In recent years, 'vulnerability' has been getting more traction in theoretical, professional and popular spaces as an alternative or complement to the concept of risk. As a group of science and technology studies scholars with different disciplinary orientations yet a shared concern with biomedicine, self and society, we investigate how vulnerability has become a salient and even dominant idiom for discussing disease and disease risk. We argue that this is at least partly due to an inherent indeterminacy in what 'vulnerability' means and does, both within and across different discourses. Through a review of feminist and disability theory, and a discussion of how vulnerability and disease both get recruited into a binary conceptualisation of normal versus abnormal, we argue that vulnerability's indeterminacy is, in fact, its strength, and that it should be used differently than risk. Using COVID-19 management in the UK as an illustration of the current ambivalence and ambiguity in how vulnerability versus risk is applied, we suggest that instead of being codified or quantified, as it has started to be in some biomedical and public health applications, vulnerability and its remedies should be determined in conjunction with affected communities and in ways that are polyvalent, flexible and nuanced. The concept of vulnerability encapsulates an important precept: we must recognise inequality as undesirable while not attempting to 'solve' it in deterministic ways. Rather than becoming fixed into labels, unidirectional causalities or top-down universalising metrics, vulnerability could be used to insist on relational, context-specific understandings of disease and disease risk-in line with contemporary social justice movements that require non-hierarchical and non- universal approaches to problems and solutions.

The introduction of HIV pre-exposure prophylaxis (PrEP) raises important questions around how new biotechnologies are negotiated within contemporary settings and how they can shape the moral governance of biocitizens, or as we explore, biosexual citizens. This article draws on qualitative interviews and focus groups to consider how the normative biosexual citizen was cast at the start of provision in Scotland by clinical and community practitioners. Our findings show how practitioners navigated ideas around who was deserving of support and access to PrEP in the context of limited resources, interpreted what legitimate risk narratives might look like for different groups and translated particular gendered, sexualised and racialised risk profiles in the context of PrEP provision. This draws attention to how normative biosexual citizenship was not determined through meeting a set of clinical criteria and adhering to a prophylaxis regime but cast through ongoing negotiations with clinical and community practitioners in relation to normative ideas of essential care, constrained resources, risk narratives and gendered and racialised bodies. Our research indicates how access to PrEP will continue to demand particular enactments of normative biosexual citizenship that may well be at odds with the experiences and needs of communities affected by HIV.

IntroductionHIV pre-exposure prophylaxis (PrEP), in which people take HIV medication to prevent HIV acquisition, underpins global HIV transmission elimination strategies. Effective prevention needs people to adhere to PrEP and remain in care during periods of risk, but this is difficult to achieve. We undertook a process evaluation of Scotland's PrEP programme to explore barriers and facilitators to PrEP adherence and retention in care and to systematically develop evidence-based, theoretically-informed recommendations to address them.MethodsWe conducted semi-structured interviews and focus groups (09/2018-07/2019) with patients who identified as gay or bisexual men and were either using PrEP, had declined the offer of PrEP, had stopped PrEP, or had been assessed as ineligible for PrEP (n = 39 of whom n = 5 (13%) identified as trans, median age 31 years and interquartile range 14 years), healthcare professionals involved in PrEP provision (n = 54 including specialist sexual health doctors and nurses of various grades, PrEP prescribing general practitioners, health promotion officers, midwifes, and a PrEP clinical secretary), and clients (n = 9) and staff (n = 15) of non-governmental organisations with an HIV prevention remit across Scotland. We used thematic analysis to map key barriers and facilitators to priority areas that could enhance adherence and retention in care. We used implementation science analytic tools (Theoretical Domains Framework, Intervention Functions, Behaviour Change Technique Taxonomy, APEASE criteria) and expert opinion to systematically generate recommendations.ResultsBarriers included perceived complexity of on-demand dosing, tendency for users to stop PrEP before seeking professional support, troublesome side-effects, limited flexibility in the settings/timings/nature of review appointments, PrEP-related stigma and emerging stigmas around not using PrEP. Facilitators included flexible appointment scheduling, reminders, and processes to follow up non-attenders. Examples of the 25 recommendations include: emphasising benefits of PrEP reviews and providing appointments flexibly within individualised PrEP care; using clinic systems to remind/recall PrEP users; supporting PrEP conversations among sexual partners; clear on-demand dosing guidance; encouraging good PrEP citizenship; detailed discussion on managing side-effects and care/coping planning activities.ConclusionsPrEP adherence and retention in care is challenging, reducing the effectiveness of PrEP at individual and population levels. We identify and provide solutions to where and how collaborative interventions across public health, clinical, and community practice could address these challenges.

