HIV Risk Perception and Pre-Exposure Prophylaxis (PrEP) Awareness Among Transgender Women from Mexico.

This study aimed to identify factors associated with HIV risk perception among Mexican transgender women (TGW). This cross-sectional survey was conducted online and at a public HIV clinic in Mexico City. Participants were ≥ 18 years old, self-identified as TGW, and reported not living with HIV. They answered questions on sexual behavior, HIV risk perception, and pre-exposure prophylaxis (PrEP) awareness. We performed a multivariate logistic regression to accomplish the study's objective. One hundred ninety-one TGW completed the survey. High HIV risk perception was associated with > 5 sexual partners, condomless receptive anal sex, sex with a male partner(s) of unknown HIV status, and PrEP awareness. Although most TGW reported low HIV risk perception, over half had risk sexual behavior, reflecting inaccurate risk assessment. Future interventions to improve accurate risk perception among TGW should promote HIV transmission and prevention knowledge and increase PrEP awareness and uptake.

RESUMEN: Este estudio tuvo como objetivo identificar los factores asociados con la percepción de riesgo al VIH entre las mujeres trans (MT) mexicanas. El reclutamiento de esta encuesta transversal se realizó en línea y en una clínica pública de VIH en la Ciudad de México. Las participantes tenían ≥ 18 años, se autoidentificaron como MT y reportaron no vivir con VIH. Respondieron preguntas sobre su comportamiento sexual, percepción del riesgo al VIH y conocimiento de la profilaxis preexposición (PrEP). Se realizó un análisis de regresión logística multivariado para cumplir con el objetivo del estudio. Ciento noventa y uno participantes completaron la encuesta. La percepción de alto riesgo al VIH se asoció con > 5 parejas sexuales, sexo anal receptivo sin condón, sexo con una pareja masculina de estado serológico desconocido y conocimiento de la PrEP. Aunque la mayoría de las MT informaron baja percepción del riesgo al VIH, más de la mitad reportaron conductas sexuales de riesgo, lo que refleja una evaluación de riesgo inexacta. Futuras intervenciones para mejorar la percepción precisa del riesgo entre las MT deben centrarse en promover el conocimiento de transmisión y la prevención del VIH, así como aumentar el conocimiento y la aceptación de la PrEP.

Impact of pre-exposure prophylaxis uptake among gay, bisexual, and other men who have sex with men in urban centers in Brazil: a modeling study.

BACKGROUND: Men who have sex with men (MSM) in Brazil remain disproportionately affected by HIV. We estimated the potential incidence reduction by five years with increased uptake of publicly-funded, daily, oral tenofovir/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) among MSM using the Cost Effectiveness of Preventing AIDS Complications microsimulation model. We used national data, local studies, and literature to inform model parameters for three cities: Rio de Janeiro, Salvador, and Manaus. RESULTS: In Rio de Janero, a PrEP intervention achieving 10% uptake within 60 months would decrease incidence by 2.3% whereas achieving 60% uptake within 24 months would decrease incidence by 29.7%; results were similar for Salvador and Manaus. In sensitivity analyses, decreasing mean age at PrEP initiation from 33 to 21 years increased incidence reduction by 34%; a discontinuation rate of 25% per year decreased it by 12%. CONCLUSION: Targeting PrEP to young MSM and minimizing discontinuation could substantially increase PrEP's impact.

Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey.

