Abstracts

Introduction

Global initiatives have sustained that a successful response to HIV depends on policies that integrate a rapid increase in large-scale testing and access to antiretroviral (ARV) treatment, considering the diversity of social contexts. In concentrated epidemics, the success of these strategies depends on mitigating barriers to access to information and services faced by populations more vulnerable to HIV - such as men who have sex with men (MSM), transgender women (TGW), female sex workers, and drug users ¹1. Fundo das Nações Unidas para a Infância. Estratégias para o enfrentamento da epidemia de HIV/aids entre adolescentes e jovens. https://www.unicef.org/brazil/media/1141/file/viva_melhor_sabendo_jovem_resultados.pdf (accessed on 13/Sep/2022).
https://www.unicef.org/brazil/media/1141... - as well as on promoting individuals’ rights to health and to non-discrimination. HIV disproportionately affects these populations both globally and in Brazil ²2. Pan American Health Organization; Joint United Nations Programme on HIV/AIDS. HIV prevention in the spotlight. An analysis from the perspective of the health sector in Latin America and the Caribbean. Washington DC: Pan American Health Organization/Joint United Nations Programme on HIV/AIDS; 2017..

In Brazil, the Ministry of Health defines combination prevention (CP) as a strategy that connects several prevention methods (biomedical, behavioral, and socio-structural) at different levels (individual, in partnerships/relationships, community, and social) to respond to individuals’ specific needs and prevent HIV transmission ³3. Departamento de Vigilância, Prevenção e Controle das Infecções Sexualmente Transmissíveis, do HIV/Aids e das Hepatites Virais, Secretaria de Vigilância em Saúde, Ministério da Saúde. Prevenção combinada do HIV. Sumário Executivo. Brasília: Ministério da Saúde; 2017.. Hence, CP aims to expand the repertoire of prevention methods, considering that, even though condoms have played a strategic role in dealing with the epidemic ⁴4. Dourado I, Silva LAV, Magno L, Lopes M, Cerqueira C, Prartes A, et al. Construindo pontes: a prática da interdisciplinaridade. Estudo PopTrans: um estudo com travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2016; 32:e00181415.^,55. Geluda K, Bosi MLM, Cunha AJLA, Trajman A. "Quando um não quer, dois não brigam": um estudo sobre o não uso constante de preservativo masculino por adolescentes do Município do Rio de Janeiro, Brasil. Cad Saúde Pública 2006; 22:1671-80., there are criticisms over the prescriptive or imposing tone that marked much of the HIV prevention discourse centered on this method. Some initiatives attempted to highlight the “negotiation” of condom use within relationships and to emphasize its erotic character, but discourses were often decontextualized from sexual experiences ⁶6. Pinheiro TF. Camisinha, homoerotismo e os discursos da prevenção de HIV/aids [Doctoral Dissertation]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2015.^,77. Lermen HS, Mora C, Neves ALM, Azize RL. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface (Botucatu) 2020; 24:e180626.. As such, the CP approach represents a new perspective for HIV policies regarding the prioritization of condom use and a broader scope of prevention methods available to individuals.

For CP to be able to address the diversity of life contexts that increase vulnerability to HIV infection, investigating how people manage their day-to-day risk is crucial. This requires assuming that individuals are autonomous and capable of making choices about prevention methods that may be mediated by their interests and the information they access ⁷7. Lermen HS, Mora C, Neves ALM, Azize RL. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface (Botucatu) 2020; 24:e180626., recognizing that such decision is as cognitive as it is context-embedded ⁷7. Lermen HS, Mora C, Neves ALM, Azize RL. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface (Botucatu) 2020; 24:e180626.^,88. Rios LF, Albuquerque AP, Santana W, Pereira AF, Oliveira Junior CJ. O drama do sexo desprotegido: estilizações corporais e emoções na gestão de risco para HIV entre homens que fazem sexo com homens. Sex Salud Soc (Rio J.) 2019; (32):65-89..

