Are Rights-Based Services Important? An Adolescent PrEP Demonstration Project in Brazil.

In this study, we systematically examined the importance of human rights standards and principles for rights-based pre-exposure prophylaxis (PrEP) provision for marginalized adolescents. Nested within a demonstration study of PrEP provision to adolescent men who have sex with men, travestis, and transgender women, we carried out interviews in São Paulo, Brazil with 25 adolescents, eight health providers, and six workers involved in community-based demand creation. Analysis focused on participants' narratives about aspects of human rights within service delivery, including the availability, accessibility, acceptability, and quality of services; informed decision-making; nondiscrimination; and privacy and confidentiality. Clients and service providers highlighted the importance of availing a range of services beyond PrEP and described how community outreach and social media helped promote accessibility. Acceptability centered around clients feeling heard and respected. Health workers appreciated having time to build trusting relationships with clients to ensure quality of care and support informed decision-making. Nondiscrimination was valued by all, including using clients' chosen pronouns. Privacy and confidentiality were primary concerns for clients who were not "out" about their sexuality or PrEP use; to mitigate this, health workers sought to accommodate clients' preferred channels of communication. Rights-based PrEP services can help promote engagement and retention in PrEP services, particularly for marginalized populations.

Preparing for future pandemics while responding to the current ones in the midst of a planetary climate crisis: Can we face this triple global health challenge?

Global health faces the triple challenge of preparing for future pandemics while responding to current ones in the midst of a climate crisis. In this commentary, we discuss the heightened focus on pandemic preparedness after the COVID-19 pandemic and the risks that this may pose to addressing the elimination of AIDS, tuberculosis, hepatitis and malaria, established in the Sustainable Development Goals as target 3.3. Considering their interconnections with the climate crisis and advocating for global health justice, we identify impasses that such a dispute over priorities can imply, and comment on four fronts of actions that could contribute convergently to both agendas as well as to facing the consequences of climate change to health: strengthening health systems, global commitment to equitable access to strategic medicines, addressing social inequalities and joining efforts for health and climate justice We conclude that addressing these fronts safeguards the health rights of the most vulnerable to existing epidemics while enhancing readiness for future pandemics. Moreover, solutions must transcend technocratic approaches, necessitating the confrontation of inequalities perpetuated by systems of power and privilege fueling both health and climate crises. Ultimately, health justice should guide responses to this intricate triple global health challenge.

"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.

"It was unusual but amazing": demand creation for PrEP among adolescents' men who have sex with men (MSM) and transgender women (TGW) in Brazil / "Foi inusitado, mas surpreendente": criação de demanda por PrEP entre homens adolescentes que fazem sexo com homens (HSH) e mulheres trans (MT) no Brasil / "Fue inusual, pero sorprendente": la creación de demanda por PrEP entre hombres adolescentes que tienen sexo con hombres (HSH) y mujeres trans (MT) en Brasil

Abstract: 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.

Resumo: Este estudo analisou desafios na criação de demanda para participação em um projeto de profilaxia pré-exposição (PrEP) ao HIV em duas capitais brasileiras. Trata-se de um estudo qualitativo realizado com homens que fazem sexo com homens e mulheres transgênero de 15 a 19 anos residentes de duas capitais brasileiras. Para esta análise, foram avaliadas 27 entrevistas semiestruturadas realizadas entre 2019 e 2020 com análise temática de conteúdo reflexiva. Para os participantes, a criação de demanda por PrEP foi essencial para o processo de interação, mediação, vínculo e apego e mostrou-se eficaz para a aceitabilidade e adesão à PrEP. As narrativas dos adolescentes mostraram que as estratégias promoveram a prevenção combinada do HIV, abriram oportunidades para reuniões de recrutamento, ajudaram a negociar e convencer os indivíduos a usar a PrEP, fortaleceram a educação entre pares e evocaram um sentimento de "estar com" e "caminhar juntos", apesar dos desafios. As interações, sejam presenciais ou online, com o uso de tecnologias sociais, desempenharam um papel crucial no recrutamento de adolescentes para o projeto, na ampliação do conhecimento sobre PrEP e demais estratégias combinadas de prevenção, e no acesso a serviços de saúde e autocuidado.

