"PrEP as a Sanitary Barrier": Notions and Experiences of Men and Health Professionals Regarding HIV PreventionAbstract
This article analyzes the notion of risk and prevention among men who have sex with men (MSM) using Pre-Exposure Prophylaxis (PrEP), from the perspective of users and healthcare professionals.
Method: Exploratory and descriptive study with a mixed-method approach. Data were collected via an online form administered to users, a focus group with professionals from the PrEP clinic in Florianópolis, Santa Catarina, and individual interviews with users.
Results: After starting PrEP, 75.51% of respondents were not diagnosed with STIs. Among MSM who reported STIs, gonorrhea and chlamydia were the most common, followed by genital herpes, HPV, and monkeypox. Reasons for not using condoms included comfort, impulsivity, pleasure, confidence, and ease of maintaining an erection. Healthcare professionals highlighted gaps in service decentralization.
Conclusion: The study revealed gaps in inconsistent condom use and STI prevention. It’s crucial to adopt an integrated approach that combines education, access to health services, and identification of high-risk behaviors, not considering regular condom use as the only form of STI prevention. These integrated measures are essential to ensure that PrEP meets the needs of the MSM community and contributes to positive and inclusive sexual health.
Keywords:
Unprotected sex; Sexual and gender minorities; Pre-exposure prophylaxis; Men; Sexually transmitted infections
Resumo
Este artigo analisa a noção de risco e prevenção em homens que fazem sexo com outros homens (HSH) em uso de Profilaxia Pré-Exposição (PrEP), sob a ótica dos usuários e dos profissionais de saúde.
Método: Estudo exploratório e descritivo com abordagem mista. Os dados foram coletados via formulário on-line aplicado aos usuários, grupo focal com profissionais do ambulatório PrEP em Florianópolis-SC e entrevistas individuais com usuários.
Resultados: Após o início da PrEP, 75,51% dos entrevistados não foram diagnosticados com ISTs. Entre os HSH que relataram ISTs, gonorreia e clamídia foram as mais comuns, seguidas por herpes genital, HPV e monkeypox. Razões para não usar preservativo incluíram conforto, impulsividade, prazer, confiança e facilidade de manter ereção. Profissionais de saúde destacaram lacunas na descentralização do serviço.
Conclusão: O estudo revelou lacunas no uso inconsistente de preservativo e na prevenção de IST. É fundamental adotar uma abordagem integrada que combine educação, acesso aos serviços de saúde e identificação de comportamentos de alto risco, não considerando o uso regular do preservativo como única forma de prevenção contra IST. Essas medidas integradas são essenciais para tentar garantir que a PrEP atenda às necessidades da comunidade de HSH e contribua para uma saúde sexual positiva e inclusiva.
Palavras-chave:
Sexo sem proteção; Minorias sexuais e de gênero; Profilaxia pré-exposição; Homens; Infecções sexualmente transmissíveis
Introduction
“Pre-exposure prophylaxis (PrEP) as a cordon sanitaire” was a term that emerged in one of the interviewees’ statements. Historically, cordon sanitaires were used during disease outbreaks such as bubonic plague and cholera. A notable example is the cordon sanitaire established in 1720 to contain the plague in Marseille, where military troops surrounded the city to prevent the escape of infected people, thus controlling the spread of the disease (Moniz, 1899).
More than four decades after the discovery of human immunodeficiency virus (HIV) infection, this virus and the disease it causes remain a global public health problem. During this period, significant efforts have been made to develop strategies to combat the disease, ranging from prevention and diagnosis to treatment and raising awareness among the general population (Morais et al., 2019).
It is notable that HIV infection affects all population groups without discrimination. However, studies indicate that some population groups, known as key populations, have specific vulnerabilities, such as sexual orientation, discrimination, stigma, difficulty accessing education and health services, and sexual practices that put them at risk (Queiroz et al., 2018).
From this perspective, the use of Pre-Exposure Prophylaxis (PrEP) with a fixed-dose combination (FDP) of the antiretrovirals tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg has emerged as an alternative for key populations more susceptible to acquiring HIV infection (Brazil, 2023). Although this alternative medication has a positive impact on disease control, it is recommended that it be accompanied by condom use, as unprotected sex can increase the risk of contracting other sexually transmitted infections (STIs) (Santos et al., 2021).
According to information released by the World Health Organization (WHO), more than 1 million new cases of curable STIs are recorded every day in individuals aged 15 to 49. This alarming statistic represents an annual total of more than 376 million new cases of the following four infections: chlamydia, gonorrhea, trichomoniasis, and syphilis (PAHO, 2019).
Studies have highlighted the need to deepen the understanding of the relationship between the occurrence of STIs and the increased use of preventive methods other than condoms, such as testing for sexual agreements. This approach would enable early diagnosis, treatment, and, consequently, interruption of the chain of STI transmission (Zucchi et al., 2018). Some studies, for the most part, have remained limited to assessing the increase in STIs in men after starting PrEP (Fata et al., 2017; Beymer et al., 2018; Jansen et al., 2020; MacGregor et al., 2021; Tabatabavakil et al., 2022; Wees et al., 2022), rather than addressing the entire context surrounding the topic, including the perspective of health service users and professionals.
