ABSTRACT

OBJECTIVE:

To understand the perceptions and experiences of transsexual and travesti women and non-binary or gender-fluid people (TGWT+) in health services where they took pre-exposure prophylaxis (PrEP) in the periods before and during the pandemic, focusing on the resignification in the relationship with services and the continuity of HIV prevention via PrEP.

METHODS:

Qualitative research and analysis of empirical material generated in the context of broader studies were conducted. A total of 45 semi-structured interviews were conducted with TGWT+ PrEP users in the city of São Paulo and analyzed using iterative thematic content analysis.

RESULTS:

The TGWT+ interviewees gave new meanings to their struggles, daily lives and ways of caring for their health and played a central role within them. With its particularities, the COVID-19 pandemic became one more event among all the others that TGWT+ face daily. Alongside the COVID-19 pandemic, the TGWT+ were faced with the HIV epidemic, but with the possibility of prevention via PrEP.

CONCLUSION:

Based on a situated and conscious perspective, more explicit in the context of the health crisis, the TGWT+ intertwined conscious actions and care practices in dialog with health services. Further research on these groups from a spatiotemporal dynamic situated in specific contexts of meaning production would make it possible to advance prevention and care strategies, especially in times of health crisis.

DESCRIPTORS:
Sexual and Gender Minorities; Pre-Exposure Prophylaxis; HIV; Qualitative Research; COVID-19

INTRODUCTION

The COVID-19 pandemic had a significant impact on health services and the population¹1 Kubo HKL, Campiolo EL, Ochikubo GT, Batista G. Impacto da pandemia do covid-19 no serviço de saúde: uma revisão de literatura. Interam J Med Heal. 2020 Jul; 3: e202003046. https://doi.org/10.31005/iajmh.v3i0.140
https://doi.org/10.31005/iajmh.v3i0.140... . The lack of articulated intersectoral policies and the discontinuity of programs amplified difficulties in accessing programs and services, especially those for HIV prevention²2 Gibb JK, DuBois LZ, Williams S, McKerracher L, Juster RP, Fields J. Sexual and gender minority health vulnerabilities during the COVID-19 health crisis. Am J Hum Biol. 2020 Sep; 32(5): e23499. https://doi.org/10.1002/ajhb.23499
https://doi.org/10.1002/ajhb.23499... .

It is well established that transgender women, travestis and non-binary or gender fluid people (TGWT+) have their right to health and access to services disproportionately affected, mainly due to gender-based violence expressed in disrespect for their identities and sexual stigma³3 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. 4. ed. Rio de Janeiro: LTC; 1981. 160p.. That is expressed in the impairment of health care in general and sexual health in particular⁴4 Magno L, Silva LAV, Veras MA, Pereira-Santos M, Dourado I. Estigma e discriminação relacionados à identidade de gênero e à vulnerabilidade ao HIV/aids entre mulheres transgênero: revisão sistemática. Cad Saude Publica. 2019 Apr; 35(4): e00112718. https://doi.org/10.1590/0102-311X00112718
https://doi.org/10.1590/0102-311X0011271... ^{), (5}5 Farias SR, Cury GC. Acesso aos cuidados em saúde de travestis e mulheres transexuais no Brasil. Res Soc Dev. 2022 Oct; 11(14): e293111436161. https://doi.org/10.33448/rsd-v11i14.36161
https://doi.org/10.33448/rsd-v11i14.3616... .

The adoption of self-care and prevention strategies for HIV and other Sexually Transmitted Infections (STIs) by TGWT+ is mediated by their peer social networks and, at the same time, by the relationship they establish with health professionals and services. Therefore, without intending to make a systematic comparison, it is pertinent to investigate, in the context of the COVID-19 pandemic and before, possible losses and gains related to HIV prevention and the use of pre-exposure prophylaxis (PrEP)⁶6 Silva Junior AL, Brigeiro M, Monteiro S. ‘Irmandade travesti é a nossa cura’: solidariedade política entre travestis e mulheres trans no acesso ao cuidado em saúde e à prevenção ao HIV. Saúde Debate. 2022 Dec; 46(especial 7): 103-16. https://doi.org/10.1590/0103-11042022E707
https://doi.org/10.1590/0103-11042022E70... .