BACKGROUND: In order to end the HIV epidemic by 2030, combination HIV prevention including pre-exposure prophylaxis (PrEP) should be widely available, especially for the most vulnerable populations. In Latin America and the Caribbean (LAC), only 14 out of 46 countries have access to PrEP. In Brazil and Mexico, PrEP has been provided at no cost through the Public Health System since 2017 and 2021, respectively. Thus, HIV physicians' perspectives about PrEP and other prevention strategies may differ. This study aimed to compare awareness, knowledge, and attitudes related to PrEP and other prevention strategies among HIV physicians from Brazil and Mexico. METHODS: Cross-sectional, web-based survey targeting physicians who prescribe antiretrovirals from both countries. Participants answered questions on socio-demographic, medical experience, awareness, knowledge, and attitudes towards PrEP and other HIV prevention strategies. We stratified all variables per country and compared frequencies using Chi-square, Fisher exact, and Wilcoxon-Mann-Whitney tests, as appropriate. RESULTS: From January-October 2020, 481 HIV physicians were included: 339(70.5%) from Brazil, 276(57.4%) male, and median age was 43 years (IQR = 36-53). Awareness of PrEP did not differ between Brazil and Mexico (84.6%), while awareness of other prevention strategies, including post-exposure prophylaxis and new PrEP technologies, was higher in Brazil. More Brazilians perceived U=U as completely accurate compared to Mexicans (74.0% vs. 62.0%, P < .001). Willingness to prescribe PrEP was 74.2%, higher among Brazilians (78.2%, P = .01). Overall, participants had concerns about consistent access to PrEP medication and the risk of antiretroviral resistance in case of acute HIV infection or seroconversion. The main barriers reported were assumptions that users could have low PrEP knowledge (62.0%) or limited capacity for adherence (59.0%). Compared to Brazilians, Mexicans reported more concerns and barriers to PrEP prescription (all; P ≤ .05), except for consistent access to PrEP medication and the lack of professionals to prescribe PrEP (both; P ≤ .01). CONCLUSIONS: Although awareness of PrEP was similar in Brazil and Mexico, differences in knowledge and attitudes may reflect the availability and stage of PrEP implementation in these countries. Strengthening and increasing information on PrEP technologies and other HIV prevention strategies among HIV physicians could improve their comfort to prescribe these strategies and facilitate their scale-up in LAC.

Impact of COVID-19 Pandemic on Sexual Minority Populations in Brazil: An Analysis of Social/Racial Disparities in Maintaining Social Distancing and a Description of Sexual Behavior.

We conducted a web-based survey to understand the impact of social distancing measures on Brazilian MSM and transgender/non-binary lives. A total of 3486 respondents were included in this analysis and the great majority were cismen (98%). The median age was 32 years (IQR: 27-40), 44% non-white, 36% low schooling and 38% low income. Most of participants reported HIV negative/unknown status (77%). Participants on-PrEP reported more condomless anal sex than those off-PrEP. Conversely, 24% off-PrEP were at substantial HIV-risk. PrEP/ART continuation were reported by the majority, despite reports of impediments to medication refill. Transgender/non-binary reported more mental health problems and challenges to access health care. Social and racial disparities were associated with unattainability of maintaining social distancing. Tailored social and economic support policies during COVID-19 pandemic should be made available to these populations. Challenges for PrEP/ART access will demand the implementation of innovative solutions to avoid the expansion of the HIV epidemic.

Low socioeconomic status is associated with self-reported HIV positive status among young MSM in Brazil and Peru.

BACKGROUND: Despite efforts to stop HIV epidemic in Latin America, new HIV cases continue to increase in the region especially among young MSM (YMSM). This study aims to assess if sociodemographic characteristics are associated with self-reported HIV positive status among YMSM from three Latin American countries. METHODS: Cross-sectional web-based survey advertised on dating apps (Grindr and Hornet) and Facebook in Brazil, Mexico and Peru. For this analysis, we included YMSM aged 18-24 years who self-reported their HIV status. We used multivariable logistic regression models for each country separately to verify if sociodemographic characteristics (race, education and income) were associated with HIV self-reported status after adjusting for behavior characteristics (sexual attraction and steady partner). RESULTS: Among 43,687 MSM who initiated the questionnaire, 27,318 (62.5%) reported their HIV status; 7001 (25.6%) of whom were YMSM. Most YMSM (83.4%) reported an HIV test in the past year, and 15.7% reported an HIV positive status in Peru, 8.4% in Mexico and 7.7% in Brazil. In adjusted models, low-income was associated with higher odds of self-reported HIV positive status in Brazil (aOR = 1.33, 95%CI: 1.01-1.75) and Peru (aOR = 1.56, 95%CI: 1.02-2.40), but not in Mexico. Lower education was associated with higher odds of self-reported HIV positive status only in Brazil (aOR = 1.35, 95%CI: 1.05-1.75). CONCLUSIONS: In this large, cross-country study, self-reported HIV positive status among YMSM was high. Lower socioeconomic status was associated with higher odds of self-reported HIV positive status in Brazil and Peru. There is an urgent need for HIV prevention interventions targeting YMSM, and efforts to address low-income YMSM are especially needed in Peru and Brazil.

