Evaluating social protection mitigation effects on HIV/AIDS and Tuberculosis through a mathematical modelling study.

The global economic downturn due to the COVID-19 pandemic, war in Ukraine, and worldwide inflation surge may have a profound impact on poverty-related infectious diseases, especially in low-and middle-income countries (LMICs). In this work, we developed mathematical models for HIV/AIDS and Tuberculosis (TB) in Brazil, one of the largest and most unequal LMICs, incorporating poverty rates and temporal dynamics to evaluate and forecast the impact of the increase in poverty due to the economic crisis, and estimate the mitigation effects of alternative poverty-reduction policies on the incidence and mortality from AIDS and TB up to 2030. Three main intervention scenarios were simulated-an economic crisis followed by the implementation of social protection policies with none, moderate, or strong coverage-evaluating the incidence and mortality from AIDS and TB. Without social protection policies to mitigate the impact of the economic crisis, the burden of HIV/AIDS and TB would be significantly larger over the next decade, being responsible in 2030 for an incidence 13% (95% CI 4-31%) and mortality 21% (95% CI 12-34%) higher for HIV/AIDS, and an incidence 16% (95% CI 10-25%) and mortality 22% (95% CI 15-31%) higher for TB, if compared with a scenario of moderate social protection. These differences would be significantly larger if compared with a scenario of strong social protection, resulting in more than 230,000 cases and 34,000 deaths from AIDS and TB averted over the next decade in Brazil. Using a comprehensive approach, that integrated economic forecasting with mathematical and epidemiological models, we were able to show the importance of implementing robust social protection policies to avert a significant increase in incidence and mortality from AIDS and TB during the current global economic downturn.

"It was unusual but amazing": demand creation for PrEP among adolescents' men who have sex with men (MSM) and transgender women (TGW) in Brazil.

This study aimed to analyze the challenges in demand creation for participation in an HIV pre-exposure prophylaxis (PrEP) project in two Brazilian capitals. This qualitative study was conducted with men who have sex with men and transgender women aged 15 to 19 years who lived in two Brazilian state capitals. For this analysis, 27 semi-structured interviews carried out from 2019 to 2020 were evaluated by reflexive thematic content analysis. For participants, PrEP demand creation was essential for their interaction, mediation, bonding, and attachment and proved effective for PrEP acceptability and adherence. Adolescents' narratives showed that the strategies promoted HIV combination prevention, opened up opportunities for recruitment meetings, helped to negotiate with and convince individuals to use PrEP, strengthened peer education, and evoked a feeling of "being with" and "walking together" despite the challenges. Face-to-face or online interactions using social technologies played a crucial role in recruiting adolescents for the project, expanding knowledge on PrEP and other combination prevention strategies and access to health services and self-care.

The intersecting effects of race, wealth, and education on AIDS incidence, mortality, and case-fatality rate: a Brazilian cohort study of 28.3 million individuals.

The relationships between race, education, wealth, their intersections and AIDS morbidity/mortality were analyzed in retrospective cohort of 28.3 million individuals followed for 9 years (2007-2015). Together with several sensitivity analyses, a wide range of interactions on additive and multiplicative scales were estimated. Race, education, and wealth were each strongly associated with all of the AIDS-related outcomes, and the magnitude of the associations increased as intersections were included. A significantly higher risk of illness (aRR: 3.07, 95%CI:2.67-3.53) and death (aRR: 4.96, 95%CI:3.99-6.16) from AIDS was observed at the intersection of Black race, lower educational attainment, and less wealth. A higher case-fatality rate (aRR: 1.62, 95%CI:1.18-2.21) was also seen for the same intersectional group. Historically oppressed groups lying at the intersections of race, education, and wealth, had a considerably higher risk of illness and death from AIDS. AIDS-related interventions will require the implementation of comprehensive intersectoral policies that follow an intersectionality perspective.

COVID-19 Vaccine Acceptance and Hesitancy among People Living with HIV: Review and Meta-Analysis.

