Abstract

This article analyzes the advertisement of pre-exposure (PrEP) and post-exposure (PEP) prophylaxis treatment for HIV considering the historical role of AIDS prevention campaigns in Brazil. A total of 24 pieces of communication on PrEP, PEP, and CP (Combined Prevention), produced from 2016 to 2019 and published on the website and social media of the Brazilian Ministry of Health were analyzed in addition to the testimony of 30 users of prophylaxis - including gays, trans women/travestis, and sex workers - in the metropolitan region of Rio de Janeiro. The materials were classified according to type, year, audience, and access information, and the results were interpreted from four axes: contextualization of the communication pieces and the experience of the interlocutors with the information; sexuality and risk; gender, emotions, and moralities; and condom displacements. The analysis indicated the erasure of expressions of sexuality and the predominance of an abstract and structured language, presupposing a rational and individualistic public, with condoms associated with “sexual risk.” Users’ reports regarding the advertisement of information on these prophylaxis reveals its insufficiency. We conclude that the potential of information and communication campaigns, guided by the sociocultural reality of social segments, has been little explored, compromising access to prophylaxis. Thus, the biomedicalization of prevention and the advance of conservatism in Brazil hinder the Brazilian response to AIDS.

Keywords:
HIV; Prevention; Communication; Risk; Sexuality

Introduction

In the trajectory of public policies to combat HIV/AIDS, the production of campaigns has been the historical path for promoting information and communication on diagnosis, prevention, and treatment of the disease among several population groups. Such strategies take on heterogeneous formats - such as brochures, videos, posters, cards, among others - and are based on guidelines of the programmatic context. The analysis of the content, the educational foundations, and the process of production, circulation, and reception of these strategies (hereinafter called “communication pieces”) allows to problematize the scope of their purposes and the moralities involved (Monteiro; Vargas, 2006MONTEIRO, S; VARGAS, E. (Org.). Educação, comunicação e tecnologia educacional: interfaces com o campo da saúde. Rio de Janeiro: Editora Fiocruz, 2006.). This perspective originates from the criticism of the informational model of communication and the literature on the valorization of subjective, political, cultural, and institutional elements of communication (Martín-Barbero, 2003MARTÍN-BARBERO, J. Dos meios às mediações: comunicação, cultura e hegemonia. Rio de Janeiro: Editora UFRJ, 2003.).

From this perspective and the symbolism of the historical strategies of AIDS communication, this paper analyzes communication pieces on the new technologies of prevention before and after exposure to HIV, known by the acronym PrEP and PEP, produced by the Brazilian Ministry of Health in the last decade. In addition to characterizing the type, year, public, programmatic guideline, and access information, we examine the contents related to sexuality and risk; gender, emotions, and morality; and condom use, as well as the statements of users of PEP and/or PrEP - gay men, trans women/travesties, and sex workers - about the sources of knowledge on prophylaxis.

Notably, the current global and national strategies for HIV/AIDS prevention have been characterized by the expansion and routinization of testing, in parallel to the dismissal of counseling (Mora et al., 2014MORA, C. et al. Ampliación de las estrategias de consejería y prueba del VIH: desafíos técnicos y tensiones ético-políticas. Salud Colectiva, Buenos Aires, v. 10, n. 2, p. 253-264, 2014.). The increasing evidence surrounding the effects of antiretroviral (ARV) treatment on reducing viral load and reducing HIV transmission, added to the uses of ARV in the prevention of infection, leveraged changes in the preventive paradigm. In this scenario, the PrEP, PEP, and the Treatment as Prevention (TasP) strategy, characterized by the stimulus to early diagnosis, followed by drug therapy for positive cases, gained prominence. Despite its significant benefits, studies indicate that the supply of TasP, PrEP, and PEP has not been accompanied by behavioral and structural interventions, such as combating homophobia and guaranteeing sexual and reproductive rights (Aggleton; Parker, 2015AGGLETON, P.; PARKER, R. Moving beyond biomedicalization in the HIV response: implications for community involvement and community leadership among men who have sex with men and transgender people. American Journal of Public Health, Washington, DC, v. 105, n. 8, p. 1552-1558, 2015. DOI: 10.2105/ajph.2015.302614
https://doi.org/10.2105/ajph.2015.302614... ; Monteiro et al., 2019MONTEIRO, S. et al. Challenges facing HIV treatment as prevention in Brazil: an analysis drawing on literature on testing. Ciência & Saúde Coletiva, Rio de Janeiro, v. 24, n. 5, p. 1796-1807, 2019. DOI: 10.1590/1413-81232018245.16512017
https://doi.org/10.1590/1413-81232018245... ). According to this perspective, biomedicalization processes prevail in the current framework of tackling the epidemic, defined by the effects of the advancement of biomedicine. In this context, the use of biotechnologies for body improvement and the intensification of care practices focused on risks become predominant in the discourses on the health and daily life of the subjects (Clarke et al., 2003CLARKE, A. E. et al. Biomedicalization: technoscientific transformations of health, illness and U.S. biomedicine. American Sociological Review, Thousand Oaks, v. 68, n. 2, p. 161-194, 2003. DOI: 10.2307/1519765
https://doi.org/10.2307/1519765... ).

