In Brazil, HIV incidence among cisgender men in the general population has been rising while decreasing among cisgender women ¹1. Mangal TD, Pascom ARP, Vesga JF, Meireles MV, Benzaken AS, Hallett TB. Estimating HIV incidence from surveillance data indicates a second wave of infections in Brazil. Epidemics 2019; 27:77-85.. Similarly, increasing trends of HIV and AIDS incidence have been reported among adolescents ²2. Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico HIV/AIDS 2017; V(1). http://antigo.aids.gov.br/pt-br/pub/2017/boletim-epidemiologico-hivaids-2017.
http://antigo.aids.gov.br/pt-br/pub/2017... ^,33. Szwarcwald CL, Souza Júnior PRB, Pascom ARP, Coelho RA, Ribeiro RA, Damacena GN, et al. HIV incidence estimates by sex and age group in the population aged 15 years or over, Brazil, 1986-2018. Rev Soc Bras Med Trop 2022; 55 Suppl 1:e0231.. This growth is more significant in cisgender men who have sex with men (MSM) and transgender women (TGW). Moreover, surveillance studies have identified an upward trend in HIV prevalence from 14% in 2009 ⁴4. 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. to 18% in 2016 ⁵5. Kerr L, Kendall C, Guimarães 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. among MSM older than 18 years; and high HIV prevalence among TGW ⁶6. Bastos FI, Bastos LS, Coutinho C, Toledo L, Mota JC, Velasco-de-Castro CA, et al. HIV, HCV, HBV, and syphilis among transgender women from Brazil: assessing different methods to adjust infection rates of a hard-to-reach, sparse population. Medicine (Baltimore) 2018; 97(1S Suppl 1):S16-24.^,77. Grinsztejn B, Jalil EM, Monteiro L, Velasque L, Moreira RI, Garcia ACF, et al. Unveiling of HIV dynamics among transgender women: a respondent-driven sampling study in Rio de Janeiro, Brazil. Lancet HIV 2017; 4:e169-76.. This trend has been observed among adolescent MSM (aMSM) ⁸8. 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. and adolescent TGW (aTGW) ⁹9. Costa AB, Fontanari AMV, Jacinto MM, Silva DC, Lorencetti EK, Rosa Filho HT, et al. Population-based HIV prevalence and associated factors in male-to-female transsexuals from Southern Brazil. Arch Sex Behav 2015; 44:521-4.^,1010. 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..

This surge in the HIV/AIDS epidemic among aMSM and aTGW may be explained by a combination of factors associated with this stage of life, such as sexual practices experimentation and stigma regarding sexual orientation and gender identity ¹¹11. Magno L, Dourado I, Silva LAV, Brignol S, Brito AM, Guimarães MDC, et al. Factors associated with self-reported discrimination against men who have sex with men in Brazil. Rev Saúde Pública 2017; 51:102.^,1212. Magno L, Dourado I, Silva LAV. Estigma e resistência entre travestis e mulheres transexuais em Salvador, Bahia, Brasil. Cad Saúde Pública 2018; 34:e00135917.^,1313. Magno L, Dourado I, Silva LAV, Brignol S, Amorim L, MacCarthy S. Gender-based discrimination and unprotected receptive anal intercourse among transgender women in Brazil: a mixed methods study. PLoS One 2018; 13:e0194306.^,1414. Magno L, Silva LAV, 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:e190003.^,1515. Guimarães MDC, Ceccato MGB, Gomes R, Rocha GM, Camelo LV, Carmo RA, et al. Vulnerabilidade e fatores associados a HIV e sífilis em homens que fazem sexo com homens, Belo Horizonte, MG. Rev Méd Minas Gerais 2013; 23:412-26.. Moreover, their increased vulnerability is related to social, economic, and organizational inequalities and structural issues ¹⁶16. 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.^,1717. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13:214-22.^,1818. 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.. Furthermore, studies report a reduction in dialogue and guidance on sexuality issues in schools, an increase in the rate of sexual initiation without using condoms, and unprotected sex. These issues are more severe in adolescents with greater social vulnerability ¹⁹19. Felisbino-Mendes MS, Paula TF, Machado ÍE, Oliveira-Campos M, Malta DC. Análise dos indicadores de saúde sexual e reprodutiva de adolescentes brasileiros, 2009, 2012 e 2015. Rev Bras Epidemiol 2018; 21:e180013.^,2020. Oliveira-Campos M, Nunes ML, Madeira FC, Santos MG, Bregmann SR, Malta DC, et al. Comportamento sexual em adolescentes brasileiros, Pesquisa Nacional de Saúde do Escolar (PeNSE 2012). Rev Bras Epidemiol 2014; 17:116-30.^,2121. Reis AAC, Malta DC, Furtado LAC. Desafios para as políticas públicas voltadas à adolescência e juventude a partir da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc Saúde Colet 2018; 23:2879-90.; among younger MSM, for example, studies have shown fewer HIV testing and higher frequency of unprotected anal sex, leading to the increased risk of the worst epidemic scenario in the coming years ²²22. Guimarães MDC, Kendall C, Magno L, Rocha GM, Knauth DR, Leal AF, et al. Comparing HIV risk-related behaviors between 2 RDS national samples of MSM in Brazil, 2009 and 2016. Medicine (Baltimore) 2018; 97(1S Suppl 1):S62-8.^,2323. Rocha GM, Guimarães MDC, Brito AM, Dourado I, Veras MA, Magno L, et al. High rates of unprotected receptive anal intercourse and their correlates among young and older MSM in Brazil. AIDS Behav 2020; 24:938-50..