The increase in HIV infections among adolescents in the last decade ⁹9. Ministério da Saúde. Boletim Epidemiológico HIV/Aids 2019; número especial. http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019.
http://www.aids.gov.br/pt-br/pub/2019/bo... underscores the need for understanding the specificities of contexts of exposure to HIV among this group. This requires acknowledging that adolescents’ vulnerability to HIV is connected to conflicts regarding their sexual rights, precarious access to health services and, at times, the inadequacy of services, which fail to safeguard privacy and/or require the presence of a parent or guardian ¹⁰10. Gibson BA, Brown SE, Rutledge R, Wickersham JA, Kamarulzaman A, Altice FL. Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community. Glob Public Health 2016; 11:1010-25.. Especially among gender- and sexuality-diverse adolescents, studies highlight the complexities of HIV prevention and vulnerability. Intergenerational relations can interfere in the adoption of prevention methods due to asymmetries of power, socioeconomic status, and sexual experience within partnerships among adolescent MSM ¹¹11. Rios LF. Homossexualidade, juventude e vulnerabilidade ao HIV/Aids no candomblé fluminense. Temas Psicol 2013; 21:1051-66.^,1212. Arrington-Sanders R, Leonard L, Brooks D, Celentano D, Ellen J. Older partner selection in young African-American men who have sex with men. J Adolesc Health 2013; 52:682-8.^,1313. Paiva C. Protagonismo erótico, classificações e formas de sociabilidade de gays idosos. Revista de Ciências Sociais 2013; 44:74-108.. Structural violence, such as homophobia and transphobia, is also responsible for a synergy of vulnerabilities that can negatively affect capacity for self-care. The range of factors that heighten the vulnerability of travestis and TGW to HIV infection - poverty, precarious housing, low educational attainment, violence, and unprotected sex, particularly in the context of sex work ⁴4. Dourado I, Silva LAV, Magno L, Lopes M, Cerqueira C, Prartes A, et al. Construindo pontes: a prática da interdisciplinaridade. Estudo PopTrans: um estudo com travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2016; 32:e00181415. - show a vicious cycle of rights violations that demand a set of responses on several levels. Programmatic barriers to accessing prevention and treatment services for HIV infection are also part of the experiences of gay, travestis, and TGW adolescents, as they usually identify these settings as unfriendly, the latter going as far as manifesting discriminatory conducts such as blaming adolescents for the exposure or disrespecting their chosen name, for example ¹⁴14. Rocon PC, Rodrigues A, Zamboni J, Pedrini MD. Dificuldades vividas por pessoas trans no acesso ao Sistema Único de Saúde. Ciênc Saúde Colet 2016; 21:2517-25.^,1515. 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..

Discrimination, homophobia, and transphobia may substantially enhance vulnerability to HIV among adolescents who fall outside the cisgender heteronormative standard. Consequently, prevention practices are informed by dimensions that go beyond adolescents’ face-to-face interactions, affecting the way they guide themselves toward prevention in their relationships. This will depend on what they know and understand, and the possibilities of prevention the experienced moment present to them.

This paper aims to understand the perspective of adolescent gay and bisexual men, travestis, and TGW about the use of HIV prevention methods in the context of their sexual practices. We aim to contribute to the discussion of adolescents’ sexual risk management in the context of current HIV public policies informed by the CP approach.

Methodology

Data were obtained as part of the formative research (FR) of the PrEP1519 study, an ongoing demonstration study on the effectiveness of daily HIV pre-exposure prophylaxis (PrEP) among adolescent MSM, travestis, and TGW aged 15 to 19 years old. More methodological information can be found in Dourado et al. ¹⁶16. 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.. This analysis focuses on data from São Paulo, Brazil.

Unlike other contexts in which the word “trasvesti” has a derogatory meaning, in Brazil, the term represents a political identity, recognized as such by the LGBTQIA+ social movement.

