Abstracts

Introduction

The first decade of the HIV/AIDS epidemic was marked by a prejudicial association between AIDS and the male gay community. This association raised significant social and programmatic consequences for this population ¹1. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men who have sex with men: stigma and discrimination. Lancet 2012; 380:439-45.^,22. Herzlich C, Pierret J. Une maladie dans l'espace public. Le Sida dans six quotidiens français. Ann Econ Soc Civilis 1988; 43:1109-34.. As knowledge advanced, it became clear that everyone can be at risk of HIV, depending on sexual practices, behaviors, and contexts of social and programmatic vulnerability ³3. Mann J, Tarantola D. AIDS in the World II: global dimensions, social roots, and responses. 2nd Ed. Oxford: Oxford University Press; 1996.. Nevertheless, HIV infection is still disproportionally higher among gay men or men who have sex with men (MSM) ⁴4. Baral S, Sifakis F, Cleghorn F, Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review. PLoS Med 2007; 4:e339.^,55. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380:367-77..

In Latin America and the Caribbean, estimates from the late 2000s indicated that the prevalence of HIV among MSM was around 14.9% and 25.4%, respectively ⁵5. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380:367-77.. Additionally, in 2019, it was estimated that 44% of the new cases of HIV were among MSM in Latin America ⁶6. Joint United Nations Programme on HIV/AIDS. Global AIDS update, 2020: seizing the moment: tackling entrenched inequalities to end epidemics. Geneva: Joint United Nations Programme on HIV/AIDS; 2020.. In Brazil, a 2009 epidemiological study, conducted in ten cities, using respondent-driven sampling (RDS) found an estimated HIV prevalence, among MSM, of 14.2% ⁷7. Kerr LR, Mota RS, Kendall C, Pinho AA, Mello MB, Guimarães MDC, et al. HIV among MSM in a large middle-income country. AIDS 2013; 27:427-35.. More recently, in 2016, another MSM-RDS study in 12 cities estimated a prevalence of 18.4% ⁸8. Kerr L, Kendall C, Guimaraes MDC, Mota RS, Veras MA, Dourado I, et al. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine (Baltimore) 2018; 97(1S Suppl 1):S9-15., about 23% higher than the prevalence found in 2009. This figure is far higher than the 0.8% HIV prevalence rate among males from the general population in Brazil ⁹9. Departamento de DST, Aids e Hepatites Virais, Secretaria de Vigilância em Saúde, Ministério da Saúde. HIV - AIDS. Boletim Epidemiológico 2014; Ano III (1). http://www.aids.gov.br/pt-br/node/73.
http://www.aids.gov.br/pt-br/node/73... . This means that the HIV epidemic in Brazil is concentrated in the key MSM population.

The literature has drawn attention to aspects of individual vulnerability among MSM, which include the number of sexual partners, unprotected sex, ulcers and inflammation caused by other sexually transmitted infections (STI), and the sharing of syringes ⁵5. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380:367-77.^,1010. Mayer KH, Nelson L, Hightow-Weidman L, Mimiaga MJ, Mena L, Reisner S, et al. The persistent and evolving HIV epidemic in American men who have sex with men. Lancet 2021; 397:1116-26.. However, individual Sexual behaviors can be determined by aspects of social vulnerability which reflect social, economic, organizational inequalities, and political power ¹1. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men who have sex with men: stigma and discrimination. Lancet 2012; 380:439-45.^,55. Beyrer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz AL, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380:367-77.^,1010. Mayer KH, Nelson L, Hightow-Weidman L, Mimiaga MJ, Mena L, Reisner S, et al. The persistent and evolving HIV epidemic in American men who have sex with men. Lancet 2021; 397:1116-26., not to mention the stigma and experiences of violence associated with sexual orientation in heteronormative societies ¹¹11. Magno L, Dourado I, Silva LAV. Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00135917.^,1212. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S, et al. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.^,1313. Bogart LM, Revenson TA, Whitfield KE, France CR. Introduction to the special section on lesbian, gay, bisexual, and transgender (LGBT) health disparities: where we are and where we're going. Ann Behav Med 2014; 47:1-4.^,1414. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health 2013; 103:813-21.^,1515. King R, Barker J, Nakayiwa S, Katuntu D, Lubwama G, Bagenda D, et al. Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda. PLoS One 2013; 8:e82937..

The dimension of programmatic vulnerability to HIV among MSM is also noteworthy. Worldwide, as in Brazil, government responses to MSM’s health needs are still inadequate, especially concerning HIV/AIDS prevention, treatment, and care ¹1. Altman D, Aggleton P, Williams M, Kong T, Reddy V, Harrad D, et al. Men who have sex with men: stigma and discrimination. Lancet 2012; 380:439-45.. This population also faces barriers in their access to health services, primarily because of the stigma and discrimination associated with non-heterosexual orientations ¹⁶16. Risher K, Adams D, Sithole B, Katuntu D, Lubwama G, Bagenda D, et al. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc 2013; 16(3 Suppl 2):18715.^,1717. Cerqueira-Santos E, Calvetti PU, Rocha KB, Moura A, Barbosa LH, Hermel E, et al. Percepção de usuários gays, lésbicas, bissexuais e transgêneros, transexuais e travestis do Sistema Único de Saúde. Interam J Psychol 2010; 44:235-45.. Finally, in recent years there has also been a notable drop in funding for AIDS nongovernmental organizations (AIDS-NGO), which are important for local community responses to the epidemic ¹⁸18. Almeida LF, Guimarães MDC, Dourado I, Veras MASM, Magno L, Leal AF, et al. Envolvimento em organizações não governamentais e a participação em ações de prevenção ao HIV/aids por homens que fazem sexo com homens no Brasil. Cad Saúde Pública 2021; 37:e00150520.^,1919. Aggleton P, Parker R. Moving beyond biomedicalization in the HIV response: implications for community involvement and community leadership among men who have sex with men and transgender people. Am J Public Health 2015; 105:1552-8.. Since the past decade (2009-2019), official epidemiological data suggest that adolescents in general ²⁰20. Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico HIV/AIDS 2020; número especial. http://www.aids.gov.br/pt-br/pub/2020/boletim-epidemiologico-hivaids-2020.
http://www.aids.gov.br/pt-br/pub/2020/bo... and young Brazilian MSM are increasingly at risk for HIV infection ²¹21. Saffier IP, Kawa H, Harling G. A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people in Brazil. BMC Infect Dis 2017; 17:675.^,2222. Coelho LE, Torres TS, Veloso VG, Grinsztejn B, Jalil EM, Wilson EC, et al. The prevalence of HIV among men who have sex with men (MSM) and young MSM in Latin America and the Caribbean: a systematic review. AIDS Behav 2021; 25:3223-37.. Despite the high estimates of HIV prevalence among adult and young adult MSM in this period, a recent systematic review indicated the scarcity of data on HIV prevalence among adolescent MSM (AMSM) ²²22. Coelho LE, Torres TS, Veloso VG, Grinsztejn B, Jalil EM, Wilson EC, et al. The prevalence of HIV among men who have sex with men (MSM) and young MSM in Latin America and the Caribbean: a systematic review. AIDS Behav 2021; 25:3223-37., and no study has been published, to date, on the factors associated with HIV infection among this population in Latin America. Therefore, we aim to estimate the prevalence of HIV among AMSM in Salvador, Bahia State, Brazil, and to analyze individual, social, and programmatic factors.