In Brazil, the introduction of PEP and PrEP are part of the strategies of Combined Prevention (CP), announced as the official preventive approach (Brasil, 2017aBRASIL. Prevenção combinada do HIV: bases conceituais para profissionais, trabalhadores(as) e gestores(as) de saúde. Brasília, DF: Ministério da Saúde, 2017a.). PEP, available for more than a decade in the Brazilian Unified Health System (SUS; Brasil, 2010BRASIL. Protocolo clínico e diretrizes terapêuticas para profilaxia pós-exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília, DF: Ministério da Saúde , 2010.), consists of the use of ARVs for 28 days, starting within 72 hours after exposure to HIV (as in cases of disruption or non-use of condoms), aimed at anyone exposed to the virus. PrEP is more recent, it began to be offered in SUS at the end of 2017 (Brasil, 2017bBRASIL. Protocolo clínico e diretrizes terapêuticas para profilaxia pré-exposição (PrEP) de risco à infecção pelo HIV. Brasília, DF: Ministério da Saúde , 2017b.). Its use implies the continued consumption of ARVs before sexual exposure to the virus, focusing on serodiscordant couples and populations with greater vulnerability to HIV (gays/men who have sex with men - MSM, trans women, and sex workers). The offer of TasP, PrEP, and PEP in the SUS has resulted in the reconfiguration of preventive actions in the programmatic scope, characterized by the predominance of a clinical perspective. Such approach contrasts with the hitherto dominant approaches, centered on condom use, testing with counseling, reducing conditions of social vulnerability to HIV, and health information and communication strategies.

Thus, a review of the literature between 2000 and 2018 attest to the decline of the role of communication regarding the response to the epidemic. The 15 studies herein identified addressed counseling, testing, and care for People Living with HIV/AIDS (PLWHA), and no CP analyses were found (Barcelos; Aguiar, 2019BARCELOS, P. E. L.; AGUIAR, A. C. A comunicação sobre HIV nas práticas de saúde no Sistema Único de Saúde (SUS) Brasil. Revista española de comunicación en salud, Madrid, supl. 2, p. 100-111, 2019. DOI: 10.20318/recs.2019.4473
https://doi.org/10.20318/recs.2019.4473... ). Another research on the social and programmatic aspects of HIV prevention points to the lack of local production and circulation of information materials on CP, for the general population and groups most vulnerable to HIV. It is argued that the lack of attention given to educational strategies results, in part, from the lack of visibility of the epidemic in the public agenda and from responses centered on biomedical technologies (Monteiro; Brigeiro, 2019MONTEIRO, 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: Comunicação, Saúde, Educação, Botucatu, v. 23, e180410, 2019. DOI: 10.1590/Interface.180410
https://doi.org/10.1590/Interface.180410... ).

Despite the emphasis on the provision of new prophylaxis, studies point toward the lack of PEP advertisement strategies. Moreover, there are significant obstacles to their access, due to stigmatizing representations regarding the “failure” in condom use or the practices considered “deviant” of users (such as prostitution and infidelity) from the point of view of health professionals (Ferraz et al., 2019FERRAZ, D. et al. Aids- and sexuality-related stigmas underlying the use of post-exposure prophylaxis for HIV in Brazil: findings from a multicentric study. Sexual and Reproductive Health Matters, Abingdon, v. 27, n. 3, p. 107-121, 2019. DOI: 10.1080/26410397.2019.1650587
https://doi.org/10.1080/26410397.2019.16... ). The gaps within the dissemination strategies for new prophylaxis offers a challenge since evidence shows that the demand for PrEP is concentrated among gay and bisexual men with high/middle income and schooling (Magno et al., 2019MAGNO, L. et al. Knowledge and willingness to use pre-exposure prophylaxis among men who have sex with men in Northeastern Brazil. Global Public Health, Abingdon, v. 14, n. 8, p. 1098-1111, 2019. DOI: 10.1080/17441692.2019.1571090
https://doi.org/10.1080/17441692.2019.15... ), with reduced demand from populations equally vulnerable to HIV, such as trans women, sex workers and gay/MSM of low purchasing power.