This study aims to estimate the COVID-19 vaccine acceptance and hesitancy among people living with HIV (PLWHA). A search for observational studies was conducted in five databases and preprinted literature. Summary estimates were pooled using a random effects model and meta-regression. Of 150 identified studies, 31 were eligible (18,550 PLWHA). The weighted prevalence of COVID-19 vaccine hesitancy overall was 29.07% among PLWHA (95%CI = 24.33-34.32; I² = 98%,) and that of vaccine acceptance was 68.66% (95%CI = 62.25-74.43; I² = 98%). Higher hesitancy prevalence was identified in low/lower-middle income countries (35.05; 95% CI = 19.38-54.78). The heterogeneity was explained by the risk of bias, region, and year of data collection. The findings conclude that the COVID-19 vaccine hesitancy rate remains high, especially in low-income countries. Evidence-informed interventions aimed at increasing COVID-19 vaccine acceptance at the national and individual levels ought to be designed to increase COVID-19 vaccine acceptance among PLWHA.

Acceptability and Usability of Self-Sampling for the Detection of Sexually Transmitted Infections Among Transgender Women: The TransOdara Multicentric Study in Brazil.

BACKGROUND: The effective testing of sexually transmitted infections (STIs) requires sampling from potential infection sites. This study aimed to assess the choice, satisfaction, and performance of self-collected samples (SCS) from potential infection sites for STI testing among transgender women in Brazil. METHODS: TransOdara was a multicentric, cross-sectional STI prevalence study conducted in 5 Brazilian cities. Using respondent-driven sampling, 1317 transgender women 18 years or older were recruited. Participants completed interviewer-led questionnaires and provided swab samples from multiple sites (anorectal, oropharyngeal, genital) for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and human papillomavirus (HPV) testing. Participants were given a choice of SCS or provider-collected samples (PCS) at each site. RESULTS: Most participants selected SCS for anorectal (74.9%; 95% confidence interval [CI], 72.4-77.3) and genital (72.7%; 95% CI, 70.2-75.1) sites, whereas fewer chose for oropharyngeal samples (49.8%; 95% CI, 47.0-52.6). For future testing, most participants expressed a preference for SCS for genital (72.2%; 95% CI, 69.5-74.7) and anorectal (70.2%; 95% CI, 67.6-72.7) sites. There was no significant difference in the positive test results for CT and NG between SCS and PCS at anorectal and oropharyngeal sites, or for HPV at anorectal and genital (penile or neovaginal) sites. CONCLUSIONS: This study demonstrated a high level of acceptability and usability of self-sampling for STI testing among transgender women. A preference for SCS was evident at the anorectal and genital sites, and the results of SCS were comparable to those of PCS. The findings suggest that multisite STI testing utilizing self-collection methods as a provided option can be effectively integrated into sexual health services for transgender women.

Racial HIV Testing Inequalities in Adolescent Men who have Sex with Men and Transgender Women in Three Brazilian Cities.

Many barriers to human immunodeficiency virus (HIV) testing among Black people exist. This study analysed the association between race/skin colour and lifetime HIV testing among adolescent men who have sex with men (AMSM) and transgender women (ATGW) in three Brazilian cities. This cross-sectional study was nested within the PrEP1519 cohort, a multicentre study of AMSM and ATGW aged 15-19 years in Belo Horizonte, Salvador, and São Paulo, Brazil. The outcome variable was the lifetime HIV testing (no or yes). The main exposure variable was self-reported race/skin colour as White and a unique Black group (composed of Pardo-mixed colour and Black, according to the Brazilian classification). Descriptive statistics and bivariate and multiple logistic regression analyses were conducted to estimate the adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) to determine the association between the main exposure and outcome, adjusted for covariates. White adolescents were tested more frequently than the unique Black group (64.0% vs. 53.7%, respectively; Ρ = 0.001). Multiple logistic regression analysis showed that the unique Black group of AMSM and ATGW had 26% (adjusted OR [aOR], 0.74; 95% CI, 0.55-0.98) and 38% (aOR, 0.62; 95% CI, 0.45-0.87) lower odds of being tested for HIV in a lifetime than Whites in model 1 and 2, respectively. Our findings highlight the role of racism in lifetime HIV testing among AMSM and ATGW. Therefore, an urgent need for advances exists in public policies to combat racism in Brazil.