Methods

Study design and study population

From April 2019 to February 2021, a cross-sectional analysis was conducted with baseline data from the AMSM PrEP1519 cohort project. Analysis included only AMSM due to the limited number of adolescent transgender women included in the cohort to date and the specificities of this population ²³23. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C, et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22.. Sexually active AMSM aged 15-19 years who lived in Salvador or its metropolitan area and agreed to take an HIV screening test were included in this study. Further details on the complete methodology for the PrEP1519 project can be found in Dourado et al. ²⁴24. Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saúde Pública 2023; 39 Suppl 1:e00143221..

During the COVID-19 pandemic, the municipality of Salvador adopted quarantine and social isolation guidelines, including reductions in public transportation and suspension of many non-essential health services. Despite this, PrEP1519 decided to continue its work during the pandemic and was able to quickly adapt to the new situation due to social media and a telemonitoring infrastructure. Further details about this adaptation can be found in Dourado et al. ²⁵25. Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 pandemic: continuing HIV prevention services for adolescents through telemonitoring, Brazil. AIDS Behav 2020; 24:1994-9. and Magno et al. ²⁶26. Magno LM, Medeiros D, Soares F, Jefferson C, Duarte FM, Grangeiro A, et al. Demand creation and HIV self-testing delivery during COVID-19 contingency measures of physical distancing among adolescents' key population enrolled in PrEP in Brazil. J Int AIDS Soc 2021; 24 Suppl 4:35..

PrEP1519 project: contact and recruitment of the target population

PrEP1519 undertakes interventions to raise awareness, to create demand, and to encourage the use of pre-exposure prophylaxis (PrEP) and other HIV preventive measures among AMSM and adolescent transgender women (ATGW) aged 15-19 years at increased risk of HIV. It is the first PrEP demonstration cohort study taking place in three Brazilian capitals: Belo Horizonte (Minas Gerais State), Salvador, and São Paulo. Its primary aim is to estimate the effectiveness of daily oral PrEP use among AMSM and ATGW aged 15-19 years who are at high risk for HIV infection ²⁴24. Dourado I, Magno L, Greco DB, Zucchi EM, Ferraz D, Westin MR, et al. Interdisciplinarity in HIV prevention research: the experience of the PrEP1519 study protocol among adolescent MSM and TGW in Brazil. Cad Saúde Pública 2023; 39 Suppl 1:e00143221.^,2525. Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 pandemic: continuing HIV prevention services for adolescents through telemonitoring, Brazil. AIDS Behav 2020; 24:1994-9.. The data included in this study will be from the Salvador only.

Previous formative research used in-depth interviews with key-informants (health workers and local LGBTQI+ leaders), focus groups, and field observations. These procedures aimed to enable a comprehensive understanding of the fieldwork process. Formative research took place from August 2018 to January 2019 with three purposes: (i) to understand the dynamics of social interactions among AMSM and ATGW in the venues where they gathered, (ii) to assess AMSM and ATGW’s needs and perceptions regarding study implementation, and (iii) to analyze AMSM and ATGW’s sexual behaviors; contexts that contribute to increasing their vulnerability to HIV, and their acceptability of PrEP ²⁷27. Zucchi EM, Couto MT, Castellanos M, Dumont-Pena E, Ferraz D, Pinheiro TF, et al. Acceptability of daily pre-exposure prophylaxis among adolescent men who have sex with men, travestis and transgender women in Brazil: a qualitative study. PLoS One 2021; 16:e0249293..

In Salvador, the results of this formative study inspired the organization of the PrEP1519 clinic entitled “PrEPara Salvador” [a play on words between PrEP and “prepara” - Get ready!] outside traditional health services, financed by PrEP1519, but embedded in an initiative to promote the human rights of the LGBTQI+ population by the Bahia State Department for Justice, Human Rights, and Social Development, supported by the local health service network of the Bahia State Health Department and the Salvador Municipal Health Department.

PrEPara Salvador operates inspired by primary health care principles, offering comprehensive care, an interdisciplinary approach, broad training for health workers, and follow-up by care navigators from the LGBTQI+ community. In April 2019, the active recruitment of the target population for PrEP enrollment used different demand-generation strategies designed by the project. Several virtual platforms were used (e.g., Facebook, WhatsApp, Instagram, Twitter, YouTube, and Spotify) and peer educators engaged with potential participants on dating and hook-up application programs (e.g., Grindr, Hornet, Tinder, and Badoo). Face-to-face initiatives involved peer education led by adolescents and young adults who systematically and periodically worked with groups of adolescents in the identified social venues (e.g., bars, parks, beaches, streets, etc.). These face-to-face initiatives were adapted during the COVID-19 pandemic. Other strategies included referrals from a health service and/or NGO and word-of-mouth referrals from PrEP users ²⁸28. Magno LS, Soares F, Eustorgio M, Grangeiro A, Ferraz D, Zucchi E, et al. Effectiveness of strategies for generating demand for PrEP and combination prevention among adolescent's men who have sex with men and transgender women in Brazil. https://theprogramme.ias2021.org/Abstract/Abstract/2071 (accessed on 29/Aug/2022).
https://theprogramme.ias2021.org/Abstrac... ^,2929. Brasil SA, Zucchi E, Silva LAV, Ferraz D, Duarte FM, Massa P, et al. ‘Reaching adolescents where they are’: innovative recruitment strategies for PrEP enrolment of adolescent’s key population in Brazil. https://theprogramme.ias2021.org/Abstract/Abstract/2158 (accessed on 29/Aug/2022).
https://theprogramme.ias2021.org/Abstrac... ^,3030. Magno LS, Soares F, Zucchi EM, Eustórgio M, Grangeiro A, Ferraz D, et al. Reaching out to adolescents at high risk of HIV infection in Brazil: demand creation strategies for PrEP and other HIV combination prevention methods. Arch Sex Behav 2022; [Online ahead of print].. Adolescent MSM reached by these recruitment activities and those who met the inclusion criteria described above were included in this study. All participants who arrived at the clinic and participated in the research received a reimbursement of BRL 30 (≈ USD 6) for their transportation and food expenses.