Preferences for PrEP modalities among gay, bisexual, and other men who have sex with men from Brazil, Mexico, and Peru: a cross-sectional study.

Background: Pre-exposure prophylaxis (PrEP) scale-up is urgent to reduce new HIV cases among gay, bisexual, and other men who have sex with men (MSM) in Latin America. Different PrEP modalities may increase PrEP uptake and adherence, especially among young MSM. Objectives: To assess preferences for PrEP modalities among MSM from Brazil, Mexico, and Peru. Design: Cross-sectional web-based study (March-May 2018) targeting MSM through advertisements on Grindr, Hornet, and Facebook. We included MSM aged ⩾ 18 years and who reported HIV-negative status. Methods: We assessed preferences for PrEP modalities with the following question: 'Considering that all following PrEP modalities were available, which one would you prefer considering a scale from 1 to 3 (1 = most preferred): daily oral PrEP, event-driven PrEP (ED-PrEP), and long-acting injectable PrEP'. We assessed factors associated with each most preferred PrEP modality per country using multivariable logistic regression models. Results: A total of 19,457 MSM completed the questionnaire (Brazil: 58%; Mexico: 31%; Peru: 11%); median age was 28 years [interquartile range (IQR): 24-34]. Overall, injectable PrEP was the most preferred modality [42%; 95% confidence interval (CI): 41-43], followed by daily PrEP (35%; 95% CI: 34-35), and ED-PrEP (23%; 95% CI: 23-24). In multivariable models, preferring injectable PrEP was associated with PrEP awareness in all three countries, while PrEP eligibility only in Brazil. Preferring daily PrEP was associated with younger age and lower income in Brazil and Mexico, and lower education only in Brazil. The odds of preferring ED-PrEP were lower among MSM aware and eligible for PrEP in Brazil and Mexico. Conclusions: Long-acting injectable PrEP was the preferred PrEP modality among MSM in Brazil, Mexico, and Peru, especially those aware and eligible for PrEP. Public health interventions to increase PrEP modalities literacy and availability in Latin America are urgent especially among MSM of young age, lower income, and lower education.

Awareness, willingness and barriers to HIV Self-testing (HIVST) among Men who Have Sex with Men (MSM) in Brazil, Mexico, and Peru: A web-based cross-sectional study.

HIV self-testing (HIVST) is an essential tool within the combined HIV prevention package and has been available in Latin America since 2015. However, HIVST use among key populations remains low. This study describes awareness, willingness, and barriers to HIVST among MSM in Brazil, Mexico, and Peru. A cross-sectional web-based survey was advertised in two geosocial networking apps (Grindr and Hornet) and Facebook in 2018. We included cisgender men ≥18 years old who self-reported HIV-negative status. We used multivariable Poisson regression models to calculate adjusted prevalence ratios (aPR) to assess the factors associated with willingness to use HIVST for each country. A total of 18,916 completed the survey, 59% from Brazil, 30% from Mexico, and 11% from Peru. Overall, 20% of MSM had never tested for HIV. Awareness and willingness to use HIVST were higher in Brazil than in Peru and Mexico (p < .001). Across the countries, the patterns of association of willingness with HIVST barriers were similar. Most participants think post-test counseling is essential and that dealing with a positive result would be difficult (aPR 1.13 to 1.37, range of aPRs across the three countries). Having the knowledge to deal with a positive HIVST resulted in increased willingness to use HIVST (aPR range: 1.11 to 1.22), while a lack of trust in HIVST compared to HIV testing in clinics was inversely associated (aPR range: 0.80 to 0.90). In general, willingness to use HIVST was associated with higher income (aPR range: 1.49 to 1.97), higher education (aPR range: 1.13 to 1.42), and willingness to use PrEP (aPR range: 1.19 to 1.72). Efforts to increase HIVST knowledge and resolve perceived barriers are warranted, especially among MSM with lower income and education from Brazil, Mexico, and Peru. Personalized virtual counseling could be crucial among this population. In addition, those willing to use HIVST are also willing to use PrEP. It indicates that HIVST delivery could be incorporated into PrEP programs within the Brazilian Public Health System and eventually in Mexico and Peru.