RESUMEN: Existen numerosas barreras para la realización de las pruebas del virus de la inmunodeficiencia humana (VIH) entre la población negra. Este estudio analizó la asociación entre la raza/color de piel y haber realizado pruebas de VIH a lo largo de la vida entre hombres adolescentes que tienen sexo con hombres (AHSH) y mujeres transgénero (AMTG) en tres ciudades brasileñas. Este estudio transversal es parte de la cohorte PrEP1519, un estudio multicéntrico de AHSH y AMTG de 15 a 19 años en Belo Horizonte, Salvador y São Paulo, Brasil. La variable de resultado fue haber realizado la prueba del VIH a lo largo de la vida (no o sí). La variable de exposición principal fue la raza/color de piel autoinformada, categorizada como blanca y un grupo negro único (compuesto por color pardo/mixto y negro, según la clasificación brasileña). Se realizaron estadísticas descriptivas y análisis de regresión logística bivariada y multivariada para estimar los odds ratios (OR) ajustados y los intervalos de confianza del 95% (IC del 95%) con el fin de determinar la asociación entre la exposición principal y el resultado, ajustado por covariables. Los adolescentes blancos se hicieron la prueba del VIH con más frecuencia que el grupo negro único (64,0% frente a 53,7%, respectivamente; Ρ = 0,001). El análisis de regresión logística múltiple reveló que el grupo negro único de AHSH y AMTG tenía 26% (OR ajustado [aOR], 0,74; IC 95%, 0,55­0,98) y 38% (aOR, 0,62; IC 95%, 0,45­0,87) menores probabilidades de realizarse la prueba del VIH a lo largo de su vida que los blancos en los modelos 1 y 2, respectivamente. Nuestros hallazgos resaltan la influencia del racismo en la realización de pruebas de VIH a lo largo de la vida entre AHSH y AMTG. Por lo tanto, es urgente avanzar en la implementación de políticas públicas para combatir el racismo en Brasil.

Income determines the impact of cash transfers on HIV/AIDS: cohort study of 22.7 million Brazilians.

Living with extremely low-income is an important risk factor for HIV/AIDS and can be mitigated by conditional cash transfers. Using a cohort of 22.7 million low-income individuals during 9 years, we evaluated the effects of the world's largest conditional cash transfer, the Programa Bolsa Família, on HIV/AIDS-related outcomes. Exposure to Programa Bolsa Família was associated with reduced AIDS incidence by 41% (RR:0.59; 95%CI:0.57-0.61), mortality by 39% (RR:0.61; 95%CI:0.57-0.64), and case fatality rates by 25% (RR:0.75; 95%CI:0.66-0.85) in the cohort, and Programa Bolsa Família effects were considerably stronger among individuals of extremely low-income [reduction of 55% for incidence (RR:0.45, 95% CI:0.42-0.47), 54% mortality (RR:0.46, 95% CI:0.42-0.49), and 37% case-fatality (RR:0.63, 95% CI:0.51 -0.76)], decreasing gradually until having no effect in individuals with higher incomes. Similar effects were observed on HIV notification. Programa Bolsa Família impact was also stronger among women and adolescents. Several sensitivity and triangulation analyses demonstrated the robustness of the results. Conditional cash transfers can significantly reduce AIDS morbidity and mortality in extremely vulnerable populations and should be considered an essential intervention to achieve AIDS-related sustainable development goals by 2030.

Modelling HIV/AIDS epidemiological complexity: A scoping review of Agent-Based Models and their application.