Background. HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2 years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation. Methods. Stage 1 involved semi-structured telephone interviews and focus groups (September 2018-July 2019) with geographically and demographically diverse patients seeking/using/declining/ stopping PrEP (n = 39), sexual healthcare professionals (n = 54), community-based organisation service users (n = 9) and staff (n = 15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP. Results. Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 long-list' recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders. Conclusions. These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.

Throughout the COVID-19 pandemic, representations of irresponsible gay men partying with little regard for viral transmission have circulated across social media; a construction of gay men that has a history that long precedes the coronavirus conjuncture. In this article, we draw on in-depth qualitative interviews with 43 queer men in London and Edinburgh, to investigate experiences of sexual and intimate practices during COVID-19 and use the concept of 'biosexual citizenship' (2018) to analyse the ethical frameworks these men used to navigate them. We argue that rather than being 'good' or 'bad' biosexual citizens, queer men have developed an array of ethically reflexive strategies in order to negotiate the difficult terrain they have had to face when trying to pursue their cultures of sex and intimacy during the pandemic. In so doing, they appear to enact biosexual citizenship through diverse sexual practices that both inevitably include and challenge both hegemonic imperatives of responsibility and well-being, as well as well-worn media representations of reckless, hedonistic gay men.

Di Feliciantonio and Brown offer an important overview of key research areas for the geographies of PrEP, TasP, and undetectabitily, and they consider what matters for the lives of gay and bisexual men. I offer two areas of further consideration. Firstly, I suggest that rather than setting the biopolitical critiques of PrEP and TasP as at odds with grassroots activism, sexual pleasure, and subjectivities, that these particular forms of biosexual activism are indeed central to subject formation and sexual practices and are constitutive of the other within HIV assemblages. Secondly, I highlight the need to consider inequalities more directly both within the context of national borders in relation to jurisdictional health policy, implementation, and access, and within gay communities themselves in relation to intersectional and embodied identities.

Objectives HIV Pre-Exposure Prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention and is key to HIV transmission elimination. However, implementation is challenging. We identified barriers and facilitators to PrEP awareness and access during the roll out of Scotland’s national PrEP programme to develop recommendations for future provision. Design Multi-perspectival qualitative approach incorporating implementation science tools. Setting Sexual health services and sexual health/HIV community-based organisations (CBOs) in Scotland. Participants Semi-structured telephone interviews and focus groups with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n=39), sexual healthcare professionals (n= 54), CBO users (n=9) and staff (n=15). Analysis Using deductive thematic analysis we mapped barriers and facilitators to PrEP awareness and access. We then applied the Theoretical Domains Framework, Behaviour Change Wheel, and Behaviour Change Technique Taxonomy to analyse barriers and facilitators to generate targeted solutions. Finally, we applied APEASE criteria, expert opinion, and the socio-ecological model to synthesise and present multi-levelled and interdependent recommendations to enhance implementation. Results Barriers and facilitators were multifaceted, relating to the macrosocial (e.g., government, service ecology), the mesosocial (e.g., values and practices of organisations and dynamics and norms of communities) and the microsocial (peer influence). We derived 28 overarching recommendations including: incentivising organisations to share expertise, addressing future generations of PrEP users, expanding the reach of PrEP services, cascading effective service innovations, changing organisational cultures, instigating and managing novel outreach, establishing monitoring systems, supporting diverse PrEP users, providing training addressing awareness and access to professionals, and development of “PrEP champions” within a range of organisations. Conclusion Improving awareness and access to PrEP sustainably will require intervention across the whole system, changing policy and practice, organisations and their cultures, communities and their social practices, and individuals themselves. These evidence-based recommendations will prove useful in extending the reach of PrEP to all who could benefit. Strengths and limitations of this study ### Competing Interest Statement The investigators named have no financial interests that impact on their responsibilities towards the scientific value or potential publishing activities associated with the study. However, the team has other interests within the field including various roles relating to HIV and sexual health within Government (Steedman, Estcourt, Nandwani, Clutterbuck), policy generation (Steedman, Nandwani, Estcourt, Saunders, Young, Flowers, HIV Scotland), practice (Steedman, Estcourt, Nandwani, Clutterbuck, Saunders) and advocacy (Young, HIV Scotland). PF reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland. RN reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland and non-executive director membership of the Board of Public Health Scotland from April 2020. JF reports research grants from Chief Scientist Office of Scotland. CSE reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland, Engineering and Physical Sciences Research Council, UK Clinical Research Collaboration, Health Protection Scotland, European Centres for Disease Control. JM, JS, IY, DC, NS, LM & JD report no competing interests. ### Funding Statement This study was funded by Chief Scientist Office grant number [HIPS/17/47]. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Glasgow Caledonian University Research Ethics Committee (REC) (HLS/NCH/17/037, HLS/NCH/17/038, HLS/NCH/17/044) and the South East of Scotland NHS REC (18/SS/0075, R&D GN18HS368) gave this study ethical approval. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes No data from this qualitative data set is publicly available. Supplementary file B provides an auditable account of anonymised data analysis.