Data collection

Figure 1 shows the general flow of data collection. Sociobehavioral information was obtained for the three months prior to interviews via a structured questionnaire containing questions on demographic information, sexual practices, preventive methods, use of alcohol and other drugs, STI history, and experiences of discrimination and violence. All the information was recorded by health professionals and interviewers who received training in how to input the data in an electronic recording platform. Interviews were conducted at the PrEPara Salvador clinic, lasting, on average, for 40 minutes.

Laboratory diagnoses of HIV were conducted using the Brazilian Ministry of Health algorithm ³¹31. Wersom ESS, Motta LR, Bazzo ML, Franchini M, Ferreira Junior OC. Manual técnico para o diagnóstico da infecção pelo HIV. Brasília: Ministério da Saúde; 2015.. Participants were screened for HIV via a rapid test on their first visit to the clinic, establishing the baseline prevalence of HIV for the PrEP1519 cohort. To determine infection, two rapid tests by different manufacturers were used to detect HIV-1 or HIV-2 antibodies and p24 antigens. All positive rapid test results were confirmed by viral load quantification tests. All participants received counselling before and after the tests. Those diagnosed with HIV received psychosocial, medical, and/or nursing care at the time of diagnosis. Moreover, the project team contacted specialized services to ensure the linkage of these participants to care and start of antiretroviral therapy (ART).

Study variables

We used the concept of health vulnerability specifically to HIV/AIDS ³²32. Ayres J, Paiva V, França-Jr I. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: Paiva V, Ayres J, Buchalla C, editors. Vulnerabilidade e direitos humanos - prevenção e promoção da saúde: livro I, da doença à cidadania. Curitiba: Juruá Editora; 2012. p. 71-94.^,3333. Magno L. Qualitative studies on truck drivers and HIV/AIDS: contributions for the analysis of vulnerability. Ciênc Saúde Colet 2019; 24:715-28.^,3434. Magno L, Castellanos ME. Meanings and vulnerability to HIV/AIDS among long-distance truck drivers in Brazil. Rev Saúde Pública 2016; 50:76.. This concept may be understood by analyzing three interrelated components: (i) individual vulnerability, to identify physical, mental or behavioral factors via risk assessments and/or other approaches; (ii) social vulnerability, to analyze the cultural, moral, political, economic, and institutional dimensions that may determine exposure to illness or death; and (iii) programmatic vulnerability, to examine the ways policies, programs, and services affect people’s social and individual situations. Vulnerability highlights the responsibility of governments and public policies as an integral part of the determinants of health and disease. In this study, the use of this concept guided the analysis beyond individual and behavioral factors associated to the risk of HIV to enable a more integral approach, encompassing issues such as barriers to access to health services, stigma, and discrimination.

The outcome variable was an HIV infection detected at baseline on the PrEP1519 cohort-Salvador site. Predictor variables were combined at hierarchically distinct levels of vulnerability for HIV (Figure 2). The most proximal level (individual vulnerability dimension) includes the following variables: age (15-17 years/18-19 years), age at the first sexual intercourse (< 15 years / ≥ 15 years), condom use at the first sexual intercourse (yes/no); use of hook-up apps (no/yes); and the following information for the three months prior: sexual partners (none/just steady partner/just casual partners/steady and casual partners); condom use during anal sex (always/not always with steady partner/not always with casual partner/not always with steady and casual partners); age of casual sexual partners (up to 5 years older/more than 5 years older); number of casual partners (none/1 to 4 /5 or more); whether condoms broke or slipped off during sex (never/at least once); group sex (no/yes); whether alcohol use ever interfered in condom use during sex (never/at least once). In this dimension, the HIV prevention practices used with steady and casual partners were also described by statements classified as always/frequently or sometimes/rarely/never: “I asked my partner to remove his penis before ejaculating”; “I used lubricant”; “I avoided being receptive during anal sex”; “my partner and I took an HIV test”; “I had sex without penetration”; and “I avoided having anal sex”.

At the intermediate level (social vulnerability dimension) the following variables were included: race/skin color (black was classified from self-reporting as pardo - i.e., brown-skinned - and black, and non-black were categorized from self-reported white, Asian, and indigenous); schooling level (high school and higher education/primary school, middle school, and youth and adult education); sexual orientation (homosexual, gay, lesbian/bisexual, heterosexual); exchanging money or favors for sex (never/at least once); self-identification as sex worker (no/yes); failure to be selected or being dismissed from a job because of sexual orientation (never/at least once); and exclusion or marginalization from family settings because of sexual orientation (never/at least once).

The distal level (programmatic vulnerability dimension) included: usual source of care (primary healthcare facility, pharmacy, hospital, doctor/nowhere, friends or relatives); participation in an organized group, social movement or LGBTQI+ NGO (no/yes); access to private health insurance (no/yes); ever received poor service at a health facility or by a health professional because of sexual orientation (never/at least once); ever received poor public service because of sexual orientation (never/at least once).

Data analysis

Initially, analysis was carried out to describe the characteristics of the sample and stratify them by age groups (15-17 years and 18-19 years). A bivariate analysis was conducted to assess differences in the distribution of participants’ characteristics vis-à-vis HIV infection, using the chi-squared test or Fisher’s exact test, with their descriptive levels of significance set at p = 0.05. For the multivariate analysis, logistic regression models were used to estimate the odds ratios (OR) of the association between predictor variables and HIV infection, variables for which a p ≤ 0.20, in the bivariate analysis, were included in the model for each dimension of HIV vulnerability, starting with the most distal (programmatic) to the most proximal level (individual). In the final model, the variables with p ≤ 0.10 at each hierarchical level of vulnerability (individual, social, and programmatic), and a satisfactory residual plot were maintained as adjustment variables for the next level. The final model was evaluated for goodness-of-fit using the Hosmer & Lemeshow test. These analyses were performed using the Stata software version 15 (https://www.stata.com).

