ABSTRACT

Objective

To describe the sociodemographic and clinical follow-up profile of the use of pre-exposure prophylaxis (PrEP) of HIV among transgender people receiving care at a reference health service for sexually transmitted infections and HIV/AIDS in São Paulo, the capital city of São Paulo state, between 2018 and 2021.

Method

This was a descriptive study with an analysis of sociodemographic data, reasons for seeking PrEP , discontinuation of use and experiences of clinical follow-up. Descriptive statistics were used.

Results

Among the 53 individuals, the majority were mixed-race (n= 25), transgender women (n= 48), heterosexual (n= 38) and had more than 11 years of study (n= 22). There was a decrease in follow-up visits (n= 14 to n= 3) after the second medical consultation.

Conclusion

It is necessary to develop strategies to increase PrEP dispensing and continuation among transgender people, especially among Black people and those with lower level of education.

Palabras clave
Profilaxis Pre-exposición; Personas Transgénero; Acceso a la Tecnología en Salud; VIH; Epidemiología Descriptiva

Study contributions

Main results

The majority of pre-exposure prophylaxis (PrEP) users were young, mixed-race, educated transgender women, reflecting a portion of the transgender population with access to healthcare. The discontinuation of clinical follow-up, especially after the second medical consultation, requires attention.

Implications for services

Individualized strategies should be prioritized to improve the dispensing of PrEP and clinical follow-up for both transgender men and transgender women.

Perspectives

Further research should focus on investigation of strategies to increase PrEP dispensing and clinical follow-up for transgender people, with an emphasis on transgender men, Black people and those with lower level of education.

Palabras clave
Profilaxis Pre-exposición; Personas Transgénero; Acceso a la Tecnología en Salud; VIH; Epidemiología Descriptiva

RESUMEN

Objetivo

Describir el perfil sociodemográfico y el seguimiento del uso de la profilaxis preexposición (PrEP) para el VIH entre las personas transexuales atendidas en un servicio de salud de referencia para infecciones de transmisión sexual y VIH/sida en la ciudad de São Paulo entre 2018 y 2021.

Método

Estudio descriptivo que analizó datos sociodemográficos, motivos de búsqueda de PrEP, interrupción del uso y experiencias de seguimiento clínico. Se utilizó estadística descriptiva.

Resultados

Entre las 53 personas, la mayoría eran morenas (n=25), mujeres trans (n=48), heterosexuales (n=38) y con más de 11 años de escolaridad (n=22). Hubo una disminución de las visitas de seguimiento (de n=14 a n=3) a partir de la segunda consulta.

Conclusión

Es necesario desarrollar estrategias para aumentar la dispensación y la continuidad del uso de la PPrE entre las personas trans, especialmente entre las personas de raza negra y con menor nivel de escolarización.

Palabras clave
Profilaxis Pre-exposición; Personas Transgénero; Acceso a la Tecnología en Salud; VIH; Epidemiología Descriptiva

INTRODUCTION

Pre-exposure prophylaxis (PrEP) of HIV involves the provision and use of a combination of antiretroviral drugs. This method has been proven effective in preventing HIV transmission. It has shown a reduction in infections in the United States, the United Kingdom, Australia, Kenya, Lesotho, Thailand and Vietnam.¹1 Buchbinder SP, Havlir DV. Getting to Zero San Francisco: A Collective Impact Approach. J Acquir Immune Defic Syndr. 2019;82 (Suppl 3):S176-S182. doi:10.1097/QAI. 0000000000002200.

2 Grulich AE, Guy R, Amin J, Jin F, Selvey C, Holden J, et al. Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study. Lancet HIV. 2018;5(11). doi:10.1016/S2352-3018(18)30215-7.
https://doi.org/10.1016/S2352-3018(18)30... -³3 UNAIDS. 2023 Global HIV Prevention Coalition Scorecards: Key Findings. Geneva: UNAIDS; 2024. p. 39.