High Rates of Sexualized Drug Use or Chemsex among Brazilian Transgender Women and Young Sexual and Gender Minorities.

(1) Background: We aimed to estimate sexualized drug use (SDU) prevalence and its predictors among sexual and gender minorities. (2) Methods: We used an online and on-site survey to enroll sexual/gender minorities people between October-December/2020, and multivariate logistic regression to obtain SDU correlates. (3) Results: We enrolled 3924 individuals (280 transgender women [TGW], 3553 men who have sex with men [MSM], and 91 non-binary), 29.0% currently on pre-exposure prophylaxis (PrEP). SDU prevalence was 28.8% (95% confidence interval [CI] 27.4-30.2). TGW had 2.44-times increased odds (95%CI 1.75-3.39) of engaging in SDU compared to MSM, regardless of PrEP use. PrEP use (aOR 1.19, 95%CI 1.00-1.41), South/Southeast region (aOR 1.26, 95%CI 1.04-1.53), younger age (18-24 years: aOR 1.41, 95%CI 1.10-1.81; 25-35 years: aOR 1.24, 95%CI 1.04-1.53), white race/color (aOR 1.21, 95%CI 1.02-1.42), high income (aOR 1.32, 95%CI 1.05-1.67), binge drinking (aOR 2.66, 95%CI 2.25-3.14), >5 sexual partners (aOR 1.88, 95%CI 1.61-2.21), condomless anal sex (aOR 1.49, 95%CI 1.25-1.79), self-reported sexually transmitted infection (aOR 1.40, 95%CI 1.14-1.71), and higher perceived HIV-risk (aOR 1.37, 95%CI 1.14-1.64) were associated with SDU. (4) Conclusions: TGW had the highest SDU odds. SDU may impact HIV vulnerability among key populations and should be addressed in HIV prevention approaches.

Factors associated with long-term HIV pre-exposure prophylaxis engagement and adherence among transgender women in Brazil, Mexico and Peru: results from the ImPrEP study.

INTRODUCTION: The HIV epidemic continues to disproportionately impact Latin-American transgender women (TGW). We assessed factors associated with long-term pre-exposure prophylaxis (PrEP) engagement and adherence among TGW enrolled in the Implementation of PrEP (ImPrEP) study, the largest PrEP demonstration study in Latin America. METHODS: HIV-negative TGW aged ≥18 years reporting 1+eligibility criteria in the 6 months prior to enrolment (e.g. sex partner known to be living with HIV, condomless anal sex [CAS], transactional sex or having a sexually transmitted infection [STI]) who could safely take PrEP were enrolled. Follow-up visits were conducted at 4 weeks and then quarterly. We conducted logistic regression to identify factors associated with long-term PrEP engagement (3+ follow-up visits in 52 weeks) and complete self-reported adherence (no missed pills in the past 30 days) during follow-up. For both outcomes, we constructed multivariable models controlling for country, socio-demographics, sexual behaviour, substance use, STIs and self-reported adherence at 4 weeks (long-term engagement outcome only). RESULTS: From March 2018 to June 2021, ImPrEP screened 519 TGW, enrolled 494 (Brazil: 190, Mexico: 66 and Peru: 238) and followed them for 52 weeks. At baseline, 27.5% of TGW were aged 18-24 years, 67.8% were mixed-race and 31.6% had >secondary education. Most, 89.9% reported CAS, 61.9% had >10 sex partners and 71.9% reported transactional sex. HIV incidence was 1.82 cases per 100 person-years (95% confidence interval [CI]: 0.76-4.38). Almost half of TGW (48.6%) had long-term PrEP engagement, which was positively associated with reporting complete adherence at week 4 (aOR:2.94 [95%CI:1.88-4.63]) and was inversely associated with reporting CAS with unknown-HIV partner (aOR:0.52 [95%CI:0.34-0.81]), migration (aOR:0.54 [95%CI:0.34-0.84]), and being from Mexico (aOR:0.28 [95%CI:0.14-0.53]). Self-reported adherence was associated with TGW aged >34 (aOR:1.61 [95%CI:1.10-2.34]) compared to those aged 25-34 and those with >secondary education (aOR:1.55 [95%CI:1.10-2.19]) and was lower among TGW from Peru (aOR:0.29 [95%CI:0.21-0.41]) or reporting PrEP-related adverse effects (aOR:0.63 [95%CI:0.42-0.92]). CONCLUSIONS: Although TGW were willing to enrol in ImPrEP, long-term PrEP engagement and complete self-reported adherence were limited, and HIV incidence remained relatively high. A successful HIV prevention agenda should include trans-specific interventions supporting oral PrEP and exploring long-acting PrEP strategies for TGW.