Ethics assessment

Our research protocol was approved by the Ethics Research Committee of the World Health Organization (protocol ID: Fiotec-PrEP Adolescent study) and of the Federal University of Bahia (# 3,224,384). Participants aged 18 or older provided written informed consent. For those under 18, enrollment was by one of two routes: (i) written informed consent provided by a parent or guardian and signing of an informed assent form by the adolescent; or (ii) only the signing of an informed assent form by the adolescent in cases in which the team psychologist and social worker judged their family ties to have been severed or that they were at risk of physical, psychological or moral violence due to their sexual orientation. This latter enrollment option was made feasible thanks to a favorable judicial ruling in response to a petition filed by the Public Prosecution Service of Bahia and was approved by the Ethics Research Committees. All participants could withdraw consent at any stage of the process or skip any questions perceived as too sensitive, personal or distressing.

Results

From April 2019 to February 2021, 288 AMSM were recruited. In total, 17 had a positive HIV test, wielding a baseline prevalence of 5.9% (95%CI: 3.7-9.3%), and all participants, except two, were unaware of their HIV status. The project team referred all cases to the specialized health service. Out of these, two participants who were aware of their HIV status were already linked to the health service and taking ART. To date, 12 AMSM have initiated ART, whereas the three who have refused treatment continue to be monitored by the project team and are encouraged to start it.

Most participants were aged 18 and 19 years (85.1%), were aged less than 15 years at their first sexual intercourse (50.2%), failed to use a condom at their first sexual intercourse (57%), and used “hook-up apps” (54.5%). In the three months before the interview, 11.5% reported having had no sexual partners, 21.9% said they had just steady partner, 34% had just casual partners, and 32.6% had steady and casual partners. As for condom use during anal sex, 29% said they always used it, 26.5% reported they did not always use it with their steady partner, 25.7% did not always use it with casual partners, and 18.8% did not always use it, whether the partner was steady or casual. Over half of the participants who had a casual partner reported this partner to be up to five years older than them and that they had engaged with one to four partners in the previous three months. Overall, 27.4% of participants reported having a condom break or slip off, 17% said they had group sex, 10.4% claimed they had exchanged money or favors for sex, and 22.5% stated that alcohol use had interfered in condom use (Table 1).

Most (86.3%) AMSM were black, 91.3% were in high school or higher education, 67.4% self-identified as homosexual or gay, 32.6% said they were bisexual and/or heterosexual, and 7.3% self-identified as sex workers. In total, 13.2% of respondents reported discrimination due to sexual orientation in an employment situation (failing to be hired or being dismissed from a job) and 42% in a family setting (exclusion or marginalization). Close to 87.5% of participants usually sought health services as a usual source of care, 18.7% had private health insurance, and 11.5% took part in an organized group, social movement or LGTBQI+ NGO. Overall, 7.3% of participants reported receiving a poor service at a health facility or by a health worker because of their sexual orientation, and 17.7% receiving poor public service because of sexual orientation (Table 1).

Differences between the two age strata were found for the variables age at the first sexual intercourse (15-17 years old and 18-19 years old), schooling level, and having private insurance: younger AMSM showed earlier first sexual intercourse, lower schooling level, and a smaller private health insurance prevalence than older adolescents (Table 1).

Considering the dimensions of vulnerability to HIV, its prevalence was significantly higher among AMSM who exchanged money or favors for sex (16.7%, OR = 4.10, 95%CI: 1.34-12.58), who had lower schooling level (16%, OR = 3.66, 95%CI: 1.10-12.23) and who regarded themselves as sex workers (19.1%, OR = 4.60, 95%CI: 1.35-15.63) at the social dimension; and failed to use health services as a usual source of care (13.9%, OR = 3.23, 95%CI: 1.06-9.77) at the programmatic dimension (Table 2).

The HIV prevention practice most used by adolescents during sex with steady and casual partners was lubricants (63.6% and 61.5% for AMSM aged 15-17, and 72.6% and 72.2% for those aged 18-19, respectively). The second most used practice for younger adolescents was avoiding being passive during anal sex with steady partners (18.2%) and asking partners to remove their penises before ejaculating when having sex with casual partners (34.6%). This last practice was also used by 32.6% and 44% of the adolescents aged 18-19 years old with steady and casual partners, respectively (Figure 3).

In the multivariate analysis, we found an association between self-identifying as a sex worker and HIV prevalence (OR = 3.74, 95%CI: 1.03-13.60). Other variables whose significance levels were borderline were using hook-up apps (OR = 3.30, 95%CI: 0.98-11.04), lower schooling level (OR = 3.59, 95%CI: 0.96-13.41), not usually using health services as a usual source of care (OR = 3.14, 95%CI: 0.97-10.17), and failing to be hired or being dismissed from a job because of sexual orientation (OR = 2.88, 95%CI: 0.89-9.28) (Table 3).

Discussion

The estimated prevalence of HIV (5.9%) among AMSM on the Salvador website of the PrEP1519 study is much higher than the prevalence estimated for the overall male population in Brazil (0.8%) ⁹9. Departamento de DST, Aids e Hepatites Virais, Secretaria de Vigilância em Saúde, Ministério da Saúde. HIV - AIDS. Boletim Epidemiológico 2014; Ano III (1). http://www.aids.gov.br/pt-br/node/73.
http://www.aids.gov.br/pt-br/node/73... . Other studies have also indicated a high burden of HIV infection among young and adolescent MSM in Latin America and Brazil. A recent systematic review of the HIV prevalence among young MSM in Latin America and the Caribbean found it to be higher than 5% among those aged under 25 years in half of the analyzed studies ²²22. Coelho LE, Torres TS, Veloso VG, Grinsztejn B, Jalil EM, Wilson EC, et al. The prevalence of HIV among men who have sex with men (MSM) and young MSM in Latin America and the Caribbean: a systematic review. AIDS Behav 2021; 25:3223-37.. In Brazil, a literature review has also found a disproportionately high prevalence and incidence of HIV among this population vis-à-vis the general population of the same age group ²¹21. Saffier IP, Kawa H, Harling G. A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people in Brazil. BMC Infect Dis 2017; 17:675..