Paradoxically, this is occurring at the same time that an increasing number of HIV control strategies and prevention methods are available in Brazil and globally. One of these strategies is combination HIV prevention, an approach that involves socio-structural and behavioral elements, notably antiretroviral as a prevention tool. In addition, pre-exposure prophylaxis (PrEP) stands out due to its efficacy and effectiveness in preventing HIV infection ²⁴24. Grangeiro A, Castanheira ER, Nemes MIB. The reemergence of the Aids epidemic in Brazil: challenges and perspectives to tackle the disease. Interface (Botucatu) 2015; 19:5-6.^,2525. Grinsztejn B, Hoagland B, Moreira RI, Kallas EG, Madruga JV, Goulart S, et al. Retention, engagement, and adherence to pre-exposure prophylaxis for men who have sex with men and transgender women in PrEP Brasil: 48 week results of a demonstration study. Lancet HIV 2018; 5:e136-45.^,2626. Montgomery MC, Oldenburg CE, Nunn AS, Mena L, Anderson P, Liegler T, et al. Adherence to pre-exposure prophylaxis for HIV prevention in a clinical setting. PLoS One 2016; 11:e0157742.^,2727. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. Genebra: World Health Organization; 2016.. PrEP became available in the Brazilian Unified National Health System (SUS), free of charge, in 2018 for several key populations aged 18 years or older. Today, it can be prescribed to anyone who needs it from 15 years old or older.

An effective response to reducing HIV incidence in adolescents requires a knowledge-based policy, specifically for this population, which presents less access to health services and limited research-based knowledge. For several reasons, such as the inadequate application of regulatory and ethical directives, the approval of research with adolescents younger than 18 years old is burdensome. It can be frustrating, which often requires legal recourse for authorizing their recruitment. The need for parent and/or guardian consent to participate in a study is a barrier to adolescents’ participation in studies regarding sexuality and HIV. This requirement may be considered an infringement on their rights and could leave a knowledge gap for adolescents younger than 18. Knowledge neglection is an issue that should have a solution since adolescents have diverse and different life contexts, which can be violent; thus, research is essential for understanding the individual, social, and cultural specificities of this population group ²⁸28. Hosek S, Pettifor A. HIV prevention interventions for adolescents. Curr HIV/AIDS Rep 2019; 16:120-8.. Therefore, the adolescents’ consent to participate in research should be sufficient in such situations. These hurdles explain why most studies limit the inclusion criteria to people aged 18.