Thus, this analysis sought to interpret the meanings of the contents of government communication pieces on PrEP and PEP and to characterize their forms of circulation among gay men/MSM, travestis/trans women, and sex workers. The analysis was organized in four axes: contextualization of the communication pieces and the experience of the interlocutors with the information; sexuality and risk; gender, emotions, and moralities; and condom displacements.

Methodology

This is a qualitative investigation, based on the contributions of research in the field of social sciences to understand the cultural meaning of health and disease processes (Castro, 2011CASTRO, R. Teoría social y salud. Buenos Aires: Lugar Editorial; Unam, 2011.). The study is part of a larger project that addressed the implementation of PrEP and PEP in the metropolitan region of Rio de Janeiro, focusing on the conditions of access and gender, sexual, and class morality involved in this proposition. Through field observations and interviews, the project analyzed the experiences of gay /MSM, travestis/trans women, and sex workers, all PEP and PrEP users, as well as the views of public administrators, healthcare providers, and community leaders involved in the implementation of these technologies. The research was approved by the Research Ethics Committee of the institution and followed the expected ethical procedures.

The methodological procedures of this study resulted from three complementary stages. The first involved the collection of materials (printed and digital) used for the advertisement of PrEP, PEP, and CP (in the latter case, only the parts that referred to both prophylaxes). In addition to the search on the website and social networks (Facebook and Instagram) of the Ministry of Health (MoH), inquiries were made to public administrators of the municipal and state levels of Rio de Janeiro, to professionals of PrEP and PEP services from five municipalities (Rio de Janeiro, Niterói, São Gonçalo, Duque de Caxias, and Nova Iguaçu), and representatives of civil society, who acted as informants for the larger project throughout 2019. A total of 44 pieces were collected, of which 24 were produced by the MoH. The communication pieces research encompassed the period from 2010 to 2020, considering the initial milestone of the implementation of PEP (Brasil, 2010BRASIL. Protocolo clínico e diretrizes terapêuticas para profilaxia pós-exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília, DF: Ministério da Saúde , 2010.) and PrEP (Brasil, 2017bBRASIL. Protocolo clínico e diretrizes terapêuticas para profilaxia pré-exposição (PrEP) de risco à infecção pelo HIV. Brasília, DF: Ministério da Saúde , 2017b.) in Brazil as a public policy. Despite the time frame for the official implementation of these strategies (2010 and 2017), the published pieces identified were only from 2016 to 2019. The analysis favored the pieces produced by the MoH, due to its historical role in the production and dissemination of HIV/AIDS prevention campaigns. This framing is justified by the role of the MoH, as an institution of the State, regarding the changes in the official preventive approach in the country. Other analyses, in progress, focus on the communication pieces and actors of the implementation of the prophylaxes at the local level.

In the second stage, based on the principles of “classical content analysis” of texts and images (Bauer; Gaskell, 2002BAUER, M. W.; GASKELL, G. (Org.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes, 2002.), the 24 pieces of communication produced by the MoH were classified according to type (folder, card, poster); central theme (PrEP, PEP, CP); target audience; programmatic guideline in force; and information on services access, as indicated in Chart 1. The empirical material was classified and coded according to semantic and contextual aspects in order to identify patterns, comparisons, and axes of analysis (forms of representation of subjects, knowledge, etc.). Thus, the preliminary examination of the material by the first two authors resulted in the identification of the following thematic axes: sexuality and risk; gender, emotions, and morality; and condom displacement. Once these axes were identified, all authors delimited the most significant aspects for each material.

The third stage refers to the analysis of the testimony of 30 users of PEP and/or PrEP, with 10 gay men, 11 travestis/trans women, and 9 sex workers (all cisgender women). The profile of the participants is described in Chart 2. The interviews, conducted in 2019 within the scope of the larger project, dealt with the social profile, daily life; sociability; discrimination; knowledge; access and use of PrEP and PEP; and experiences with health services, especially in relation to sexual practices, risk management, and HIV prevention. We focused here only on the answers relating to the sources of knowledge of the prophylaxes and the recalling of recent prevention campaigns, aiming to illustrate the circulation of information.

