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.

Zero knowledge and high interest in the use of long-acting injectable pre-exposure prophylaxis (PrEP) among adolescent men who have sex with men and transgender women in two capital cities in Brazil.

BACKGROUND: Adolescent men who have sex with men (aMSM) and transgender women (aTGW) are affected disproportionately by human immunodeficiency virus (HIV) infection. Although new methods of pre-exposure prophylaxis (PrEP), such as long-acting injectable (LAI-PrEP), have been approved by the Food and Drug Administration, their acceptability among aMSM/aTGW is not well known. METHODS: Forty-eight semi-structured interviews were conducted to assess the knowledge and interest in LAI-PrEP among aMSM/aTGW enrolled in a daily oral PrEP cohort from two capital cities of Brazil since 2019. RESULTS: Previous knowledge of LAI-PrEP remains scarce, but the high interest regarding its use has been reported. Interest in the use of LAI-PrEP is associated with eliminating the burden of daily responsibility or the risk of missing the necessary medications, lowering the costs of this method, increasing confidentiality, and decreasing the frequency of visiting PrEP clinics. The reported barriers to uptake included fear of injection, doubts on its effectiveness, side effects, and greater dependence on a health provider. CONCLUSIONS: There is an urgent need to strengthen the preventive strategies against HIV infection among the youth, enhance their knowledge and those of healthcare providers, and offer safe and new options.

Acceptability of daily pre-exposure prophylaxis among adolescent men who have sex with men, travestis and transgender women in Brazil: A qualitative study.

BACKGROUND: Adolescents face socio-structural, personal and programmatic barriers to HIV prevention services, highlighting the importance of understanding knowledge and acceptability as essential aspects to promote their broader access to pre-exposure prophylaxis (PrEP). We analyzed the acceptability of PrEP among adolescent men who have sex with men (MSM), travestis and transgender women (TGW). METHODS: A qualitative investigation was conducted as part of the formative research of the PrEP15-19 study, an ongoing demonstration study that analyzes the effectiveness of daily PrEP among adolescent MSM, travestis and TGW aged 15-19 in three Brazilian cities. A total of 37 semi-structured interviews and 6 focus groups were conducted. Building from thematic analysis focusing on participants' sexual encounters, perceptions about PrEP efficacy, and vulnerability contexts, we analyzed prospective acceptability of PrEP. FINDINGS: Knowledge about PrEP was incipient and characterized by adolescents' frequent doubts about its prescription and efficacy. The 'ideal' use of PrEP appeared together with consistent condom use, especially in casual sex. PrEP use was also mentioned as depending on increased learning about prevention management over time. Main barriers to PrEP use included the incorporation of a daily medication into participants' routine and its impact on their social lives, especially related to stigma. Concerns over short- and long-term side effects were also reported as barriers to PrEP use. TGW and travestis contrasted using PrEP with the precarity of their life conditions, and some expressed a critical vision about PrEP by associating it with pharmaceuticalization and trans necropolitics. CONCLUSIONS: Participants' low knowledge and acceptability of PrEP are circumscribed by a rigid perception of condom as the ideal prevention method and the context of their sexual relations. Prospective acceptability highlights that the successful uptake of PrEP depends on overcoming barriers of access to health services and confronting transphobia and homophobia as part of care.

Indigenous engagement in health: lessons from Brazil, Chile, Australia and New Zealand.

BACKGROUND: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people. AIM: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. METHODS: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. FINDINGS: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Maori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. CONCLUSIONS: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links.

Análise crítica da interculturalidade na Política Nacional de Atenção às Populações Indígenas no Brasil

[RESUMO]. A preocupação com um cuidado culturalmente apropriado e intercultural, baseado na articulação e complementariedade entre saberes em saúde, vem sendo uma prioridade para garantir a atenção primária à saúde (APS) dos povos indígenas desde a Conferência de Alma-Ata. No Brasil, país de significativa variedade sociocultural no contexto indígena sul-americano, existe há 16 anos uma Política Nacional de Atenção à Saúde das Populações Indígenas (PNASPI) focada no conceito de atenção diferenciada. Esse conceito, considerado como incompleto e contraditório, é variavelmente operacionalizado na APS de indígenas. Sendo assim, o presente artigo propõe uma análise da formulação e operacionalização desse conceito na PNASPI. Essa análise torna evidente o caráter etnocêntrico da PNASPI, as numerosas contradições e negligências que não contemplam de fato o intercâmbio e articulação com o saber tradicional e as visões êmicas indígenas de saúde e dos processos de padecimento/cura. A reversão dessas limitações exigirá maior reflexividade, questionamento e vigilância epistemológicos tanto das ciências sociais e políticas quanto dos movimentos sociais e de controle social indígenas para redefinir em termos interculturais a APS de indígenas no Brasil.