Resumen: Este estudio analizó los desafíos para crear demanda para la participación en un proyecto de profilaxis pre-exposición (PrEP) al VIH en dos capitales brasileñas. Se trata de un estudio cualitativo realizado con hombres que tienen sexo con hombres y mujeres transgénero de 15 a 19 años residentes de dos capitales brasileñas. Para este análisis, se evaluaron 27 entrevistas semiestructuradas realizadas entre 2019 y 2020 con un análisis temático de contenido reflexivo. Para los participantes, crear la demanda por PrEP fue fundamental para el proceso de interacción, mediación, vínculo y apego y demostró ser eficaz para la aceptabilidad y adhesión de la PrEP. Los relatos de los adolescentes mostraron que las estrategias promovieron la prevención combinada del VIH, posibilitaron reuniones de reclutamiento, ayudaron a negociar y convencer a las personas a usar la PrEP, fortalecieron la educación entre pares y evocaron un sentimiento de "estar con" y "caminar juntos", a pesar de los desafíos. Las interacciones, ya sean de manera presencial o online, con el uso de las tecnologías sociales, tuvieron un papel fundamental en el reclutamiento de adolescentes para el proyecto, en la ampliación del conocimiento sobre la PrEP y las demás estrategias de prevención combinadas, y en el acceso a servicios de salud y autocuidado.

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.

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.

A Transgender Chatbot (Amanda Selfie) to Create Pre-exposure Prophylaxis Demand Among Adolescents in Brazil: Assessment of Acceptability, Functionality, Usability, and Results.

BACKGROUND: HIV incidence rates have increased in adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW). Thus, it is essential to promote access to HIV prevention, including pre-exposure prophylaxis (PrEP), among these groups. Moreover, using artificial intelligence and online social platforms to create demand and access to health care services are essential tools for adolescents and youth. OBJECTIVE: This study aims to describe the participative process of developing a chatbot using artificial intelligence to create demand for PrEP use among AMSM and ATGW in Brazil. Furthermore, it analyzes the chatbot's acceptability, functionality, and usability and its results on the demand creation for PrEP. METHODS: The chatbot Amanda Selfie integrates the demand creation strategies based on social networks (DCSSNs) of the PrEP1519 study. She was conceived as a Black transgender woman and to function as a virtual peer educator. The development process occurred in 3 phases (conception, trial, and final version) and lasted 21 months. A mixed methodology was used for the evaluations. Qualitative approaches, such as in-depth adolescent interviews, were used to analyze acceptability and usability, while quantitative methods were used to analyze the functionality and result of the demand creation for PrEP based on interactions with Amanda and information from health care services about using PrEP. To evaluate Amanda's result on the demand creation for PrEP, we analyzed sociodemographic profiles of adolescents who interacted at least once with her and developed a cascade model containing the number of people at various stages between the first interaction and initiation of PrEP (PrEP uptake). These indicators were compared with other DCSs developed in the PrEP1519 study using chi-square tests and residual analysis (P=.05). RESULTS: Amanda Selfie was well accepted as a peer educator, clearly and objectively communicating on topics such as gender identity, sexual experiences, HIV, and PrEP. The chatbot proved appropriate for answering questions in an agile and confidential manner, using the language used by AMSM and ATGW and with a greater sense of security and less judgment. The interactions with Amanda Selfie combined with a health professional were well evaluated and improved the appointment scheduling. The chatbot interacted with most people (757/1239, 61.1%) reached by the DCSSNs. However, when compared with the other DCSSNs, Amanda was not efficient in identifying AMSM/ATGW (359/482, 74.5% vs 130/757, 17.2% of total interactions, respectively) and in PrEP uptake (90/359, 25.1% vs 19/130, 14.6%). The following profiles were associated (P<.001) with Amanda Selfie's demand creation, when compared with other DCS: ATGW and adolescents with higher levels of schooling and White skin color. CONCLUSIONS: Using a chatbot to create PrEP demand among AMSM and ATGW was well accepted, especially for ATGW with higher levels of schooling. A complimentary dialog with a health professional increased PrEP uptake, although it remained lower than the results of the other DCSSNs.

Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil.