Despite the potential of PrEP to interrupt transmission and prevent new infections, there are disparities in access to this medication that need to be addressed to ensure equity in its use.⁴4 Powell VE, Gibas KM, DuBow J, Krakower DS. Update on HIV Preexposure Prophylaxis: Effectiveness, Drug Resistance, and Risk Compensation. Curr Infect Dis Rep. 2019;21(8):28. doi: 10.1007/s11908-019-0685-6
https://doi.org/10.1007/s11908-019-0685-... There is growing concern about the barriers to access faced by transgender people, often resulting from negative and stigmatizing experiences within health services.⁵5 Ogunbajo A, Storholm ED, Ober AJ, Bogart LM, Reback CJ, Flynn R, et al. Multilevel Barriers to HIV PrEP Uptake and Adherence Among Black and Hispanic/Latinx Transgender Women in Southern California. AIDS Behav. 2021;25:2301-15. doi: https://doi.org/10.1007/s10461-021-03159-2.
https://doi.org/10.1007/s10461-021-03159...

6 Kimani M, van der Elst EM, Chirro O, Wahome E, Ibrahim F, Mukuria N, et al. “I wish to remain HIV negative”: Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya. PLoS One. 2021;16(1):e0244226. doi: https://doi.org/10.1371/journal.pone.024422
https://doi.org/10.1371/journal.pone.024... -⁷7 Nieto O, Fehrenbacher AE, Cabral A, Landrian A, Brooks RA. Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users. AIDS Care. 2021;33(2):244-52. doi: 10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17...

An increase in HIV prevalence was observed in a systematic review, ranging from 18% in 2012 to 24% in 2021.⁸8 Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS ONE. 2021;16(12):e0260063.. doi: https://doi.org/10.1371/journal.pone.0260063
https://doi.org/10.1371/journal.pone.026... This increase is not believed to be related to PrEP use itself, but rather that the provision of this procedure for transgender women has been limited. Health services are generally unprepared to meet the specific needs of the transgender population in an inclusive and sensitive manner. Barriers in accessing health services may have contributed to the increased HIV prevalence in this group. Such barriers remain one of the main challenges for the transgender population in the context of PrEP.⁵5 Ogunbajo A, Storholm ED, Ober AJ, Bogart LM, Reback CJ, Flynn R, et al. Multilevel Barriers to HIV PrEP Uptake and Adherence Among Black and Hispanic/Latinx Transgender Women in Southern California. AIDS Behav. 2021;25:2301-15. doi: https://doi.org/10.1007/s10461-021-03159-2.
https://doi.org/10.1007/s10461-021-03159...

6 Kimani M, van der Elst EM, Chirro O, Wahome E, Ibrahim F, Mukuria N, et al. “I wish to remain HIV negative”: Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya. PLoS One. 2021;16(1):e0244226. doi: https://doi.org/10.1371/journal.pone.024422
https://doi.org/10.1371/journal.pone.024... -⁷7 Nieto O, Fehrenbacher AE, Cabral A, Landrian A, Brooks RA. Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users. AIDS Care. 2021;33(2):244-52. doi: 10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17...

Social marginalization and discrimination experienced by transgender people result in lower utilization of healthcare services.⁹9 James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. This situation is exacerbated by barriers such as lack of information about PrEP, bias in healthcare settings, and health care professionals’ concerns about drug interactions, which can discourage transgender people from seeking or continuing treatment.¹⁰10 Bass SB, Kelly PJ, Brajuha J, Gutierrez-Mock L, Koester K, D’Avanzo P, et al. Exploring barriers and facilitators to PrEP use among transgender women in two urban areas: implications for messaging and communication. BMC Public Health. 2022;22(17). doi: https://doi.org/10.1186/s12889-021-12425-w
https://doi.org/10.1186/s12889-021-12425... The intersectionality of factors such as race/skin color, socioeconomic status, and contexts of vulnerability, including geographic location – such as peripheral areas – can worsen access to preventive measures, creating significant disparities in access to PrEP among transgender people.¹⁰10 Bass SB, Kelly PJ, Brajuha J, Gutierrez-Mock L, Koester K, D’Avanzo P, et al. Exploring barriers and facilitators to PrEP use among transgender women in two urban areas: implications for messaging and communication. BMC Public Health. 2022;22(17). doi: https://doi.org/10.1186/s12889-021-12425-w
https://doi.org/10.1186/s12889-021-12425...