In the COVID-19 pandemic, especially in Brazil, the possibilities of dealing with exposure to the virus, illness, and its repercussions were mediated by living conditions and access to goods, services and social rights⁷7 Marques ALM, Sorentino IS, Rodrigues JL, Machin R, Oliveira E, Couto MT. O impacto da covid-19 em grupos marginalizados: contribuições da interseccionalidade como perspectiva teórico-política. Interface (Botucatu). 2021; 25(suppl 1): e200712. https://doi.org/10.1590/Interface.200712
https://doi.org/10.1590/Interface.200712... . In this sense, COVID-19 is treated here as an “event”⁸8 Romano JO, Bittencourt TP, Uema L, Aguiar CBO, Ferreira LR. La pandemia covid-19 como acontecimiento y la disputa política de los discursos negacionista y científico. In: Bosco E, Igreja RL, Valladares L, coords. A América Latina frente ao governo da covid-19: desigualdades, crises, resistências. Brasília, DF: Faculdade Latino-Americana de Ciências Sociais; 2022. p. 143-177. in the social and political field that has increased the barriers to accessing services on the one hand and, on the other hand, increased the search for healthcare alternatives based on networks and paths that are not necessarily institutional. The proposal by Romano et al.⁸8 Romano JO, Bittencourt TP, Uema L, Aguiar CBO, Ferreira LR. La pandemia covid-19 como acontecimiento y la disputa política de los discursos negacionista y científico. In: Bosco E, Igreja RL, Valladares L, coords. A América Latina frente ao governo da covid-19: desigualdades, crises, resistências. Brasília, DF: Faculdade Latino-Americana de Ciências Sociais; 2022. p. 143-177. to consider the pandemic as an event rather than a “disaster” or a “catastrophe” is based on the ideas of Byung-Chul Han⁹9 Han B-C. La emergencia viral y el mundo de mañana. In: Amadeo P, editor. Sopa de Wuhan: pensamiento contemporáneo em tiempos de pandemias. Buenos Aires: ASPO; 2020. p. 97-112., who proposes twisting the hegemonic idea of “epidemic” and starting to describe and explain this reality from the different subjects who are, in fact, the protagonists of the stories surrounding it.

Considering perceptions and experiences from before and during the pandemic, we will analyze the relationships that TGWT+ has established with the services where they receive PrEP. We will explore the possible reframing of these services and look into the continuity of HIV prevention. The proposal is to deepen research that reflects on TGWT+ from a space-time dynamic situated in specific contexts, to rethink prevention and care strategies, especially in times of crisis.

METHODS

The empirical material analyzed was produced in PrEP 1519¹⁰10 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 Publica. 2023 Mar; 39(suppl 1). https://doi.org/10.1590/0102-311XEN143221
https://doi.org/10.1590/0102-311XEN14322... , Combina!,¹¹11 Grangeiro A, Couto MT, Peres MF, Luiz O, Zucchi EM, Castilho EA, et al. Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): protocol for a pragmatic clinical trial at public healthcare clinics in Brazil. BMJ Open. 2015 Aug 25; 5(8): e009021. http://dx.doi.org/10.1136/bmjopen-2015-009021
http://dx.doi.org/10.1136/bmjopen-2015-0... and COBra¹²12 Ferraz D, Dourado I, Zucchi EM, Mabire X, Magno L, Grangeiro AD, et al. Effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult men who have sex with men and transgender women participating in two PrEP cohort studies in Brazil: COBra study protocol. BMJ Open. 2021 Apr; 11(4): e045258. https://doi.org/10.1136/bmjopen-2020-045258
https://doi.org/10.1136/bmjopen-2020-045... studies. PrEP 1519 and Combina! are studies that demonstrate the effectiveness of daily PrEP. PrEP 1519 was conducted with adolescent cisgender men who have sex with men (MSM) and TGWT+, and Combina! was conducted with adults. COBra, using a mixed methodology (qualitative and quantitative), assessed the impact of the COVID-19 pandemic on the sexual and mental health of PrEP users who were being followed up in the two studies above.