[ABSTRACT]. Concern for culturally appropriate and intercultural care, based on the articulation and complementarity among health knowledges, has been a priority for ensuring primary health care for indigenous peoples since the Alma-Ata Conference. In Brazil, a country with significant sociocultural variety in the South American indigenous context, a National Policy for the Care of Indigenous Peoples (PNASPI) was established 16 years ago, focusing on the notion of differentiated care. This concept, considered incomplete and contradictory, has been variably operationalized in indigenous primary health care. Therefore, the present article proposes an analysis of the formulation and operationalization of this concept in PNASPI. The analysis brings to light the ethnocentric nature of PNASPI, the numerous contradictions and oversights that fail to encompass the interchange and articulation with traditional knowledges and the indigenous emic views of health and the processes of illness/cure. The reversal of these limitations will require greater reflexivity, problematization, and epistemological surveillance of both the social and political sciences as well as social movements and indigenous social control to redefine indigenous primary health care in Brazil in intercultural terms.

[RESUMEN]. La preocupación por un cuidado culturalmente apropiado e intercultural, basado en la articulación y complementariedad entre saberes en salud, es una prioridad para garantizar la atención primaria de salud de los pueblos indígenas desde la Conferencia de Alma-Ata. En Brasil, un país con una significativa variedad sociocultural en el contexto indígena de América del Sur, existe desde hace 16 años una Política Nacional de Atención a la Salud de las Poblaciones Indígenas (PNASPI) enfocada en el concepto de atención diferenciada. Este concepto, considerado incompleto y contradictorio, es ejecutado de manera variable en la atención primaria de salud de las poblaciones indígenas. Este artículo propone un análisis de la formulación y ejecución de ese concepto en la PNASPI. Este análisis hace evidente el carácter etnocéntrico de la PNASPI, las numerosas contradicciones y negligencias que no contemplan de hecho el intercambio y la articulación con el saber tradicional y las visiones émicas indígenas de salud y de los procesos de enfermedad/curación. La reversión de esas limitaciones requerirá mayor reflexividad, cuestionamiento y vigilancia epistemológica tanto desde las ciencias sociales y políticas como desde los movimientos sociales y de control social indígenas para redefinir en términos interculturales la atención primaria de salud de estas poblaciones en Brasil.

[Critical analysis of interculturality in the National Policy for the Care of Indigenous Peoples in BrazilAnálisis crítico de la interculturalidad en la Política Nacional de Atención a las Poblaciones Indígenas en Brasil]. / Análise crítica da interculturalidade na Política Nacional de Atenção às Populações Indígenas no Brasil.

Concern for culturally appropriate and intercultural care, based on the articulation and complementarity among health knowledges, has been a priority for ensuring primary health care for indigenous peoples since the Alma-Ata Conference. In Brazil, a country with significant sociocultural variety in the South American indigenous context, a National Policy for the Care of Indigenous Peoples (PNASPI) was established 16 years ago, focusing on the notion of differentiated care. This concept, considered incomplete and contradictory, has been variably operationalized in indigenous primary health care. Therefore, the present article proposes an analysis of the formulation and operationalization of this concept in PNASPI. The analysis brings to light the ethnocentric nature of PNASPI, the numerous contradictions and oversights that fail to encompass the interchange and articulation with traditional knowledges and the indigenous emic views of health and the processes of illness/cure. The reversal of these limitations will require greater reflexivity, problematization, and epistemological surveillance of both the social and political sciences as well as social movements and indigenous social control to redefine indigenous primary health care in Brazil in intercultural terms.