Longitudinal studies, for example, underrepresent transgender women.¹¹11 Zarwell M, John SA, Westmoreland D, Mirzayi C, Pantalone DW, Golub S, et al. PrEP uptake and discontinuation among a U.S. national sample of transgender men and women. AIDS Behav. 2021 Apr;25(4):1063-71. doi: 10.1007/s10461-020-03064-0
https://doi.org/10.1007/s10461-020-03064... In Brazil, there is an insufficient or inadequate representation of transgender people in studies on oral PrEP. Analyses of such studies are often grouped together with men who have sex with men.¹²12 Souza MVL, Silva RR, Oliveira MCP, Silva LA, Silva MVG, Vargas D, et al. Acesso a PrEP por homens cisgênero e transexuais: Um estudo de abordagem qualitativa. Res Soc Develop. 2021;10(1):e44310111843. doi: http://dx.doi.org/10.33448/rsd-v10i1.11843
https://doi.org/10.33448/rsd-v10i1.11843...

13 Silva Junior AL, Brigeiro M, Monteiro S. Health, enhancement and lifestyle: the use of the HIV pre-exposure prophylaxis (PrEP) among gay men, trans women and travestis. Physis. 2023;33:e33082. doi: http://dx.doi.org/10.1590/S0103-7331202333082
https://doi.org/10.1590/S0103-7331202333... -¹⁴14 Pereira CCA, Torres TS, Luz PM, Hoagland B, Farias A, Brito JDU, et al. Preferences for pre-exposure prophylaxis (PrEP) among sexual and gender minorities: a discrete choice experiment in Brazil. The Lancet Regional Health - Americas. 2023;19. doi: https://doi.org/10.1016/j.lana.2023.100432.
https://doi.org/10.1016/j.lana.2023.1004... In developed countries, the majority of people who use prophylaxis are men who have sex with men, of White/race skin color, and with a high level of education.⁵5 Ogunbajo A, Storholm ED, Ober AJ, Bogart LM, Reback CJ, Flynn R, et al. Multilevel Barriers to HIV PrEP Uptake and Adherence Among Black and Hispanic/Latinx Transgender Women in Southern California. AIDS Behav. 2021;25:2301-15. doi: https://doi.org/10.1007/s10461-021-03159-2.
https://doi.org/10.1007/s10461-021-03159...

6 Kimani M, van der Elst EM, Chirro O, Wahome E, Ibrahim F, Mukuria N, et al. “I wish to remain HIV negative”: Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya. PLoS One. 2021;16(1):e0244226. doi: https://doi.org/10.1371/journal.pone.024422
https://doi.org/10.1371/journal.pone.024...

7 Nieto O, Fehrenbacher AE, Cabral A, Landrian A, Brooks RA. Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users. AIDS Care. 2021;33(2):244-52. doi: 10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17...

8 Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS ONE. 2021;16(12):e0260063.. doi: https://doi.org/10.1371/journal.pone.0260063
https://doi.org/10.1371/journal.pone.026...

9 James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.

10 Bass SB, Kelly PJ, Brajuha J, Gutierrez-Mock L, Koester K, D’Avanzo P, et al. Exploring barriers and facilitators to PrEP use among transgender women in two urban areas: implications for messaging and communication. BMC Public Health. 2022;22(17). doi: https://doi.org/10.1186/s12889-021-12425-w
https://doi.org/10.1186/s12889-021-12425...

11 Zarwell M, John SA, Westmoreland D, Mirzayi C, Pantalone DW, Golub S, et al. PrEP uptake and discontinuation among a U.S. national sample of transgender men and women. AIDS Behav. 2021 Apr;25(4):1063-71. doi: 10.1007/s10461-020-03064-0
https://doi.org/10.1007/s10461-020-03064...

12 Souza MVL, Silva RR, Oliveira MCP, Silva LA, Silva MVG, Vargas D, et al. Acesso a PrEP por homens cisgênero e transexuais: Um estudo de abordagem qualitativa. Res Soc Develop. 2021;10(1):e44310111843. doi: http://dx.doi.org/10.33448/rsd-v10i1.11843
https://doi.org/10.33448/rsd-v10i1.11843...

13 Silva Junior AL, Brigeiro M, Monteiro S. Health, enhancement and lifestyle: the use of the HIV pre-exposure prophylaxis (PrEP) among gay men, trans women and travestis. Physis. 2023;33:e33082. doi: http://dx.doi.org/10.1590/S0103-7331202333082
https://doi.org/10.1590/S0103-7331202333...

14 Pereira CCA, Torres TS, Luz PM, Hoagland B, Farias A, Brito JDU, et al. Preferences for pre-exposure prophylaxis (PrEP) among sexual and gender minorities: a discrete choice experiment in Brazil. The Lancet Regional Health - Americas. 2023;19. doi: https://doi.org/10.1016/j.lana.2023.100432.
https://doi.org/10.1016/j.lana.2023.1004...