OBJECTIVE: To end the AIDS epidemic by 2030, despite the increasing poverty and inequalities, policies should be designed to deal with population heterogeneity and environmental changes. Bottom-up designs, such as the Agent-Based Model (ABM), can model these features, dealing with such complexity. HIV/AIDS has a complex dynamic of structural factors, risk behaviors, biomedical characteristics and interventions. All embedded in unequal, stigmatized and heterogeneous social structure. To understand how ABMs can model this complexity, we performed a scoping review of HIV applications, highlighting their potentialities. METHODS: We searched on PubMed, Web of Science, and Scopus repositories following the PRISMA extension for scoping reviews. Our inclusion criteria were HIV/AIDS studies with an ABM application. We identified the main articles using a local co-citation analysis and categorized the overall literature aims, (sub)populations, regions, and if the papers declared the use of ODD protocol and limitations. RESULTS: We found 154 articles. We identified eleven main papers, and discussed them using the overall category results. Most studies model Transmission Dynamics (37/154), about Men who have sex with Men (MSM) (41/154), or individuals living in the US or South Africa (84/154). Recent studies applied ABM to model PrEP interventions (17/154) and Racial Disparities (12/154). Only six papers declared the use of ODD Protocol (6/154), and 34/154 didn't mention the study limitations. CONCLUSIONS: While ABM is among the most sophisticated techniques available to model HIV/AIDS complexity. Their applications are still restricted to some realities. However, researchers are challenged to think about social structure due model characteristics, the inclusion of these features is still restricted to case-specific. Data and computational power availability can enhance this feature providing insightful results.

Association between in-country migration and HIV infection among transgender women from northeastern Brazil: a respondent-driven sampling survey.

BACKGROUND: Migration is common among transgender women (TGW), often driven by the desire to escape stigma, find acceptance, establish new connections, access body modifications, or enter new avenues of sex work. Given the heightened mobility of TGW, they are mostly vulnerable to human immunodeficiency virus (HIV) due to migration. This study aimed to evaluate the association between in-country migration and HIV infection among TGW in Northeast Brazil. METHODS: The DIVAS was a cross-sectional, multicity study investigating risk behaviors and sexually transmitted infections (STI) among TGW in 2016-2017. A total of 864 TGW were recruited through respondent-driven sampling from three capital cities in Northeast Brazil. Logistic regression estimating odds ratios (OR) and 95% confidence intervals (CI) was used to assess the relationship between in-country migration and HIV infection. RESULTS: The prevalence of HIV among TGW was 24.5%, 21.4% among those aged 18-34 and 36.1% among those ≥ 35 years old. In-country migration increased the odds of HIV infection among TGW aged 18-34 years (OR = 1.84; 95%CI:1.04-3.27) and even higher among those aged ≥ 35y old (OR = 3.08; 95%CI:1.18-8.04). CONCLUSIONS: These data reinforce the pressing need for public health policies that provide comprehensive access and strategies for demand creation for HIV/AIDS prevention and care for TGW who are already highly vulnerable to infection.

Adverse effects of daily oral pre-exposure prophylaxis in men who have sex with men and transgender women: a systematic review and meta-analysis.

The adverse effects of oral pre-exposure prophylaxis (PrEP) using tenofovir disoproxil fumarate are barriers to PrEP initiation and continuation. Although serious effects are rare and predictable, evidence for this assessment among men who have sex with men (MSM) and transgender women (TGW) is still limited. This study assesses the adverse effects of daily oral PrEP in MSM and TGW. This is a systematic review and meta-analysis of clinical trials and cohort studies on the use of daily oral PrEP selected from the PubMed/MEDLINE, Embase, LILACS, and Cochrane CENTRAL databases. Data extraction included adverse effects and changes in renal and hepatic markers. Random effects models were used to summarize the risk of adverse effects throughout the study. Heterogeneity was assessed using the Cochran's Q test and the inconsistency test (I2). The risk of bias and the certainty of the evidence were assessed using the Cochrane Collaboration recommendations. The search identified 653 references. Of these, 10 were selected. All studies assessed the eligibility of renal and hepatic markers. The use of daily oral PrEP was not associated with grade 3 or 4 adverse events (RR = 0.99; 95%CI: 0.83-1.18; I2 = 26.1%), any serious adverse event (RR = 1.04; 95%CI: 0.58-1.87; I2 = 88.4%), grade 3+4 creatinine level (RR = 0.66; 95%CI: 0.24-1.84; I2 = 79.9%), and grade 3 or 4 hypophosphatemia (RR = 0.56; 95%CI: 0.15-2.10). The certainty of the evidence ranged from high to moderate for the outcomes analyzed. Daily oral PrEP is safe and well tolerated by MSM and TGW. Adverse effects were minimal and evenly distributed between intervention and control.