This article analyzed 45 semi-structured interviews with TGWT+ PrEP users in São Paulo city. Recruitment ensured sample diversification by race/color, schooling, and socioeconomic status (income, occupation, and places of residence, and work). The interviews were carried out by trained researchers in health services from 2018 to 2019, and then via videoconference in the first half of 2021, due to the COVID-19 pandemic.

There were two interview scripts: before and during the COVID-19 pandemic. Although different, the two scripts questioned the interviewees’ relationship with the services and sought to understand their feelings, worries, and concerns about starting and adhering to PrEP, as well as the positive aspects of prophylaxis, such as the ideas of protection, safety, and peace of mind. The interviews conducted during the pandemic explored the impact of COVID-19 on the participants’ living conditions and their continued use of PrEP.

When using iterative thematic inquiry¹³13 Neale J. Iterative categorization (IC): a systematic technique for analysing qualitative data. Addiction. 2016 Jun; 111(6): 1096-106. https://doi.org/10.1111/add.13314
https://doi.org/10.1111/add.13314... , the aim was to understand the symbolic and material universe of the interviewees and to grasp their perceptions of the relationships they established with the services before and during the pandemic. After examining the content of the interviews, a systematic analysis of the units of meaning selected from the speeches was carried out, assessing their contributions to the overall analytical corpus¹⁴14 Achilli EL. Investigar en antropología social: los desafíos de transmitir un oficio. Rosario: Centro de Estudios Antropológicos en Contextos Urbanos, Laborde Livros Editor; 2005. 98p.. The statements were then linked to the analysis themes, ultimately establishing a dialog between the material analyzed, the literature on the subject, and the theoretical framework. In this sense, fictitious names were used to ensure the anonymity of the participants.

It is important to emphasize that the intention was not to compare the answers given before and during COVID-19. In addition, the participants’ perspectives, who constructed their narratives based on life events in time and space, were taken as a reference. In this way, the categories transgender woman, travesti, and non-binary or gender-fluid person comprise historical, social, economic, symbolic, and political dimensions that transcend conjunctures.

The term “transgender women” is commonly used in the USA and other countries to refer to women who were assigned the male sex at birth¹⁵15 Leite BO, Magno L, Soares F, MacCarthy S, Brignol S, Bastos FI, et al. HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies. BMC Public Health. 2022 Nov; 22(1): 2120. https://doi.org/10.1186/s12889-022-14589-5
https://doi.org/10.1186/s12889-022-14589... . In Brazil and some other Latin American countries, however, the terms “travesti(s)” or “trans women” are also used and re-signified by activist groups and communities¹⁶16 Rodovalho AM. Cis by trans. Rev Estud Fem. 2017 Jan-Apr; 25(1): 365-73. https://doi.org/10.1590/1806-9584.2017v25n1p365
https://doi.org/10.1590/1806-9584.2017v2... ^{), (17}17 Carvalho M. “Travesti”, “mulher transexual”, “homem trans” e “não binário”: interseccionalidades de classe e geração na produção de identidades políticas. Cad Pagu. 2018 May; (52): e185211. https://doi.org/10.1590/1809444920100520011
https://doi.org/10.1590/1809444920100520... ^{), (18}18 Fernández J. Cuerpos desobedientes: travestismo e identidad de género. Buenos Aires: Edhasa; 2004. 213p.. For this reason, the term “travesti” was used as an identity and political category from an emic perspective. People who identify as non-binary or gender fluid do not use the binary terms male and female to define themselves and may identify themselves as trans¹⁷17 Carvalho M. “Travesti”, “mulher transexual”, “homem trans” e “não binário”: interseccionalidades de classe e geração na produção de identidades políticas. Cad Pagu. 2018 May; (52): e185211. https://doi.org/10.1590/1809444920100520011
https://doi.org/10.1590/1809444920100520... .

Lastly, to better understand the two historical moments and examine similarities or differences, the data obtained were broken down into thematic axes: a) routines, b) reception/restraint/confidence in services, and c) time/space dimension.