Thus, we identify the relevance of expanding the understanding of this discussion on the use of PrEP, with possible increases in STIs, described in the literature, and the narratives of the notion of risk and prevention in this population segment. The results of this research may support health professionals and managers, with a broader view of planning and implementing actions to prevent and break the chain of transmission of STIs, as well as contribute to improving the quality of life of at-risk populations.
Therefore, the present study aimed to analyze notions of risk and prevention among men who have sex with men (MSM) using oral PrEP, considering the perspectives of both users and healthcare professionals. The specific objectives were to investigate the sexual practices and meanings attributed to prevention by MSM using PrEP; to explore healthcare professionals’ perceptions of the decentralization of PrEP services; and to unravel the impact of PrEP use on the incidence of sexually transmitted infections (STIs) among MSM.
Methods
This is an exploratory and descriptive study with a mixed-method approach, which used intra-method triangulation. The following techniques were applied: an online questionnaire with users, a focus group with professionals from the PrEP clinic in Florianópolis, Santa Catarina state, Brazil, and in-depth individual interviews using thematic oral history.
The methodological choice for this study was based on qualitative approaches that prioritize understanding barriers and facilitators in public health contexts, as conducted by Pimenta et al. (2022) in the ImPrEP Stakeholders study. This study, which analyzed the challenges and opportunities in accessing PrEP for vulnerable populations in Brazil, adopted a qualitative methodology based on interviews with key stakeholders, allowing for an in-depth analysis of the perceptions and experiences of the stakeholders involved. The choice of a similar approach is justified by the need to capture the complexity and multidimensionality of the phenomenon under investigation, thus ensuring greater robustness and consistency in the research.
Gay MSM receiving treatment at the PrEP Clinic in Florianópolis were invited to participate in the questionnaire and interview. Inclusion criteria were being over 18 years of age and having been using oral PrEP for at least one month. Men who had not been sexually active in the last month and bisexual MSM were excluded. Healthcare professionals were invited to participate in the focus group.
Data collection from users was conducted in two stages. The first took place at the PrEP Outpatient Clinic in October, November, and December 2023. The researcher visited the clinic three times a week, in shifts previously agreed upon with the team, and waited in the waiting room. She invited participants to participate in the study and then administered a Google Form. The instrument, consisting of open- and closed-ended questions, was administered in an office setting to ensure participant privacy. At the end of the form, 49 participants had the option to indicate their interest in continuing to the next stage: in-depth individual interviews.
In the second phase, between December 2023 and January 2024, 14 participants who expressed interest in being contacted were given the opportunity to provide more detailed information. Participants in this phase were contacted via WhatsApp, as provided in the contact form, to schedule an interview. The interview could be in-person at the PrEP Clinic itself, or via video via the Google Meet platform, according to their preference.
Professionals were invited to participate in the study, and data were collected through an online focus group via the Google Meet platform, lasting approximately 30 minutes, on March 18, 2024, following a semi-structured script, based on a guide of previously outlined topics.
For data analysis, in the first stage, the collected data were tabulated and consolidated in an electronic spreadsheet (Microsoft Excel® software), and the results were expressed in tables for better understanding. For the second and third stages, the content analysis technique described by Bardin (1977) was used.
To guarantee the anonymity of the participants, the statements were identified with the codenames H1, H2, H3, and so on for men who have sex with men (MSM) in the second stage of the study, and E1, E2, E3 and E4 for the health professionals who participated in the focus group.
As this is a study with human beings, respecting and considering the essential ethical aspects for the effective development of the research, as provided for in Resolution No. 510/2016 (Brazil, 2016), the research was submitted to UFSC Research Ethics Committee and approved through opinion 6,324,279.
Results and Discussion
In the first stage of the research, information was collected through a Google Forms form with 49 MSM who agreed to participate in the research.
Table 1 presents the sociodemographic characteristics of the sample. The majority (95.9%) are over 25 years old, 67.35% have higher education, and 65.31% identify as White. More than half are single men with casual partners (57.14%). Regarding income, the majority (36.73%) earn 3 to 6 minimum wages, followed by 28.57% with 1 to 3 minimum wages, and 26.53% with more than 9 minimum wages.
Although the study was conducted with individuals over 18 years of age and PrEP is recommended for people 15 years of age and older (UNAIDS, 2022; Brazil, 2022), only 4.1% of the study participants were under 25 years of age. Furthermore, there was a predominance of men with higher education and self-identified as White. These data are consistent with the existing literature on sociodemographic characteristics of other published studies on PrEP.
Further analyzing sociodemographic variables, the data presented show that the sample is predominantly composed of individuals with higher education and income, which may influence risk perception and access to prevention strategies. However, it is important to consider how factors such as race, social class, and sexual orientation interact to increase or reduce vulnerability in different contexts.