At the end of 2017, Brazil adopted HIV pre-exposure prophylaxis (PrEP) as part of a combination prevention strategy for the most at-risk populations. However, Brazil does not have specific guidelines for PrEP use among adolescents aged < 18 years. Therefore, researchers from different health disciplines conducted PrEP1519, the first PrEP demonstration cohort study, ongoing in three Brazilian cities - Salvador, Belo Horizonte, and São Paulo - among adolescent men who have sex with men and transgender women, aged 15-19 years. This study aims to evaluate the effectiveness of PrEP in real-world settings. Quantitative and qualitative methods were integrated to obtain data on PrEP acceptability, uptake, use, and adherence. Moreover, comprehensive services and friendly environments were implemented in the PrEP1519 clinics. This study aims to describe the collaborative efforts of interdisciplinary practices in the development of the PrEP1519 study. The articulation of researchers from different institutions and areas is challenging; but it also allows for a broader outlook on questions regarding the direction of the research, while enriching the decisions needed to be taken during the interactions and negotiations among the different individuals, including the youth team and participants. Furthermore, it reflects on the communication process between cultures and languages considering the trans-epistemic arena of knowledge production about HIV, sexually transmitted infections, PrEP, and other combination prevention strategies for adolescents.

Use of HIV prevention methods and contexts of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women in São Paulo, Brazil.

We aimed to understand the perspective and use of HIV prevention methods in context of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women (TGW). In-depth interviews and focus group discussions were conducted with 22 adolescent gay and bisexual men, travestis, and TGW aged between 15 and 19 years in São Paulo, Brazil, as part of the formative research of the PrEP1519 study, an ongoing daily oral pre-exposure prophylaxis (PrEP) demonstration study among adolescents. Participants' knowledge repertoire about prevention methods and their experience with them concentrated on condoms, which were regarded as the most well-known, "compulsory" practice, whose use was an individual responsibility. Prior HIV/STI testing was reported by a few participants as a measure to decide to discontinue condom use in stable relationships, whereas seeking testing after condomless sex was an attempt to repair a "failure" in prevention. The importance of commercial sex was striking among TGW and travestis, in which condom use often depended on clients' decision, and drug use and risk of violence hindered decision-making and self-care. Adolescents showed little knowledge, frequent confusion, and no experience with post-exposure prophylaxis and PrEP. An incipient appropriation of the diversity of prevention methods and a rigid normativity about the use of condoms are key drivers in adolescents' perception and use of HIV prevention methods. Adolescents' risk management seems to be restricted in terms of their autonomy and ability to assess exposure across contexts, failing to include antiretroviral-based (ARV) methods, thus requiring tailored and context-sensitive strategies for an effective combination prevention approach.

Aceitabilidade ao autoteste de HIV entre adolescentes Homens que fazem Sexo com Homens, travestis e mulheres transexuais em três capitais brasileiras / Acceptability of HIV self-test among adolescent Men who have Sex with Men, travestis and transgender women in Brazil

RESUMO Introdução: O objetivo deste estudo é analisar a aceitabilidade do autoteste de HIV entre adolescentes Homens que fazem Sexo com Homens e mulheres travestis e transexuais em três capitais brasileiras. Método: estudo qualitativo, com 6 Grupos Focais e 37 Entrevistas em profundidade, envolvendo 58 participantes, nas cidades de Belo Horizonte, Salvador e São Paulo, cuja análise temática de conteúdo orientou-se pelo Theoretical Framework of Acceptability. Resultados: boa aceitabilidade do autoteste de HIV, ainda que não homogênea entre participantes. Entre os aspectos positivos dos testes estão, por exemplo, a agilidade, a privacidade, a autonomia no monitoramento da própria saúde e a gestão emocional e de estigma. Em outra direção tem-se a preocupação em como lidar com um eventual resultado reagente e o questionamento do autoteste como estratégia de prevenção. O local de dispensação do autoteste é decisivo para potencializar ou não o uso, a depender da competência cultural para acolher a diversidade sexual e de identidade de gênero de adolescentes. Conclusão: Este estudo identificou o autoteste de HIV como uma estratégia fundamental para o incremento da autonomia e autocuidado entre adolescentes. Estas devem ser consideradas para maior adequação às culturas juvenis locais e, consequentemente, maior adesão à testagem.