Results and discussion

Contextualization and dissemination of the communication pieces

Among the 24 pieces of communication - hereinafter identified as M followed by a number, as seen in Chart 1 - there was a predominance of the card type (20), followed by photo (2) and pamphlet (2), and most were produced during a period of government changes, involving the governments Dilma Rousseff (2016), Michel Temer (2017 and 2018), and Jair Bolsonaro (2019). This context, marked by instability in institutions and the advancement of conservative forces, is reflected in the progressive erosion of the federal HIV prevention policy in Brazil, with episodes of censorship and lack of investments in this type of campaign (Seffner; Parker, 2016SEFFNER, F.; PARKER, R. A neoliberalização da prevenção do HIV e a resposta brasileira à aids. In: BASTHI, A.; PARKER, R.; TERTO JR., V. (Coord.). Mito vs realidade: sobre a resposta brasileira à epidemia de HIV e aids em 2016. Rio de Janeiro: Associação Brasileira Interdisciplinar de Aids, 2016. p. 22-30.) and sex education in schools, from the perspective of sexual and reproductive rights (Paiva; Antunes; Sanchez, 2020PAIVA, V.; ANTUNES, M. C.; SANCHEZ, M. N. O direito à prevenção da aids em tempos de retrocesso: religiosidade e sexualidade na escola. Interface: Comunicação, Saúde, Educação, Botucatu, v. 24, e180625, 2020. DOI: 10.1590/Interface.180625
https://doi.org/10.1590/Interface.180625... ). Programmatic and symbolic effects resulting from the change of name of the former Department of Sexually Transmitted Infections/AIDS and Viral Hepatitis, which in 2019 was renamed the Department of Chronic Diseases and Sexually Transmitted Infections, were also observed. During this period, no explicit changes were identified in the CP guidelines, but the distribution of the pieces according to the year of production suggests variations: 2016 (two pieces), 2017 (seven pieces), 2018 (13 pieces), and 2019 (two pieces).

Most of the 24 analyzed pieces report on new prevention technologies and some reinforce the combining nature of the prophylaxes. We identified 10 exclusive pieces on PEP and 7 on PrEP; 2 focuses on both without appealing to CP, and 5 publicize the two prophylaxes under the scope of CP. Although the discourse of implementation of policies prevails the idea of an overlapping between technologies, in the promotion pieces they appear as parallel realities (as observed in Figure 1). The targeting of the populations most vulnerable to HIV and their forms of representation are diverse. Some pieces on PrEP appeal to the LGBT population through the discreet use of rainbow colors. Others state the public nominally: “gays, MSM, travestis, transsexuals, sex workers, serodiscordant couples.” In the case of PEP, most of them generally mention individuals “exposed to the risk of HIV infection.”

Approximately half of the pieces were made for commemorative dates (Carnival and World AIDS Day, on December 1^st). Several are part of the CP campaign, entitled “Vamos Combinar?” (“Shall we agree?”), released on December 1^st (card M5 and photo M6), while another part is limited to the dissemination of information to potential users, healthcare providers, and public administrators. Colors, figures, and letters sizes are fundamental in the discursive enunciations of the materials. In this direction, the use of images of drug vials (M11, M23, M24) and tablets (M3) illustrates the protagonism of drugs in HIV prevention.

As for access to PEP and PrEP, the indication to search for health services prevails on the official website of the Program or in the main digital media of the MoH. No specific equipment is mentioned, such as Voluntary Counseling and Testing Centers (Centro de Testagem e Aconselhamento - CTA) or Specialized Care Services (Serviços de Atenção Especializadas - SAE), historically responsible for the dissemination of information and provision of testing and condoms (Grangeiro et al., 2009GRANGEIRO, A. et al. Voluntary counseling and testing (VCT) services and their contribution to access to HIV diagnosis in Brazil. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 9, p. 2053-2063, 2009. DOI: 10.1590/S0102-311X2009000900019
https://doi.org/10.1590/S0102-311X200900... ). Some pieces suggest that the public seek “healthcare service” or “health professional” to learn more about prophylaxis. Such forms of access seem to reflect a “normalization” of new prevention strategies at different care levels.

