotiating PrEP as a prevention strategy will require improved levels of HIV literacy among potential PrEP users to be effective. We suggest the need to consider critical HIV literacy, which encompasses the ability to know, understand and use HIV-related information within existing risk-reduction practices.24 As levels of HIV knowledge are

directly affected by a range of factors, such as proximity to HIV,25 inequalities in HIV literacy within communities affected by HIV will play an important role in understanding the barriers to PrEP use. These factors have direct implications for both the nature of how PrEP-related HIV risk prevention is delivered and by whom. For many participants, PrEP was not seen as a necessary or welcome addition to their repertoire of risk management strategies. Our findings suggest that risk Brefeldin_A perception and candidacy will play a critical role in decisions to use PrEP, a finding echoed by Golub et al.26 For some of the HIV-negative and/or untested participants in our study, the rejection of PrEP as unnecessary emerged from a perception that they were not at risk of HIV transmission. HIV risk was managed often through the sexual exclusion of HIV-positive sexual partners or through reliance on monogamous sexual relationships. These findings suggest that PrEP implementation strategies will need to engage with these wider, socially embedded risk-reduction practices, including how HIV stigma might affect risk perception.