La preocupación por un cuidado culturalmente apropiado e intercultural, basado en la articulación y complementariedad entre saberes en salud, es una prioridad para garantizar la atención primaria de salud de los pueblos indígenas desde la Conferencia de Alma-Ata. En Brasil, un país con una significativa variedad sociocultural en el contexto indígena de América del Sur, existe desde hace 16 años una Política Nacional de Atención a la Salud de las Poblaciones Indígenas (PNASPI) enfocada en el concepto de atención diferenciada. Este concepto, considerado incompleto y contradictorio, es ejecutado de manera variable en la atención primaria de salud de las poblaciones indígenas. Este artículo propone un análisis de la formulación y ejecución de ese concepto en la PNASPI. Este análisis hace evidente el carácter etnocéntrico de la PNASPI, las numerosas contradicciones y negligencias que no contemplan de hecho el intercambio y la articulación con el saber tradicional y las visiones émicas indígenas de salud y de los procesos de enfermedad/curación. La reversión de esas limitaciones requerirá mayor reflexividad, cuestionamiento y vigilancia epistemológica tanto desde las ciencias sociales y políticas como desde los movimientos sociales y de control social indígenas para redefinir en términos interculturales la atención primaria de salud de estas poblaciones en Brasil.

Análise crítica da interculturalidade na Política Nacional de Atenção às Populações Indígenas no Brasil / Critical analysis of interculturality in the National Policy for the Care of Indigenous Peoples in Brazil / Análisis crítico de la interculturalidad en la Política Nacional de Atención a las Poblaciones Indígenas en Brasil

RESUMO A preocupação com um cuidado culturalmente apropriado e intercultural, baseado na articulação e complementariedade entre saberes em saúde, vem sendo uma prioridade para garantir a atenção primária à saúde (APS) dos povos indígenas desde a Conferência de Alma-Ata. No Brasil, país de significativa variedade sociocultural no contexto indígena sul-americano, existe há 16 anos uma Política Nacional de Atenção à Saúde das Populações Indígenas (PNASPI) focada no conceito de atenção diferenciada. Esse conceito, considerado como incompleto e contraditório, é variavelmente operacionalizado na APS de indígenas. Sendo assim, o presente artigo propõe uma análise da formulação e operacionalização desse conceito na PNASPI. Essa análise torna evidente o caráter etnocêntrico da PNASPI, as numerosas contradições e negligências que não contemplam de fato o intercâmbio e articulação com o saber tradicional e as visões êmicas indígenas de saúde e dos processos de padecimento/cura. A reversão dessas limitações exigirá maior reflexividade, questionamento e vigilância epistemológicos tanto das ciências sociais e políticas quanto dos movimentos sociais e de controle social indígenas para redefinir em termos interculturais a APS de indígenas no Brasil.

ABSTRACT Concern for culturally appropriate and intercultural care, based on the articulation and complementarity among health knowledges, has been a priority for ensuring primary health care for indigenous peoples since the Alma-Ata Conference. In Brazil, a country with significant sociocultural variety in the South American indigenous context, a National Policy for the Care of Indigenous Peoples (PNASPI) was established 16 years ago, focusing on the notion of differentiated care. This concept, considered incomplete and contradictory, has been variably operationalized in indigenous primary health care. Therefore, the present article proposes an analysis of the formulation and operationalization of this concept in PNASPI. The analysis brings to light the ethnocentric nature of PNASPI, the numerous contradictions and oversights that fail to encompass the interchange and articulation with traditional knowledges and the indigenous emic views of health and the processes of illness/cure. The reversal of these limitations will require greater reflexivity, problematization, and epistemological surveillance of both the social and political sciences as well as social movements and indigenous social control to redefine indigenous primary health care in Brazil in intercultural terms.