The FR aimed to investigate the dynamics of social interaction, sexual experiences, use and acceptability of HIV prevention methods, and recruitment strategies in central São Paulo, the epicenter of the HIV epidemic in Brazil. From May to September 2018, venues attended by adolescents with a high concentration of MSM, travestis, and TGW were mapped out both in face-to-face settings and online spaces via participant observation. Next, between August 2018 and January 2019, key-informants were selected - mainly in bars, parties, and urban parks - by the research group, aided by two peer educators, and invited to participate in semi-structured interviews and focus group discussions (FGDs). Male adolescents were interviewed by a young cisgender man, and transgender adolescents, by a young cisgender woman. Interviewers had been trained in qualitative data collection. In total, two FGDs were conducted by T.F.P., a cisgender male researcher, and the FGD with transgender participants was assisted by G.B.M. as an observer. Interviews and FGDs were conducted in private rooms lasting, on average, for 90 and 120 minutes, respectively. A total of 22 adolescents participated in the FR, of which five, in both interviews and FGDs.

The following topics were covered in the interviews: (a) networks and social venues, (b) gender identity, sexual orientation, and sexuality, (c) vulnerability to HIV, violence, and discrimination, (d) knowledge of and motivation to use PrEP and HIV self-testing, and (e) perceptions on the recruitment strategies planned by the PrEP1519 study. Data on the use of prevention methods and risk management analyzed in this study were based on topics (b), (c), and (d). The interview guide can be found elsewhere ¹⁷17. 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..

An FGD was conducted with nine cisgender MSM adolescents and another with three TGW and travestis. They were guided by an active imagination exercise: each group was asked to collectively construct a verisimilar sexual scene ¹⁸18. Paiva V. A psicologia redescobrirá a sexualidade? Psicol Estud 2008; 13:641-51. representing the experience of a gay or bisexual male adolescent and of a travesti or TGW adolescent, respectively. Next, each group debated the scene and its relationship with group members’ practices.

Interviews and FGDs were audio-recorded, transcribed, and revised. A thematic analysis ¹⁹19. Alhojailan MI. Thematic analysis: a critical review of its process and evaluation. West East Journal of Social Sciences 2012; 1:39-47. was carried out in the following steps: (i) detailed reading of the transcripts to achieve “impregnation”; (ii) definition of the thematic categories “thinking about HIV prevention”, “feelings regarding condom use”, and “specific contexts and risk of infection”; (iii) extraction of contents according to the categories; and (iv) analysis of each category in dialogue with the literature and theoretical references. To ensure anonymity, participants’ quotes are characterized by participants’ codename or group (MSM or transgender and gender-diverse, TGD), gender identity, sexual orientation, age, and technique (interview or FGD).

The study protocol was approved by the Research Ethics Review Committee of the University of São Paulo (protocol n. 70798017.3.0000.0065). Participants aged 18 or over signed an informed consent form, and those aged between 15 and 17 years signed an informed assent form.

Results

In total, 13 out of the 22 participants were aged 16 or 17 years old; 15 self-identified as men, four, as TGW, and three, as travestis; half (11) defined their sexual orientation as gay (all men), six, as bisexual, two as pansexual, and three (all TGW and travestis) as heterosexual; 12 self-identified as white, 8, as black or brown-mixed, and one, as indigenous. Most had incomplete (11) or complete (8) secondary education, lived with their families, and were unemployed (Box 1).

Participants mentioned parties, nightclubs, public venues, and friends’ houses, among others, as their preferred environment for hanging out with friends and finding partners. Nearly half mentioned using hook-up apps.

The repertoire of adolescents’ HIV prevention methods

Adolescents’ knowledge and experience repertoire about prevention methods focused on condoms. Participants found other methods secondary and less familiar. All participants knew about testing, but only a few had been tested. Some showed knowledge and doubts about ARV prophylaxes, both pre- and post-exposure (PEP and PrEP), and none (or their partners) had had any experience with such methods.

In building this repertoire, participants learned, in schools and in their families, that using condoms was a prevention norm mediated by notions of respect, responsibility, and consequences: “I am very, very responsible. So, the question of using condoms... my parents always, from early on, always said: ‘If you start having sex, use condoms. These STDs exist. There will be consequences for you’” (Iago, 17, bisexual, man, interview).

On the other hand, participants were critical of access to prevention information by reporting that this learning process in school and health service interactions often took place with a certain disconnection vis a vis their life contexts. These included the school approach to sexually transmitted infections (STIs), which failed to consider homo and trans-affective relationships and lacked accessible language and prevention agents where people actually were.