In this sense, Lermen et al. (2020LERMEN, H. S. et al. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface: Comunicação, Saúde, Educação, Botucatu, v. 24, e180626, 2020. DOI: 10.1590/Interface.180626
https://doi.org/10.1590/Interface.180626... ) state that the information published on the posters of campaigns of the MoH for the World AIDS Day (2013-2017) can be interpreted only by an audience “initiated” in the CP. This means participating in a group with privileged access to information on HIV prevention, capable of understanding the meanings of the acronyms PEP and PrEP themselves. Converging with this observation, we identified that most gay users and some travestis/trans women interviewed seem to master what we can understand as a “biomedicalized grammar of HIV prevention.” Their statements suggest that information about new technologies circulated mostly among the network of friends, through the internet (without detailing specific sources) and eventually by reading popular magazines.

Among travestis and trans women, the knowledge of PrEP was also based on their participation in studies from research institutions. The arrival in these institutions resulted from the referral of the network of friends, who received stimuli to recruit acquaintances for clinical studies or who recommended the institution due to their positive experiences. Sex workers were the most absent from PrEP services and with less knowledge on the prophylaxes. Several interviewees, specially those with regular exposure to HIV and frequent use of PEP, stated that they became aware of PrEP due to the referral of PEP service professionals.

Sexuality and risk in the modes of enunciation of the prophylaxes

When we take communicational language as a kind of enunciation device, we question to what extent practices and discourses seek the control, classification, and management of individuals (Foucault, 2014FOUCAULT, M. A vontade de saber. 9. ed. Rio de Janeiro: Paz e Terra, 2014. (História da sexualidade, v. 1).). Based on this look and on the constructive character of the social world, we understand that materials are not exempt from rational and moral choices. For example, in the PEP materials the mention of sex is accompanied by the term “risk” or “exposure.” The only material that brings up sexual practices is the M3 card (Figure 2): “PrEP is available on SUS.” The written and structured message correlates the effect of the drug with the type of sexual practice: “7 days of use for anal intercourse; and 20 days for vaginal intercourse.”

Studies on the motivations for the search for prophylaxis indicate that risk perception is fundamental (Hoagland et al., 2017HOAGLAND, B. et al. Awareness and willingness to use pre-exposure prophylaxis (PrEP) among men who have sex with men and transgender women in Brazil. Aids and Behavior, New York, v. 21, n. 5, p. 1278-1287, 2017. DOI: 10.1007/s10461-016-1516-5
https://doi.org/10.1007/s10461-016-1516-... ). The analyzed pieces, however, do little to explore this dimension, except for some on PEP that explain practices with potential risk of HIV transmission: “sex without a condom,” “unprotected sex,” “sexual violence.” Other risk situations, such as less protection in stable relationships or difficulty in negotiating condom use, were not identified.

The language of prevention seems to be directed at asexual or infantilized bodies, such as the M22 card, which displays a childish drawing of a human figure carrying a slight smile. The image is accompanied by a decontextualized message about the timely search for PEP, with an imperative phrase: “If you have exposed yourself to the risk of contracting HIV, be like Pedro.”

Most of the 24 pieces use an abstract and structured language about the preventive needs of each prophylaxis, as illustrated by card M10: “Differences between PEP and PrEP.” The card presents the AIDS virus in the middle of two robotic figures, in reference to game characters, and enunciate the comparison: “PrEP: It is a lifestyle. Recommended for those who do not have HIV but are more exposed to the virus (travestis and trans people, gay men and other MSM, sex workers, and serodiscordant partners.” “PEP is an emergency. Indicated for those who may have been exposed to HIV in situations such as unprotected sex, sexual violence, and work accidents.” Another aspect observed was the identification of pieces on PEP only from 2016, although this prophylaxis was implemented in 2010, suggesting that its dissemination by government social networks only gained strength when it was integrated to the guidelines of CP, adopted in the country in 2016.

As pointed out, part of the users interviewed learned of the existence of PrEP from the PEP services professionals. Additionally, gay men and trans women reported the need to communicate to their friends and sexual partners about PrEP, considering the advantages of its use and the perception of scarcity in dissemination:

This situation was recorded by Frankis et al. (2016FRANKIS, J. et al. Who will use pre-exposure prophylaxis and why? Understanding PrEP awareness and acceptability amongst men who have sex with men in the UK - a mixed methods study. Plos One, San Francisco, v. 11, n. 4, e0151385, 2016. DOI: 10.1371/journal.pone.0151385
https://doi.org/10.1371/journal.pone.015... ), indicating that the use of HIV prevention medications among gay men/MSM produces effects and relationships not foreseen in the prescriptive prophylaxis regimens, and that sociability relationships and sexual practices are associated with the use of PrEP.