High acceptability of PrEP teleconsultation and HIV self-testing among PrEP users during the COVID-19 pandemic in Brazil.

In March 2020, telemedicine and HIV self-testing were adopted by Brazilian Public Health services to minimize disruptions in pre-exposure prophylaxis (PrEP) access and delivery during the COVID-19 pandemic. To understand the acceptability of PrEP teleconsultation and HIV self-testing, we conducted a web-based study during social distancing period (April-May, 2020) among men who have sex with men and transgender/non-binary individuals using social media. Out of the 2375 HIV negative respondents, 680 reported PrEP use and were included in this analysis. Median age was 33 years (IQR: 28-40), 98% cisgender men, 56% white, 74% high education, and 68% middle/high income. Willingness to use HIVST was 79% and 32% received an HIV self-testing during social distancing period. The majority reported preference for PrEP/HIV self-testing home delivery instead of collecting at the service. PrEP teleconsultation was experienced by 21% and most reported feeling satisfied with the procedures. High acceptability of PrEP teleconsultation was reported by 70%. In ordinal logistic model, having higher education was associated with high aceptability of PrEP teleconsultation (aOR:1.62; 95%CI: 1.07-2.45). Our results point out that PrEP teleconsultation and PrEP/HIV self-testing home delivery could be implemented by PrEP services in Brazil to avoid PrEP shortage during the COVID-19 pandemic and thereafter as an option to increase retention and adherence.

Are men who have sex with men at higher risk for HIV in Latin America more aware of PrEP?

INTRODUCTION: PrEP awareness in Latin America has been poorly characterized, with studies in Brazil, Mexico, and Peru highlighting awareness of 65% among gay, bisexual and other men who have sex with men (MSM). We assessed the association between higher risk of HIV infection, indicative of PrEP eligibility, and PrEP awareness among MSM from these countries. METHODS: This was a secondary analysis of a web-based survey advertised on social media platforms from March-June 2018 in Brazil, Mexico and Peru. Eligible individuals were cisgender MSM, ≥18 years old, HIV negative or of unknown status, who lived in these countries, and provided informed consent. Higher risk of HIV infection was defined as having 10 or more points in the HIV Risk Index for MSM (HIRI-MSM). We used multivariable Poisson regression models to calculate adjusted prevalence ratios (aPR) testing the association between higher risk for HIV and PrEP awareness. RESULTS: After exclusions, 19,457 MSM were included in this analysis. In Brazil, 53.8% were classified as higher risk for HIV, 51.9% in Mexico, and 54.2% in Peru. Higher risk for HIV was minimally associated with PrEP awareness among those in Brazil (aPR 1.04, 95% CI 1.01, 1.06), but no such association was observed in Mexico or Peru. Having more than a high school education, high income, daily use of geosocial networking (GSN) applications, and substance use were associated with PrEP awareness. CONCLUSION: Higher risk of HIV infection was associated with increased PrEP awareness in Brazil. However, this association was weak indicating that PrEP awareness could be strengthened with further prevention efforts. In the remaining countries, results were non-conclusive between risk and awareness. Interventions to increase PrEP awareness are paramount to increase PrEP willingness and uptake and in turn prevent new HIV infections. Social media platforms could play an important role to achieve this goal.