“In middle school, they never said anything. But in high school, around the ninth year, they talked a lot about avoiding pregnancy, how to use, how not to use [condoms]. About sexually transmitted diseases too”.

Interviewer: “Did they talk about LGBT issues?”.

“No. They just told people not to make fun of others in the audience, like, the ones they knew were [LGBT] and such. But they never said, like: ‘You who are male and into men, use this here, don’t use that there’. They didn’t say how to go about it. They’d only say how to go about it when it was about men with women” (Douglas, 16 gay man, interview).

“So, the least that can be done is to make this information accessible. It’s no use putting a thousand words, 3 meters long each, and expect that the person will understand. It has to be accessible information. And to be accessible, it has to be a part of this reality in which she is” (TGD, FGD).

Considering this critical view of school, family, and health-related settings, most adolescents regarded their access to internet and social media, and interaction with friends, partners, and HIV collectives as valuable sources of information that helped build their repertoire of HIV prevention.

Values, feelings, and contexts that orient adolescents’ prevention repertoire

Condom use played a central role in HIV prevention, whether as the most well-known and familiar method or as a “compulsory” practice, hierarchically superior to other methods and whose use was an individual responsibility.

Interviewer: “But if your partner says, ‘Ah, I don’t want to wear a condom, I don’t want to use lube’. What happens?”.

“Everything ends. Doesn’t even happen. It’s ‘goodbye and never again’. Not even a little kiss” (Carla, heterosexual TGW, 18, interview).

Such norm also appeared in the expression of adolescents’ feelings, sensations, and motivation in their practices. They reported that condom use provided “comfort” resulting from the sense of protection, whereas the opposite was commonly perceived as a mistake that generated fear and guilt: “To me, it’s horrible to think about having sex without a condom. Like, I think this has become a principle” (Rafael, gay man, 17, interview).

Even when pleasure justified not using condoms, feelings of shame and regret came up later. Male adolescents reported guilt over not having planned any prevention. These feelings were present even when both partners had tested negative for HIV.

“He [partner] did syphilis, HIV, everything. Nothing was positive. Everything was negative. I said: ‘ok, great’. I’d also got tested a couple of months earlier. But I hadn’t had sexual intercourse [then]. I only had sex with him. But even so, it was that desperation, that desire, and intercourse ended up happening without a condom. But I regret it to this day” (Iago, gay man, 18, interview).

Similarly, an adolescent travesti reported the conflict between the annoyance of having to use condoms and the perception of the consequent risk of infection: “The risk is part of me, I don’t like to have sex with a condom. I think it’s the pits. I think it’s a total pain. I don’t like it, but I force myself” (Maiara, pansexual travesti, 19, interview).

For some people, concern about the non-use or incorrect use of condoms led them to seek an HIV test. For one young woman in particular, this experience brought about changes to her prevention practices in subsequent sexual practices: “It’s a concern for me. Like, the first few times I had intercourse, I remember I was very paranoid. The first time, I wasn’t careful, I was, gee, crazy. And then I think I took a test to see if I had HIV. I think I did it three weeks later, because you can’t do it [before], right? And then I did it, but it came out as nothing. Then, I calmed down and started being careful” (Juliana, asexual and bisexual TGW, 19, interview).

When condoms were unavailable at the time of intercourse or when it was hard to use them, participants usually avoided penetrative practices as an alternative strategy, which they proposed and advocated themselves.

Adolescents’ activated their prevention repertoire based on a dynamic interaction between information, values, feelings, and specific contexts in which they assessed their sexual practices as more prone to HIV infection.

They perceived casual sex as a greater risk to them, and took upon themselves to be responsible for using condoms. Thus, they cited planning to always have condoms with them as a way to prepare for sexual encounters.

“But usually they [the partners] had some [condoms]. So, there were always some anyway. If they didn’t, I’d have some” (Eduardo, gay man, 18, interview).

