Introduction Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In the Southern United States, where young Black men who have sex with men (YBMSM) have the highest rates of new HIV infection, PrEP uptake remains low. As part of a longitudinal cohort study, YBMSM were offered optional, non-incentivized PrEP as a standard of HIV prevention care service. Among those who declined PrEP, we sought to understand their motivations, as well as their overall perceptions of PrEP as a prevention tool.

Methods The EleMENt study is an observational HIV/STI incidence cohort of HIV-negative YBMSM aged 18–29 years in Atlanta, Georgia. We conducted 24 in-depth, semi-structured interviews with men who declined optional PrEP offered by the study. Topics included PrEP knowledge, attitudes, and intentions. We employed a phenomenological lens to identify common themes in participant accounts of the decision to forgo PrEP.

Results Participants fell into two categories of PrEP refusal: those who indicated no current or future interest (“nevers”) and those ambivalent about taking PrEP, but who had thus far not filled a prescription (“maybes”). YBMSM in both groups expressed mistrust of biomedical interventions, and despite being indicated for PrEP, often perceived themselves as low risk for HIV acquisition. They employed “othering” strategies, in which PrEP was described as appropriate for individuals in serodiscordant partnerships or with many casual partners. They viewed taking a daily pill as a burdensome measure only appropriate for extremely high-risk men (i.e., “the risky Other”). These perceptions were accentuated by instances of family members actively discouraged participants from taking PrEP.

Conclusion We discuss the role of future research exploring low risk estimation among YBMSM as a potential site of resistance to a public health designation of “high risk” amidst historical legacies of medical mistrust in Black communities. Such concerns must be addressed to design effective HIV and PrEP-specific interventions for this population.