The importance of considering these factors was based on research by Pimenta et al. (2022), which demonstrated structural barriers - such as poverty, racism, and gender inequality, as well as stigma and discrimination against non-hegemonic gender identities and sexualities - that hinder adherence, especially among MSM, transvestites, and trans women with lower income and social capital. The inadequacy of services to users’ life and work contexts also compromises the effectiveness of PrEP. Therefore, analyzing inequalities in access, considering social markers, is essential to strengthen this and other combined prevention strategies.
Regarding condom use, 20% of participants did not have a steady partner, and only 12.82% of those who did used condoms in all relationships. With casual partners, 6.12% did not have this type of relationship, while 34.78% of those who did used condoms in all relationships (Table 2).
Regarding condomless sex practices, the results indicate that its use varies according to the type of sexual partner. A lower proportion of use was observed when the partner was considered steady, while this proportion increased in cases of casual partners, as already indicated in previous national surveys such as the Survey of Knowledge, Attitudes and Practices in the Brazilian Population (PCAP) conducted in 2004, 2008 and 2013 (Brazil, 2005; 2011; 2016).
However, in relation to sexual relations considered high risk, such as group sex and chemsex (a practice that involves the use of psychoactive drugs to prolong and intensify sexual experiences), even among PrEP users, due to the risk of infection by other STIs, such as gonorrhea, chlamydia and genital herpes, the use of condoms is suggested, or those who do not use condoms may be encouraged to test more frequently to diagnose possible STIs and initiate early treatment.
Davis (2020) published a study analyzing PrEP clinical trials and the construction of the concept of Homo adhaerens, an ideal subject who combines high-risk behavior with rigorous treatment adherence. Activists in the United States question this approach, advocating for greater access to PrEP or criticizing the limited perspective that focuses exclusively on adherence and efficacy. Ultimately, they argue that PrEP clinical trials fail to consider the social realities that influence adherence, resulting in knowledge that fails to meet the needs of the most vulnerable groups.
After starting PrEP use, 75.51% of respondents self-reported not having been diagnosed with STIs. Among MSM who reported having been diagnosed with an STI, gonorrhea and chlamydia were the most mentioned (33.33% each), followed by genital herpes, HPV (16.66% each), and monkeypox (8.33%). None of the participants reported a diagnosis of hepatitis (Table 3).
STIs represent a global public health challenge, involving eight pathogens, including viruses and bacteria, that are responsible for most cases. Five of these microorganisms are associated with curable STIs, such as syphilis, chlamydia, gonorrhea, trichomoniasis, and HPV, while other infections, such as hepatitis B, herpes simplex, and HIV, have no cure (PAHO, 2019).
It is encouraging to note that most participants were free of any STIs diagnosed after starting PrEP. However, the incidence of gonorrhea, chlamydia, and other STIs among those who reported diagnoses after starting PrEP is concerning, as observed in other studies (Gravett et al., 2020; Zeggagh, 2020; MacGregor et al., 2021; Wees et al., 2022). This suggests the continued need for monitoring and education about the prevention of STIs other than HIV among PrEP users.
In the second stage, interested MSM participated in online interviews, where they discussed concepts of risk, prevention, and condom use, sharing their perceptions about PrEP and STIs. In the third stage, an online Focus Group was held with professionals from the Florianópolis PrEP Clinic in March 2024.
Although the clinic is multidisciplinary, only nurses agreed to participate in the focus group. Two professionals working with PrEP reported having been in this role for at least five years, the other two for a year and a half.
The results will be presented in categories for better understanding and analysis of the speeches.
Getting to Know PrEP
The first topic addressed was knowledge about and use of the Outpatient PrEP service. Five participants reported coming from other municipalities and already using PrEP.
I was already doing prep monitoring in Chapecó, I’m from Rio but I was living in Chapecó since February 22 [...] then I moved to Florianópolis for work reasons [...] (H1).
[...] I think I myself went after PrEP when I discovered that there was this option in Curitiba, since I went to a testing center there, in 2019 (H5).
I arrived in Florianópolis in 2017 and was already doing research on PrEP, at PrEP Brasil, it was research to implement PrEP at Fiocruz in Rio [...] (H6).
I was already using PrEP in a city where I lived, so I stopped for a while (H7).
Because I moved to Florianópolis about a year ago and in the city where I lived, I lived in the interior of Paraná, I had never heard about it, I didn’t even know it existed (H12).
One of the men emphasizes in his statement above that he lived in the countryside and did not have access to PrEP. This situation is found in several Brazilian states; distribution and promotion are concentrated in large urban centers, and the population in the countryside lacks knowledge or access.
In Santa Catarina, PrEP is distributed across 52 services, 5 in the capital Florianópolis, 3 in the Greater Florianópolis Region, 15 in coastal municipalities and the remainder, 29 services, distributed throughout the state (Brazil, 2023).
For nurses, the centralization of PrEP care, the lack of access to medication by other populations, as well as the lack of knowledge within the health network regarding PrEP have been the main challenges faced.
[...] when we read the Ministry of Health’s CTA manual, it talks a lot about key audiences [...] we can’t reach this key audience, we can’t have access, no matter how many extramural actions we have, no matter how many external interventions, there is an audience that is still uncovered [...] (E1).