Introduction HIV pre-exposure prophylaxis (PrEP) is a key component of HIV combination prevention. Effective prevention needs people to adhere to PrEP during periods of risk and remain in care. However, relevant models of care are under-researched. Using data from the first two years of Scotland’s PrEP programme, we explored barriers and facilitators to PrEP adherence and retention in care and systematically developed evidence-based, theoretically-informed recommendations to enhance future adherence and retention.Methods We conducted semi-structured interviews and focus groups (09/2018-07/2019) with geographically and demographically diverse patients who were either using/declined/stopped or had been assessed as ineligible for PrEP (n=39), healthcare professionals involved in PrEP provision (n= 54), non-governmental organisation service users (n=9) and staff (n=15) across Scotland. We used thematic analysis to map key barriers and facilitators to priority areas that could enhance adherence and retention in care. Next, we used analytic tools from implementation science (Theoretical Domains Framework, Intervention Functions, Behaviour Change Technique Taxonomy, APEASE criteria) and expert opinion to systematically generate recommendations to enhance future PrEP adherence and retention in care.Results Barriers and facilitators to adherence and retention in care were diverse and multi-layered. Barriers included perceived complexity of event-based dosing, the tendency for users to stop PrEP before seeking professional support, troublesome side-effects, limited flexibility in the settings, timings, and nature of appointments for follow up, enduring PrEP-related stigma and emerging stigmas around not using PrEP. Facilitators included flexible appointment scheduling, reminders, and processes to follow up non-attenders. We generated 25 wide-ranging but specific recommendations for key stakeholders, for example, emphasising the benefits of PrEP reviews and providing appointments flexibly within individualised PrEP care; using clinic systems to remind/recall PrEP users for review; supporting PrEP conversations among sexual partners; clear guidance on event-based dosing; encouraging/commitment to good PrEP citizenship; and detailed discussion on managing side-effects and care/coping planning activities.Conclusions PrEP adherence and retention in care is challenging for many people. Such challenges reduce the benefits of PrEP at individual and population levels. Our findings identify and provide solutions to where and how collaborative interventions across public health, clinical, and community practice could address these challenges.### Competing Interest StatementThe investigators named have no financial interests that impact on their responsibilities towards the scientific value or potential publishing activities associated with the study. However, the team has other interests within the field including various roles relating to HIV and sexual health within Government (Steedman, Estcourt, Nandwani, Clutterbuck), policy generation (Steedman, Nandwani, Estcourt, Saunders, Young, Flowers, HIV Scotland), practice (Steedman, Estcourt, Nandwani, Clutterbuck, Saunders) and advocacy (Young, HIV Scotland). PF reports research grants from National Institute of Health Research UK, Chief Scientist Office of Scotland. CSE, RN, JF, JM, JS, IY, DC, NS, LM & JD report no competing interests.### Funding StatementThis work was funded through Scottish Chief Scientist Office grant reference HIPS/17/47 Optimising services for people at highest risk of HIV: Developing best practice in delivering HIV pre-exposure prophylaxis (PrEP) through evaluation of early implementation across Scotland. The grant ran from June 2018 to October 2020. During this study, LMcD was funded by the UK Medical Research Council and Chief Scientist Office of the Scottish Government Health and Social Care Directorates at the MRC/CSO Social & Public Health Sciences Unit, University of Glasgow (MC\_UU\_12017/11, SPHSU11; MC\_UU\_00022/3, SPHSU18).### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The Glasgow Caledonian University Research Ethics Committee (HLS/NCH/17/037, HLS/NCH/17/038, HLS/NCH/17/044) and the South East Scotland National Health Service Research Ethics Committee (18/SS/0075, R&D GN18HS368) provided ethical approval.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesData that supports the findings and suggestions of this study are explained within the the supplementary material for this article, which presents elements of the original dataset.* APEASE : Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects and safety, Equity BBV : Blood borne viruses BCT : Behaviour Change Technique BCTT : Behaviour Change Technique Taxonomy BCW : Behaviour Change Wheel GBMSM : Gay, bisexual, and other men who have sex with men HIV : Human immunodeficiency virus PrEP : Pre-exposure prophylaxis STI : Sexually transmitted infection TDF : Theoretical Domains Framework

An anonymisation protocol produced as part of a pilot project to assess the feasibility of re-use of 12 diverse qualitative datasets related to Human Immunodeficiency Virus (HIV), which were produced as part of several research projects undertaken between 1997 and 2013.