The overlap of stigmatizing representations derived from the focus of PrEP in people whose practices are considered “deviant” and their discreet dissemination regulate their approach in commercial and affective interactions, as reported by three prostitutes in group interviews:

Gender, emotions, and morality

The few images with real subjects represent cisgender women, such as the M23 and M24 cards, produced in 2018. The message highlights that prevention depends on individual choice and decision in relation to new technologies as indicated by the phrase: “Your life is your own. So are your choices. Each woman with their form of prevention.” The images depict smiling, white, and modern young adult women holding the medicine box of PrEP or PEP. Although the images are accompanied by a brief explanation of the efficacy of each drug, including “populations at greatest risk,” the messages do not address the context for prophylaxis use in the female universe. As reported above, there is a perception that prophylaxis is primarily aimed at men with homosexual practices. The following reports are illustrative:

Studies indicate that sex workers are not included in PrEP clinical trials and that they face more barriers to access the prophylaxes (Murray; Brigeiro; Monteiro, 2021MURRAY, L. R.; BRIGEIRO, M.; MONTEIRO, S. A retreat from human rights? A reflection on the place of sex workers in contemporary HIV prevention. Global Public Health , Abingdon, 2021. No prelo. DOI: 10.1080/17441692.2021.1896762
https://doi.org/10.1080/17441692.2021.18... ). PrEP marketing, in turn, is not inclusive for transgender people and does not address assistance for the use of hormones (Sevelius et al., 2016SEVELIUS, J. M. et al. “I am not a man”: trans-specific barriers and facilitators to PrEP acceptability among transgender women. Global Public Health , Abingdon, v. 11, n. 7-8, p. 1060-1075, 2016. DOI: 10.1080/17441692.2016.1154085
https://doi.org/10.1080/17441692.2016.11... ). These findings suggest a hierarchy among the “key populations,” which permeates the different moments of the formulation of the prophylaxes.

A third material evokes the female image, a young woman with closed eyes, head down and with her hands on her face (card M21 - “Tips for facing the hangover”). Focusing on drunkenness and the possibility of forgetting condom use, the piece associates alcohol consumption and PEP use. The emotional policies of fear, dread, and disgust portrayed in this material produce representations of supposed norms and deviations. In this case, youth, gender, and sexuality are articulated, materializing sex as good or bad, healthy or sick, clean or disgusting. These poles are related to images that express joy at the use of the drug and shame or fear over the non-use of condoms; both in a scenario of individual choice.

In general, the content of the materials presents the definition and forms of consumption of the prophylaxis, frequently using text and image in flowchart format (present in M3, M7, M12, M15, M18). Sometimes, the same composition of text and image is decorated with colored dots, representing confetti for advertising during Carnival. Such images seem to recreate the logic of the “imperative of choice,” which permeates the guidelines of the PrEP, presupposing an ideal subject aligned with the rationalist and individualistic view of prevention (Oscar, 2019OSCAR, R. C. Pílulas diárias anti-HIV: a construção de uma narrativa antropológica sobre a profilaxia de pré-exposição à aids (PrEP). 2019. 186 f. Tese (Doutorado em Saúde Coletiva) - Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, 2019.). The portrayed structures insist on the importance of discipline with the ARVs time regimes, aiming toward therapeutic success and the relationship with healthcare professionals. However, the routines of counseling, consultations, and testing do not appear in the analyzed pieces. Calling for human rights and tackling stigma remain in the background. Only the M1 piece refers to prevention as a right.

The emphasis on certain expressions of gender and generation (female and juvenile) contrasts with the absence of images related to the male body or to sexual and gender diversity. Other studies on materials produced by the MoH show the reduction in the use of images evoking various bodies and social interactions. For Cadaxa, Sousa, and Mendonça (2015CADAXA, A. G.; SOUSA, M. F.; MENDONÇA, A. V. M. Conteúdos promotores de saúde em campanhas de aids no Facebook dos ministérios da saúde do Brasil e do Peru. Revista Panamericana de Salud Pública, Washington, DC, v. 38, n. 6, p. 457-463, 2015.), the messages and videos published on the MoH’s Facebook on December 1, 2013, present diffuse traits about social markers, such as sexual orientation, schooling, and gender, while the emphasis on individual risks appears clearer. Lermen et al. (2020LERMEN, H. S. et al. Aids em cartazes: representações sobre sexualidade e prevenção da aids nas campanhas de 1º de dezembro no Brasil (2013-2017). Interface: Comunicação, Saúde, Educação, Botucatu, v. 24, e180626, 2020. DOI: 10.1590/Interface.180626
https://doi.org/10.1590/Interface.180626... ), whose empirical material is at the peak of the incorporation of CP, also indicate that, despite the diversity in the public portrayed (travestis, young people, pregnant women), the messages emphasize self-surveillance through regular testing.