A comparison of HIV prevalence in two national HIV surveillance studies found an upward trend among MSM aged 18 to 25 years, rising from 4% in 2009 to 9.4% in 2016 ³⁵35. Kerr LRFS, Pontes AK, Camillo AC, Brito AM, Motta-Castro ARC, Leal AF, et al. Increasing prevalence rate among MSM in Brazil: results of a comparison of 2009 and 2016 national surveys. J Int AIDS Soc 2018; 21 Suppl 6:e25148.. Brazilian studies that have monitored HIV prevalence among adolescent conscripts to the Armed Forces over two decades, estimate a higher prevalence among those who identify as MSM than those who identify as heterosexual, also finding an upward trend in that prevalence among AMSM over time: 0.56% in 2002 ³⁶36. Szwarcwald CL, Carvalho MF, Barbosa Junior A, Barreira D, Speranza FAB, Castilho EA. Temporal trends of HIV-related risk behavior among Brazilian military conscripts, 1997-2002. Clinics (São Paulo) 2005; 60:367-74., 1.23% in 2007 ³⁷37. Szwarcwald CL, Andrade CL, Pascom ARP, Fazito E, Pereira GFM, Penha IT. HIV-related risky practices among Brazilian young men, 2007. Cad Saúde Pública 2011; 27 Suppl 1:S19-26., and 1.32% in 2016 ³⁸38. Sperhacke RD, Motta LR, Kato SK, Vanni AC, Paganella MP, Oliveira MCP, et al. HIV prevalence and sexual behavior among young male conscripts in the Brazilian army, 2016. Medicine (Baltimore) 2018; 97(1S Suppl 1):S25-31.. In line with this trend, official data published by the Brazilian Ministry of Health show a significant increase in the rate of detection of AIDS cases among male adolescents aged 15 to 19 years, with a rising from 3.7 cases per 100,000 inhabitants in 2009 to 6.1 cases per 100,000 inhabitants in 2019 ²⁰20. Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico HIV/AIDS 2020; número especial. http://www.aids.gov.br/pt-br/pub/2020/boletim-epidemiologico-hivaids-2020.
http://www.aids.gov.br/pt-br/pub/2020/bo... .

As for the HIV care continuum, only two of the AMSM recruited for PrEP1519 knew their HIV status, a far cry from the 90% set in the first target of the 2020 The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 strategy, by which 90% of people living with HIV should be aware of their HIV status ³⁹39. Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic, 2014. https://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/90-90-90_en.pdf (accessed on 29/Aug/2022).
https://www.unaids.org/en/media/unaids/c... , and way below the 85% already reached in Brazil ⁴⁰40. Marsh K, Eaton JW, Mahy M, Sabin K, Autenrieth CS, Wanyeki I, et al. Global, regional and country-level 90-90-90 estimates for 2018: assessing progress towards the 2020 target. AIDS 2019; 33 Suppl 3:S213-26.. This means that most participants were not using ART, a treatment which could have a positive effect not only on them individually by improving their clinical status ⁴¹41. Grinsztejn B, Hosseinipour MC, Ribaudo HJ, Swindells S, Eron J, Chen YQ, et al. Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: results from the phase 3 HPTN 052 randomised controlled trial. Lancet Infect Dis 2014; 14:281-90., but also collectively by preventing the transmission of the virus when viral loads reach undetectable levels ⁴²42. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016; 316:171-81.^,4343. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365:493-505.^,4444. Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection. JAMA 2019; 321:451-2.. Nevertheless, the project team was successful in getting most participants diagnosed with HIV linked to specialized health services. Unfortunately, three participants rejected all team efforts to link them to health services and ART.

Studies show that access to HIV testing is incipient among adult Brazilian MSM in general ⁴⁵45. Magno L, Leal AF, Knauth D, Dourado I, Guimarães MDC, Santana EP, et al. Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil. BMC Infect Dis 2020; 20:865.^,4646. Brito AM, Kendall C, Kerr L, Mota RMS, Guimarães MDC, Dourado I, et al. Factors associated with low levels of HIV testing among men who have sex with men (MSM) in Brazil. PLoS One 2015; 10:e0130445.^,4747. Bay MB, Freitas MR, Lucas MCV, Souza ECF, Roncalli AG. HIV testing and HIV knowledge among men who have sex with men in Natal, Northeast Brazil. Braz J Infect Dis 2019; 23:2-7.. A 2009 study with adult MSM in Salvador found that 63% had never taken an HIV test ⁴⁸48. Brignol S, Dourado I, Amorim LD, Kerr LRFS. Vulnerability in the context of HIV and syphilis infection in a population of men who have sex with men (MSM) in Salvador, Bahia State, Brazil. Cad Saúde Pública 2015; 31:1035-48.. In 2016, a study with adult MSM in 12 cities across Brazil found that 44% of its participants who had taken a test and were diagnosed with HIV were unaware of their HIV status ⁴⁹49. Prado I, Barros C, Dourado I, Magno L, Guimarães M, Kendall C, et al. HIV treatment cascade among MSM in Brazil. In: Hakim J, McCormack S, Sabin C, Gulick R, Elliott R, et al., editors. Abstract book. 22nd International AIDS Conference. Amsterdam: International AIDS Society; 2018. p. 847.. Stigma and discrimination related to sexual orientation have been described in the literature as possible barriers to access to testing services ⁵⁰50. Magno L, Silva L, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, et al. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epidemiol 2019; 22 Suppl 1:e190003.^,5151. Monteiro S, Brigeiro M. Prevenção do HIV/Aids em municípios da Baixada Fluminense, Rio de Janeiro, Brasil: hiatos entre a política global atual e as respostas locais. Interface (Botucatu) 2019; 23:e180410.. That is why it is important to promote HIV testing among AMSM in different ways than traditional ones, using, for example, community initiatives at social venues with peer-educators ⁵²52. Stromdahl S, Hoijer J, Eriksen J. Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey. Sex Transm Infect 2019; 95:575-9. and HIV self-testing ²⁵25. Dourado I, Magno L, Soares F, Massa P, Nunn A, Dalal S, et al. Adapting to the COVID-19 pandemic: continuing HIV prevention services for adolescents through telemonitoring, Brazil. AIDS Behav 2020; 24:1994-9.^,4545. Magno L, Leal AF, Knauth D, Dourado I, Guimarães MDC, Santana EP, et al. Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil. BMC Infect Dis 2020; 20:865.^,5353. Okoboi S, Twimukye A, Lazarus O, Castelnuovo B, Agaba C, Immaculate M, et al. Acceptability, perceived reliability and challenges associated with distributing HIV self-test kits to young MSM in Uganda: a qualitative study. J Int AIDS Soc 2019; 22:e25269., which is a simple option, recommended by the World Health Organization ⁵⁴54. World Health Organization. WHO recommends HIV self-testing. Geneva: World Health Organization; 2016., but it is still little known and only moderately accepted among Brazilian MSM aged 18 years and over ⁴⁵45. Magno L, Leal AF, Knauth D, Dourado I, Guimarães MDC, Santana EP, et al. Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil. BMC Infect Dis 2020; 20:865.^,5555. Torres TS, De Boni RB, Vasconcellos MT, Luz PM, Hoagland B, Moreira RI, et al. Awareness of prevention strategies and willingness to use preexposure prophylaxis in Brazilian men who have sex with men using apps for sexual encounters: online cross-sectional study. JMIR Public Health Surveill 2018; 4:e11..

