Background UK and USA guidelines recommend offering antiretroviral treatment (ART) for HIV prevention to patients at risk of sexually transmitting HIV irrespective of CD4 cell count. We explored the attitudes of HIV+ men who have sex with men (MSM) towards use of ART, and ART for HIV prevention.

Methods 24 men (16 on ART and 8 not on ART) attending an HIV clinic in central London, UK participated in semi-structured interviews (May 2010-February 2011). Thematic analysis was conducted.

Results Era of HIV diagnosis, and meanings ascribed to CD4 cell count and ART influenced men’s attitudes towards starting ART. Men diagnosed with HIV before 2001 considered themselves to be fortunate to be on ART; while those diagnosed later were more likely to have fatalist attitudes and perceived starting ART as resigning to “popping pills for life” and “getting closer to death”. They also experienced resentment and lack of control over their health if they felt physically well but were told to start ART due to low CD4 cell count. Most men believed being on ART with undetectable viral load reduces but does not eliminate HIV infectivity, so engaging in unprotected anal intercourse with non-concordant partners (ncUAI) was considered as reckless. However, some men believed that ART reliably prevents HIV transmission and engaged in ncUAI. Men usually discussed their ART/viral load status with partners prior to engaging in ncUAI but some considered this unnecessary due to the reduced risk of HIV transmission. Engaging in UAI with HIV+ men with undetectable viral load was also perceived to reduce the risk of HIV super-infection.

Conclusions Health promotion among HIV+ MSM should address fatalistic attitudes towards ART, and negative effects of low CD4 cell count and delaying ART. The limited effectiveness of ART for HIV prevention also needs to be emphasised, along with STI risk.