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.

"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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Violence, discrimination, and sexual health practices among adolescent men who have sex with men, transgender women and travestis in three cities in Brazil / Violência, discriminação e práticas de saúde sexual entre homens adolescentes que fazem sexo com homens, mulheres transgêneros e travestis em três cidades do Brasil / Violencia, discriminación y prácticas de salud sexual entre hombres adolescentes que tienen sexo con hombres, mujeres transgénero y travestis en tres ciudades de Brasil

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.

A epidemia de HIV afeta desproporcionalmente homens adolescentes que fazem sexo com homens (AHSH) e mulheres transgênero e travestis. Nos últimos 10 anos, a prevalência do HIV aumento. A violência afeta a vida dessas populações adolescentes, comprometendo sua capacidade de autocuidado e tornando-as mais vulneráveis à infecção pelo HIV. Este estudo buscou examinar a associação entre diferentes tipos de vitimização por violência e discriminação e práticas de saúde sexual entre essas populações adolescentes em relacionamentos estáveis e casuais. Realizamos um estudo transversal usando dados basais do estudo de coorte PrEP1519. Usamos o escore médio de práticas de saúde sexual como desfecho e o escore cumulativo de discriminação (familiar, comunitária, educacional, religiosa, online e em espaços públicos) e violência (parceiro físico, sexual e íntimo) como variável de exposição. Realizamos análises de regressão linear para estimar a associação entre exposição e desfecho. No todo, 90% dos AHSH e 95% dos mulheres transgênero e travestis sofreram pelo menos uma forma de violência nos três meses anterior à pesquisa e cerca de 45% dos mulheres transgênero e travestis sofreram violência sexual no mesmo período. Vivenciar discriminação dentro de ambientes de cuidados de saúde (instituições ou provedores) foi negativamente associado às práticas de saúde sexual. A discriminação e a violência afetam negativamente práticas de saúde sexual. A prevenção contra o HIV e o cuidado a AHSH e mulheres transgênero e travestis devem escutar suas experiências e enfrentar a discriminação e da violência nessa população.

La epidemia del VIH afecta desproporcionadamente a los hombres adolescentes que tienen sexo con hombres (AHSH) y las mujeres transgénero y travestis. En los últimos 10 años, la prevalencia del VIH aumento. La violencia afecta la vida de estas poblaciones adolescentes, comprometiendo su capacidad de autocuidado y haciéndolas más vulnerables a la infección por VIH. Este estudio buscó examinar la asociación entre los diferentes tipos de victimización por violencia y discriminación y las prácticas de salud sexual entre estas poblaciones adolescentes en relaciones estables y casuales. Realizamos un estudio transversal utilizando datos basales del estudio de cohorte PrEP1519. Utilizamos el puntaje promedio de las prácticas de salud sexual como resultado y el puntaje acumulativo de discriminación (familiar, comunitario, educativo, religioso, en línea y en espacios públicos) y la violencia (pareja física, sexual e íntima) como variable de exposición. Realizamos análisis de regresión lineal para estimar la asociación entre la exposición y el resultado. En total, el 90 % de los AHSH y el 95 % de los mujeres transgénero y travestis experimentaron al menos una forma de violencia en los tres meses anteriores a la encuesta, y alrededor del 45 % de los mujeres transgénero y travestis experimentaron violencia sexual en el mismo período. Experimentar discriminación dentro de los ambientes de atención médica (instituciones o proveedores) se asoció negativamente con las prácticas de salud sexual. La discriminación y la violencia afectan negativamente las prácticas de salud sexual. La prevención contra el VIH y el cuidado a AHSH y mujeres transgénero y travestis deben escuchar sus experiencias y hacer frente a la discriminación y la violencia en esa población.