In our study, whose inclusion criterion was sexual activity, the mean age at first sexual intercourse was found to be 13.9 years old (± 3.1), with over half reporting failing to use protection on these occasions. In Brazil, individuals’ average age at first sexual intercourse is during adolescence ⁵⁶56. Borges AL, Fujimori E, Kuschnir MC, Chofakian CBN, Moraes AJP, Azevedo GD, et al. ERICA: sexual initiation and contraception in Brazilian adolescents. Rev Saúde Pública 2016; 50 Suppl 1:15s.^,5757. Paiva V, Calazans G, Venturi G, Dias R. Idade e uso de preservativo na iniciação sexual de adolescentes brasileiros. Rev Saúde Pública 2008; 42 Suppl 1:45-53., and national studies have shown that the age is decreasing among boys in the general population: from 14.7 years old in the sexual behavior survey of the Brazilian population conducted in 2005 ⁵⁷57. Paiva V, Calazans G, Venturi G, Dias R. Idade e uso de preservativo na iniciação sexual de adolescentes brasileiros. Rev Saúde Pública 2008; 42 Suppl 1:45-53. to 12.9 years old in the national school health survey in 2015 ⁵⁸58. Felisbino-Mendes MS, Paula TF, Machado IE, Oliveira-Campos M, Malta DC. Analysis of sexual and reproductive health indicators of Brazilian adolescents, 2009, 2012 and 2015. Rev Bras Epidemiol 2018; 21 Suppl 1:e180013.. The survey of knowledge, attitudes, and practices in the Brazilian population, conducted by the Brazilian Ministry of Health in 2013, showed that 34.9% of men indicated that they had started their sexual life before they were aged 15 years ⁵⁹59. Departamento de DST, Aids e Hepatites Virais, Secretaria de Vigilância em Saúde, Ministério da Saúde. Pesquisa de conhecimentos, atitudes e práticas na população brasileira. Brasília: Ministério da Saúde; 2016. (Série G. Estatística e Informação em Saúde).. Furthermore, some of our AMSM reported sexual intercourse with steady and casual partners in the three months prior to the interviews, averaging 4.5 (± 5.5) casual partners, which could reflect the sexual fluidity typical at this stage in life. Another point is the high proportion of participants who reported not always using condoms during anal sex (71%), which is consistent with the findings of other studies of Brazilian adolescents ³⁶36. Szwarcwald CL, Carvalho MF, Barbosa Junior A, Barreira D, Speranza FAB, Castilho EA. Temporal trends of HIV-related risk behavior among Brazilian military conscripts, 1997-2002. Clinics (São Paulo) 2005; 60:367-74.^,3838. Sperhacke RD, Motta LR, Kato SK, Vanni AC, Paganella MP, Oliveira MCP, et al. HIV prevalence and sexual behavior among young male conscripts in the Brazilian army, 2016. Medicine (Baltimore) 2018; 97(1S Suppl 1):S25-31.^,5858. Felisbino-Mendes MS, Paula TF, Machado IE, Oliveira-Campos M, Malta DC. Analysis of sexual and reproductive health indicators of Brazilian adolescents, 2009, 2012 and 2015. Rev Bras Epidemiol 2018; 21 Suppl 1:e180013.^,6060. Oliveira DC, Pontes APM, Gomes AMT, Ribeiro MCM. Conhecimentos e práticas de adolescentes acerca das DST/HIV/AIDS em duas escolas públicas municipais do Rio de Janeiro. Esc Anna Nery Rev Enferm 2009; 13:833-41.. The National Adolescent School-based Health Survey found a reduction in the proportion of condom use at their last sexual intercourse among Brazilian adolescents in the general population from 75.9% in 2009 to 66.2% in 2015 ⁵⁸58. Felisbino-Mendes MS, Paula TF, Machado IE, Oliveira-Campos M, Malta DC. Analysis of sexual and reproductive health indicators of Brazilian adolescents, 2009, 2012 and 2015. Rev Bras Epidemiol 2018; 21 Suppl 1:e180013..

In the individual vulnerability dimension, an association was found between using an app to find sexual partners and HIV prevalence, although the statistical significance of the association was borderline (p-value slightly over 0.05).