Condom displacements

In analyzing the changes in the logic of prevention, condom displacement is highlighted. The historical placement of condoms as the main method of prevention, throughout the initial decades of the epidemic, is a tributary of communication initiatives, which either mobilized an imperative tone, or invited its eroticization and insisted on the value of mutual care. Most of the interviewees remembered prevention campaigns during Carnival and other events but did not evoke any of the pieces contemplated in the study. Some expressed expectations, learning, and criticism: “I remember the generic catchphrase of ‘use condom,’ Pabllo Vittar biting a purple and yellow condom, that classic SUS condom, right? During Carnival this is more evident, but outside of Carnival it goes away” (Mauricio, gay, 32). “Apart from the ImPrEP [project for the implementation of PrEP], at the LGBT Parade of Niterói and Copacabana, which I attended, I don’t remember other campaigns” (Fabíola, transsexual woman, 25).

The reference to condoms, via text or image, is recurrent in the materials, but gains different meanings according to the type of prophylaxis. In the case of PrEP, its use is associated with the need for protection of other STIs, as illustrated by the message, in an imperative tone and framed by the silhouette of the male condom, the M9 card: “Am I protected from all STIs while taking PrEP? No. only PrEP prevents HIV, it does not protect from other STIs, such as syphilis and gonorrhea. It also does not prevent pregnancy. So, use a condom.” In the PEP pieces, the enunciation of the condom is tied to the risks of its forgetfulness or disruption during use. In the context of CP materials, condoms are part of the “constellation” of biomedical prevention strategies. On card M5, the red ribbon - a symbol of the fight against AIDS - is represented by two intertwined human hands (male and female) and several drawings, symbolisms, and phrases that refer to pills, condoms, HIV tests, female and male gender, transsexuality, and the question: “Shall we agree? Prevention is living.” Additionally, we noticed that the female condom appears in less than half of the materials; only the M1 folder illustrates its placement.

Essentially, the condom is presented as a complement to ARVs or an alternative among the preventive options of biomedical nature, which can supposedly be adapted to the needs of each subject. However, apart from the physician’s presence, no other spaces or communication processes are explained to assist these choices.

The messages of the pieces presuppose the competence of the public to understand the meaning of acronyms (PrEP, PEP, CP), access social media to identify the locations of the services and, above all, recognize their practices or identities (sexual, gender, social) in the terms: “vulnerable groups,” “risks,” “exposures,” “combine.” That is, the pieces seem to aim only at reinforcing information already known to the public. However, within all interviews the meaning of the term Combined Prevention, at least in terms of public policy, was unknown by the interviewees, except for a transsexual woman (Sheila, 26), who reported having taken a peer educator course funded by the MoH.

Final considerations

Guided by the assumption that the pieces of communication are symbolically and historically involved in the biopolitical core of social construction of knowledge-power-discourse on sexuality and the conformation of the subjects, the analysis of the 24 pieces on PrEP, PEP, and CP and the statements of the interviewees provided reflections about the relations between communication, sexuality, and preventive technologies. The erasure of sexual and gender diversity and the predominance of a technical and rational language can, in part, be caused by the resurgence of moralizing discourses and moral panics in the current political scenario, in addition to the biomedicalization of responses to the epidemic.

