ABSTRACT

More than half of new HIV infections in 2018 were among key populations, including gay men and other Men who have Sex with Men (MSM). Stigma can have several behavioral consequences, adversely reflecting on the lives of individuals and can be translated into barriers to access to public health services. This paper aimed to analyze the main barriers to accessing HIV testing at a Curitiba Testing and Counseling Center and the linkage of gay men and other MSM with the health service for early HIV treatment. Primary data were collected following the qualitative method, triangulating field observations, document analysis, and interviews. The results pointed to the lack of trained professionals, difficulty receiving health services, acceptance of sexuality, fear of results, and lack of information as the main barriers to testing. Difficulty in accepting the diagnosis, prejudice, and discrimination were some barriers identified to start treatment. We can conclude that the expansion of access to guarantee the rights of those who have more difficulty entering the Unified Health System (SUS) is still a significant challenge.

KEYWORDS:
HIV; Homosexuality, Male; Health evaluation

Introduction

In Brazil, more than half of the new Human Immunodeficiency Virus (HIV) infections in 2018 occurred among the most vulnerable populations: sex workers, drug users, gay men and other Men who have Sex with Men (MSM), transgender people, people deprived of liberty, and their partners¹1. Joint United Nations Programme on HIV/Aids. Communities at the centre. Global Aids update 2019. [acesso em 2020 jan 1]. Disponível em: https://www.unaids.org/en/resources/documents/2019/2019-global-AIDS-update.
https://www.unaids.org/en/resources/docu... . Gay men and other MSM accounted for 17% of new infections globally. Also, according to estimates by Unaids¹1. Joint United Nations Programme on HIV/Aids. Communities at the centre. Global Aids update 2019. [acesso em 2020 jan 1]. Disponível em: https://www.unaids.org/en/resources/documents/2019/2019-global-AIDS-update.
https://www.unaids.org/en/resources/docu... from 2010 to 2018, Brazil experienced a 21% increase in new HIV infections, which corresponds to more than eight thousand cases.

One of the population groups most vulnerable to HIV infection²2. Brignol S, Dourado I, Amorim LD, et al. Vulnerabilidade no contexto da infecção por HIV e sífilis numa população de homens que fazem sexo com homens (HSH) no Município de Salvador, Bahia, Brasil. Cad. Saúde Pública. 2015; 31(5):1-14.,³3. Torres RMC, Cruz MM, Perissèc ARS, et al. High HIV infection prevalence in a group of men who have sex with men. The Brazilian Journal of Infected Diseases. 2017; 21(6):596-605, MSM are up to 22 times more likely to acquire HIV than adults in the general population¹1. Joint United Nations Programme on HIV/Aids. Communities at the centre. Global Aids update 2019. [acesso em 2020 jan 1]. Disponível em: https://www.unaids.org/en/resources/documents/2019/2019-global-AIDS-update.
https://www.unaids.org/en/resources/docu... . MSM are defined as men who have sex with other men, regardless of whether they have sex with women or have a personal or social identity associated with this behavior, such as those who fall into the ‘gay’ or ‘bisexual’ categories¹1. Joint United Nations Programme on HIV/Aids. Communities at the centre. Global Aids update 2019. [acesso em 2020 jan 1]. Disponível em: https://www.unaids.org/en/resources/documents/2019/2019-global-AIDS-update.
https://www.unaids.org/en/resources/docu... . The MSM category is defined by sexual activity and not sexual orientation or gender identity.

As at the onset of the HIV epidemic, a predominance of cases is again observed among MSM in Brazil, which is also found in other countries⁴4. Snowden JM, Wei C, McFarland W, et al. Prevalence, correlates and trends in seroadaptive behaviours among men who have sex with men from serial cross-sectional surveillance in San Francisco, 2004-2011. Sexually Transmitted Infections. 2014; 90(6):498-504.,⁵5. Van Sighem A, Vidondo B, Glass TR, et al. Swiss HIV Cohort Study. Resurgence of HIV infection among men who have sex with men in Switzerland: mathematical modelling study. PLoS One. 2012 [acesso em 2019 jul 20]; 7(9):e44819.. The survey carried out in ten Brazilian cities in 2009 using the Respondent Driven Sample (RDS) method to recruit MSM, considered to be a difficult-to-access population, had an HIV prevalence of 12.1%, but only 49% had been tested for HIV at least once⁶6. Kerr LRFS, Mota RS, Kenadll C, et al. HIV MSM Surveillance Group. HIV among MSM in a large middle-income country. AIDS. 2013; 27(3):427-435.. The results of a second national survey that used the same RDS method in twelve Brazilian cities in 2016 showed a prevalence of 17.5% in MSM⁷7. Keer LRFS, Kendall C, Guimarães MDC, et al. HIV prevalence among men who have sex with men in Brazil: results of the 2nd national survey using respondent-driven sampling. Medicine. 2018; 97(supl1):S9-S15., a considerable increase if also compared with the first survey.