The literature indicates that mobile apps are increasingly used by MSM to seek out and hook up with sexual partners ⁶¹61. Chow EP, Cornelisse VJ, Read TR, Hocking JS, Walker S, Chen MY, et al. Risk practices in the era of smartphone apps for meeting partners: a cross-sectional study among men who have sex with men in Melbourne, Australia. AIDS Patient Care STDS 2016; 30:151-4.^,6262. Simões JA. Gerações, mudanças e continuidades na experiência social da homossexualidade masculina e da epidemia de HIV-Aids. Sex Salud Soc (Rio J.) 2018; (29):313-39.. The association between app use and HIV infection among MSM is still debatable, requiring further investigation. Although some studies show a negative or non-existent association ⁶³63. Phillips 2nd G, Magnus M, Kuo I, Rawls A, Peterson J, Jia Y, et al. Use of geosocial networking (GSN) mobile phone applications to find men for sex by men who have sex with men (MSM) in Washington, DC. AIDS Behav 2014; 18:1630-7.^,6464. Wei L, Chen L, Zhang H, Yang Z, Zou H, Yuan T, et al. Use of gay app and the associated HIV/syphilis risk among noncommercial men who have sex with men in Shenzhen, China: a serial cross-sectional study. Sex Transm Infect 2019; 95:496-504.^,6565. Beymer MR, Weiss RE, Bolan RK, Rudy ET, Bourque LB, Rodriguez JP, et al. Sex on demand: geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles county. Sex Transm Infect 2014; 90:567-72., one study found a direct association ⁶⁶66. Hong H, Xu J, McGoogan J, Dong H, Xu G, Wu Z. Relationship between the use of gay mobile phone applications and HIV infection among men who have sex with men in Ningbo, China: a cross-sectional study. Int J STD AIDS 2018; 29:491-7., and others have found the use of these apps and the Internet to seek partners to be associated with other STIs ⁶⁵65. Beymer MR, Weiss RE, Bolan RK, Rudy ET, Bourque LB, Rodriguez JP, et al. Sex on demand: geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles county. Sex Transm Infect 2014; 90:567-72.^,6767. Lau JT, Kim JH, Lau M, Tsui HY. Prevalence and risk behaviors of Chinese men who seek same-sex partners via the internet in Hong Kong. AIDS Educ Prev 2003; 15:516-28.^,6868. Chan PA, Crowley C, Rose JS, Kershaw T, Tributino A, Montgomery MC, et al. A network analysis of sexually transmitted diseases and online hookup sites among men who have sex with men. Sex Transm Dis 2018; 45:462-8. and with sexual practices of higher risk for HIV ⁶⁹69. Rendina HJ, Jimenez RH, Grov C, Ventuneac A, Parsons JT. Patterns of lifetime and recent HIV testing among men who have sex with men in New York city who use Grindr. AIDS Behav 2014; 18:41-9.^,7070. Lehmiller JJ, Ioerger M. Social networking smartphone applications and sexual health outcomes among men who have sex with men. PLoS One 2014; 9:e86603., especially among young MSM ⁷¹71. Winetrobe H, Rice E, Bauermeister J, Petering R, Holloway IW. Associations of unprotected anal intercourse with Grindr-met partners among Grindr-using young men who have sex with men in Los Angeles. AIDS Care 2014; 26:1303-8.. Interestingly, however, many of these studies failed to analyze data on young and adolescent MSM. Age seems to be a significant factor in the use of these technologies ⁶¹61. Chow EP, Cornelisse VJ, Read TR, Hocking JS, Walker S, Chen MY, et al. Risk practices in the era of smartphone apps for meeting partners: a cross-sectional study among men who have sex with men in Melbourne, Australia. AIDS Patient Care STDS 2016; 30:151-4.. A qualitative study with adolescents from the LGBTQI+ community in the United States found that many individuals used the Internet for dating in general for the anonymity it offered, fear of rejection and judgement upon revealing their sexual orientation to straight people, and fear of stigma and discrimination in face-to-face dates ⁷²72. Hillier L, Mitchell KJ, Ybarra ML. The Internet as a safety net: findings from a series of online focus groups with LGB and Non-LGB young people in the United States. J LGBT Youth 2012; 9:225-46..

Our study also showed that elements from the social (self-identifying as a sex worker, low schooling level, and discrimination), and programmatic dimensions (not using official healthcare services) were associated with the prevalence of HIV infection.

When referring to adolescents aged less than 18 years, strictly speaking, the term “sex worker” is inadequate because, in this case, according to the Brazilian legislation, having sex for money constitutes sexual exploitation ⁷³73. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul. - a “multidimensional” phenomenon of “extreme violation of human rights” that calls for the combined efforts of different sectors of society ⁷⁴74. Bellenzani R, Malfitano APS. Juventude, vulnerabilidade social e exploração sexual: um olhar a partir da articulação entre saúde e direitos humanos. Saúde Soc 2006; 15:115-30.. There is little research on adolescent sex work, which is a complex topic both legally and ethically. Even so, some studies indicate that many adult MSM who are sex workers began working at a very young age, sometimes via sexual exploitation involving the use of coercion or violence ⁷⁵75. Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, et al. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385:260-73.. Studies indicate that adult MSM who are sex workers report more cases of unprotected anal sex, a high number of sexual partners, and greater exposure to social and programmatic vulnerability to HIV, with limited access to health services. Furthermore, they experience intersectional stigma (relative to their sexual orientation and their sex work), violence, and legal complications, which makes them a key population for HIV, one that has not received due attention by HIV prevention services ⁷⁵75. Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, et al. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet 2015; 385:260-73.^,7676. Wolffers I, van Beelen N. Public health and the human rights of sex workers. Lancet 2003; 361:1981.^,7777. Beyrer C, Crago A-L, Bekker L-G, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex workers. Lancet 2015; 385:287-301.. Worldwide, violations against sex workers’ human rights are recorded, including the criminalization of sex work and police violence, all of which makes this population’s vulnerability to HIV even greater ⁷⁷77. Beyrer C, Crago A-L, Bekker L-G, Butler J, Shannon K, Kerrigan D, et al. An action agenda for HIV and sex workers. Lancet 2015; 385:287-301..

Other studies have noted the complexity of the programmatic vulnerability faced by adolescents in general, such as limited access to health services and few initiatives to promote sexual health ⁷⁸78. Donahue C, Robinson J, Granato SA, Tirera F, Billy DA, Koné A, et al. Adolescent access to and utilisation of health services in two regions of Cote d'Ivoire: a qualitative study. Glob Public Health 2019; 14:1302-15.^,7979. Dick B, Ferguson BJ. Health for the world's adolescents: a second chance in the second decade. J Adolesc Health 2015; 56:3-6.. Thus, the data from our study justify an intersectoral approach to sexual health initiatives, involving not just the health sector but also education and human rights. Sex education in schools is effective in imparting knowledge on HIV, encouraging greater autonomy in condom use, and delaying the first sexual intercourse ⁸⁰80. Fonner VA, Armstrong KS, Kennedy CE, O'Reilly KR, Sweat MD. School based sex education and HIV prevention in low- and middle-income countries: a systematic review and meta-analysis. PLoS One 2014; 9:e89692.. A study of the effects of comprehensive sex education programs in schools in Mexico found that students who took part in them were more likely to try to convince a sexual partner to use a condom ⁸¹81. Castro F, Rojas-Martinez R, Villalobos-Hernandez A, Allen-Leigh B, Breverman-Bronstein A, Billings DL, et al. Sexual and reproductive health outcomes are positively associated with comprehensive sexual education exposure in Mexican high-school students. PLoS One 2018; 13:e0193780.. In Bangladesh, teacher-led classroom training in HIV/AIDS increased adolescents’ understanding of how HIV is transmitted and can be prevented ⁸²82. Sarma H, Islam MA, Khan JR, Chowdhury KIA, Gazi K. Impact of teachers training on HIV/AIDS education program among secondary school students in Bangladesh: a cross-sectional survey. PLoS One 2017; 12:e0181627..