Based on the work of Romano⁸8 Romano JO, Bittencourt TP, Uema L, Aguiar CBO, Ferreira LR. La pandemia covid-19 como acontecimiento y la disputa política de los discursos negacionista y científico. In: Bosco E, Igreja RL, Valladares L, coords. A América Latina frente ao governo da covid-19: desigualdades, crises, resistências. Brasília, DF: Faculdade Latino-Americana de Ciências Sociais; 2022. p. 143-177. and Han⁹9 Han B-C. La emergencia viral y el mundo de mañana. In: Amadeo P, editor. Sopa de Wuhan: pensamiento contemporáneo em tiempos de pandemias. Buenos Aires: ASPO; 2020. p. 97-112., these axes were investigated in terms of the variations in the symbolic and material construction of services and whether they were given new meanings as a result of COVID-19.

The studies Combina!, PrEP 1519, and COBra were approved by the Research Ethics Committee of Hospital das Clínicas and Faculdade de Medicina da Universidade de São Paulo, with opinions No. 2.131.668, No. 3.082.360 and No. 3.988.973, respectively.

All participants were informed about the study’s objectives and their rights regarding participation, as well as their rights in relation to participation, and signed an Informed Consent Form. Parental consent was waived once judicial authorization was granted, in order to preserve the person’s right to participate.

RESULTS

Characterization of TGWT+

Most interviewees defined themselves as trans women (41), white (22) or mixed-race (15), heterosexual (38), and aged 15 to 52 (Chart 1), and the age distribution was similar between those interviewed before and during the pandemic.

Categories included more recently in LGBTQIAPN+ groups, such as “pansexual”, “asexual”, and “non-binary”, were mentioned by the younger participants; one defined themselves as travesti, one as gender-fluid, and another as a non-binary trans person.

Sex work was mentioned by 31 participants, some of whom said they also worked with make-up or hairdressing sometimes. Five participants stated that they had once been sex workers but at the time had other jobs or were beneficiaries of government programs/social benefits. They did not rule out the possibility of returning to sex work if necessary. Nine interviewees said they had never engaged in sex work, all of whom were younger (aged 15 to 21).

Table 1 shows other characteristics, such as housing and schooling.

The COVID-19 event and the changes in routines

As sex work is one of the ways to elucidate the construction of the world of most of the TGWT+ interviewed, it was proven that the pandemic changed the routine of those who engaged in it. The routine also changed for those who did not, although the impact on daily life was less arduous. At the beginning of the pandemic work activities were very restricted in the first three months,. In a later period, sex work, like so many other activities, took on a new meaning: virtual platforms began to be exploited in the face of a shortage of street customers and the temporary closure of private clubs.

In this context of readaptation, the prevention of HIV and other STIs was no longer central. The COVID-19 event took center stage in terms of protection and prevention.

The COVID-19 pandemic also redefined the role of PrEP professionals and services: as per the interviewees, they were no longer confined to sexual health, but also encompassed the prevention and care of the new health emergency. Moreover, the service and the health professionals were revalued in the context of the health crisis because they organized themselves to continue offering HIV prevention and PrEP.

Hospitality and trust in the service that goes beyond HIV prevention

All the interviewees acknowledged that the services where they were monitored for PrEP before and during the pandemic were places of hospitality, safety, and trust, where they could talk about different aspects of their lives “almost” without judgment. “Almost” because, for the interviewees, judgment related to sex work or being TGWT+ remained a subtle but insidious symbolic and material barrier with the potential to hinder PrEP adherence. Cecília (Pre-Pandemic/Trans Woman) understood these signs with eloquence: “I did not experience prejudice... [but] they [health professionals] are always surprised by who I am”, she mentioned, referring to the fact that she belongs to the TGWT+ group.

TGWT+ people have health demands that go beyond sexual health and predate COVID-19, and these include procedures associated with gender transition. In this sense, these health services not only provide HIV prevention via PrEP but also include, for example-and in some cases-hormone therapy.

