Introduction Traditional risk-reduction counselling has had limited effect in modifying patterns of high-risk sexual behaviour among MSM. New methods like Personalised Cognitive Counselling (PCC) can be used to understand and address contexts of HIV transmission risk.

Methods We conducted interviews and focus groups with HIV-uninfected MSM in 3 stages: I) 4 FGs (n=38) to explore community norms of male sexual interaction, HIV/STI testing practices, and acceptability of PCC; II) Interviews (n=15) where MSM narrated and reflected on a recent experience of receptive condomless anal intercourse (CAI) with an HIV-infected or unknown status partner; and III) 3 FGs (n=29) to discuss composite narratives of sexual risk constructed from Stage II interviews.

Results In exploratory FGs, fear was the guiding principle of HIV counselling/testing. CAI was commonly reported, HIV status rarely discussed, and testing decisions motivated by fear of recent infection. Counselling interactions were described as robotic, repeating stale information in encounters where patients were routinely stigmatised, criticised for engaging in CAI, and threatened with inevitable seroconversion. Negative results were considered to validate prior sexual practices, which then continued unchanged. Stage II interviews used narratives to articulate cognitive processes, partnership interactions, and social contexts where CAI was tacitly encouraged. Limited access to condoms, alcohol prior to sex, and preferences for “bare” sex were cited as justifications for CAI. When common narrative elements were re-presented to Stage III FGs as composite vignettes, participants reverted to standard counselling recommendations, mandating condom use and regular HIV/STI testing, without acknowledging disjunctions between the guidelines and their lived experiences.

Conclusion In contrast to static information transfer, narrative techniques to reconstruct and reflect on recent encounters provide depth and relevance to counselling interactions, addressing multiple dimensions of HIV/STI risk experienced by MSM in Latin America.