ABSTRACT Introduction: The objective of this study is to analyze the acceptability of the HIV self-test among male adolescents who have sex with male and transgender women in three Brazilian capitals. Method: qualitative study, with 6 focus groups and 37 in-depth interviews with 58 participants, from the cities of Belo Horizonte, Salvador and São Paulo, whose thematic analysis was based on the Theoretical Framework of Acceptability. Results: the HIV self-test had good acceptability, although it was not homogeneous among participating adolescents. Positive aspects include, for example, agility, privacy, autonomy, monitoring one's health, and emotional and stigma management. In another direction are concerns about how to deal with an eventual reactive result and whether self-testing is a prevention strategy. The place where self-tests are given out is decisive to improving their use, which depends on cultural competence to accommodate sexual and gender diversities of adolescents. Conclusion: This study has shown that HIV self-testing is a fundamental strategy to increase adolescent autonomy and self-care. These should be considered to better adapt the test to local youth cultures and, consequently, achieve better compliance.

Seroprevalence of anti-SARS-CoV-2 antibodies and factors associated with infection among adolescent men who have sex with men and transgender women in Salvador, Brazil.

BACKGROUND: Brazil was strongly affected by the COVID-19 pandemic and the impact of the pandemic on sexual and gender minorities' youth remains unknown. This study aimed to estimate the seroprevalence of SARS-CoV-2 antibodies and associated factors among adolescent men who have sex with men (AMSM) and transgender women (ATGW) participants of a human immunodeficiency virus (HIV) pre-exposure prophylaxis cohort study (PrEP1519). METHODS: This is a cross-sectional design conducted between June and October 2020 in Salvador, Brazil. Serum samples were collected from AMSM and ATGW aged 16-21 years between June-October 2020. IgG and IgM anti-SARS-CoV-2 were detected by chemiluminescence immunoassay, and data were collected through a socio-behavioral questionnaire. RESULTS: Among the 137 participants, the seroprevalence of anti-SARS-CoV-2 IgG and IgM was 20.4%; 16.8% of the participants were positive for IgG, and 11.7% for IgM. In the multivariable analysis, the seroprevalence was two times higher among those who never wore masks (OR= 2.22; 95% CI: 1.08-4.57) and among those who believed that they could be easily cured of the disease (OR= 2.05; 95% CI: 1.05-4.01). CONCLUSIONS: The high seroprevalence of SARS-CoV-2 antibodies among gender and sexual minority youth seems to be informed by behaviors and attitudes that contrast with public health measures and the potential severity of the disease when vaccination was still not available.

Reaching Out to Adolescents at High Risk of HIV Infection in Brazil: Demand Creation Strategies for PrEP and Other HIV Combination Prevention Methods.

Using baseline data from the PrEP1519 cohort, in this article we aimed to analyze: (i) the effectiveness of demand creation strategies (DCS) to enroll adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW) into an HIV combination prevention study in Brazil; (ii) the predictors of DCS for adolescents' enrollment; and (iii) the factors associated with DCS by comparing online and face-to-face strategies for enrollment. The DCS included peer recruitment (i.e., online and face-to-face) and referrals from health services and non-governmental organizations (NGOs). AMSM and ATGW who agreed to participate in the study could opt to enroll in either PrEP (PrEP arm) or to use other prevention methods (non-PrEP arm). Bivariate and multivariate analyses were conducted and logistic regression odds ratios were estimated. The DCS reached 4529 AMSM and ATGW, the majority of which were derived online (73.8%). Of this total, 935 (20.6%) enrolled to participate (76.6% in PrEP arm and 23.4% in non-PrEP arm). The effectiveness of enrolling adolescents into both arms was greater via direct referrals (235/382 and 84/382, respectively) and face-to-face peer recruitment (139/670 and 35/670, respectively) than online (328/3342). We found that a combination under DCS was required for successful enrollment in PrEP, with online strategies majorly tending to enroll adolescents of a higher socioeconomic status. Our findings reinforce the need for DCS that actively reaches out to all adolescents at the greatest risk for HIV infection, irrespective of their socioeconomic status.

"I Can't Take This Shitty Quarantine Anymore": Sexual Behavior and PrEP Use Among Young Men Who Have Sex with Men and Transgender Women in Brazil During the COVID-19 Pandemic.