I think one of the issues is the centralization of PrEP and not being so widespread in relation to the rest of the network (E3).
[...] within our network, there is still a lack of awareness of PrEP. Our own doctors and nurses are still unaware of PrEP. [...]. It is a national policy, but it is not widely disseminated. [...] (E1).
In São Paulo, administrators have decentralized PrEP provision to reduce HIV incidence, using mobile units and community partnerships. The city has a mobile CTA unit and the Jorge Beloqui Prevention station on the subway, which offers extended-hour services. Furthermore, the SPrEP channel on the e-saúdeSP app allows for online care. These strategies expand the dissemination and provision of PrEP, reaching the outskirts of cities and decentralizing care (AIDS News Agency, 2023).
In the “PrEP in PHC” project, Coelho and Pádua (2023) implemented PrEP at the Saco dos Limões Primary Health Care Unit (UBS) in Florianópolis to improve PrEP accessibility for vulnerable populations. From June 2023 to January 2024, 19 users, primarily Black or mixed-race MSM aged 25 to 29, initiated PrEP. The project demonstrated effectiveness in reducing access barriers and promoting and preventing HIV/AIDS through an integrated PHC approach, combining prescription, dispensing, and follow-up.
It can be observed that, even discreetly, this decentralization movement is already being thought about and reproduced in the APS in Florianópolis.
Two users interviewed became aware of PrEP after undergoing routine STI testing or using PEP due to unprotected consensual sexual exposure.
I don’t remember exactly, but it was probably when I went to do some exam, some test, I’m gay, right [...] (H1).
And then I was going to start using PEP, I was going to use it for 28 days [...], I used it about three times a year because of that and then I thought it was better to use PrEP because in case it happened [...] (H13).
Some health service users heard about PrEP through the internet, searching for other topics related to HIV/STI.
[...] I’m not from the health field, but I see a lot about STIs on Drauzio Varella’s channel and I end up getting information about it by listening to Podcasts (H1).
Look, I think it was through Google, at a time when we were looking for this HIV vaccine situation, we saw that PrEP existed and I searched, oh where is there PrEP in Florianópolis, Google said it was [...] (H2).
I was the one who searched randomly [...], my search wasn’t even so much for PrEP, it was for some type of prophylactic antibiotic [...]. And then some situations happened that worried me and I went to search on the internet and saw a news story (H4).
Through social networks (H7).
Participants discovered PrEP through various sources, including healthcare providers, friends, the internet, social media, and apps. This highlights the importance of diverse strategies for promoting PrEP and the need to expand healthcare services in regions where information is scarce.
Safety in the use of PrEP
When asked about the safety of using PrEP, the vast majority reported feeling safe, as highlighted in the statements below:
Quite a lot [...], and what I observe is that PrEP seems to create a certain sanitary cordon, practically all the guys I’ve been with in the last few months all use PrEP, that is, everyone takes the tests, it’s like a vaccine, that creates it (H1).
Yes, I do all the exams correctly, I take them correctly, so it gives me the confidence to continue (H3).
Yes, I’ve been here in Floripa for over 5 years. During all that time, I’ve spent two years researching, and very few times have I used a condom. (H6).
One of the nurses reports a feeling of insecurity, which appears in everyday work.
Some people arrive a little unsure whether PrEP is really safe for HIV, whether they would be putting themselves at risk [...] (E3).
Other professionals reported that users’ main insecurities regarding PrEP are side effects and drug interactions, as mentioned below.
[...] the part about side effects, what you can feel, what you can’t, from the patients who do it on demand [...] they bring up many questions in relation to kidney function (E2).
[...] I don’t think anything has been said yet regarding questions about interactions. There’s still a belief that PrEP, for example, will interact with alcohol. Sometimes there’s this understanding that it will overload the kidneys, it will overload the liver, so I won’t drink [...]. (E3).
From the perspective of both one of the men and the professionals, safety would also come from the fact that the PrEP user undergoes STI testing periodically.
[...] PrEP is also a certain lifestyle, of protection against HIV, but you end up doing other tests, all the STIs that I get other than HIV either have a vaccine or are curable (H1).
[...] in addition to not contracting HIV, all this monitoring that we do with the patient, we end up diagnosing other STIs that if it weren’t for PrEP, they wouldn’t have diagnosed [...] (E1).
[...] because we were monitoring STIs that were not previously diagnosed, diagnoses began to appear (E2).
Regarding trust in science and the SUS, some interviewees pointed to and compared PrEP to a vaccine, to a type of sanitary cordon that would protect a portion of users, as we can see in the following reports:
[...] that is, everyone gets tested, it’s like a vaccine, this creates... [...] this creates a certain sanitary cordon, a sense of security and I also haven’t heard of people who take PrEP and become infected and I also trust science, I feel safe (H1).
[...], it is very rare to hear of any case in the literature of people who were using PrEP and contracted HIV, there is always some bias in these studies (H4).
[...] so I think it’s something very advantageous because, well, for free, the SUS pays for everything (H12).