Brazil has regulations, policies, and programs that could be used for a similar end. For example, the Brazilian 1990 Statute of the Child and Adolescent is an important legislative milestone for championing adolescent health and holding the State accountable for providing means for their protection without any type of discrimination ⁷³73. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 16 jul.. Its public health system has had a national policy for the comprehensive care of adolescents and youth since 2005, which includes sexual health and the need for educational initiatives ⁸³83. Secretaria de Atenção à Saúde, Ministério da Saúde. Saúde integral de adolescentes e jovens : orientações para a organização de serviços de saúde. Brasília: Ministério da Saúde; 2007. (Série A. Normas e Manuais Técnicos).. Since 2007, the Programa Saúde na Escola (Health at School Program) has provided healthcare and other disease prevention and health promotion measures, including sexual health ⁸⁴84. Secretaria de Atenção à Saúde, Ministério da Saúde. Marco legal: saúde, um direito de adolescentes. Brasília: Ministério da Saúde; 2007. (Série A. Normas e Manuais Técnicos)..

However, HIV and STI prevention in Brazil is being hampered by a curtailment of open discussions for adolescents about sex education in schools, especially because of rising political and religious conservatism in the last decade or so ⁸⁵85. Malta M, Beyrer C. The HIV epidemic and human rights violations in Brazil. J Int AIDS Soc 2013; 16:18817.^,8686. Reis Brandão E, Cabral CDS. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters 2019; 27:1669338.^,8787. Preventing teenage pregnancies in Brazil. Lancet 2020; 395:468.. Furthermore, moral factors influence the care offered by health workers at specialized HIV/AIDS health services ⁸⁸88. Silva LAV, Duarte FM, Magno L, Dourado I, Squire C. Moral barriers to HIV prevention and care for gay and bisexual men: challenges in times of conservatism in Brazil. Sociol Health Illn 2021; 43:424-40., which makes it harder for public policies to promote HIV prevention, especially among AMSM. Moreover, these contexts of vulnerability may have been further aggravated by the COVID-19 pandemic, as it affected the worldwide access to HIV prevention and testing services among MSM ⁸⁹89. Rao A, Rucinski K, Jarrett BA, Ackerman B, Wallach S, Marcus J, et al. Perceived interruptions to HIV prevention and treatment services associated with COVID-19 for gay, bisexual, and other men who have sex with men in 20 countries. J Acquir Immune Defic Syndr 2021; 87:644-51.^,9090. Sanchez TH, Zlotorzynska M, Rai M, Baral SD. Characterizing the impact of covid-19 on men who have sex with men across the United States in April, 2020. AIDS Behav 2020; 24:2024-32..

The limits of this study include its small convenience sampling, the distribution of the events in comparisons, which may have influenced analytical statistical power, and the baseline population for a cohort targeting HIV and STI prevention, which could have selected other people at increased vulnerability to be included in this study. Moreover, the limitation of the statistical model restricted to the collection of individual data is noteworthy, having as its theoretical scope a concept of vulnerability implying contextual analysis. Despite this, our study has the advantage of covering adolescents at higher risk of infection who attend partner meeting places, allowing for a better understanding of groups that should be priorities for public policies.

Conclusions

We identified a high prevalence of HIV among the AMSM recruited to the PrEP1519 project in Salvador. Furthermore, our study found that factors from the individual (use of apps to find sexual partners), social (sex work, education and discrimination), and programmatic dimensions (place in which healthcare was sought) were associated with the prevalence of HIV infection, albeit some of those showed borderline statistical significances.

The investigation of the dimensions of vulnerability for HIV among AMSM is important to identify what factors are behind not only the relationship between the etiological agent and the individual but also the role of the sociocultural and political environment and the intersubjective context, which are all implicated in the illness ³²32. Ayres J, Paiva V, França-Jr I. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: Paiva V, Ayres J, Buchalla C, editors. Vulnerabilidade e direitos humanos - prevenção e promoção da saúde: livro I, da doença à cidadania. Curitiba: Juruá Editora; 2012. p. 71-94..

The debate surrounding sexuality and HIV prevention must transpose the moral and religious sphere in which it is currently framed in Brazil, to a context that considers the scientific evidence about what interventions are effective for tackling the vulnerability of this population to HIV. We suggest ramping up HIV combined prevention activities and offering positive sexual health initiatives in LGBTQI+ social venues and schools by local health services in conjunction with key actors, such as teachers, universities, NGOs, LGBTQI+ entities, the judicial branch, and the public prosecution. Moreover, we recommend expanding conventional HIV testing and self-testing to enable the early diagnosis of new infections, as well as strengthening specialized services, so that AMSM already living with HIV can get access to ART. Finally, daily oral PrEP is a promising prevention technology for adolescents aged under 18 years, which can expand the set of choices for combination prevention programs.

Acknowledgments

We are grateful to the adolescents who participated in this study and their parents and guardians, to the Brazilian Unified National Health System (SUS) for donating PrEP medications, condoms, rapid tests, and providing additional care services for PrEP1519 participants via the Brazilian Ministry of Health, to the Bahia State Health Department, and to Oswaldo Cruz Foundation (Fiocruz) and Fiocruz Support Foundation (FIOTEC) for supporting this study. This project was made possible thanks to Unitaid’s funding and support. Unitaid accelerates access to innovative health products and lays the foundations for their scale-up by countries and partners. Unitaid is a hosted partnership of World Health Organization.

References

Publication Dates

History