RESUMEN La preocupación por un cuidado culturalmente apropiado e intercultural, basado en la articulación y complementariedad entre saberes en salud, es una prioridad para garantizar la atención primaria de salud de los pueblos indígenas desde la Conferencia de Alma-Ata. En Brasil, un país con una significativa variedad sociocultural en el contexto indígena de América del Sur, existe desde hace 16 años una Política Nacional de Atención a la Salud de las Poblaciones Indígenas (PNASPI) enfocada en el concepto de atención diferenciada. Este concepto, considerado incompleto y contradictorio, es ejecutado de manera variable en la atención primaria de salud de las poblaciones indígenas. Este artículo propone un análisis de la formulación y ejecución de ese concepto en la PNASPI. Este análisis hace evidente el carácter etnocéntrico de la PNASPI, las numerosas contradicciones y negligencias que no contemplan de hecho el intercambio y la articulación con el saber tradicional y las visiones émicas indígenas de salud y de los procesos de enfermedad/curación. La reversión de esas limitaciones requerirá mayor reflexividad, cuestionamiento y vigilancia epistemológica tanto desde las ciencias sociales y políticas como desde los movimientos sociales y de control social indígenas para redefinir en términos interculturales la atención primaria de salud de estas poblaciones en Brasil.

Scoping review: national monitoring frameworks for social determinants of health and health equity.

BACKGROUND: The strategic importance of monitoring social determinants of health (SDH) and health equity and inequity has been a central focus in global discussions around the 2011 Rio Political Declaration on SDH and the Millennium Development Goals. This study is part of the World Health Organization (WHO) equity-oriented analysis of linkages between health and other sectors (EQuAL) project, which aims to define a framework for monitoring SDH and health equity. OBJECTIVES: This review provides a global summary and analysis of the domains and indicators that have been used in recent studies covering the SDH. These studies are considered here within the context of indicators proposed by the WHO EQuAL project. The objectives are as follows: to describe the range of international and national studies and the types of indicators most frequently used; report how they are used in causal explanation of the SDH; and identify key priorities and challenges reported in current research for national monitoring of the SDH. DESIGN: We conducted a scoping review of published SDH studies in the PubMed(®) database to obtain evidence of socio-economic indicators. We evaluated, selected, and extracted data from national scale studies published from 2004 to 2014. The research included papers published in English, Italian, French, Portuguese, and Spanish. RESULTS: The final sample consisted of 96 articles. SDH monitoring is well reported in the scientific literature independent of the economic level of the country and magnitude of deprivation in population groups. The research methods were mostly quantitative and many papers used multilevel and multivariable statistical analyses and indexes to measure health inequalities and SDH. In addition to the usual economic indicators, a high number of socio-economic indicators were used. The indicators covered a broad range of social dimensions, which were given consideration within and across different social groups. Many indicators included in the WHO EQuAL framework were not common in the studies in this review due to their intersectoral and interdisciplinary nature. CONCLUSIONS: Our review illustrates that the attention to SDH monitoring has grown in terms of its importance and complexity within the scientific health literature. We identified a need to make indicators more wide-ranging in order to include a broader range of social conditions. The WHO EQuAL framework can provide intersectoral and interdisciplinary means of building a more comprehensive standardised approach to monitoring the SDH and improving equity in health.

Assessing the relevance of indicators in tracking social determinants and progress toward equitable population health in Brazil.

BACKGROUND: The importance of the social determinants of health (SDH) and barriers to the access and utilization of healthcare have been widely recognized but not previously studied in the context of universal healthcare coverage (UHC) in Brazil and other developing countries. OBJECTIVE: To evaluate a set of proposed indicators of SDH and barriers to the access and utilization of healthcare - proposed by the SDH unit of the World Health Organization - with respect to their relevance in tracking progress in moving toward equitable population health and UHC in Brazil. DESIGN: This study had a mixed methodology, combining a quantitative analysis of secondary data from governmental sources with a qualitative study comprising two focus group discussions and six key informant interviews. The set of indicators tested covered a broad range of dimensions classified by three different domains: environment quality; accountability and inclusion; and livelihood and skills. Indicators were stratified according to income quintiles, urbanization, race, and geographical region. RESULTS: Overall, the indicators were adequate for tracking progress in terms of the SDH, equity, gender, and human rights in Brazil. Stratifications showed inequalities. The qualitative analysis revealed that many of the indicators were well known and already used by policymakers and health sector managers, whereas others were considered less useful in the Brazilian context. CONCLUSIONS: Monitoring and evaluation practices have been developed in Brazil, and the set of indicators assessed in this study could further improve these practices, especially from a health equity perspective. Socioeconomic inequalities have been reduced in Brazil in the last decade, but there is still much work to be done in relation to addressing the SDH.