This study analyzes how the COVID-19 pandemic affected sexual behavior and use of HIV prevention methods among young transgender women (YTGW) and young gay, bisexual and other men who have sex with men (YGBMSM) participating in an HIV pre-exposure prophylaxis (PrEP) demonstration study in Brazil. Online interviews with 39 participants aged 15-22 years old were conducted between September and November 2020 and analyzed based on social constructionism and human rights-based approaches to health. The pandemic disrupted interviewees' routines, negatively affecting their life conditions. Among those who did not have a steady partner, social distance measures led to temporary interruption of sexual encounters and increased sexting and solo sex. Conversely, for those who had a steady relationship such measures contributed to increasing sexual practices and intimacy. Participants who had sexual encounters during the pandemic reported having continued to use PrEP. However, home confinement with family, lack of privacy, loss of daily routines and changes in housing impaired PrEP adherence and attendance at follow-up consultations. These results highlight the importance of maintaining HIV-service delivery for these groups during a public health crisis, as well as to address the structural drivers of the epidemic with comprehensive HIV prevention policies and by ensuring access of YGBMSM and YTGW to social protection policies.

Epidemia de HIV, tecnologias de prevenção e as novas gerações: tendências e oportunidades para a resposta à epidemia / Epidemia del VIH, tecnologías de prevención y las nuevas generaciones: tendencias y oportunidades para responder a la epidemia / HIV epidemic, prevention technologies, and the new generations: trends and opportunities for epidemic response

Resumo: 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.

Resumen: 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.

Abstract: 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.

Use of HIV prevention methods and contexts of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women in São Paulo, Brazil / O uso de métodos de prevenção do HIV e o contexto das práticas sexuais de adolescentes homens gays e bissexuais, travestis e mulheres transgênero na cidade de São Paulo, Brasil / Uso de métodos de prevención del VIH y contextos de prácticas sexuales de adolescentes gays y hombres bisexuales, travestis y mujeres transgénero en São Paulo, Brasil

We aimed to understand the perspective and use of HIV prevention methods in context of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women (TGW). In-depth interviews and focus group discussions were conducted with 22 adolescent gay and bisexual men, travestis, and TGW aged between 15 and 19 years in São Paulo, Brazil, as part of the formative research of the PrEP1519 study, an ongoing daily oral pre-exposure prophylaxis (PrEP) demonstration study among adolescents. Participants' knowledge repertoire about prevention methods and their experience with them concentrated on condoms, which were regarded as the most well-known, "compulsory" practice, whose use was an individual responsibility. Prior HIV/STI testing was reported by a few participants as a measure to decide to discontinue condom use in stable relationships, whereas seeking testing after condomless sex was an attempt to repair a "failure" in prevention. The importance of commercial sex was striking among TGW and travestis, in which condom use often depended on clients' decision, and drug use and risk of violence hindered decision-making and self-care. Adolescents showed little knowledge, frequent confusion, and no experience with post-exposure prophylaxis and PrEP. An incipient appropriation of the diversity of prevention methods and a rigid normativity about the use of condoms are key drivers in adolescents' perception and use of HIV prevention methods. Adolescents' risk management seems to be restricted in terms of their autonomy and ability to assess exposure across contexts, failing to include antiretroviral-based (ARV) methods, thus requiring tailored and context-sensitive strategies for an effective combination prevention approach.

O estudo teve como objetivo compreender a perspectiva e o uso de métodos de prevenção do HIV no contexto das práticas sexuais de homens gays e bissexuais, travestis e mulheres transgênero adolescentes. Foram realizados grupos focais e entrevistas em profundidade com 22 adolescentes gays e bissexuais, travestis e mulheres transgênero entre 15 e 19 anos de idade na cidade de São Paulo, Brasil, como parte da pesquisa formativa do estudo PrEP1519, um estudo de demonstração, em andamento, sobre profilaxia pré-exposição (PrEP) diária em adolescentes. O repertório de conhecimentos e a experiência dos participantes com métodos de prevenção estiveram concentrados no preservativo, visto como a prática mais conhecida, "compulsória", e cujo uso era da responsabilidade do indivíduo. Testagem prévia para ISTs/HIV era relatada por alguns participantes enquanto medida para decidir sobre a descontinuação do uso de preservativos em relações estáveis, enquanto a busca de testagem depois de sexo sem preservativo aparecia como uma tentativa de reparar uma "falha" na prevenção. O sexo comercial figurava de maneira importante entre as mulheres transgênero e travestis, em que o uso de preservativo muitas vezes dependia da decisão do cliente, e o uso de drogas e o risco de violência dificultavam o processo de decisão e o autocuidado. Os adolescentes demonstravam pouco conhecimento, confusão frequente e nenhuma experiência com a profilaxia pós-exposição sexual (PEP) e a PrEP. Fatores chave na percepção e no uso dos métodos de prevenção do HIV por adolescentes incluem uma apropriação incipiente da gama de métodos de prevenção e uma normatividade rígida quanto ao uso de preservativos. O manejo do risco pelos adolescentes parece estar limitada em termos da autonomia e capacidade de avaliar a exposição em diferentes contextos, e deixa de incluir métodos baseados em antirretrovirais; assim, exige estratégias customizadas e sensíveis ao contexto para uma abordagem efetiva de prevenção combinada.