15 Murthy BP, Krishna N, Jones T, Wolkin A, Avchen RN, Vagi SJ. Public Health Emergency Risk Communication and Social Media Reactions to an Errant Warning of a Ballistic Missile Threat — Hawaii, January 2018. MMWR Morb Mortal Wkly Rep. 2019;68(7):174-6. Available from: https://www.cdc.gov/mmwr/volumes/68/wr/mm6807a2.htm

16 Thompson KA, Blank G, Toy J, Moore DM, Lachowsky N, Bacani N, et al. Chronic Hepatitis B Infection Among Preexposure Prophylaxis Users Enrolled in a Population-Based Program in British Columbia, Canada. Open Forum Infect Dis. 2021;8(11)-¹⁷17 Rotsaert A, Reyniers T, Jacobs BKM, Vanbaelen T, Burm C, Kenyon C, et al. PrEP user profiles, dynamics of PrEP use and follow-up: a cohort analysis at a Belgian HIV centre (2017-2020). J Int AIDS Soc. 2022;25(7):e25953. doi: 10.1002/jia2.25953.
https://doi.org/10.1002/jia2.25953... This profile is similar to that presented in Brazil,¹⁹19 Wood S, Gross R, Shea JA, Bauermeister JA, Franklin J, Petsis D, et al. Barriers and Facilitators of PrEP Adherence for Young Men and Transgender Women of Color. AIDS Behav. 2019;23(10):2719-29. which may reflect those who effectively access healthcare services, although there is an unknown population that is unable to access such services. In the case of transgender people, little is known about the profile of those who access PrEP.

Therefore, studies evaluating transgender people who do not have other sexual orientations are therefore necessary. These analyses would enable a better understanding of the profile of access to prophylaxis among transgender people. This study aimed to describe the sociodemographic profile and clinical follow-up of the use of PrEP of HIV among transgender people receiving care at a reference health service for sexually transmitted infections and HIV/AIDS in São Paulo, the capital city of São Paulo state, between 2018 and 2021.

METHOD

Study design and setting

This was a descriptive study that included adult transgender men and women who received PrEP at the STD/AIDS Reference and Training Center in São Paulo.

Setting

The healthcare service is a state-level reference for the diagnosis and treatment of sexually transmitted infections. It was one of the first HIV reference and training centers in Brazil, established in 1988, and includes a testing and counseling center, emergency room, clinical analysis laboratory, day and 24-hour hospitalization, HIV/AIDS, viral hepatitis and transvestite and transgender outpatient clinics. It provides care for approximately 7,000 users per month. It is staffed by multidisciplinary teams comprised of nurses, infectious disease doctors and specialists, pharmacists, psychologists, biologists, among other professionals.

Participants

Transgender men and women aged 18 years or older who self-identified as such and received at least one combination of PrEP medications between January 2018 and June 2021 were included. Individuals who received PrEP and were transferred to another healthcare service were excluded, due to the unavailability of data following the transfer. This period was prioritized to ensure uniformity in data collection forms, which were modified after 2021. Clinical follow-up was considered up to the third medical consultation in order to minimize loss to follow-up.

Variables

The variables included in this study were: age (in years: 18-24, 25-29, 30-34, > 35), country of origin, gender identity (transgender man, transgender woman), sexual orientation (bisexual, heterosexual, homosexual), race/skin color (White, Indigenous, mixed-race, Black), homeless (no, yes), schooling (in years: 1-3, 4-7, 8-11, > 11), reason for attending the healthcare service (general information/care, PEP, PrEP), reason for seeking PrEP (referred by a healthcare professional, informed by a non-governmental organization, awareness through printed communication or internet), previous PrEP (self-initiative, did not start, participated in a research project), sex with an HIV-positive partner (no, yes, do not know), sex in exchange for money (no, yes), use of injectables (no, yes), needle sharing for steroid use (no, yes), history of kidney problems (no, don’t know, yes), loss to follow-up after medical consultations (no; yes, but returned; yes and did not return); prescriber (nurse, doctor), frequency of condom use (never, less than half the time, half the time, more than half the time, always), alcohol use (no, yes), substance use (no, yes: nitrite, cocaine, crack, marijuana, party drugs, male sexual stimulant, solvent), adverse effects from PrEP (no, yes: diarrhea, flatulence, nausea, vomiting, abdominal pain, other adverse effects), reason for stopping PrEP (Lack of medication, adverse effects, forgetfulness, absence from home, other), hepatitis B vaccination (one dose, two doses, complete schedule, referred for vaccination).