On the other hand, unplanned sexual encounters came up in the reports as a troubling dynamic or as incompatible with the use of condoms. Thus, the idea of impulsivity or lack of self-control due to their age group gained space among male adolescents: “I’m an adolescent, my hormones are all over the place, in a way. So, like, what if it happens? So, I have to be prepared for that. (...) Every time I go out with people who I’m more than friends with, I take some with me. Not least because I don’t know, like I said, I don’t know when it might happen, at what moment. (...) Once I didn’t [use a condom]. (...) Because, like, the possibility of it happening didn’t come to mind [laughs]. But then it happened. And then he didn’t have one [a condom], I didn’t have one, but it ended up happening because our hormones were all over the place, right?” (Lucas, bisexual man, 17, interview).

In encounters with older partners, whom they perceived as more experienced, adolescents expressed their expectation that their partners would lead the way regarding condom use. Cisgender adolescents also saw older partners as sources of information and prevention care, whereas in the case of transgender adolescents, only if they were stable partners.

Participants also mentioned the use of alcohol, a recurring element in participants’ reports of sociability, as a factor affecting their judgment and, therefore, their ability to use condoms.

The context of commercial sex stood out in TGW and travestis’ reports. Referred to as a form of survival, condom use often depended on the decision of clients, who could be sexually dominant, pay more for sex without condoms or condition the encounter to the use of drugs. TGW and travestis also added risk of violence and, thus, the need for constant alertness to this, thus experiencing this context as potentially dangerous and marked by subjection to the client’s will, more difficult decision-making and, therefore, greater exposure to infection.

“Back when I saw clients, there was the question of, like, at the moment of sexual intercourse you’d get the condom out and the client would say: ‘If we do it without one, I’ll pay you more’. (...) And we’re driven by money at that moment, right? Because we’re not there for pleasure. It’s out of need. (...) And it’s happened to me” (Byanca, heterosexual TGW, 19, interview).

On the other hand, meanings of trust, love, and intimacy, considered protective factors in HIV risk assessments, marked stable relationships, especially in closed relationship arrangements for one or both persons. In concurrent partnerships, condoms were either unused or used only sporadically with stable partners, but used consistently with casual partners.

“Sometimes we use condoms. But most of the time we don’t. Because we always trust each other a lot. Actually, he has a closed relationship. He says that he doesn’t have sex with anyone. But he knows that I sometimes do (...) I always have sex with condoms with other people outside my relationship” (Maiara, pansexual travesti, 19, interview).

Participants reported prior HIV/STI testing as one of couples’ measures to decide not to use condoms in a stable relationship. A few participants also cited seeking testing after condomless sex as an attempt to repair a “failure” in prevention. Furthermore, disruptions in the dynamics of stable relationships led to changes in participants’ risk perception, which could be illustrated by situations in which HIV testing was sought soon after a relationship ended.

An HIV prevention repertoire with little knowledge or access to ARV

Note that adolescents showed little knowledge and familiarity with ARV-based prevention methods, causing them to play a secondary role or almost no role at all in their prevention repertoires.

We found frequent confusion between indications for PEP and PrEP use and, to a lesser extent, doubts or misperceptions whether PrEP protected against STIs other than HIV. An exception was a male adolescent who cited his interest in using PrEP, but eventually decided not to seek out a clinic as he thought, since he was a minor, of the possibility of a health provider contacting his parents. In the FGD with male adolescents, one participant claimed that PEP was indicated as a preventive strategy in a casual, condomless sexual encounter between a boy and an older man (47 years old) with undetectable HIV who would support him in seeking PEP if he felt very concerned.

“The guy can tell the boy about PEP: ‘if you’re not comfortable, you can take PEP’. If he knew the guy was HIV positive, he would take PEP right away...” (MSM, FGD).

No participants had any experience using PrEP and most had no prior knowledge about it either. Thus, they viewed PrEP as additional protection or as a palliative method in the absence of condoms. We also found recurrent doubts regarding the effectiveness of PrEP and its possible adverse effects.

Travesti and TGW adolescents observed structural inequalities in their personal experiences and social environment, shaping their perspective of PrEP and PEP and, as such, it was significantly different from that of cisgender adolescents. Among transgender adolescents, HIV prophylaxes would be an insufficient healthcare measure, considering the experiences of transphobia, family exclusion, and structural racism they faced, which would require a strong response from the State. The association between PrEP and PEP, and cisgender and white people’s privileged access to prevention were also part of transgender participants’ narratives.