The findings of this study are consistent with the persistence of the challenges regarding the approach to sexuality and gender relations in the trajectory of HIV communication strategies, which concern the reaffirmation of certain gender stereotypes (Jardim; Perucci, 2012JARDIM, L. N.; PERUCCHI, J. Encrencas de gênero nas campanhas brasileiras de prevenção ao HIV/aids para a idade adulta avançada. Ex aequo, Lisboa, v. 26, p. 103-117, 2012.). However, some authors identify significant contributions from campaigns. Alves (2013ALVES, W. Entre sentidos e desejos: as campanhas de carnaval para prevenção contra o HIV (1999-2009). Líbero, São Paulo, v. 16, n. 31, p. 89-104, 2013.) highlights the campaign trend of the 2000s and 1990s in expanding audiences and messages, such as the inclusion of people living with HIV/AIDS and the substitution of the language of interdiction by messages of appreciation of pleasure. According to Paiva, Antunes, and Sanchez (2020PAIVA, V.; ANTUNES, M. C.; SANCHEZ, M. N. O direito à prevenção da aids em tempos de retrocesso: religiosidade e sexualidade na escola. Interface: Comunicação, Saúde, Educação, Botucatu, v. 24, e180625, 2020. DOI: 10.1590/Interface.180625
https://doi.org/10.1590/Interface.180625... ), the massive dissemination of information, added to community actions, played a relevant role in promoting sociocultural changes in the country, including the effective use of condoms. The discontinuity of these actions, in concomitance to the progressive restriction of sexual education in schools, has been shifting effective preventive attitudes by practices such as sexual abstinence among new generations.

The minimization of the expressions of sexuality in the field of images and its substitution by a strong appeal to rationality are in line with Carrara’s arguments (2015CARRARA, S. Moralidades, racionalidades e políticas sexuais no Brasil contemporâneo. Mana, Rio de Janeiro, v. 21, n. 2, p. 323-345, 2015. DOI: 10.1590/0104-93132015v21n2p323
https://doi.org/10.1590/0104-93132015v21... ) about the disciplinary effects of inclusive discourse of “sexual rights” and the recognition of citizenship in the light of an imaginary “sexual regimes.” In this direction, we consider that the messages associated with prophylaxis are related to gendered and sexualized biotechnologies in certain individuals (young women, cisgender) and bodies inscribed under the abstract denomination of the “most vulnerable populations.”

The communication pieces also mobilize strategies for controlling sexual expressions seen as “undisciplined” under the name “lifestyle” or “emergency,” evoking asexual bodies or subjects. We also noticed that the pieces of communication do not incorporate social and relational factors that motivate the use of prophylaxis, such as type of affective-sexual relationship, risk perception, serological status, among others (Mitchell et al., 2016MITCHELL, J. W. et al. HIV-negative male couples’ attitudes about pre-exposure prophylaxis (PrEP) and using PrEP with a sexual agreement. Aids Care, Abingdon, v. 28, n. 8, p. 994-999, 2016. DOI: 10.1080/09540121.2016.1168911
https://doi.org/10.1080/09540121.2016.11... ). The content of the pieces reiterates sexual risk as something obvious and objective and presupposes a rational and individualistic audience, guided by evidence-based precepts, distancing themselves from the real life of the subjects.

It should be noted that the analysis of communication pieces and user reports does not have the scope of a reception study. The empirical sources used, however, allowed us to identify that the information on prophylaxis was spread by the network of personal contacts, by the health professionals of PEP services, and by research institutions. These data indicate restrictions in the dissemination of new prophylaxis and lack of regular campaigns. In fact, these gaps emerged significantly in the interviewees’ statements, as well as suggestions to overcome this situation. These findings, added to the low appreciation of the communication aspects in the documents that guide the implementation and access to HIV prophylaxis, suggest that the circulation of information on PEP and PrEP is controlled or selective, related to a circuit of agents and institutional relations. The lack of reference to social organizations in the dissemination of prophylaxis is also remarkable and it would be appropriate to be explored in the future.

The protagonism of biomedical knowledge and supplies in the images and messages analyzed and the little evidence of a relationship of continuity of these preventive strategies compared to those structured in previous decades, suggest a limitation to the HIV/AIDS prevention policies in the country. We can see that currently the preventive approach in Brazil, instead of moving towards the publicization of a common basis of practices and information for the population, has contributed to the intensification of individualism in the context of prevention, as outlined by Oscar (2019OSCAR, R. C. Pílulas diárias anti-HIV: a construção de uma narrativa antropológica sobre a profilaxia de pré-exposição à aids (PrEP). 2019. 186 f. Tese (Doutorado em Saúde Coletiva) - Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, 2019.), and to the erasure of the subjects of prevention themselves (and their identities and practices).

Given the historical role of HIV prevention and care campaigns, we can assume that communication actions on CP, including coping with stigma and vulnerability to HIV, would help reduce inequities in access to new prophylaxis. This reflection concerns the potential of information and communication strategies to promote cultural changes and expand access to available preventive strategies, to the detriment of the crystallization of biomedical rationalities. In short, the challenge of identifying the most relevant symbols, languages, and communication channels to reduce the distance between the recipient public and preventive strategies persists.

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