Before the pandemic, the interviewees gave positive reports about the services and their professionals. Olívia (Pre-Pandemic/Trans Woman) commented that she felt welcomed for the first time in a health service: “Oh, I felt... normal. I was very well welcomed”. The mention of feeling “normal” echoes a desire Olívia had held ever since she decided to leave home to “live life as a woman”.

Sophie said she felt welcomed and pointed out that this story of hospitality came from her mother, who was living with HIV:

Stella spoke about how she was welcomed when she thought she had been exposed to HIV and arrived “desperate” at the service:

Mentions of hospitality and trust in PrEP services remain firm in the statements of those interviewed during the pandemic. However, the COVID-19 event brought out new meanings among participants: some began to question whether PrEP “can be used for other diseases”, in the sense of antiretroviral use aimed at prevention. Alana (During the Pandemic/Trans Woman), for example, assured that she always thanks the service for providing her with an “antiviral” pill that “certainly frees” her from COVID-19. Thus, the crisis caused by the pandemic strained conceptions about communicable diseases, their prevention, treatment, and scope.

Lívia (During the Pandemic/Trans Woman), going further, ensured that: “Because I take PrEP, I think that if a person has a disease and I have sex with them without a condom, maybe I am passing on the cure to them as if it were a vaccine”. According to the interviewees, all these queries and assumptions are listened to and clarified carefully by the health professionals.

Although they expressed trust in and acceptance of the services, some TGWT+ did not exempt certain health professionals from criticism related to severe and systematic scrutiny of their lives, including procedures related to care by health professionals, such as having to answer a questionnaire every three months. However, these complaints do not disqualify the image that the services are protected institutional areas.

Among some TGWT+, the difference in treatment in public and private health services is striking. Two of them, one before and one during COVID-19 admitted that they had sought private health services and had been mistreated, being called by their male names. They also reported aggressive attitudes from health workers, doctors, or nurses. Although they recognized that these episodes could happen in the public sphere, the interviewees reinforced that these incidents in the private sphere were “terrible”, “dangerous”, and “offensive”.

Age is a differentiator in the perception of hospitality. The need for restraint appears to be a complaint among the older interviewees especially among those who lived alone. Among younger women, especially those who live with their families, this need is divided between families and health services. As Marlucia pointed out:

Temporal/spatial dimension

If one thing was different before and during the pandemic, it was the way in which time and distances were calculated and rearranged. A constant complaint about access to health services before the pandemic had to do with the hours spent commuting.

Milena, a sex worker in the Jardins neighborhood of São Paulo, commented:

In the case of Laís, the time spent commuting and at work are potential barriers to adherence to PrEP:

Pietra reported the same problem and added her dissatisfaction with the organization of the service flow:

Sometimes, however, the welcoming and attentive professional service made the interviewees decide to spend more time commuting and in more crowded clinics. Carla commented on this:

During the pandemic, when it was impossible for users to travel, the service organized “logistics”, in native terms, by which PrEP could reach homes. This included not only PrEP, but also hormone therapies - when prescribed - and HIV self-tests, among other supplies. Another possibility was for people to seek PrEP from the services, which would prepare whatever was necessary for prompt withdrawal.

Although the health services that provide hormone therapy are not necessarily those that provide PrEP, there seems to be a perception that the spaces that offer PrEP, hormone therapy, or other resources are re-signified as a common area of continuity of care. From an interpretative perspective, the health team loses its human form and merges with the place where it works, forming the “service”, a lively area of struggle for a group whose voice is hardly heard.

It is not the purpose of this paper to think about how these logistics were organized but to understand their impact on the lives of TGWT+, considering that complaints of “lost time” due to commuting were frequent before the pandemic.

As reported by Isabel:

Luna (During the Pandemic/Trans Woman) commented that appointments went much faster during the pandemic: “I make an appointment at [name of service] with the girl via WhatsApp, and then I see the doctor, and everything goes faster”.