“So, PrEP and PEP are for who? Who has access to them? Who can have the luxury of... also... anyways... (...) I think that it was produced for people who fuck around, people with white privilege, that are cisgender, right, that... so I think that these problems also have to be solved with the other forms of prevention, and not just put out there, like, this palliative measure and leave the population to keep talking medicine for their entire life and die without any protections, without the State saying anything, without... anyway... these other groups of society saying anything, right?” (TGD, FGD).

Following a similar logic, travesti and TGW adolescents criticized the disconnect between prevention information, PrEP access and delivery, and transgender people’s life contexts. Addressing broader concerns, such as body care, gender transition, and an increase in life expectancy was a necessary part of prevention care, in addition to ensuring that this information arrived at the places where these people were and transmitted in a way that they understood.

“I speak pajubá [a transgender dialect], so the least I can do is to bring this language that exists, that is known, and make it so that the information [about PrEP] is accessible, right? Putting out a thousand-meter-long words and hoping that the girls will understand, it won’t help at all and even if she understands, like, is she going to take her time to go and want to know more about it, right? It has to be accessible information... and to be accessible it has to be part of her reality” (TGD, FGD).

Discussion

Our findings indicate two central elements in how adolescent MSM, travestis, and TGW perceive and use HIV prevention methods: a very incipient appropriation of the diversity of the available prevention methods and a rigid normativity about the mandatory use of condoms, considered the ideal prevention method. Consequently, their perceptions and practices are not informed by up-to-date and in-depth knowledge about prevention strategies and access to health services, thus negatively impacting their autonomy when choosing a prevention method ²⁰20. Terto Jr. V. Diferentes prevenções geram diferentes escolhas? Reflexões para a prevenção de HIV/AIDS em homens que fazem sexo com homens e outras populações vulneráveis. Rev Bras Epidemiol 2015; 18:156-68..

Thus, adolescents’ risk management seems to be restricted in terms of their autonomy and ability to assess exposure across contexts. This management reproduces values and knowledge constructed mainly throughout the 1980s and 1990s, a period which lacked the adequate information and technology that has become available in more recent years, such as partner HIV testing. It is equally important to highlight that adolescents’ risk management does not include precisely what has been prioritized in the global response to HIV in the past few years: ARV-based methods. It can be argued that the construction of their knowledge repertoire about HIV prevention has been narrowly based on HIV testing and ARV-based strategies due to a society which has more weakly mobilized itself to respond to the HIV epidemic than in past decades. Also, in this scenario, the original definition of CP clashes with the negligence of the Brazilian government to structurally intervene, in the last decade, in the fight against AIDS in Brazil ²¹21. Monteiro SS, Brigeiro M, Vilella WV, Mora C, Parker R. Desafios do tratamento como prevenção do HIV no Brasil: uma análise a partir da literatura sobre testagem. Ciênc Saúde Colet 2019; 24:1793-807.. The rise of authoritarian conservative agents and the fragmentation of progressive forces have contributed to a backlash on sexual rights in the country ²²22. Brandão ER, Cabral CS. Sexual and reproductive rights under attack: the advance of political and moral conservatism in Brazil. Sex Reprod Health Matters 2019; 27:1669338.^,2323. Cueto M, Lopes G. Backlash in global health and the end of AIDS' exceptionalism in Brazil, 2007-2019. Glob Public Health 2022; 17:815-26..

The sense of obligation and hierarchy attributed to condom use is part of the social construction of the discourse of HIV prevention, which assumes that condoms are the only effective method available. This was hegemonic in prevention policies for years before the emergence of biomedical prevention strategies, observable in the attitude of health professionals and in certain campaigns ⁶6. Pinheiro TF. Camisinha, homoerotismo e os discursos da prevenção de HIV/aids [Doctoral Dissertation]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2015.. Reiterated in school settings, such premise focused on promoting condom use as the most appropriate way to have a safe and healthy sex life ²⁴24. 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.. On the other hand, public health discourse failed to consider difficulties regarding condom use or individuals’ autonomy in decision-making, thus making such norm idealized and out of context.