To fill this knowledge gap, the projectStudy of the Effectiveness of PrEP among Adolescent Men Who Have Sex with Men and Transgender Women Aged 15 to 19 Years at Substantial Risk of HIV Infection (Project PrEP1519)was established as a demonstration study. This project aims to evaluate PrEP effectiveness and its contribution to reducing the HIV incidence of the target population. It used a cohort design with a three-year follow-up period in three sites in Brazil (Salvador, Belo Horizonte, and São Paulo). Furthermore, the project compared the results of different demand-creation strategies for the recruitment, enrollment, and linkage of adolescents to the PrEP1519 services and friendly settings for LGBTQIA+ adolescents. The project is composed of a multi-professional health team and researchers that foster interdisciplinarity between epidemiologists, physicians, nursing professionals, pharmacists, social scientists, and health planning/administration personnel. This team produces data for project monitoring and promotes research-based knowledge to guide public policies in Brazil and abroad, aiming to extend the PrEP age range to adolescents aged 15 to 17. This objective was recently achieved (2022) by expanding access to PrEP in the SUS for people 15 years old or older ²⁹29. Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde; Secretaria de Vigilância em Saúde, Ministério da Saúde. Protocolo clínico e diretrizes terapêuticas para profilaxia pós-exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2022..

This Supplement aims to present the methodological, quantitative, qualitative, and review research-based data to foster the debate on preventing HIV and other sexually transmitted infections (STIs) among aMSM and aTGW in Brazil. The papers used the baseline results from the PrEP1519 project and related topics in articles such as essays and literature reviews.

The first two articles describe the foundations of PrEP1519, with Dourado et al. ³⁰30. 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. focusing on the study methodology, highlighting that the adopted design is based on a collaborative effort of interdisciplinary practices. The paper by Barros et al. ³¹31. Barros SG, Brasil SA, Rossi TRA. The social construction of the PrEP1519 study: conditions of possibility for advances in HIV/AIDS prevention. Cad Saúde Pública 2023; 39 Suppl 1:e00201621. analyzed the genesis of the PrEP1519 study and the possible conditions for its development. They showed that PrEP1519 resulted from the articulation of health managers, scientists, and activist stakeholders. The articulation of agents from different fields, with diverse dispositions and points of view at the three locations, contributed to the formulation of a project that sought to generate clinical, epidemiological, and social knowledge to develop broader strategies and an inclusive policy.

Subsequently, the papers seek to establish reflections on adolescents’ risk, pleasure, and processes for deciding and incorporating PrEP as a preventive method, as well as the role of different strategies used in the project to inform and sensitize adolescents to the use of prevention. Silva et al. ³²32. Silva LAV, Brasil SA, Duarte FM, Cunha LA, Castellanos MEP. Between risk and pleasure: reflections on HIV prevention and care in the current context of PrEP use by men who have sex with men. Cad Saúde Pública 2023; 39 Suppl 1:e00139221. reflected on the relationship between risk and pleasure in the field of HIV care and prevention, putting into perspective the mediation of these new biomedical prevention and care technologies, especially PrEP. Their synthesis showed that adolescents’ sexual protective methods are opposed to the adolescents’ body, which appears to be more open, unstable, and somewhat unpredictable. They are also opposed to different prevention norms and discourses, including preventing other STIs. Pena et al. ³³33. Pena ÉD, Westin MR, Duarte MJ, Greco M, Silva AP, Martinez YF, et al. When prevention is the best remedy: HIV pre-exposure prophylaxis (PrEP) among adolescents gays and transgender women in Belo Horizonte, Minas Gerais State, Brazil. Cad Saúde Pública 2023; 39 Suppl 1:e00097921., showed that the incorporation of PrEP as an HIV prevention strategy needs a better understanding of the use of medication and needs to analyze different narratives of aMSM and aTGW, such as adolescents participating in the PrEP1519 Belo Horizonte. Martins et al. ³⁴34. Martins GB, Pinheiro TF, Ferraz D, Grangeiro A, Zucchi EM. Use of HIV prevention methods and contexts of the sexual practices of adolescent gay and bisexual men, travestis, and transgender women in São Paulo, Brazil. Cad Saúde Pública 2023; 39 Suppl 1:e00161521. sought to understand the perspective of adolescent gay and bisexual men, in addition to transgender women, about the use of HIV prevention methods regarding their sexual practices. The formative research in downtown São Paulo oriented a qualitative investigation with key adolescent informants who shared their views on the dynamics of social interaction, sexual experiences, use and acceptability of HIV prevention methods, and demand-creation of new strategies to inform and to create interest for PrEP. Their findings suggested that public health policy for HIV prevention must recognize adolescents' diversity of life contexts to provide guidance and expand access to information, linkage, and retention in prevention care in health services.