Study protocol: epidemiological and clinical characteristics of acute viral hepatitis in Brazilian health services.

INTRODUCTION: Acute viral hepatitis is a disease of great clinical importance. This study proposes actions to better characterise cases of acute hepatitis in Brazil and to provide relevant information to institutionalised health policies within the Unified Health System. Available data on acute hepatitis in Brazil need to be re-evaluated regarding the different hepatotropic agent (hepatitis A to E virus) frequencies, as well as other agents that can cause similar clinical conditions, such as Herpes Simplex Virus 1 and 2(HSV1, HSV2), Varicella Zoster Virus (VZV), Cytomegalovirus (CMV), Epstein Barr Virus (EBV), Human Herpes Virus 6 and 7 (HHV6, HHV7), arbovirus (yellow fever, dengue, chikungunya, Zika), parvovirus B19, adenovirus, parechovirus, enterovirus, HIV, leptospirosis, toxoplasmosis and syphilis, in addition to autoimmune hepatitis. In this context, the primary aim of this study is the clinical-epidemiological and molecular characterisation of acute viral hepatitis in Brazilian health services from all geographical regions of the country. The present article describes the study protocol. METHODS AND ANALYSIS: This study will evaluate 2280 patients with symptoms and/or signs suggestive of acute liver disease in Brazilian health institutions in all five geographic Brazilian regions. Demographic, epidemiological and clinical data will be collected, as well as blood samples to be analysed at Hospital Israelita Albert Einstein Clinical Laboratory. ETHICS AND DISSEMINATION: Ethics approval was obtained at the national research ethics committee (Conselho Nacional de Ética em Pesquisa- CONEP-CAAE 00952818.4.1001.0071) and at all participating sites. Results will be published in journals and presented at scientific meetings.

Telemedicine as a tool for PrEP delivery during the COVID-19 pandemic in a large HIV prevention service in Rio de Janeiro-Brazil.

COVID-19 public health responses such as social distancing and community containment measures protocols are critical to preventing and containing the spread of coronavirus. Brazil accounts for almost half of Latin American HIV cases and Rio de Janeiro is the city with the second largest number of AIDS. Clinical appointments and pharmacy antiretroviral refills may be impaired due to restricted traffic and possible lockdowns, preventing people living with HIV and those using PrEP from accessing needed antiretrovirals. We hereby describe the telemedicine procedures implemented in a large PrEP delivery service in Rio de janeiro in the context of the COVID-19 pandemic. At the initial teleconsultation, individuals undergoe HIV rapid testing and are assessed by phone for PrEP related procedures. Individuals receive a digital prescription to retrieve a 120-day PrEP supply plus two HIV self-test kits. Subsequent follow-up teleconsultations will be performed remotely by phone call, including instructions for the HIV self-test performance, which results are to be sent using a digital picture. Participants will attend the service only for PrEP refill. The use of telemedicine procedures is being effective to avoid PrEP shortage and reduce the time PrEP users spend at the service during the COVID-19 pandemic and social distancing recommendations.

STOP HPV study protocol: a nationwide case-control study of the association between oropharyngeal cancer and human papillomavirus (HPV) infection in Brazil.

INTRODUCTION: Human papillomavirus (HPV) is the most common sexually transmitted infection and is associated with several types of cancer. The number of cases of HPV-associated head and neck squamous cell carcinomas (HNSCCs), especially oropharyngeal carcinomas, has increased significantly in recent years despite decreased tobacco smoking rates. Currently, no data concerning the risk factors and prevalence of HPV in HNSCC patients in all regions of Brazil are available, making it difficult to promote advances in this field of public health. Therefore, our goal is to determine the impact of infection by HPV, including HPVs with different genotypes, on head and neck cancer and the risk factors associated with the development of head and neck cancer in all regions of Brazil. METHODS AND ANALYSIS: This is a case-control study that will include 622 patients and 622 controls from all regions of Brazil. A questionnaire will be applied to gather information on sociodemographic, behavioural and health factors. Oral, cervical or penile/scrotal, and anal specimens and serum samples will be collected from all participants. Formalin-fixed paraffin-embedded tissue from tumour biopsies will be analysed only in the case group. Molecular and serological analyses will be performed to evaluate the presence and role of HPV in the development of head and neck cancer. ETHICS AND DISSEMINATION: This project was approved by the research ethical committee of the proposing institution (Hospital Moinhos de Vento, number 2.852.060). Ethical approval from the collaborators is currently under evaluation and is not yet complete. The results of this study will be presented at meetings with the Brazilian Ministry of Health through technical reports and to the scientific community at national and international events, with subsequent publication of scientific articles.