Joana (During the Pandemic/Trans Woman) was blunt about receiving PrEP, both before and during the pandemic: “I am taking PrEP. I have never had any problems getting PrEP”. This comment was common among TGWT+, although there were complaints about hormone therapy in the period before the pandemic. According to Caroline (During the Pandemic/Trans Woman): “This thing, I was supposed to do it, but I did not, you know? I have so many things on my plate, I work and everything... and when I go to this area [where the service is located], I have to spend the whole day there. It is so tiring”.

When talking about commuting, it is also important to consider material issues. Each transport ticket has a cost that is sometimes difficult to cover, especially when several rides are required over short periods. It is worth noting that offering to pay for transportation - a measure adopted in the PrEP1519 study to mitigate barriers to access - does not necessarily change the perception that going to the service is expensive.

We should also mention that half of the participants interviewed during the pandemic changed the frequency of PrEP use in some way. Not because of a lack of medication but because they reduced or stopped having erotic-sexual encounters. Also, in the case of the PrEP1519 study, the answers given during the pandemic show that the use of PrEP may have contributed to a programmatic mediation that allowed participants to make autonomous and informed decisions about when or not to use prophylaxis, which is in line with the results of Ferraz and collaborators¹⁹19 Ferraz D, Rossi TA, Zucchi EM, de Deus LFA, Mabire X, Ferguson L, et al. “I can’t take this shitty quarantine anymore”: sexual behavior and PrEP use among young men who have sex with men and transgender women in Brazil during the COVID-19 pandemic. Arch Sex Behav. 2023 Feb; 52(2): 689-702. https://doi.org/10.1007/s10508-022-02364-x
https://doi.org/10.1007/s10508-022-02364... .

DISCUSSION

First, it is essential to note that there are no specific references to criticism of public health services or profound changes in their meaning due to the COVID-19 event. Thus, the interviewees reported some changes in the follow-up to PrEP during the pandemic. These changes were positive because they reduced the time spent at the services or the number of visits to them, replacing them with virtual consultations and contacts and dispensing of medication at home. These data, in themselves, establish PrEP services and their professionals as relatively efficient in everyday situations and bulwarks in moments of crisis. One of the reasons for this construction may be that most of health workers who work in services frequented by TGWT+ are trained to provide support and help maintain adherence and bonding.

Although episodes of embarrassment or discomfort occur, the service is mentally mapped²⁰20 Mauss M. Ensayo sobre las variaciones estacionales en las sociedades esquimales: un estudio de morfología social. Sociol Antropol. 1971; 1: 359-430. as the space “where PrEP is”, as one of the interviewees assured us. In this sense, PrEP was territorialized²¹21 Unsain RF, Couto MT, Zucchi EM, Ferraz DAS, Escorse M, Silveira RA, et al. Territorialidades, desplazamientos, performatividades de géneros y sexualidades: juventudes LGBTQIA+ en las áreas suburbanas de la ciudad de São Paulo, Brasil. Sex Salud Soc. 2021; (37): e21212. https://doi.org/10.1590/1984-6487.sess.2021.37.e21212a
https://doi.org/10.1590/1984-6487.sess.2... in the pre-pandemic moment as a complex area where the user must converge, and it continued to be territorialized during the pandemic, albeit in reverse, in the sense that the service could be present in the user’s home. Thus, PrEP traveled to the place of residence, reinforcing the bond of care established even before the COVID-19 event. That also happened, according to some interviewees, with other forms of care and treatment, such as hormone therapy, which continued during the crisis. In this way, the pandemic emerged as a facilitator because it promoted, at least conjuncturally, resolutions to the logistics of access to medication.