El objetivo del trabajo fue comprender la perspectiva y el uso de los métodos de prevención del VIH en el contexto de prácticas sexuales de adolescentes gays y bisexuales, travestis y mujeres transgénero (TGW). Se organizaron debates y grupos de discusión en profundidad con 22 adolescentes gais y hombres bisexuales, travestis y TGW con edades entre 15 y 19 años en São Paulo, Brasil, como parte de la investigación formativa del estudio PrEP1519, un estudio experimental diario en curso sobre profilaxis preexposición (PrEP) entre adolescentes. El repertorio de conocimiento de los participantes sobre lo anterior y su experiencia con métodos de prevención se concentró en los condones, siendo considerada como la mejor práctica conocida, "obligatoria", y cuyo uso era de responsabilidad individual. Algunos mencionaron pruebas previas de VIH/ETS, como medida para decidir suspender el uso del condón en relaciones estables, mientras que la búsqueda de pruebas tras el sexo sin condón fue un intento de arreglar un "fallo" en la prevención. El sexo comercial fue importante entre TGW y travestis, en donde el uso del condón a menudo dependía de la decisión del cliente, así como el consumo de drogas y riesgo de violencia convertían en algo más complicado la toma de decisiones y el autocuidado. Los adolescentes mostraron poco conocimiento, una frecuente confusión y no tener experiencia con la profilaxis posexposición (PEP) y PrEP para el VIH. Una incipiente apropiación de la diversidad de los métodos de prevención y una rígida normatividad sobre el uso de condones son factores clave en la percepción y uso de métodos de prevención VIH por parte de los adolescentes. La gestión del riesgo por los adolescentes parece estar restringida en términos de su autonomía y habilidad para evaluar la exposición a través de contextos y limitaciones para incluir métodos basados en ARV, por lo tanto se requieren estrategias a medida y sensibles con el contexto para un enfoque combinado de prevención.

Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil / Interdisciplinaridade na pesquisa sobre prevenção do HIV: a experiência do protocolo de estudo PrEP1519 entre HSH adolescentes e mulheres trans no Brasil / Interdisciplinariedad en la investigación de la prevención del VIH: la experiencia del protocolo de estudio PrEP1519 entre adolescentes HSH y TGW en Brasil

At the end of 2017, Brazil adopted HIV pre-exposure prophylaxis (PrEP) as part of a combination prevention strategy for the most at-risk populations. However, Brazil does not have specific guidelines for PrEP use among adolescents aged < 18 years. Therefore, researchers from different health disciplines conducted PrEP1519, the first PrEP demonstration cohort study, ongoing in three Brazilian cities - Salvador, Belo Horizonte, and São Paulo - among adolescent men who have sex with men and transgender women, aged 15-19 years. This study aims to evaluate the effectiveness of PrEP in real-world settings. Quantitative and qualitative methods were integrated to obtain data on PrEP acceptability, uptake, use, and adherence. Moreover, comprehensive services and friendly environments were implemented in the PrEP1519 clinics. This study aims to describe the collaborative efforts of interdisciplinary practices in the development of the PrEP1519 study. The articulation of researchers from different institutions and areas is challenging; but it also allows for a broader outlook on questions regarding the direction of the research, while enriching the decisions needed to be taken during the interactions and negotiations among the different individuals, including the youth team and participants. Furthermore, it reflects on the communication process between cultures and languages considering the trans-epistemic arena of knowledge production about HIV, sexually transmitted infections, PrEP, and other combination prevention strategies for adolescents.