Authorship Correction: Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men.

[This corrects the article DOI: 10.2196/13771.].

Factors Associated With Willingness to Use Pre-Exposure Prophylaxis in Brazil, Mexico, and Peru: Web-Based Survey Among Men Who Have Sex With Men.

BACKGROUND: HIV disproportionally affects key populations including men who have sex with men (MSM). HIV prevalence among MSM varies from 17% in Brazil and Mexico to 13% in Peru, whereas it is below 0.5% for the general population in each country. Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir is being implemented in the context of combination HIV prevention. Reports on willingness to use PrEP among MSM have started to emerge over the last few years. Previously reported factors associated with willingness to use PrEP include awareness, higher sexual risk behavior, and previous sexually transmitted infection. OBJECTIVE: This study aimed to evaluate the factors associated with willingness to use daily oral PrEP among MSM in 3 Latin American, middle-income countries (Brazil, Mexico, and Peru). METHODS: This Web-based, cross-sectional survey was advertised in 2 gay social network apps (Grindr and Hornet) used by MSM to find sexual partners and on Facebook during 2 months in 2018. Inclusion criteria were being 18 years or older, cisgender men, and HIV-negative by self-report. Eligible individuals answered questions on demographics, behavior, and PrEP (awareness, willingness to use, barriers, and facilitators). Multivariable logistic regression modeling was performed to assess the factors associated with willingness to use daily oral PrEP in each country. RESULTS: From a total sample of 43,687 individuals, 44.54% of MSM (19,457/43,687) were eligible and completed the Web-based survey-Brazil: 58.42% (11,367/19,457), Mexico: 30.50% (5934/19,457), and Peru: 11.08% (2156/19,457); median age was 28 years (interquartile range: 24-34), and almost half lived in large urban cities. Most participants were recruited on Grindr (69%, 13,349/19,457). Almost 20% (3862/19,352) had never tested for HIV, and condomless receptive anal sex was reported by 40% (7755/19,326) in the previous 6 months. Whereas 67.51% (13,110/19,376) would be eligible for PrEP, only 9.80% (1858/18,959) of participants had high HIV risk perception. PrEP awareness was reported by 64.92% (12,592/19,396); this was lower in Peru (46.60%, 1002/2156). Overall, willingness to use PrEP was reported by 64.23% (12,498/19,457); it was highest in Mexico (70%, 4158/5934) and lowest in Peru (58%, 1241/2156). In multivariate regression models adjusted for age, schooling, and income in each country, willingness to use PrEP was positively associated with PrEP awareness and PrEP facilitators (eg, free PrEP and HIV testing) and negatively associated with behavioral (eg, concerned by daily pill regimen) and belief barriers (eg, sexual partners may expect condomless sex). CONCLUSIONS: In this first cross-country, Web-based survey in Latin America, willingness to use PrEP was found to be high and directly related to PrEP awareness. Interventions to increase awareness and PrEP knowledge about safety and efficacy are crucial to increase PrEP demand. This study provides important information to support the implementation of PrEP in Brazil, Mexico, and Peru.

The 12 city HIV Surveillance Survey among MSM in Brazil 2016 using respondent-driven sampling: a description of methods and RDS diagnostics.