Violence, discrimination, and sexual health practices among adolescent men who have sex with men, transgender women and travestis in three cities in Brazil.

The HIV epidemic has a disproportionate impact on adolescent and young men who have sex with men (AMSM) and transgender women and travestis (ATGW), with an increased HIV prevalence over the last 10 years. Violence affects the lives of these populations, undermining their ability to self-care and making them more vulnerable to HIV infection. In this study, we aimed to examine the association between different types of victimization by violence and discrimination and sexual health practices of these adolescent populations in steady and casual relationships. We conducted a cross-sectional study using baseline data from the cohort of PrEP1519 project. We used the mean score of sexual health practices as our outcome and the cumulative score of discrimination (within family, community, education, religious, online and public spaces) and violence (physical, sexual and intimate partner) as our exposure variable. We performed linear regression analyses to estimate the association between exposure and outcome. We found that 90% of AMSM and 95% of ATGW experienced at least one form of violence in the three months prior to this study and about 45% of ATGW suffered sexual violence during the same period. Experiencing discrimination within healthcare settings (from facilities or providers) was negatively associated with sexual health practices. Discrimination and violence negatively affect sexual health practices. HIV prevention and care of AMSM and ATGW people should involve listening to their experiences and addressing discrimination and violence in this population.

HIV epidemic, prevention technologies, and the new generations: trends and opportunities for epidemic response. / Epidemia de HIV, tecnologias de prevenção e as novas gerações: tendências e oportunidades para a resposta à epidemia.

The United Nations has underscored the possibility of ending the HIV epidemic as a public health problem. However, an increase in the incidence among adolescents and youth has indicated a greater distance between HIV responses and the specificities of the new generations, which can maintain the epidemic for an extended period. Regards this matter, it is debated that the provision of a range of preventive methods, even if highly effective, and a conservatism that has internalized stigma within government policies, hinder the proper and essential dialogue between current preventive policies and the needs of the new generations. These generations are marked by a social representation of AIDS as a mild disease, by new gender and sexuality performances, and by the search for a more critical role in affective and sexual encounters, which includes frequent use of dating apps and substances. The hierarchy of the delivery of prevention methods is presented as a proposal for a new policy, prioritizing pre-exposure prophylaxis (PrEP) and addressing the social determinants of the HIV epidemic, including strategies to mitigate stigma. The importance of the participation of adolescents and youth in constructing the policy and the need for an intersectoral response are also reinforced.

A Organização das Nações Unidas tem destacado a possibilidade de eliminar a epidemia de HIV como um problema de saúde pública. Porém, um aumento da incidência em adolescentes e jovens tem indicado um maior distanciamento entre a resposta ao HIV e as especificidades próprias das novas gerações, que pode estender a epidemia por um longo período. Frente a isso, é discutido que a oferta de uma cesta universal de métodos preventivos, mesmo que altamente eficazes, e um conservadorismo que internalizou o estigma em políticas governamentais, inviabilizam o adequado e necessário diálogo entre as atuais políticas preventivas e as necessidades das novas gerações. Estas gerações que são marcadas por uma representação social da aids com menor gravidade; novas performances de gênero e de orientação sexual; e a busca de um maior protagonismo nas interações afetivas e sexuais, o que inclui o uso mais frequente de aplicativos de encontro de parcerias e de substâncias na cena de sexo. É apresentado como proposta de uma nova política a hierarquização da oferta de métodos preventivos, com a priorização da profilaxia pré-exposição (PrEP) e o enfrentamento dos determinantes sociais da epidemia do HIV, incluindo estratégias de redução do estigma. Reforça-se, ainda, a importância da participação de adolescentes e jovens na construção da política e a necessidade de uma resposta intersetorial.