No final de 2017, Brasil adotou a profilaxia pré-exposição do HIV (PrEP) como parte de uma estratégia de prevenção combinada para as populações com maior risco de infecção. Entretanto, o país não dispõe de diretrizes específicas para o uso da PrEP entre adolescentes abaixo de 18 anos de idade. Assim, pesquisadores de diferentes disciplinas de saúde realizaram o PrEP1519, o primeiro estudo de coorte de demonstração da PrEP, atualmente em andamento em três cidades brasileiras - Salvador, Belo Horizonte e São Paulo - entre homens adolescentes que fazem sexo com homens e mulheres transgênero, entre 15 e 19 anos de idade. O estudo busca avaliar a efetividade da PrEP em contextos da vida real. Foram integrados métodos quantitativos e qualitativos para obter dados sobre a aceitabilidade, adoção, uso e adesão à PrEP. Além disso, foram implementados serviços integrados e ambientes acolhedores nas clínicas PrEP1519. O estudo busca descrever os esforços colaborativos das práticas interdisciplinares no desenvolvimento do estudo PrEP1519. A articulação de pesquisadores de diferentes instituições e áreas representa um desafio, mas permite um olhar mais abrangente sobre questões relativas à direção da pesquisa, ao mesmo tempo em que enriquece as decisões necessárias durante as interações e negociações entre diferentes indivíduos, inclusive a equipe de jovens e os participantes. Além disso, reflete o processo de comunicação entre culturas e linguagens, considerando a arena trans-epistêmica da produção de conhecimento sobre HIV, infecções sexualmente transmissíveis, PrEP e outras estratégias de prevenção combinada para adolescentes.

A finales de 2017, Brasil adoptó la profilaxis previa a la exposición al VIH (PrEP) como parte de una estrategia de prevención combinada para las poblaciones de mayor riesgo. Sin embargo, Brasil no tiene directrices específicas para el uso de la PrEP entre los adolescentes < 18 años. Por lo tanto, investigadores de diferentes disciplinas sanitarias llevaron a cabo el PrEP1519, el primer estudio de cohorte de demostración de la PrEP, en curso en tres ciudades brasileñas -Salvador, Belo Horizonte y São Paulo- entre hombres adolescentes que tienen relaciones con hombres y mujeres transexuales, de entre 15 y 19 años. El objetivo de este estudio es evaluar la eficacia de la PPrE en entornos reales. Se integraron métodos cuantitativos y cualitativos para obtener datos sobre la aceptabilidad, la aceptación, el uso y la adherencia de la PrEP. Además, se implementaron servicios integrales y entornos amigables en las clínicas de PrEP1519. Este estudio pretende describir los esfuerzos de colaboración de las prácticas interdisciplinarias en el desarrollo del estudio PrEP1519. La articulación de investigadores de diferentes instituciones y áreas supone un reto; pero también permite ampliar la visión de las cuestiones relativas a la dirección de la investigación, a la vez que enriquece las decisiones que debían tomarse durante las interacciones y negociaciones entre los diferentes individuos, incluyendo el equipo de jóvenes y los participantes. Además, reflexiona sobre el proceso de comunicación entre culturas y lenguas teniendo en cuenta el ámbito trans-epistémico de la producción de conocimiento sobre el VIH, las infecciones de transmisión sexual, la PrEP y otras estrategias de prevención combinada para adolescentes.

Use of HIV prevention methods and contexts of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women in São Paulo, Brazil / O uso de métodos de prevenção do HIV e o contexto das práticas sexuais de adolescentes homens gays e bissexuais, travestis e mulheres transgênero na cidade de São Paulo, Brasil / Uso de métodos de prevención del VIH y contextos de prácticas sexuales de adolescentes gays y hombres bisexuales, travestis y mujeres transgénero en São Paulo, Brasil

We aimed to understand the perspective and use of HIV prevention methods in context of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women (TGW). In-depth interviews and focus group discussions were conducted with 22 adolescent gay and bisexual men, travestis, and TGW aged between 15 and 19 years in São Paulo, Brazil, as part of the formative research of the PrEP1519 study, an ongoing daily oral pre-exposure prophylaxis (PrEP) demonstration study among adolescents. Participants' knowledge repertoire about prevention methods and their experience with them concentrated on condoms, which were regarded as the most well-known, "compulsory" practice, whose use was an individual responsibility. Prior HIV/STI testing was reported by a few participants as a measure to decide to discontinue condom use in stable relationships, whereas seeking testing after condomless sex was an attempt to repair a "failure" in prevention. The importance of commercial sex was striking among TGW and travestis, in which condom use often depended on clients' decision, and drug use and risk of violence hindered decision-making and self-care. Adolescents showed little knowledge, frequent confusion, and no experience with post-exposure prophylaxis and PrEP. An incipient appropriation of the diversity of prevention methods and a rigid normativity about the use of condoms are key drivers in adolescents' perception and use of HIV prevention methods. Adolescents' risk management seems to be restricted in terms of their autonomy and ability to assess exposure across contexts, failing to include antiretroviral-based (ARV) methods, thus requiring tailored and context-sensitive strategies for an effective combination prevention approach.