Reports of confidence in the effectiveness of PrEP and science are promising, but they also highlight the importance of a holistic approach to promoting sexual health, including education, counseling, and integrated health services.
It is important to highlight that, in 2024, people using PrEP, aged 15 to 45, were included in the target audience for HPV vaccination (Brazil, 2024). This expansion aimed to protect priority groups with greater exposure to the virus, reinforcing prevention and health promotion.
Notions of risk and prevention
Regarding condom use after starting PrEP and the notion of risk related to this use, we had some diverse reports from men, as highlighted in the following comments:
[...] they (health professionals) would ask me, do you use a condom and I do and actually before PrEP I did, not that I don’t use it now but my frequency has decreased a lot because of the safety you have [...] (H1).
It depends on the person, the relationship, like oral sex, you can’t do it with a condom, always without one, in insertive sex it depends a lot on the person (H2).
[...] despite taking it, it’s good to take that precaution, always use a condom, and be careful when doing it [...] (H3).
I think my biggest concern is the extra exposure to other viruses that I can get when I have sex without a condom [...], since there is either a vaccine or treatment for almost everything (H5).
I use PrEP, right? It’s okay, but I don’t stop using it, I haven’t stopped using condoms [...] (H11).
[...] but I think it’s just an extra precaution, I don’t feel safe having sex without a condom either [...] (H13).
Corroborating the above statements, the study by Silva et al. (2023) investigated the relationship between risk and pleasure in HIV prevention and care among MSM. The research analyzed condomless sexual practices and PrEP use among young MSM, highlighting how this strategy redefines prevention by reducing the risk of infection while simultaneously increasing pleasure, safety, and freedom. However, the study also problematizes ambivalences, tensions, and moral conflicts, such as the possible increase in condomless sex. From a praxiographic perspective, the authors understand HIV prevention as a fluid and non-linear process, involving multiple knowledge, emotions, and interactions, reinforcing the complexity and dynamism of this field.
One of the interviewees also reports that he has reduced the frequency of condom use due to the current treatment and vaccination for STIs.
[...] I’ve already taken it, I have the hepatitis B vaccine, which is the one you take in childhood, I took the second dose of hepatitis A last week, it was privately, but I went there and took it, I took the dose and I think it’s the ninth valent of HPV [...], so much so that syphilis is a terrible thing but it seems to me that the treatment is very easy and hepatitis C is the same thing, I don’t know if it’s easy but it is curable, all of this gave me peace of mind (H1).
Before PrEP was introduced in Brazil, studies were already investigating how MSM manage risks and their strategies for coping with HIV infection. A 2013 study revealed that this population develops their own autonomy, using everyday information, values, and beliefs to manage STD and HIV/AIDS risks, creating “safety belts” that allow them to take risks with a margin of safety, even amid uncertainty (Moraes; Spink, 2013).
Damacena et al. (2022) conducted a 2019 study on HIV knowledge and risk practices in three Brazilian municipalities, including Florianópolis. The results showed low knowledge about prevention methods, especially PrEP, and unprotected sex practices in all cities. The proportions of lifetime HIV testing were 65.9% for the general population and over 80% for MSM.
The term “safe sex” is generally associated with the idea of exclusive condom use, but not everyone adheres to this prevention method. Besides condom use, other prevention methods are also relevant, such as getting vaccinated against hepatitis B and HPV, and regularly testing for HIV and other STIs (Brazil, 2022). PrEP users perform these actions throughout their prophylaxis follow-up.
Many users have misconceptions about the medication and its limitations, which highlights the need for ongoing education and clarification from healthcare professionals, as we can see in the statements below.
Some people are worried about the side effects, okay? Others don’t know that it’s specific for HIV, not for other STIs, okay? [...] (E1).
We have to validate this in practically every service, which is only HIV [...]. That’s why we keep track of the other STs for screening, right? (E2).
When asked “what are the reasons for not using a condom in all sexual relations”, health service users listed some such as: comfort, pleasure, difficulty maintaining an erection, confidence in PrEP, already being vaccinated against other STIs, among others listed below.
Having sex without a condom is much more enjoyable, and since I use PrEP and am vaccinated against hepatitis A and B and HPV, I feel safe not using a condom. I’m aware of my exposure to other STIs, like syphilis, but I know they’re curable, and that reassures me (H1).
Makes it difficult to maintain an erection (H2).
Condoms during oral sex don’t work very well because the taste, texture and smell of the condom make me nauseous (H4).
Pleasure and confidence in prep, or impulsivity (H5).
Maintain regularity in relation to my exams (H6).
Sometimes because I don’t carry a condom in my wallet... and sometimes because I’m drunk (H7).
Comfort (H9).
It’s happened that my partner has removed the protection. Sometimes I feel a little helpless insisting on putting it on (H12).
Furthermore, the reports of difficulties listed above are consistent with those described in other published research and highlight the importance of addressing issues related to sexuality in promoting sexual health (Fonte et al., 2017; Brum; Souza; Cerqueira, 2022; Brum, 2023).