Las Naciones Unidas señalan la posibilidad de eliminar la epidemia del VIH como un problema de salud pública. Sin embargo, un incremento de la incidencia de esta enfermedad en adolescentes y jóvenes muestra una mayor distancia entre la respuesta al VIH y las especificidades de las nuevas generaciones, lo que puede extender la epidemia durante un largo periodo. En este contexto, se discute que la oferta de una canasta universal de métodos preventivos, aunque altamente efectivos, y que un conservadurismo que interiorizó el estigma en las políticas gubernamentales hacen inviable un adecuado y necesario diálogo entre las políticas preventivas actuales y las necesidades de las nuevas generaciones. Estas generaciones están marcadas por una representación social del sida con menos gravedad, por nuevas actuaciones de género y orientación sexual y por la búsqueda de un mayor protagonismo en las interacciones afectivas y sexuales, que incluye el uso más frecuente de aplicaciones para encontrar parejas y de sustancias en la escena sexual. Se presenta como propuesta de una nueva política la priorización de la oferta de métodos preventivos, con la priorización de la profilaxis preexposición (PrEP) y la confrontación de los determinantes sociales de la epidemia del VIH, que incluyen estrategias para reducir el estigma. También refuerza la importancia de la participación de los adolescentes y jóvenes en la construcción de la política y la necesidad de una respuesta intersectorial.

Demand creation and retention strategies for oral pre-exposure prophylaxis for HIV prevention among men who have sex with men and transgender women: a systematic review and meta-analysis.

BACKGROUND: Men who have sex with men (MSM) and transgender women (TGW) have a disproportionately higher risk of human immunodeficiency virus (HIV) infection than other groups. Oral HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool and should be offered to those at higher risk. Identifying demand creation strategies (DCS) and retention strategies (RS) to improve PrEP persistence is essential to control the HIV epidemic. AIM: We aimed to identify the (DCS and RS with higher proportions among MSM and TGW. METHODS: A systematic review and meta-analysis of prospective studies were conducted, with studies retrieved from five databases until November, 2022 following the Cochrane and PRISMA guidelines. The study protocol was registered in PROSPERO (CRD42022323220). The outcomes were DCS and RS for PrEP use among MSM and TGW. Strategies used for users enrolled in the PrEP-recruited (DCS) were classified as face-to-face (peer educator recruitment at social venues, nongovernmental organizations, and parties; direct referrals by health services; friends and/or sexual partners); online (chatbot or peer educator recruitment on social media [e.g., , Instagram or Facebook] or dating/hook-up apps [e.g., Grindr, Tinder, Badoo, and Scruff]); and mixed (face-to-face and online). RS was classified as provider counseling (face-to-face by a health professional; prevention of HIV risk counseling, distribution of condoms, lubricants, and testing for HIV or other sexually transmitted infections); online counseling (text messages, chatbots, telephone calls, social media, and peer educators); and mixed (all previous strategies). Subgroup analyses were conducted for each treatment strategy. Meta-analyses were performed using the R software version 4.2.1. RESULTS: A total of 1, 129 studies were retrieved from the five databases. After eligibility, 46 studies were included. For MSM, most DCS and RS were online at 91% (95% CI: 0.85-0.97; I2=53%), and 83% (95% CI: 0.80-0.85; I2=17%) respectively. For TGW, mixed DCS and RS were the most frequent at85% (95% CI: 0.60-1.00; I2=91%) and online counseling at 84% (95% CI: 0.64-0.95) compared to other strategies. CONCLUSION: Critical issues play. Pivotal role in increasing PrEP awareness among MSM and TGW, minimizing access gaps, and ensuring retention of PrEP services. Offering oral PrEP using online DCS and RS can reach and retain high numbers of MSM and TGW, and reduce HIV incidence in these populations.

When Ethics and the Law Collide: A Multicenter Demonstration Cohort Study of Pre-Exposure Prophylaxis Provision to Adolescent Men Who Have Sex With Men and Transgender Women in Brazil.