In general, our results contrast significantly with various studies in which experiences of stigmatization and discrimination in interactions with health professionals were central reasons for difficulties in adhering to and continuing to use PrEP. Disrespect for gender identity²²22 Wilson EC, Jalil EM, Castro C, Fernandez NM, Kamel L, Grinsztejn B. Barriers and facilitators to PrEP for transwomen in Brazil. Glob Public Health. 2019 Feb; 14(2): 300-8. https://doi.org/10.1080/17441692.2018.1505933
https://doi.org/10.1080/17441692.2018.15... ^{), (23}23 Monteiro S, Brigeiro M. Experiências de acesso de mulheres trans/travestis aos serviços de saúde: avanços, limites e tensões. Cad Saúde Publica. 2019 Apr; 35(4): e00111318. https://doi.org/10.1590/0102-311XER111318
https://doi.org/10.1590/0102-311XER11131... ^{), (24}24 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 Feb; 33(2): 244-52. https://doi.org/10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17... , ignorance about “transsexuality”,²⁴24 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 Feb; 33(2): 244-52. https://doi.org/10.1080/09540121.2020.1769835
https://doi.org/10.1080/09540121.2020.17... and representations of trans people as “too sexually active”, implicitly or explicitly²⁵25 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 Jul; 25(7): 2301-15. https://doi.org/10.1007/s10461-021-03159-2
https://doi.org/10.1007/s10461-021-03159... , are part of the daily use of PrEP by TGWT+ in various contexts, both in Brazil and in other countries, showing the structural dimension of AIDS stigma²⁶26 Churcher S. Stigma related to HIV and AIDS as a barrier to accessing health care in Thailand: a review of recent literature. WHO South East Asia J Public Heal. 2013 Jan-Mar; 2(1): 12-22. https://doi.org/10.4103/2224-3151.115829
https://doi.org/10.4103/2224-3151.115829... and transphobia that permeates different contexts of the HIV epidemic (concentrated and generalized), health systems (public, private and mixed) and various conditions of wealth distribution and poverty of the population.

Although there were common elements in the period prior to and concomitant with the pandemic, there were also adjustments and strategies to reframe public health services. Thus, along with the understanding that this was a critical moment and that the struggle for survival, in the sense of resisting different forms of structural violence, was still crucial, there was also the need for careful planning in order to avoid possible contact with the COVID-19 virus, which included assessing whether or not to continue doing sex work.

In other words, if the HIV/AIDS epidemic is an event⁸8 Romano JO, Bittencourt TP, Uema L, Aguiar CBO, Ferreira LR. La pandemia covid-19 como acontecimiento y la disputa política de los discursos negacionista y científico. In: Bosco E, Igreja RL, Valladares L, coords. A América Latina frente ao governo da covid-19: desigualdades, crises, resistências. Brasília, DF: Faculdade Latino-Americana de Ciências Sociais; 2022. p. 143-177., this type of event is procedural, a permanent and continuous process that is known and can be prevented. In turn, COVID-19, also as an event - and at an early stage - was perceived by the participants as circumstantial and impossible to handle. In this way, it is a temporary event, even if unknown and unpredictable.

In fact, for some participants, the connection between the HIV-AIDS and COVID-19 events materialized in the use of PrEP. As highlighted in the results, the idea that PrEP users could be more protected against coronavirus infection was profusely present. This idea was possibly based on a news broadcast at the beginning of the crisis²⁷27 Fundação Oswaldo Cruz. Fiocruz investiga ação de antirretrovirais contra covid-19 [Internet]. Rio de Janeiro: Agência Fiocruz de Notícias, 2020 Apr 7 [cited 2024 May 23]. Disponível em: Disponível em: https://portal.fiocruz.br/noticia/fiocruz-investiga-acao-de-antirretrovirais-contra-covid-19
https://portal.fiocruz.br/noticia/fiocru... . Such reports reveal the participants’ perception that sustaining the behavior of HIV prevention could put them at an advantage when facing this unknown and unpredictable event (COVID-19). This aspect was understood similarly by the adolescent and young participants and the adult interviewees.

By experiencing HIV as a continuous event, the TGWT+ took on a conscious logic of using preventive technology to avoid possible exposure to a threatening virus in people who are more vulnerable because they are sex workers. Not only because of this but also because they wanted to be protected from possible exposure to HIV: “It is the only one that has no cure, I need to take it, I cannot forget it”, said Ana (During the pandemic/Trans woman).