Understanding the variables that hinder condom use among MSM can contribute to improving therapeutic management and developing more effective public policies.
Challenges and perspectives from the professionals’ perspective
Despite the challenges, professionals recognized the benefits of PrEP beyond HIV prevention, including screening for other STIs and empowering users to prevent disease. Regular monitoring of users allows for the early diagnosis of other STIs, contributing to public health and individual and collective prevention.
[...] I think it’s important that we also try to separate a little bit between individual and collective benefits. The benefits that the user himself has in relation to HIV prevention [...], but also from a collective point of view, it’s an epidemiological issue [...] (E3).
I think that this issue of prevention itself, like HIV, is very visual for us who are dealing with it in the day-to-day care [...] So, it’s really cool when we see PrEP actually contributing directly to this HIV prevention (E2).
Thinking from the point of view of people with different HIV status in a relationship, where a person lives with HIV, and even undetectable, knowing that they do not transmit it, they can share this responsibility in relation to care [...] (E3).
The professionals highlighted the increase in the number of professionals and the decentralization of PrEP care as strategies to be implemented to improve service to users, as we can see in the statements below.
Increase the number of professionals (E4).
There would need to be moments of education and health with them, of professional qualification, because we have other professionals in other parts of the network who could also be performing this type of function [...] (E3).
[...] have more professionals to meet the demand [...], I think it is about aligning the APS once and for all to also offer its spontaneous demand service [...] (E2).
[...], disseminate to the network, be a strategy for expanding service to the entire network (E1).
Maciel et al. (2023) studied the decentralization of PrEP provision in Rio de Janeiro. In 2018, there was only one dispensing unit, serving 486 users. By 2022, the number of units had increased to 105, serving 3,994 users. This decentralization has proven effective in expanding access to PrEP, allowing new users to obtain the medication close to their homes.
An integrative review of HIV PrEP reveals that knowledge about PrEP is generally low among healthcare professionals, except among HIV specialists, who feel more comfortable prescribing it. The conclusion suggests that barriers such as cost, lack of knowledge, and lack of information could be overcome with training and continuing education, increasing availability, access, and adherence to prophylaxis among the target population (Botéchia et al., 2022).
To overcome the identified challenges, the nurses suggested decentralizing care, increasing the number of professionals, and training the healthcare network to overcome these challenges. Decentralizing PrEP would make the service more accessible, while training would improve the quality of care.
When asked about desirable training or qualifications to improve professionals’ knowledge and skills, participants highlighted the importance of presenting existing data on PrEP within the network itself and exploring the multidisciplinary team, as evidenced in the statements below.
[...] try to also clearly present the data we have in relation to PrEP, the impact of PrEP in the municipality, even bringing epidemiological data on the impact of PrEP, to try to raise awareness among professionals so that they truly understand that it does have a positive impact [...] (E3).
[...] showing the effectiveness of PrEP, I think that’s really lacking. What’s the situation like here in the municipality where we work, you know? (E1).
[...] explore the multidisciplinary vision even in relation to other professional categories [...] pharmaceutical professionals have a lot to contribute in relation to the issue of PrEP, right? (E3).
PrEP is a promising strategy for HIV prevention, but its implementation faces a number of challenges. A focus group discussion led by nurses at the PrEP Outpatient Clinic in Florianópolis highlighted the challenges faced in providing care to users and the prospects for improving the effectiveness and accessibility of this service.
This study did not address PrEP discontinuation to maintain focus on the primary objective, but recognizes its relevance for future research. PrEP discontinuation among MSM is a significant challenge, as evidenced by Rogers et al. (2023), who highlight the need for long-acting formulations, such as injectables and subdermal implants, to improve adherence. Interviews with 49 MSM who discontinued oral PrEP revealed interest in new options, but also concerns about safety, efficacy, and frequency of clinic visits. The preference for methods that reduce frequent visits suggests that long-acting formulations may increase persistence.
The Florianópolis PrEP clinic, until the completion of this research, still did not offer injectable PrEP.
This study was limited by the fact that it included only individuals treated at the PrEP outpatient clinic at the Policlínica Centro/Florianópolis, which restricts its scope to a single region. It would be appropriate for the study to be replicated in other parts of the city, including other municipalities, to increase representativeness and understanding of the topic.
Final considerations
The study revealed gaps in inconsistent condom use and STI prevention. The focus shouldn’t be solely on condom use, as inconsistency is a fact. Prevention efforts should continue, but without considering condoms as the only form of prevention.
Regular monitoring of users is essential, as this allows for early diagnosis of STIs, contributing to interrupting the chain of transmission and positively impacting public health. This approach promotes both individual and collective prevention, ensuring better outcomes for the community.
It is crucial to adopt an integrated approach that combines education, access to health services, and identification of high-risk behaviors. These measures are essential to ensure that PrEP meets the needs of the MSM community and contributes to positive and inclusive sexual health.
The results of the focus group with professionals reinforce that, despite the difficulties, decentralizing the provision of PrEP and ongoing training are essential to improve the effectiveness and accessibility of the service, maximizing its impact on the prevention of HIV and other STIs.