INTRODUCTION: This paper details the methods used in the second national Biological and Behavioral Surveillance Survey (BBSS) of HIV, syphilis, and hepatitis B and C among men who have sex with men in Brazil. METHODS: Respondent-driven sampling (RDS) was used in 12 cities in 2016. The targeted sample size was initiated with five to six seeds in each city. HIV, syphilis, and Hepatitis B and C rapid tests were offered to participants. RDS Analyst with Gile's successive sampling (SS) estimator was used to adjust results as recommended and a weight for each individual was generated for further analysis. Data for the 12 cities were merged and analyzed using Stata 14.0 complex survey data tools with each city treated as its own stratum. RESULTS: Duration of data collection varied from 5.9 to 17.6 weeks. 4,176 men were recruited in the 12 cities. Two sites failed to achieve targeted sample size due to a six-month delay in local IRB approval. No city failed to reach convergence in our major outcome variable (HIV). CONCLUSION: The comprehensive BBSS was completed as planned and on budget. The description of methods here is more detailed than usual, due to new diagnostic tools and requirements of the new STROBE-RDS guidelines.

PrEP adopted by the brazilian national health system: What is the size of the demand?

BACKGROUND: Brazil's response to the HIV epidemic now includes free access to preexposure prophylaxis (PrEP) to populations at substantial risk for HIV infection including men who have sex with men (MSM). We used nationally representative demographic, epidemiologic, and surveillance data to offer estimates for the number of MSM at substantial risk for HIV infection who might be eligible and willing to use PrEP in Brazil. METHODS: Starting from the age/sex-stratified population, we calculated the number of men aged 15 to 64 years, in 5-year age groups, and the proportion of those who report sex with other men during their lifetime. We focused on 11 cities (representing all regions) that are responsible for a significant fraction of the HIV burden of the country and used city-specific HIV prevalence estimates to infer the fraction of MSM who are HIV-negative. We then derived the proportion of HIV-negative MSM under substantial risk for HIV infection defined as having unprotected receptive anal intercourse in the 6 months before study participation. Finally, PrEP uptake among the eligible was inferred from the PrEP Brazil study. RESULTS: Our results show that PrEP demand in these 11 cities is of 66,120 men aged 15 to 64 years. When we consider the lower and upper bounds for the available parameters, we find that PrEP demand in these 11 cities might vary from 33,378 to 97,962 men. If PrEP is restricted to those aged 15 to 49 years, demand drops by 20%. PrEP demand varies considerably by city, mostly because of the differences in population size and city-specific HIV prevalence. DISCUSSION: We have shed light on the probable size of PrEP demand in Brazil certain that the incorporation of PrEP as part of Brazil's combination prevention for populations at substantial risk for HIV infection is a necessary challenge. PrEP will not only prevent HIV infections, it will also expand testing among the most vulnerable with the added benefit of offering combination prevention for the uninfected and immediate treatment for those already infected. As such, expected added benefits of PrEP will be earlier linkage to care, prompt treatment initiation leading to health benefits and decreased transmission.

HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling.

This paper reports human immuno-deficiency virus (HIV) prevalence in the 2nd National Biological and Behavioral Surveillance Survey (BBSS) among men who have sex with men (MSM) in 12 cities in Brazil using respondent-driven sampling (RDS).Following formative research, RDS was applied in 12 cities in the 5 macroregions of Brazil between June and December 2016 to recruit MSM for BBSS. The target sample size was 350 per city. Five to 6 seeds were initially selected to initiate recruitment and coupons and interviews were managed online. On-site rapid testing was used for HIV screening, and confirmed by a 2nd test. Participants were weighted using Gile estimator. Data from all 12 cities were merged and analyzed with Stata 14.0 complex survey data analysis tools in which each city was treated as its own strata. Missing data for those who did not test were imputed HIV+ if they reported testing positive before and were taking antiretroviral therapy.A total of 4176 men were recruited in the 12 cities. The average time to completion was 10.2 weeks. The longest chain length varied from 8 to 21 waves. The sample size was achieved in all but 2 cities.A total of 3958 of the 4176 respondents agreed to test for HIV (90.2%). For results without imputation, 17.5% (95%CI: 14.7-20.7) of our sample was HIV positive. With imputation, 18.4% (95%CI: 15.4-21.7) were seropositive.HIV prevalence increased beyond expectations from the results of the 2009 survey (12.1%; 95%CI: 10.0-14.5) to 18.4%; CI95%: 15.4 to 21.7 in 2016. This increase accompanies Brazil's focus on the treatment to prevention strategy, and a decrease in support for community-based organizations and community prevention programs.