PURPOSE: To explore legal and ethical challenges related to adolescents' participation in human immunodeficiency virus (HIV) research that may affect their best interests. METHODS: We analyzed the ethical principles and legal aspects of the participation of 15-17-year-old men who have sex with men and transgender women in the pre-exposure prophylaxis (PrEP) 1519 study, a PrEP demonstration cohort study in three Brazilian cities. The analyses of ethics review committees' (ERCs) evaluations and court decisions followed ethical and human rights principles. An HIV vulnerability score was created, and descriptive statistics and multivariate logistic regression were performed using data from 347 participants. RESULTS: The ERCs evaluated the benefits and risks of research participation, all finding that the benefits outweighed the risks. ERCs deferred responsibility for decisions about waiving parental consent to the judiciary. State courts reached different decisions about waiving parental consent, reflecting variation in recognition of adolescents' evolving capacities and the adolescent as a subject of sexual rights and the primary agent capable of deciding on their health and best interests. The most vulnerable adolescent participants were found in sites where the blanket waiver was in place. DISCUSSION: Judicializing the ethical review process is detrimental to fulfilling the ethical principle of justice and vulnerable adolescents' access to health research. ERCs must be sufficiently independent and autonomous and have the capacity to respect, protect, and help fulfill the rights of participants while ensuring the generation of adequate evidence to inform public health practice.

Violence, Discrimination, and High Levels of Symptoms of Depression Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil.

PURPOSE: This study aimed at describing the prevalence of symptoms of depression among 15-19 year old adolescent men who have sex with men (aMSM) and transgender women (aTGW), who were recruited in an HIV pre-exposure prophylaxis cohort study in three Brazilian capital cities. The study also examined potential associations, including violence and discrimination, with severe symptoms of depression among aMSM. METHODS: This is a cross-sectional study of baseline data among 730 aMSM and 56 aTGW recruited between February 2019 and February 2021. Sociodemographic and behavioral data were collected. The 20-item Center for Epidemiologic Studies Depression scale was used to screen for symptoms of depression. Scores of ≥22 points indicate the presence of severe symptoms associated with major depression. Logistic regression was used to assess independent associations among aMSM, adjusting for sociodemographic variables. RESULTS: Our findings indicate a high prevalence of symptoms of depression (overall prevalence = 58.5% and 69.6%; 21.2% and 25.0% for mild/moderate, and 37.3% and 44.6% for severe) among these aMSM and aTGW, respectively. Psychological violence (aOR = 1.74; 95% CI = 1.12-2.70), sexual violence (aOR = 1.79; 95% CI = 1.07-2.98), and discrimination due to sexual orientation (aOR = 1.71; 95% CI = 1.23-2.38) were independently associated with severe symptoms of depression in aMSM. DISCUSSION: The high prevalence of severe symptoms of depression and its association with psychological and sexual violence and discrimination creates cycles of vulnerability and carries important public health implications. Thus, our findings indicate public policies should consider assessing depression, psychological and sexual violence, as well as discrimination, especially in populations that will be targeted by interventions, such as the use of pre-exposure prophylaxis.

Same-Day Initiation of Oral Pre-Exposure Prophylaxis is High Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil.

PURPOSE: This study analyzed the sociodemographic and behavioral characteristics of adolescent men who have sex with men (aMSM) and transgender women (aTGW) initiating oral pre-exposure prophylaxis (PrEP) in human immunodeficiency virus (HIV) prevention clinics. METHODS: PrEP1519 is a prospective, multicenter, open-label PrEP demonstration cohort study of aMSM and aTGW aged 15-19 years living in three large Brazilian capital cities. For this analysis, we included adolescents who enrolled in PrEP1519 from February 2019 to August 2021. Adolescents who visited PrEP clinics were classified into four groups based on PrEP eligibility and on their decision to use PrEP: (1) ineligible for same-day PrEP initiation; (2) eligible for same-day PrEP initiation, initiated PrEP at first visit; (3) eligible for PrEP initiation, initiated PrEP after the first visit; and (4) eligible for same-day PrEP initiation but declined. The groups that were eligible for same-day PrEP initiation were compared using the Chi-square and Fisher's exact tests. RESULTS: Of the 1,254 adolescents enrolled in the PrEP1519 study, 61 (4.9%) were considered ineligible for same-day PrEP initiation. Of the 1,193 eligible for same-day PrEP initiation, 1,113 (93.3%) initiated PrEP [1,054 initiated PrEP in the first visit (88.3%) and 59 in subsequent visits (4.9%)] and 80 (6.7%) did not. Despite 90% of the PrEP decliners reporting a low risk of HIV infection, most reported condomless anal sex in the past six months (70%). DISCUSSION: Same-day PrEP initiation among aMSM and aTGW was high, highlighting that this strategy was important to promote PrEP initiation among adolescents with increased vulnerability to HIV in Brazil.