The variables were categorized into sociodemographic factors, reasons for seeking PrEP , PrEP eligibility criteria , HIV infection risk assessment, potential PrEP exclusion criteria, adverse effects, PrEP adherence , laboratory results and final procedures and were collected at first visit and at two subsequent times (Table 1).

Data source and measurement

Data were obtained from the Medication Logistic Control System (Sistema de Controle Logístico de Medicamentos - SICLOM), available at https://siclom.aids.gov.br . These data include: (i) first consultation form for PrEP (user’s first day at the health service and PrEP initiation); (ii) the follow-up form 30 days after prophylaxis initiation; and (iii) the PrEP clinical follow-up form (completed every 30, 60, 90 or 120 days, depending on the number of pills dispensed by the healthcare professional).

Discontinuation was defined as when the individual did not return the healthcare service after exceeding 40% the days covered by the medication provided during the last visit, as recommended by the Ministry of Health.¹⁸18 Brasil. Ministério da Saúde. Painel PrEP - Profilaxia Pré-Exposição [Internet]. Brasília: Ministério da Saúde; 2024 [citado em 18 de agosto de 2024]. Disponível em: https://www.gov.br/aids/pt-br/assuntos/prevencao-combinada/prep-profilaxia-pre-exposicao/painel-prep.
https://www.gov.br/aids/pt-br/assuntos/p...

Data analysis

The anonymized data were compiled in Microsoft Excel and analyzed descriptively using the R Studio, version 4.1.1.

Ethical aspects

The study was approved by the Research Ethics Committee (REC) of the Escola de Enfermagem da Universidade de São Paulo, opinion No. 6,128,586 of 06/19/2023, certificate of submission for ethical appraisal (CAAE) 69454123.8.0000.5392, and by the REC of the DST AIDS Reference and Training Center in São Paulo, Opinion No. 6,267.75 of 08/29/2023, CAAE 69454123.8.3001.5375.

RESULTS

A total of 53 transgender people were included in the study (Table 1). The majority of people were Brazilian (n=51), transgender women (n=48), heterosexual (n=38), mixed-race (n=25), lived in their own or rented housing (n=48) and had more than 11 years of study (n=22).

The primary motivation for seeking PrEP was the individual’s own desire to access it (n=51), followed by awareness raised through printed communication or online media (n=31). Sex in exchange for money was reported by 43 participants. Injectable drug use and sharing of equipment were recorded in 1 and 2 cases, respectively (Table 1). A decrease in follow-up attendance and in the number of those who did not return after the initial loss to follow-up (from n=14 at the first medical consultation to n=3 at the third medical consultation). Most prescriptions were written by doctors during the first consultation (n=36), the second (n=24) and the third (n=16) (Table 2).

A large proportion reported using condoms during sexual intercourse most of the time (n=24 at the first consultation) or always (n=17 at the first consultation). Many responses regarding alcohol use were missing. Most participants reported using illicit drugs during the first evaluation (n=37); at the third evaluation, there were (n=6). The most frequently used substances were cocaine, marijuana and party drugs (Table 2).

Most participants did not report adverse effects from PrEP use (n=25) at the first consultation (n=19 at the second). Diarrhea was the most commonly cited issue among the reported adverse effects. The main reasons for discontinuing PrEP were forgetting to take antiretroviral drugs (n=3 at the first consultation) and running out of medication. The majority of participants completed the hepatitis B vaccination schedule (n=29) at the first consultation, and n=20 at the second (Table 2).

DISCUSSION

The majority of transgender people who received PrEP at a reference health service in São Paulo were young adults, transgender women, of mixed-race/skin color, and had complete high school. These data align with the profile identified by the Ministry of Health, which shows a predominance of transgender women with higher level of education among this population.¹⁸18 Brasil. Ministério da Saúde. Painel PrEP - Profilaxia Pré-Exposição [Internet]. Brasília: Ministério da Saúde; 2024 [citado em 18 de agosto de 2024]. Disponível em: https://www.gov.br/aids/pt-br/assuntos/prevencao-combinada/prep-profilaxia-pre-exposicao/painel-prep.
https://www.gov.br/aids/pt-br/assuntos/p...