Hence, even those adolescents who consider it “a pain” to use condoms force themselves (or try to) to do so because they only recognize protection in this method, incorporating a logic of compulsoriness. In this regard, questionings and views that deviate from the norm are perceived as irresponsible, a notion reinforced by the common idea that adolescents are too immature to make decisions and act accordingly. Thus, condomless sex is seen as less of a conscious choice and more as something that they were “driven” to do out of “desperation” or because their hormones are “all over the place”.

Based on this perspective, participants question the place of testing, PrEP, and PEP as feasible prevention options in their lives. Although they recognize that these methods offer them protection, they seem reluctant to view them as legitimate prevention possibilities, as if this would be tantamount to denying the importance of condoms and, consequently, to an irresponsible or dangerous attitude.

However, it is commonly observed that these prevention discourses do not encompass the various processes involved in daily life and the contexts in which sexual practices take place. While they reproduce the discourse of individual responsibility for care, adolescents also reflect on how contextual aspects shape their prevention possibilities. Thus, aspects related to the intersubjectivity of sexual encounters (such as feelings, expectations, and relationships), young people’s sociability (such as alcohol use and establishing networks), and structural and programmatic barriers (such as homophobia, transphobia, and difficulties in accessing health services) have an important impact on young people’s vulnerability to HIV infection.

In some narratives, the feelings of horror and regret attributed to condomless sex seem to reflect, to some extent, the social construction of the AIDS stigma, which was part of the policy discourse for HIV prevention, based on fear and intimidation ²⁵25. Portinari DB, Wolfgang BM, Marie S. Imagens e marcas: um imaginário ligado à epidemia de HIV-Aids no Brasil. Alceu 2017; 17:45-60.. Therefore, interpreting infections as the consequence of an individual’s fault may reproduce discourses about a moral and social order related to an emphasis on lifestyle and sexuality that has blamed gay and trans people, and prostitutes in particular, since the beginning of the AIDS epidemic ²⁵25. Portinari DB, Wolfgang BM, Marie S. Imagens e marcas: um imaginário ligado à epidemia de HIV-Aids no Brasil. Alceu 2017; 17:45-60..

We found that participants received school guidance from the point of view of heterosexual relationships between cisgender people with a focus on pregnancy and STI prevention. This illustrates the hegemony of a heterocisnormative standard that deviates from what the School Health Program (PSE) established regarding their duty to ensure that discussions about adolescent sexuality provide a space for reflection and choices, enabling a healthy and safe sex life regardless of gender and sexual orientation ²⁶26. Ataliba P, Mourão L. Avaliação de impacto do Programa Saúde nas Escolas. Psicol Esc Educ 2018; 22:27-35.. Added to this is the current political context, which bears on sexuality education programs for adolescents: conservative discourses have increasingly taken up space in the area of prevention, making it difficult to address STIs by discussing sexuality, gender, and human rights ²⁷27. Terto Jr. V. A aids é um problema para todos. http://www.ihu.unisinos.br/159-noticias/entrevistas/564732-a-aids-e-um-problema-de-todos (accessed on 17/May/2021).
http://www.ihu.unisinos.br/159-noticias/... . Particularly among travestis and TGW, discrimination and violence usually occur during childhood and adolescence, in which educators and students fail to respect their gender identities and treat them as abject in the school environment. This may result in isolation and social exclusion, which usually leads these students to drop out of school. Their subsequent marginalization offers them fewer opportunities in the formal labor market ²⁸28. Andrade LN. Travestis na escola: assujeitamento e resistência à ordem normativa [Doctoral Dissertation]. Fortaleza: Faculdade de Educação, Universidade Federal do Ceará; 2012., and is a risk factor for HIV infection ²⁹29. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66..