Adherence, Safety, and Feasibility of HIV Pre-Exposure Prophylaxis Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil (PrEP1519 Study).

PURPOSE: To evaluate the adherence, safety, and feasibility of pre-exposure prophylaxis (PrEP) in real-world settings among adolescent men who have sex with men (AMSM) and transgender women (ATGW). METHODS: PrEP1519 is a single-arm, multicentric demonstration cohort study of daily oral PrEP among AMSM and ATGW aged 15 to 19 years in Brazil. Study visits occurred at baseline, weeks 4, 12, and then quarterly until 96 weeks. Descriptive statistics and a mixed logistic model for longitudinal data evaluated the factors associated with high adherence. RESULTS: One thousand sixteen AMSM and ATGW accessed the PrEP1519 clinics. Of those, 998 (98.2%) underwent clinical triage. Forty one were diagnosed with human immunodeficiency viruses (HIV) at baseline (4.0%) and 79 (7.9%) were not eligible for PrEP. Of the 878, 795 (90.5%) enrolled in PrEP, 82 (10.3%) were lost to follow-up, and 713 were included. There was no significant decrease in creatinine clearance; only two participants had grade-III aspartate aminotransferase elevation. Incident HIV infection occurred in eight participants (incidence rate [IR] = 1.64 per 100 person-years [PY]): two in 15-17 years (IR = 2.24 per 100 PY) and six in 18-20 years (IR = 1.51 per 100 PY). PrEP adherence was higher among those with more years of schooling, those reporting no difficulties in PrEP use due to side effects, and who had low HIV risk perception in the past three months. DISCUSSION: PrEP for AMSM and ATGW was safe and feasible in real-world settings. However, a higher IR among young adolescents and a higher adherence among less vulnerable people indicate the need for greater care, considering the specificities of this age group.

Oral Pre-Exposure Prophylaxis for HIV Discontinuation in a Large Cohort of Adolescent Men Who Have Sex With Men and Transgender Women in Brazil.

PURPOSE: This study aimed to describe pre-exposure prophylaxis (PrEP) for HIV discontinuation in adolescent men who have sex with men (aMSM) and adolescent transgender women (aTGW) and to identify factors associated with discontinuation. METHODS: The PrEP1519 study included a cohort of aMSM and aTGW aged 15-19 years old, and it was conducted in three large Brazilian capital cities. For this analysis, we included adolescents who initiated PrEP. PrEP discontinuation was defined as no possession of PrEP pills for >90 days. Kaplan-Meier curves were used to analyze the probabilities of discontinuation, and survival distributions stratified by covariates were compared using log-rank or Wilcoxon tests. Cox regression models were used to estimate the adjusted hazard ratio (aHR) with a 95% confidence interval (95% CI). RESULTS: We included 908 adolescents, 829 (91.30%) aMSM and 79 (8.70%) aTGW, most of whom were 18-19 years (80.29%). The incidence rate of discontinuation was 75.6 per 100 person-years. The probability of discontinuation was 52.61% in the first year. The multivariate analysis demonstrated that the aTGW (aHR = 1.63; 95% CI: 1.02-1.64) and adolescents with a medium (aHR = 1.29; 95% CI: 1.02-1.64) or low (aHR = 1.65; 95% CI: 1.29-2.12) perceived risk of HIV infection had an increased risk of discontinuation, whereas the adolescents with a partner living with HIV had a lower risk of discontinuation (aHR = 0.57; 95% CI: 0.35-0.91). DISCUSSION: Adolescents with a high risk for discontinuation may need additional support that emphasizes the value of PrEP as a tool for HIV prevention because PrEP discontinuation was associated with a disconnect between HIV risk perception and HIV prevention.