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

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

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

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

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

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

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.

Autonomy and Care in Context: The Paradox of Sex Workers' Acceptability of HIV Self-Tests in São Paulo, Brazil.

Cisgender female sex workers (CFSW) continue to face structural barriers to HIV prevention. We analyzed the acceptability of the oral HIV self-test (HIV-ST) among CFSW as part of a pragmatic trial on HIV prevention in Brazil. Data from in-depth interviews conducted with 12 women from diverse sex worker contexts and participant observation were analyzed using thematic analysis. CFSW valued autonomy in their workplaces and saw the HIV-ST as a possibility for self-care. Some feared clients' reactions, manager reprimands, and a positive result. HIV and sex work stigma largely drove self-care practices and perceived acceptability of the self-test. We argue that the autonomy offered by the self-test presents a paradox: increasing autonomy on the one hand while risking sidestepping structural dimensions of HIV vulnerability on the other. These nuances must be considered in interventions promoting the HIV-ST by considering the specificities of sex worker contexts, addressing stigma, and effectively involving CFSW and their organizations in intervention development.

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.

At the heart of the COVID-19 crisis: Perceived concerns of changes in long-term cancer care in French women with cancer.

OBJECTIVE: In the COVID-19 crisis context, the main objective of the study is to investigate factors associated with perceived concerns of change in long-term cancer care in patients currently under treatment. METHODS: A French population-based cross-sectional study was performed using an online questionnaire in April 2020. All persons currently receiving cancer treatment and belonging to the Seintinelles Association (https://www.seintinelles.com) were included in this present analysis. Individual sociodemographic characteristics, medical status and information regarding cancer care were collected. Multivariate binomial logistic regression analysis was performed. RESULTS: We included 298 women in the analysis. Younger participants (OR = 0.96 [0.94-0.99]), the need to visit healthcare facilities to receive treatment (OR = 2.93 [1.16-8.52]), deterioration in the quality of communication with the medical team since the beginning of the COVID-19 crisis (OR = 3.24 [1.61-7.02]) and being cared for by a university hospital or a public hospital (OR = 2.19 [1.16-4.23] versus comprehensive cancer centre) were associated with a perceived fear of change in long-term cancer care. CONCLUSION: To address patients' concerns regarding changes in their long-term cancer care, medical teams should consider the patients' own perceptions of the situation and provide clear, appropriate, precise information on cancer care, especially in the centres mostly affected by the COVID-19 crisis.

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

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

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.

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.

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.

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.

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.

Politics and pandemics.

This Special Issue of Global Public Health on Politics & Pandemics brings together 26 articles and commentaries that address diverse aspects of the politics of COVID-19 and related issues. These papers are grouped together in six topical areas: theories and politics of global health, health systems and policies, country responses, social inequalities, social responses, and the politics of science and technology. The goal of the Special Issue is to give readers a sense of the range of topics that have been a focus for research in relation to the COVID-19 pandemic and to provide diverse examples of how research and analysis on the political dimensions of the pandemic can contribute to confronting the COVID-19 crisis.

FOREST protocol: a qualitative study exploring health and sexuality of transmasculine individuals in France.

INTRODUCTION: While current research on sexuality and health often explores sexual behaviours among heterosexual and gay cisgender individuals, little is known about the sexualities of transgender people, especially transmasculine people. When data are available, sexual health is often reduced to risk exposure, not considering in detail social context and determinants that could contribute to a more comprehensive approach, such as general health, class, race, exposure to violence or social representations. Recognising this gap, identified in both national (French) and international scientific literature, this study aims to explore the sexual health of transmasculine people, employing an intersectional approach and considering both positive and negative health determinants. METHODS: This 2-year research based in the disciplinary field of social psychology, with a gender perspective, and will apply qualitative methods. We adopt a community-based research approach, integrating one university and one community-based organisation in the coordination of the study. In a triangulation perspective, two rounds of semistructured interviews will be performed with key informants (medical practitioners, community-based support services workers, etc) and with people self-identifying as transmasculine. Focus groups will complement data collection. ETHICS AND DISSEMINATION: FOREST protocol was approved by the Comité d'Évaluation Éthique (CEEI) de l'Institut National de la Santé Et de la Recherche Médicale (CEEI/International Review Board 00003888). The research adopts the principles of open science, and findings will be published assuring participants' confidentiality. Informative flyers and videos will be elaborated to communicate study findings to participants, stakeholders and the transcommunities at large, and data will be stored in lasting archives.

Effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult men who have sex with men and transgender women participating in two PrEP cohort studies in Brazil: COBra study protocol.

INTRODUCTION: The COVID-19 pandemic and its control measures have impacted health and healthcare provision in various levels. Physical distancing measures, for instance, may affect sexual health, impacting access to HIV prevention supplies and changing sexual behaviour, as well as mental health, increasing feelings of unsafety and weakening community support ties. These effects can be worsened among socially marginalised groups, such as men who have sex with men (MSM) and transgender women (TGW). Brazil is among the countries most affected by COVID-19 in the world, where control measures have been inconsistently implemented. We aim to investigate the effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult MSM and TGW in Brazil. METHODS: Convergent mixed-method prospective cohort study, nested in two ongoing HIV pre-exposure prophylaxis (PrEP) cohorts in Brazil, named PrEP1519 and Combina. Participants will be invited to answer, at baseline and after 6 months, a questionnaire about the effects of the COVID-19 pandemic on sexual behaviour, HIV prevention and mental health. Data on HIV infection and sexually transmitted infections (STI) will be collected as part of routine follow-up from the cohorts. Main outcome measures (HIV infection, STI and depression symptoms) will be observed within 12 months after baseline. Sample size is estimated at 426 participants. Complementarily, 50 participants will be invited to in-depth interviews through video calls or interactive voice response, and 20 will be invited to chronicle their lives during the pandemic through digital diaries. Triangulation will be done across qualitative methods and with the quantitative data. ETHICS AND DISSEMINATION: The study was approved by Research Ethics Committees from the Brazilian Universities coordinating the study. Findings will be published in scientific journals and presented at meetings. Informative flyers will be elaborated to communicate study findings to participants and key stakeholders.

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.

[Treatment adherence, access and AIDS assistance quality in Brazil. ]. / Adesão ao tratamento, acesso e qualidade da assistência em Aids no Brasil.

The patient adherence to highly active antiretroviral therapy (HAART) is a crucial matter to AIDS treatment effectiveness and its' impact. This article aims to discuss the association between adherence and quality of health service providing care to people living with AIDS (PLWA), highlighting quality of the services as a central point to adherence and access. It is based on results of our previous studies about the health care to PLWA in Brazil. Our studies point out that the groups of patients who are followed-up in health services providing care for less than 100 patients presented greater estimated risk of non-adherence than services following more than 500 patients. Also, smaller health services showed greater estimated risk to be ranged in the worst quality of services groups. This is related to the low complexity of smaller health care services, such as: lack of minimum human resources and material structures, poor organization on work process, medical-centered care and poor technical management. New studies in adherence and quality of services are needed. Nevertheless, the existent findings have already pointed out the need to review the current distribution of AIDS care services as well as to make the quality of services more homogenous thorough the country. These are high priorities in order to keep acceptable levels of adherence to HAART in Brazil.