Thus, it can be seen that HIV as a social construction is present in the daily lives of TGWT+ PrEP users, with increased protection being the most frequently evoked reason for its use, which is also the case in other studies²²22 Wilson EC, Jalil EM, Castro C, Fernandez NM, Kamel L, Grinsztejn B. Barriers and facilitators to PrEP for transwomen in Brazil. Glob Public Health. 2019 Feb; 14(2): 300-8. https://doi.org/10.1080/17441692.2018.1505933
https://doi.org/10.1080/17441692.2018.15... ^{), (28}28 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 Jan; 16(1): e0244226. https://doi.org/10.1371/journal.pone.0244226
https://doi.org/10.1371/journal.pone.024... .

It is worth noting that the lack of reference to sex work as the only means of earning a living for most of the adolescent/young women interviewed may indicate a generational turning point linked to a more significant presence of LGBTQIAPN+ movements, despite the two conservative governments that had been in power in the previous six years (former presidents Temer, from 2016 to 2018, and Bolsonaro, from 2019 to 2022). However, when the younger women were asked about sex work, transactional sex did not necessarily take on the connotation of work²⁹29 Groes-Green C. Exploração ou gratidão? Patronagem íntima e a gramática moral das trocas sexuais econômicas entre jovens curtidoras e europeus mais velhos, expatriados, em Maputo - Moçambique. Cad Pagu. 2016; (47): e16476. https://doi.org/10.1590/18094449201600470006
https://doi.org/10.1590/1809444920160047... . Although the participants highlighted improvements in the situation of TGWT+ people, they also pointed out the difficulties and structural violence that this population experiences on a daily basis.

When considering distances and commuting to services, it is also important to consider the COVID-19 event as a driver of care models based on telemedicine, perceived by the interviewed TGWT+ as particularly effective. As shown by Ferraz et al.¹⁹19 Ferraz D, Rossi TA, Zucchi EM, de Deus LFA, Mabire X, Ferguson L, et al. “I can’t take this shitty quarantine anymore”: sexual behavior and PrEP use among young men who have sex with men and transgender women in Brazil during the COVID-19 pandemic. Arch Sex Behav. 2023 Feb; 52(2): 689-702. https://doi.org/10.1007/s10508-022-02364-x
https://doi.org/10.1007/s10508-022-02364... , in dialog with Hoagland et al.³⁰30 Hoagland B, Torres TS, Bezerra DRB, Geraldo K, Pimenta C, Veloso VG, et al. Telemedicine as a tool for PrEP delivery during the COVID-19 pandemic in a large HIV prevention service in Rio de Janeiro-Brazil. Braz J Infect Dis. 2020 Jul-Aug; 24(4): 360-4. https://doi.org/10.1016/j.bjid.2020.05.004
https://doi.org/10.1016/j.bjid.2020.05.0... , telemedicine implemented in different health services in Brazil has strengthened the relationship of men who have sex with men and TGWT+ with health professionals, as well as adherence to PrEP.

Both before and during the pandemic, the TGWT+ transcended the fortuitous, in the sense of considering COVID-19 as contingent and continued with HIV prevention via PrEP. In this way, the health services and their professionals endured the health crisis of the pandemic together with the TGWT+, an event that, after the initial crisis, was represented as having a lower impact on the possibility of contracting HIV.

The findings and analysis show that the TGWT+ interviewed confronted the COVID-19 pandemic after the initial shock, leading and re-signifying their struggles, daily lives, and ways of taking care of their health.

In this way, the COVID-19 pandemic - without minimizing the importance of the crisis resulting from its emergence and after its most critical phase -became yet another event among all the others they face on a daily basis. Alongside the COVID-19 pandemic, they experience the HIV epidemic, but with the possibility of prevention with PrEP.

The relationship of trust and respect established between the TGWT+ and PrEP services before the pandemic was maintained during the event but reorganized to meet the demands of limiting physical contact and mobility to control COVID-19. In addition to the wisdom of the community and the agency that enabled the participants to adapt, the reorganization of the PrEP service was fundamental to continuing to ensure access to and follow-up of prophylaxis.

TGWT+ does not establish a passive relationship with the PrEP service. Based on a situated and conscious perspective, which is even more explicit at a time of crisis, they interweave thoughtful and practical actions aimed at resistance.

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