The structural and individual aspects that lead cisgender aMSM and aTGW to present a high vulnerability to HIV and other STIs were analyzed in three articles. Magno et al. ³⁵35. Magno L, Medeiros DS, Soares F, Grangeiro A, Caires P, Fonseca T, et al. Factors associated to HIV prevalence among adolescent men who have sex with men in Salvador, Bahia State, Brazil: baseline data from the PrEP1519 cohort. Cad Saúde Pública 2023; 39 Suppl 1:e00154021. estimated the prevalence of HIV and associated factors among aMSM using the baseline data from the PrEP1519 in Salvador; they found a higher HIV prevalence than estimated for the overall male population in Brazil. Furthermore, the study found that individual, social, and programmatic factors were associated with HIV infection among aMSM. Westin et al. ³⁶36. Westin MR, Martinez YF, Silva AP, Greco M, Marques LM, Campos GB, et al. Prevalence of syphilis and sexual behavior and practices among adolescents MSM and TrTGW in a Brazilian multi-center cohort for daily use of PrEP. Cad Saúde Pública 2023; 39 Suppl 1:e00118721. highlighted acquired syphilis as a relevant reemerging infection in global public health, particularly among young key populations. Their findings corroborate the epidemiological trend of a high prevalence of syphilis among aMSM and aTGW and the important vulnerability markers.

Two articles discuss the challenges of linking health services to the experiences of using PrEP in the daily life of adolescents − central themes for increasing the effectiveness of PrEP. In the first, Oliveira et al. ³⁷37. Oliveira RLS, Silva LAV, Duarte FM, Brasil SA, Castellanos MEP, Magno L, et al. Building bridges to care: the experience of peer navigation in enabling linkage to PrEP for adolescent men who have sex with men and transgender women. Cad Saúde Pública 2023; 39 Suppl 1:e00176821. analyzed the linkage of aMSM and aTGW to the PrEP clinic in Salvador by the mediation of peer navigators. They showed that navigators and adolescents worked together, affected each other, and needed each other to “do” or to produce an emotional bond with care. Santos et al. ³⁸38. Santos LA, Unsain RF, Brasil SA, Silva LAV, Duarte FM, Couto MT. PrEP perception and experiences of adolescent and young gay and bisexual men: an intersectional analysis. Cad Saúde Pública 2023; 39 Suppl 1:e00134421. explored the perceptions and experiences of young homosexual, bisexual, and other MSM from São Paulo and Salvador regarding the search, use, and adherence to PrEP using the intersectional approach, i.e., discussing personal/relational aspects and structural and symbolic dimensions as facilitators and barriers to the continuum of care in PrEP. Their analyses revealed that, in individual/subjective terms, the possibilities of use and the search for PrEP are part of a learning process based on experiences and ideals of pleasure and freedom in the perception of risk and the management of HIV prevention.

Finally, aspects are discussed that may represent barriers to PrEP initiation. Lamônica et al. ³⁹39. Lamônica JS, Magno L, Santos JEJS, Dourado I, Santos AM, Santos MP. Unwillingness to indicate PrEP by health professionals of specialized HIV/AIDS services in Northeastern Brazil. Cad Saúde Pública 2023; 39 Suppl 1:e00121322. analyzed factors associated with unwillingness to indicate PrEP by health providers of specialized HIV/AIDS services in Bahia State, Northeast Brazil. The study identified a high level of knowledge of PrEP, but a sizeable proportion of health professionals are unwilling to indicate PrEP. They suggest the expansion of training in combination with HIV prevention, including PrEP, for health providers, especially for physicians and nurses.

We expect that the publication of these results will help to push the agenda for HIV and STIs prevention for adolescents and attract the attention of all relevant stakeholders, including public health authorities, to the specific needs of adolescents.

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