We describe a pilot project designed to assess the feasibility of re-use across 12 diverse qualitative datasets related to Human Immunodeficiency Virus (HIV) in the UK, from research projects undertaken between 1997 and 2013 – an approach which is chronically underused. First, we consider the sweeping biomedical changes and imperatives relating to HIV in this time frame, offering a rationale for data re-use at this point in the epidemic. We then reflexively situate the processes and procedures we devised for this study with reference to relevant methodological literature. Hammersley’s and Leonelli’s contributions have been particularly instructive through this process, and following their lead, we conclude with further considerations for those undertaking qualitative data re-use, reflecting on the extent to which qualitative data re-use as a practice requires attention to both the given and the constructed aspects of data when assembled as evidence.

Background Technology, including mobile apps, has the potential to support self-management of long-term conditions and can be tailored to enhance adoption. We developed an app to support asthma self-management among people with limited health literacy in a web-based workshop (to ensure physical distancing during the COVID-19 pandemic). Objective The aim of this study is to develop and test a prototype asthma self-management mobile app tailored to the needs of people with limited health literacy through a web-based workshop. Methods We recruited participants from a primary care center in Malaysia. We adapted a design sprint methodology to a web-based workshop in five stages over 1 week. Patients with asthma and limited health literacy provided insights into real-life self-management issues in stage 1, which informed mobile app development in stages 2-4. We recruited additional patients to test the prototype in stage 5 using a qualitative research design. Participants gave feedback through a concurrent thinking-aloud process moderated by a researcher. Each interview lasted approximately 1 hour. Screen recordings of app browsing activities were performed. Interviews were audio-recorded and analyzed using a thematic approach to identify utility and usability issues. Results The stakeholder discussion identified four themes: individual, family, friends, and society and system levels. Five patients tested the prototype. Participants described 4 ways in which the app influenced or supported self-management (utility): offering information, providing access to an asthma action plan, motivating control of asthma through support for medication adherence, and supporting behavior change through a reward system. Specific usability issues addressed navigation, comprehension, and layout. Conclusions This study proved that it was possible to adapt the design sprint workshop to a web-based format with the added advantage that it allowed the development and the testing process to be done efficiently through various programs. The resultant app incorporated advice from stakeholders, including sources for information about asthma, medication and appointment reminders, accessible asthma action plans, and sources for social support. The app is now ready to move to feasibility testing.

AbstractPrEP in Scotland came with great expectation and celebration. As the first country in the UK to offer PrEP through the National Health Service (NHS), Scotland was heralded as a leader in HIV prevention. This chapter asks: how has the anticipation of PrEP shaped provision and use within the health system; how does the emergent and ongoing orientation of PrEP towards specific risk practices affect awareness, access and use, but also wider narratives of prevention, inequalities and ‘progress’; and, what kinds of biosexual citizens does it demand and produce? The chapter explores how the implementation of PrEP and the specific nature of its roll-out contribute to an orientation towards certain (gendered) PrEP users and PrEP use. It considers how the anticipation of PrEP as a biotechnology for particular risk practices, bodies and communities shapes promissory HIV prevention futures and determines what success and ‘celebration’ could be.

Pre-exposure prophylaxis (PrEP) has been hailed as a revolutionary intervention for HIV prevention. PrEP's controversial status in the UK has generated significant media coverage. It is important to understand what role the media plays in framing PrEP policy issues. We undertook a qualitative analysis of UK newsprint articles between 2012 and 2016 to examine how PrEP was framed as a public health intervention up until a controversial policy decision not to provide PrEP in England. We identified how scientific evidence was deployed to shape two narratives: ir/responsible citizens focused on imagined PrEP users and their capacity to use PrEP effectively; and the public health imperative, which described the need for PrEP. Our analysis demonstrates the particular ways in which scientific evidence contributed to the certainty of PrEP as an effective intervention within UK newsprint. Scientific evidence also played a key role in framing PrEP as an intervention specifically for cis-gendered gay and bisexual men, playing into wider debates about who is a deserving patient and the appropriate use of public resources. Practitioners in the UK and elsewhere should be aware of these constructions of the PrEP user to ensure equitable access to PrEP beyond gay and bisexual men.