The study population was limited to people who have access to health services and thus the possibility of obtaining medication for HIV prevention. This profile potentially excludes the experiences of Black transgender women and men who have lower level of education, as well as their access to PrEP.

Socially vulnerable transgender women face greater difficulty accessing health services⁷7 Nieto O, Fehrenbacher AE, Cabral A, Landrian A, Brooks RA. Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users. AIDS Care. 2021;33(2):244-52. doi: 10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17... and PrEP.¹⁹19 Wood S, Gross R, Shea JA, Bauermeister JA, Franklin J, Petsis D, et al. Barriers and Facilitators of PrEP Adherence for Young Men and Transgender Women of Color. AIDS Behav. 2019;23(10):2719-29. Improving access to education and income for transgender people, as well as the organization of health services, is essential, given these barriers and the need to overcome them.²⁰20 Antonini M, Silva IE, Elias HC, Gerin L, Oliveira AC, Reis RK. Barreiras para o uso da Profilaxia Pré-Exposição (PrEP) ao HIV: uma revisão integrativa. Rev Bras Enferm. 2023;76(3). doi: https://doi.org/10.1590/0034-7167-2021-0963pt
https://doi.org/10.1590/0034-7167-2021-0...

Illicit drug use was frequently reported among transgender people using PrEP, particularly cocaine, at the start of prophylaxis. Since people using PrEP will be followed over time, this represents an opportunity for healthcare professionals to address broader issues, such as harm reduction, which is necessary for people using PrEP.²¹21 Bórquez A, Rich K, Farrell M, Degenhardt L, McKetin R, Tran LT, et al. Integrating HIV pre-exposure prophylaxis and harm reduction among men who have sex with men and transgender women to address intersecting harms associated with stimulant use: a modelling study. J Int AIDS Soc. 2020;23(S1):e25495. Available from: http://onlinelibrary.wiley.com/doi/10.1002/jia2.25495/full

This study highlighted the importance of health services in preventing hepatitis B, underscoring the need to check and start vaccination during the first PrEP consultation. The follow-up of people on PrEP may represent an opportunity to update their vaccination schedule. In Canada, 46% of cisgender men and women and transgender women with hepatitis B did not receive adequate monitoring during their PrEP follow-up between 2018 and 2019.¹⁶16 Thompson KA, Blank G, Toy J, Moore DM, Lachowsky N, Bacani N, et al. Chronic Hepatitis B Infection Among Preexposure Prophylaxis Users Enrolled in a Population-Based Program in British Columbia, Canada. Open Forum Infect Dis. 2021;8(11) Increasing awareness and education about hepatitis B among professionals who prescribe PrEP is therefore a priority.²²22 Thompson KA, Blank G, Toy J, Moore DM, Lachowsky N, Bacani N, et al. Chronic Hepatitis B Infection Among Preexposure Prophylaxis Users Enrolled in a Population ‒Based Program in British Columbia, Canada. Open Forum Infect Dis. 2021;8(11). doi: https://doi.org/10.1093/ofid/ofab492
https://doi.org/10.1093/ofid/ofab492... This approach is particularly important when considering the high prevalence of hepatitis B among transgender people, requiring inclusive and accessible strategies for this population.²³23 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(4):e169-e176. doi: 10.1016/S2352-3018(17)30015-2.
https://doi.org/10.1016/S2352-3018(17)30...

In this study, few individuals reported adverse effects, most of which were mild, similar to the findings of a systematic review.²⁴24 Pereira M, Castro CT, Magno L, Oliveira TA, Gomes FS, Neves FMF, et al. Adverse effects of daily oral pre-exposure prophylaxis in men who have sex with men and transgender women: a systematic review and meta-analysis. Cad Saude Publica. 2023;39 Suppl 1:e00089522. doi: 10.1590/0102-311XEN089522.
https://doi.org/10.1590/0102-311XEN08952... ,²⁵25 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Stigma and discrimination related to gender identity and vulnerability to HIV/AIDS among transgender women: A systematic review. Cad Saude Publica. 2019;35(4):e00112718. doi: 10.1590/0102-311X00112718.
https://doi.org/10.1590/0102-311X0011271... These effects should not pose barriers to the use of PrEP, minimizing health professionals’ concerns about adverse effects from antiretroviral drugs. in PrEP prescription.⁵5 Ogunbajo A, Storholm ED, Ober AJ, Bogart LM, Reback CJ, Flynn R, et al. Multilevel Barriers to HIV PrEP Uptake and Adherence Among Black and Hispanic/Latinx Transgender Women in Southern California. AIDS Behav. 2021;25:2301-15. doi: https://doi.org/10.1007/s10461-021-03159-2.
https://doi.org/10.1007/s10461-021-03159... The occurrence of adverse effects should be monitored by these professionals, as well as efforts to remove barriers to PrEP access.