It is worth noting that new studies can be developed with larger populations and in different contexts, and that different spaces should be used to obtain information.2
References
-
AGÊNCIA DE NOTÍCIAS DA AIDS. Cidade de São Paulo aposta na descentralização da oferta de PrEP, no compromisso político e visão estratégica para diminuir a incidência de HIV no município. 9 ago. 2023. Disponível em: www.agenciaids.com.br
» www.agenciaids.com.br - BARDIN, L. Análise de conteúdo. Lisboa Edições 70, 1977, p. 95-101.
- BEYMER, M. R.; DeVOST, M. A.; WEISS, R. E.; DIERST-DAVIES, R.; SHOVER, C. L.; LANDOVITZ, R. J.; BENIASIANS, C.; TALAN, A. J.; FLYNN, R. P.; KRYSIAL, R.; McLAUGHLIN, K.; BOLAN, R. Does HIV pre-exposure prophylaxis use lead to a higher incidence of sexually transmitted infections? A case-crossover study of men who have sex with men in Los Angeles, California. Sex Transm Infect, v. 94, p. 457-462, 2018.
- BOTÉCHIA, J. Z. et al. Conhecimentos, práticas e obstáculos dos profissionais de saúde sobre a profilaxia pré-exposição ao HIV (PREP): uma revisão integrativa. Brazilian Journal of Development, Curitiba, v.8, n.5, p.40158-40176, May, 2022.
- BRASIL. Ministério da Saúde. Secretaria de Vigilância Saúde. Programa Nacional de DST e Aids. Pesquisa de Conhecimento Atitudes e Práticas na População Brasileira de 15 a 54 anos, 2004. Brasília: MS, 2005.
- BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Pesquisa de conhecimento, atitudes e práticas na população brasileira, 2008. Brasília: MS, 2011. 126 p.: il. - (Série G. Estatística e Informação em Saúde).
- BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de DST, Aids e Hepatites Virais. Pesquisa de conhecimento, atitudes e práticas na população brasileira, 2013. Brasília: MS, 2016.
- BRASIL. Ministério da Saúde. Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Secretaria de Vigilância em Saúde. Protocolo Clínico e Diretrizes Terapêuticas para profilaxia pré-exposição (PrEP) de risco à infecção pelo HIV. 1ª ed. rev. Brasília-DF, 2022.
- BRASIL. Ministério da Saúde. Departamento de HIV/Aids, Tuberculose, hepatites virais e Infecções Sexualmente Transmissíveis. Prevenção combinada PrEP. Onde encontrar PrEP. Brasília-DF: MS, dez. 2023.
- BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Coordenação-Geral de Vigilância do HIV/AIDS e das Hepatites Virais. Nota Técnica nº8/2023 - CGAHV/.DCCISVS/MS. Dispõe sobre recomendações e atualizações acerca do uso da Prolaxia Pré-Exposição de risco à infecção pelo HIV (PrEP) oral, incluindo a modalidade “sob demanda”. Brasília-DF: MS, 2023.
- BRASIL. Ministério da Saúde. Imunização. Ministério da Saúde anuncia a ampliação da vacina contra o HPV para usuários da PrEP. Brasília-DF: MS, jul. 2024.
- BRUM, M. M.; SOUZA, L. R.; CERQUEIRA, A. T. A. R. Autoconhecimento e autocontrole: uma análise de comportamentos acerca do uso de preservativos entre homens que fazem sexo com homens. Revista Brasileira de Doenças Infecciosas, v. 26, supl. 1, jan. 2022.
- BRUM, M. M. Uso de preservativos em homens que fazem sexo com outros homens: história individual e práticas culturais. Tese (Doutorado) - Faculdade de Medicina, Universidade Estadual Paulista Júlio de Mesquita Filho, Campus Botucatu. Botucatu-SP, 2023.
- COELHO, L. S.; PÁDUA, M. F. Profilaxia Pré-Exposição (PrEP) ao HIV na Atenção Primária à Saúde: reduzindo iniquidades. APS em Revista, v. 5, n. 3, p. 118-124, set-dez., 2023.
- DAMACENA, G. N. et al. Conhecimento e práticas de risco à infecção pelo HIV na população geral, homens jovens e HSH em três municípios brasileiros em 2019. Cadernos de Saúde Pública, v. 38, n. 4, e00155821, 2022.
- DAVIS, C. Homo adhaerens: Risk and adherence in biomedical HIV prevention research. Social Studies of Science, v. 50, n. 6, p. 860-880, 2020.
- FATA, L. L. et al. Rate of Asymptomatic Bacterial Sexually Transmitted Infections (STIs) in Men who Have Sex with Men on Pre Exposure Prophylaxis (PrEP). Open Forum Infect Dis, v. 4, Edi suppl. 1 Oct., 2017.
- FONTE, V. R. F. et al. Fatores associados ao uso do preservativo entre jovens homens que fazem sexo com homens. Enfermería Global, n. 46, abr. 2017.
