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.

"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.

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.

"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.

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.

Methodological issues in qualitative research on HIV prevention: an integrative review.

In view of the growing concern about the use of qualitative approach in health research, this article aims to analyze how the qualitative theoretical-methodological framework of HIV prevention is presented in empirical research. We conducted an integrative literature review with the following guiding questions: "How is the qualitative theoretical-methodological framework expressed in empirical research on HIV prevention?"; "What are the limits and potentials of the qualitative methodological designs employed?". In the qualitative methodological discussion, five dimensions guided the methodological course and the presentation of findings, from the analysis of the characterization of qualitative studies to the contextualization of the studies and the methodological approaches used, highlighting the use of semi-structured interviews with thematic content analysis. We also examined social categories and analytical references, drawing attention to the plurality of these theoretical-conceptual references and to the authors' polyphony, and identified the limits and potentials of qualitative research. This study focuses on a scientific topic that is related to a wide variety of social groups and analyzes how they are affected by it, examining issues related to social inequality and other analytical possibilities surrounding HIV prevention, and providing resources for a comprehensive methodological discussion. Hence, avoiding the risk of conducting qualitative research based on checklists that limit inventiveness and openness to different designs and forms of execution and analysis is as pivotal as ensuring that the research is consistent and detailed in publications.

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.

Telehealth effectiveness for pre-exposure prophylaxis delivery in Brazilian public services: the Combine! Study.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) delivery based on user needs can enhance PrEP access and impact. We examined whether telehealth for daily oral PrEP delivery could change the indicators of care related to prophylactic use in five Brazilian public HIV clinics (testing centres, outpatient clinics and infectious disease hospitals). METHODS: Between July 2019 and December 2020, clients on PrEP for at least 6 months could transition to telehealth or stay with in-person follow-up. Clients were clinically monitored until June 2021. A desktop or mobile application was developed, comprising three asynchronous consultations and one annual in-person consultation visit. Predictors influencing telehealth preference and care outcomes were examined. The analysis encompassed intent-to-treat (first choice) and adjustments for sexual practices, schooling, age, duration of PrEP use and PrEP status during the choice period. RESULTS: Of 470 users, 52% chose telehealth, with the adjusted odds ratio (aOR) increasing over time for PrEP use (aOR for 25-months of use: 4.90; 95% CI: 1.32-18.25), having discontinued PrEP at the time of the choice (aOR: 2.91; 95% CI: 1.40-6.06) and having health insurance (aOR: 1.91; 95% CI: 1.24-2.94) and decreasing for those who reported higher-risk behaviour (aOR for unprotected anal sex: 0.51; 95% CI: 0.29-0.88). After an average follow-up period of 1.6 years (95% CI: 1.5-1.7), the risk of discontinuing PrEP (not having the medication for more than 90 days) was 34% lower with telehealth (adjusted hazard ratio: 0.66; 95% CI: 0.45-0.97). When adjusted by mixed linear regression, no differences in adherence (measured by mean medication possession rate) were found between in-person and telehealth (p = 0.486) or at pre- and post-telehealth follow-ups (p = 0.245). Sexually transmitted infections increased between the pre-follow-up and post-follow-up choices and were not associated with in-person or telehealth (p = 0.528). No HIV infections were observed. CONCLUSIONS: Our findings indicate that telehealth for PrEP delivery can enhance service rationalization and reinforce the prevention cascade. This approach reduces prophylaxis interruptions and is mainly preferred by individuals with lower demands for healthcare services.

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.

Important steps for PrEP uptake among adolescent men who have sex with men and transgender women in Brazil.

HIV Pre-exposure prophylaxis (PrEP) is an effective prevention tool, but there are still few studies about PrEP uptake among adolescents. We aimed to analyze the PrEP uptake process and factors associated with daily oral PrEP initiation among adolescent men who have sex with men (aMSM) and transgender women (aTGW) in Brazil. Baseline data from the first demonstration PrEP cohort study among aMSM and aTGW 15-19 years old (yo) ongoing in three large Brazilian cities (PrEP1519). After completing informed consent procedures, participants were enrolled in the cohort from February/2019 to February/2021. A socio-behavioral questionnaire was applied. Factors associated with PrEP initiation were assessed using a logistic regression model with adjusted prevalence ratios (aPR) and 95% confidence intervals (95%CI). Among recruited participants, 174 (19,2%) were aged 15-17 yo and 734 (80,8%) 18-19 yo. The rate of PrEP initiation was 78.2% and 77.4% for 15-17 yo and 18-19 yo, respectively. Factors associated with PrEP initiation were: black or mixed race (aPR 2.31; 95%CI: 1.10-4.84) among the younger adolescents 15-17 yo; experienced violence and/or discrimination due to their sexual orientation or gender identity (aPR 1.21; 95%CI: 1.01-1.46); transactional sex (aPR 1.32; 95%CI: 1.04-1.68); and having had between 2 to 5 sexual partners in the previous three months (aPR 1.39; 95%CI: 1.15-1.68) among those 18-19 yo. Unprotected receptive anal intercourse in the previous six months was associated with PrEP initiation in both age groups (aPR 1.98; 95%CI: 1.02-3.85 and aPR 1.45; 95%CI: 1.19-1.76 among 15-17 yo and 18-19 yo, respectively). The biggest challenge to promoting PrEP use for aMSM and aTGW was in the first steps of the PrEP uptake process. Once they were linked to the PrEP clinic, initiation rates were high.

Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort.

Adolescent men who have sex with men (AMSM) are at a heightened vulnerability for human immunodeficiency virus (HIV). This study aimed to estimate the prevalence of HIV and associated individual, social, and programmatic factors among AMSM in Salvador, Bahia State, Brazil. This is a cross-sectional study which analyzed baseline data from the PrEP1519 cohort in Salvador. Descriptive, bivariate, and multivariate analyses were conducted using the dimensions of vulnerability to HIV as hierarchical levels of analysis. Logistic regression models were used to estimate the odds ratios (OR) of the association between predictor variables and HIV infection. The prevalence of HIV infection among the 288 AMSM recruited to the project was 5.9% (95%CI: 3.7-9.3). Adjusted analysis showed a statistically significant association between self-identifying as a sex worker (OR = 3.74, 95%CI: 1.03-13.60) and HIV infection. Other associations with borderline statistical significance were the use of application programs to find sexual partners (OR = 3.30, 95%CI: 0.98-11.04), low schooling level (OR = 3.59, 95%CI: 0.96-13.41), failing to be hired or being dismissed from a job because of sexual orientation (OR = 2.88, 95%CI: 0.89-9.28), and not using health services as a usual source of care (OR = 3.14, 95%CI: 0.97-10.17). We found a high HIV prevalence among AMSM in Salvador. Furthermore, our study found that individual, social, and programmatic factors were associated with HIV infection among these AMSM. We recommend intensifying HIV combined-prevention activities for AMSM.

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.