Discontinuation of PrEP use due to forgetfulness was observed in this study. In other therapeutic regimens that require regular medication intake, such as diabetes treatment and HIV infection, the use of digital technologies, such as cell phone alerts and reminders in electronic calendars, can help with medication adherence.²⁶26 Park JYE, Li J, Howren A, Tsao NW, De Vera M. Mobile Phone Apps Targeting Medication Adherence: Quality Assessment and Content Analysis of User Reviews. JMIR Mhealth Uhealth. 2019 Jan 31;7(1):e11919. doi: 10.2196/11919.
https://doi.org/10.2196/11919...

The use of PrEP is primarily determined by the user through an evaluating process with the health professional regarding the risks of transmission. There is no adherence in the same sense as in infection treatment. Given the follow-up through health services, this is an important factor to be analyzed, regarding PrEP continuation, due to its relevance for HIV prevention. In this study, many transgender people discontinued PrEP follow-up as early as the second consultation. A study involving 294 transgender people in the United States enrolled between October 2017 and May 2018 revealed that 49% discontinued use after one year.¹¹11 Zarwell M, John SA, Westmoreland D, Mirzayi C, Pantalone DW, Golub S, et al. PrEP uptake and discontinuation among a U.S. national sample of transgender men and women. AIDS Behav. 2021 Apr;25(4):1063-71. doi: 10.1007/s10461-020-03064-0
https://doi.org/10.1007/s10461-020-03064...

The reasons for seeking PrEP show the importance of healthcare professionals and non-governmental organizations in facilitating access to prophylaxis. It is necessary to expand partnerships between health services and various social organizations to establish a collaborative network that promotes prevention and create more welcoming and judgment-free environments encouraging individuals to seek and continue follow-up care.²⁷27 Jackson-Gibson M, Ezema AU, Orero W, Were I, Ohiomoba RO, Mbullo PO, et al. Facilitators and barriers to HIV pre-exposure prophylaxis (PrEP) uptake through a community-based intervention strategy among adolescent girls and young women in Seme Sub-County, Kisumu, Kenya. BMC Public Health. 1o de dezembro de 2021;21(1284). doi: https://doi.org/10.1186/s12889-021-11335-1
https://doi.org/10.1186/s12889-021-11335... Education and awareness campaigns on PrEP can also increase knowledge and acceptance of PrEP as an effective HIV prevention method. The study also showed the influence of social media in disseminating information about seeking PrEP. This is a resource that can be incorporated by health services, aligning with what is called a digital presence.²⁸28 Nichiata LYI, Passaro T. mHealth e saúde pública: a presença digital do Sistema Único de Saúde do Brasil por meio de aplicativos de dispositivos móveis. RECIIS - Revista Eletrônica de Comunicação, Informação & Inovação em Saúde. 2023;17(3):503-16, 2023. doi: https://doi.org/10.29397/reciis.v17i3.3663.
https://doi.org/10.29397/reciis.v17i3.36...

This study has limitations that should be considered when interpreting the results. First, the sample size was small, with 53 transgender people followed throughout the study period. This may limit the generalization of the results to other transgender populations in different contexts. The study used secondary data from service records, which may have introduced biases due to potential incompleteness or inconsistency in the information recorded. Another limitation is the loss to follow-up observed during clinical follow-up, especially after the second visit. This loss may have influenced the findings, as the analysis considered the first three follow-up visits, which limited a comprehensive assessment of long-term PrEP continuity.

In conclusion, the majority of transgender people using PrEP at a reference health service in São Paulo were young, mixed-race transgender women with higher level of education. High discontinuation rates in clinical follow-up after the second consultation were observed, suggesting the need for actions to increase PrEP continuity. Given this narrow window of opportunity, strategic prevention actions aimed at this population, such as hepatitis B vaccination, should be prioritized during the initial consultations.

REFERENCES

Publication Dates

History