O estudo teve como objetivo compreender a perspectiva e o uso de métodos de prevenção do HIV no contexto das práticas sexuais de homens gays e bissexuais, travestis e mulheres transgênero adolescentes. Foram realizados grupos focais e entrevistas em profundidade com 22 adolescentes gays e bissexuais, travestis e mulheres transgênero entre 15 e 19 anos de idade na cidade de São Paulo, Brasil, como parte da pesquisa formativa do estudo PrEP1519, um estudo de demonstração, em andamento, sobre profilaxia pré-exposição (PrEP) diária em adolescentes. O repertório de conhecimentos e a experiência dos participantes com métodos de prevenção estiveram concentrados no preservativo, visto como a prática mais conhecida, "compulsória", e cujo uso era da responsabilidade do indivíduo. Testagem prévia para ISTs/HIV era relatada por alguns participantes enquanto medida para decidir sobre a descontinuação do uso de preservativos em relações estáveis, enquanto a busca de testagem depois de sexo sem preservativo aparecia como uma tentativa de reparar uma "falha" na prevenção. O sexo comercial figurava de maneira importante entre as mulheres transgênero e travestis, em que o uso de preservativo muitas vezes dependia da decisão do cliente, e o uso de drogas e o risco de violência dificultavam o processo de decisão e o autocuidado. Os adolescentes demonstravam pouco conhecimento, confusão frequente e nenhuma experiência com a profilaxia pós-exposição sexual (PEP) e a PrEP. Fatores chave na percepção e no uso dos métodos de prevenção do HIV por adolescentes incluem uma apropriação incipiente da gama de métodos de prevenção e uma normatividade rígida quanto ao uso de preservativos. O manejo do risco pelos adolescentes parece estar limitada em termos da autonomia e capacidade de avaliar a exposição em diferentes contextos, e deixa de incluir métodos baseados em antirretrovirais; assim, exige estratégias customizadas e sensíveis ao contexto para uma abordagem efetiva de prevenção combinada.

El objetivo del trabajo fue comprender la perspectiva y el uso de los métodos de prevención del VIH en el contexto de prácticas sexuales de adolescentes gays y bisexuales, travestis y mujeres transgénero (TGW). Se organizaron debates y grupos de discusión en profundidad con 22 adolescentes gais y hombres bisexuales, travestis y TGW con edades entre 15 y 19 años en São Paulo, Brasil, como parte de la investigación formativa del estudio PrEP1519, un estudio experimental diario en curso sobre profilaxis preexposición (PrEP) entre adolescentes. El repertorio de conocimiento de los participantes sobre lo anterior y su experiencia con métodos de prevención se concentró en los condones, siendo considerada como la mejor práctica conocida, "obligatoria", y cuyo uso era de responsabilidad individual. Algunos mencionaron pruebas previas de VIH/ETS, como medida para decidir suspender el uso del condón en relaciones estables, mientras que la búsqueda de pruebas tras el sexo sin condón fue un intento de arreglar un "fallo" en la prevención. El sexo comercial fue importante entre TGW y travestis, en donde el uso del condón a menudo dependía de la decisión del cliente, así como el consumo de drogas y riesgo de violencia convertían en algo más complicado la toma de decisiones y el autocuidado. Los adolescentes mostraron poco conocimiento, una frecuente confusión y no tener experiencia con la profilaxis posexposición (PEP) y PrEP para el VIH. Una incipiente apropiación de la diversidad de los métodos de prevención y una rígida normatividad sobre el uso de condones son factores clave en la percepción y uso de métodos de prevención VIH por parte de los adolescentes. La gestión del riesgo por los adolescentes parece estar restringida en términos de su autonomía y habilidad para evaluar la exposición a través de contextos y limitaciones para incluir métodos basados en ARV, por lo tanto se requieren estrategias a medida y sensibles con el contexto para un enfoque combinado de prevención.