- GRAVETT, R. M. et al. Sexually transmitted infections and sexual behaviors of men who have sex with men in an American Deep South PrEP clinic. International Journal of STD and Aids, v. 31, n. 2, p. 127-135, 2020.
- JANSEN, K. et al. STI in times of PrEP: high prevalence of chlamydia, gonorrhea, and mycoplasma at different anatomic sites in men who have sex with men in Germany. BMC Infectious Diseases, v. 20, n. 1, p. 110, 2020.
- MAC GREGOR, L. et al. Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM. Sex Transm Infect., v. 97, n. 7, p. 507-513. 2021.
- MACIEL, A. L. B. et al. Ampliação do acesso à profilaxia pré-exposição através da descentralização da dispensação no município do Rio de Janeiro, de 2018 a 2022. Revista Brasileira de Doenças Infecciosas, v. 27, supl. 1, out. 2023.
- MONIZ, G. Considerações sobre a Peste Bubônica. Typ. e Encadernação do Diário da Bahia, Praça Castro Alves. Salvador-BA, 1899.
- MORAES, L. G.; SPINK, M. J. O gerenciamento dos riscos no cenário da aids: estratégias adotadas por homens que fazem sexo com homens em parceria casual. Athenea Digital. Revista de Pensamiento e Investigación Social, v. 13, n. 3, p. 39-56, nov. 2013.
- MORAIS, A. M. F. et al. Profilaxia pré-exposição a HIV: revisão de literatura. Rev Inic Cient Ext., v. 2, n. 1, p. 62-8, 2019.
-
OLIVEIRA, B. D. Infecção pelo vírus HIV: evidências sobre a profilaxia pré-exposição. Pensar Acadêmico, Centro Universitário UNIFACIG, p. 1-16, 2021. Disponível em: https://pensaracademico.unifacig.edu.br/index.php/repositoriotcc/article/view/3188
» https://pensaracademico.unifacig.edu.br/index.php/repositoriotcc/article/view/3188 - ORGANIZAÇÃO PAN-AMERICANA DA SAÚDE. A cada dia, há 1 milhão de novos casos de infecções sexualmente transmissíveis curáveis. Brasília: OPAS, jun. 2019.
- PIMENTA, M. C. et al. Barreiras e facilitadores do acesso de populações vulneráveis à PrEP no Brasil: Estudo ImPrEP Stakeholders. Cadernos de Saúde Pública, v. 38, n. 1, p. 1-12, 2022.
- QUEIROZ, A. A. F. L. N. et al. Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users. Rev Bras Enferm., v. 71, n. 4, p. 1949-55, 2018.
- SANTOS, F. L. et al. Relação da profilaxia pré-exposição (PrEP) com o uso do preservativo no Brasil. Brazilian Journal of Health Review, Curitiba, v.4, n.4, p. 18133-18138, jul.-ago. 2021.
- SILVA, L. A. V da. et al. Between risk and pleasure: reflections on HIV prevention and care in the current context of PrEP use by men who have sex with men. Cadernos de Saúde Pública, v. 39, n. supl. 1, p. 1-13, 2023.
- ROGERS, B. G. et al. Perspectives on long-acting formulations of pre-exposure prophylaxis (PrEP) among men who have sex with men who are non-adherent to daily oral PrEP in the United States. BMC Public Health, v. 23, n. 1, p. 1643, 2023.
- TABATABAVAKILI, S. et al. Incidence of Hepatitis C Virus Infections Among Users of Human Immunodeficiency Virus Pre-exposure Prophylaxis. Clinical Gastroenterology and Hepatology, v. 20, p. 674-681, 2022.
- ZUCCHI, E. M. et al. Da evidência à ação: desafios do Sistema Único de Saúde para ofertar a profilaxia pré-exposição sexual (PrEP) ao HIV às pessoas em maior vulnerabilidades. Cad. Saúde Pública, v. 34, n. 7, p. 1-16, 2018.
- UNAIDS Brasil. PrEP 15+: Atualização do protocolo amplia possibilidade de acesso a este método de prevenção do HIV. Brasília-DF, 2022.
- ZEGGAGH, J. et al. Incidência e fatores de risco para DSTs entre HSH em PrEP: uma análise post-hoc do estudo ANRS IPERGAY. Jornal da Sociedade Internacional de AIDS, v. 23, supl. 4, 2020.
- WEES, D. A. V. et al. Quantifying heterogeneity in sexual behaviour and distribution of STIs before and after pre-exposure prophylaxis among men who have sex with men. Sex Transm Infect, v. 98, p. 395-400, 2022.
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All research data are available in this text.
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1
An open relationship refers to an emotional-sexual dynamic in which partners maintain relationships with other people beyond their primary relationship, based on agreements of transparency and consent. This configuration can occur in the other categories listed in Table 1.
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2
M. de Oliveira: conception and design, analysis and interpretation of data; writing of the article final approval of the version to be published.M. Grisotti: theanalysis and interpretation of data; relevant critical review of intellectual content; final approval of the version to be published. The authors are responsible for all aspects of the work, ensuring the accuracy and integrity of any part of the work.
All research data are available in this text.