BACKGROUND:Adjusting to life with a chronic condition is challenging, especially for people with limited health literacy, which is associated with low compliance with self-management activities and poor clinical outcomes.OBJECTIVE:We explored how people with limited health literacy understand asthma and undertake self-management practices.DESIGN:We adapted the arts-based qualitative methodology Photovoice.SETTING AND PARTICIPANTS:We sampled ethnically diverse adults with asthma and limited health literacy from four primary healthcare clinics in Malaysia. After a semistructured in-depth interview, a subset of participants took part in the Photovoice component in which participants undertook a 2-week photo-taking activity and subsequent photo-interview. Interviews, conducted in participants' preferred language, were audio-recorded, transcribed verbatim, translated and analysed thematically. We used the Sorensen's framework (Domains: access, understand, appraise, apply) to describe participants' experience of living with asthma, what they understood about asthma and how they decided on self-management practices.RESULTS:Twenty-six participants provided interviews; eight completed the Photovoice activities. Participants with limited health literacy used various sources to access information about asthma and self-management. Doctor-patient communication had a pivotal role in helping patients understand asthma. The lack of appraisal skills was significant and experiential knowledge influenced how they applied information. Self-management decisions were influenced by sociocultural norms/practices, stigmatizing experiences, and available social support.CONCLUSION:Locally tailored multilevel interventions (interpersonal, health system, community and policy) will be needed to support people with limited health literacy to live optimally with their asthma in an ethnically diverse population.PATIENT/PUBLIC CONTRIBUTION:Patients were involved in the study design, recruitment, analysis and dissemination.

Background Widely accessible, acceptable, equitable, HIV pre-exposure prophylaxis (PrEP) services are central to HIV transmission elimination. Multi-stakeholder collaboration, activism and government support enabled Scotland to implement a publicly-funded national PrEP programme delivered through sexual health services from 2017. Although innovations in PrEP implementation occur, they are rarely analysed or consolidated. We address this gap in Scotland by: 1) examining diverse perspectives on barriers and facilitators to the key steps of PrEP implementation (i.e., awareness, access, uptake, initiation, adherence and retention in care) and 2) using implementation science theories to systematically specify transferable ways to improve these steps. Method Semi-structured interviews and focus groups (2018–2019) with geographically and demographically diverse sexual health clinic patients seeking/using/declining or stopping PrEP (n=39), sexual healthcare professionals (n= 54), community-based organisation (CBO) service users (n=9) and staff (n=15). Thematic analysis identifying barriers and facilitators to implementing PrEP was complemented by analyses using the Behaviour Change Wheel to specify detailed recommendations for enhancing PrEP implementation. Results Barriers and Facilitators to the key steps ranged from: macrosocial (political will, competitive dynamics in the service ecology, structural racism); mesosocial (effective monitoring systems and reporting); to microsocial (staff skills and self-efficacy, low HIV literacy). Enhancing implementation across the key steps included: incentivising organisations to share expertise (funding mechanisms, equitable partnership work); targeted culturally sensitive, normalising and awareness-raising interventions; co-production of nationally co-ordinated training and patient resources (e.g. for managing side-effects, adherence support, improving cultural competencies); guidance for correct use of event-based PrEP; supporting PrEP provision in diverse settings to reach underserved communities. Conclusion Systematic analysis of what had and had not worked, and why has enabled development of wide-ranging but specific recommendations for policy-makers, clinicians, CBOs and individuals to optimise PrEP awareness, access, uptake, initiation, adherence and retention in care. These recommendations could be used to improve all PrEP services.

Good sexual health requires navigating intimate relationships within diverse power dynamics and sexual cultures, coupled with the complexities of increasing biomedicalisation of sexual health. Understanding this is important for the implementation of biomedical HIV prevention. We propose a socially nuanced conceptual framework for sexual health literacy developed through a consensus building workshop with experts in the field. We use rigorous qualitative data analysis to illustrate the functionality of the framework by reference to two complementary studies. The first collected data from five focus groups (FGs) in 2012 (n = 22), with gay, bisexual and other men who have sex with men aged 18-75 years and 20 in-depth interviews in 2013 with men aged 19-60 years. The second included 12 FGs in 2014/15 with 55 patients/service providers involved in the use/implementation of HIV self-testing or HIV prevention/care. Sexual health literacy goes well beyond individual health literacy and is enabled through complex community practices and multi-sectoral services. It is affected by emerging (and older) technologies and demands tailored approaches for specific groups and needs. The framework serves as a starting point for how sexual health literacy should be understood in the evaluation of sustainable and equitable implementation of biomedical sexual healthcare and prevention internationally.