Transphobia and commercial sex in trans adolescents’ lives have specific features in terms of social and structural vulnerability. In addition to a preponderance of the heteronormative logic, in which decisions and pleasure are up to the man ³⁰30. Pelúcio L. Na noite nem todos os gatos são pardos: notas sobre a prostituição travesti. Cadernos Pagu 2005; (25):217-48., money plays an important role in these negotiated relationships, since, by receiving higher offers, travestis and trans women may submit to clients’ wishes, even if it may place them at greater risk of violence or exposure to HIV infection ²⁹29. Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28:1059-66.. The greater susceptibility of younger travestis to violence in the context of sex work, when compared to older people, can be attributed to the fact that they have not yet learned “street tricks” ³⁰30. Pelúcio L. Na noite nem todos os gatos são pardos: notas sobre a prostituição travesti. Cadernos Pagu 2005; (25):217-48.. PrEP use may be of particular importance in those cases, as it gives sex workers the autonomy to exercise prevention before meeting clients and thus, to be free from their interference.

In casual encounters, participants mentioned alcohol consumption as an important factor in whether condoms were used or not. How disinhibition and/or altered consciousness affect sexual encounters must be contextualized in the sociability of young adults and adolescents, as several studies have already indicated ³¹31. Brito I, Precioso JAG, Correia C, Albuquerque C, Samorinha C, Cunha-Filho H, et al. Fatores associados ao consumo de álcool na adolescência, em função do género. Psicol Saúde Doenças 2015; 16:392-410.^,3232. Martins RA, Ribeiro CF, Cruz LAN. Depressão e consumo de álcool em adolescentes: análise da produção no período de outubro de 2008 a março de 2017. Revista de Atenção à Saúde 2019; 17:91-100.. To individualize alcohol consumption in the prevention debate is to lose sight of the social dimension of HIV vulnerability.

Adolescents’ narratives suggest that, in relationships with a significant age gap, older partners represented sexual experience, greater knowledge, and decision-making capacity. This can also appear as an asymmetry in relationships in which the autonomy of the “less experienced” party gives way to the expectation that the “experienced” party will lead the sexual encounter. Thus, as stated by Rios ¹¹11. Rios LF. Homossexualidade, juventude e vulnerabilidade ao HIV/Aids no candomblé fluminense. Temas Psicol 2013; 21:1051-66., such relationships can create an inequality that makes adolescents more vulnerable to HIV infection: even if they know and recognize the importance of using condoms, this prevention method might not be used because either the adolescent has none, the partner’s decided or persuaded them not to use them or even due to socioeconomic asymmetry.

Narratives of individual responsibility and “burden” can also be seen as an expression of biomedical rationality in which health plasticity depends on risk management by enhancing healthy states and avoiding possible problems ³³33. Ortega F, Zorzanelli R. Corpo em evidência: a ciência e a redefinição do humano. Rio Janeiro: Civilização Brasileira; 2010.. Thus, it is up to the individual to morally assess successes and failures in achieving or maintaining bodily and health ideals. From a political perspective, such assumption may imply the State shifting its responsibility for health procedures on the individual and the collectivity for health self-management, as pointed out in analyses of December 1st campaigns in Brazil, centered on the idea of individual ​​accountability for HIV transmission in times of CP ⁷7. Lermen HS, Mora C, Neves ALM, Azize RL. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface (Botucatu) 2020; 24:e180626.. It is, therefore, central to assume the potential of risk management intrinsically associated with the recognition of individuals’ autonomy and the evidence-informed, human rights-based character of the globally agreed proposition on CP strategy ³⁴34. Hankins CA, De Zalduondo BO. Combination prevention: a deeper understanding of effective HIV prevention. AIDS 2010; 24 Suppl 4:70-80..

Public health policies for HIV prevention must recognize adolescents’ diversity of life contexts to guide and expand access to information, linkage, and retention to prevention care in health services. The dismantling of sexuality education programs and the backlash against sexual rights by a government agenda based on fundamentalist religious values has severely affected the current generation. Guided by the promotion and protection of human rights, health policies and comprehensive sexuality education programs must also problematize the hegemonic heterocisnormative standard that has underpinned prevention efforts and programs.

Acknowledgments

We are grateful to the adolescents who participated in this study. We also thank the Oswaldo Cruz Foundation (Fiocruz) and Fiocruz Support Foundation (FIOTEC) for providing management support to this study; Unitaid, Brazilian Ministry of Health, and the Brazilian Coordination for the Improvement of Higher Educatrion Personnel (CAPES).

References

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