Stigma was defined as an attribute that profoundly discredits a person, labeling the individual with a tarnished identity in the face of society⁸8. Goffman E. Estigma: Notas sobre a manipulação da identidade deteriorada. Rio de Janeiro: LTC; 2021.. According to a study by Genberg et al.⁹9. Genberg BL, Kawichai S, Chingono A, et al. Assessing HIV/AIDS stigma and discrimination in developing countries. AIDS and Behavior. 2007; 12(5):772-780., from a relational perspective, the association of the stigma of living with HIV can lead to adverse effects on prevention and treatment adherence due to the fear of isolation or social rejection. Parker¹⁰10. Parker R. Interseções entre Estigma, Preconceito e Discriminação na Saúde Pública. In: Monteiro S, Villela W, organizadores. Estigma e Saúde. Rio de Janeiro: Editora Fiocruz; 2013. believes that discrimination is a behavioral response to negative attitudes and a materialized stigma. Discrimination actions can have several behavioral consequences, reflecting negatively on the lives of stigmatized individuals¹⁰10. Parker R. Interseções entre Estigma, Preconceito e Discriminação na Saúde Pública. In: Monteiro S, Villela W, organizadores. Estigma e Saúde. Rio de Janeiro: Editora Fiocruz; 2013..

Several forms of discrimination generated by the stigmatization of homosexuality increase individual vulnerability, decrease self-esteem and the perception of their rights. They hinder the structuring of full identity, leading to internalized homophobia¹¹11. Silva AS. Por um lugar ao sol: construindo a memória política da homossexualidade (ou Homossexualidade: a história dos vencidos?). Bagoas. 2012 [acesso em 2019 maio 18]; (8):77-102.. Different forms of discrimination can be translated into barriers to access public health services. According to Obrist et al.¹²12. Obrist B, Iteba N, Lengeler C, et al. Access to health care in contexts of livelihood insecurity: a framework for analysis and action. PLOS Medicine. 2007; 4(10):1584-1588., access to health services can be determined by situations of the population’s vulnerability, which depends on human, physical, financial, and social capital.

A study by Assis and Jesus¹³13. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciênc. Saúde Colet. 2012; 17(11):2865-2875. identifies advances in reducing inequalities and expanding access to the Unified Health System (SUS) network, especially in PHC, since the publication of the 1988 Brazilian Magna Carta, which ensured health as a universal right guaranteed by the State.

However, there were also limits related to accessibility, fragmentation, decentralization, and regionalization of the care network, with inadequacy in receiving and caring for specific groups, besides regional asymmetries. Social inequalities emerge in other studies, even in developed countries such as Canada and some European countries¹⁴14. Cock KM, Fleming PL, Karon JM, et al. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health. 2001; (91):1060-1068.,¹⁵15. Montaner JS, Tyndall MW, Wood E, et al. Prevalence and correlates of untreated human immunodeficiency virus type 1 infection among persons who have died in the era of modern antiretroviral therapy. J Infect Dis. 2003; (188):1164-1170.,¹⁶16. Del Amo J, Broring G, Fenton K. HIV health experiences among migrant Africans in Europe: how are we doing? AIDS. 2003; (17):2261-2263.. According to Travassos et al.¹⁷17. Travassos C, Oliveira EXG, Viacava F. Desigualdades geográficas e sociais no acesso aos serviços de saúde no Brasil: 1998 e 2003. Ciênc. Saúde Colet. 2006; 11(4):975-986.⁽⁹⁷⁶⁾, access

The analysis proposed in this paper is nested in broader research called ‘Assessment of access by Men who have Sex with Men to the Curitiba Guidance and Counseling Center’, where a single case study was carried out using quantitative and qualitative approaches. The assessment was based on an interventional research project at the Guidance and Counseling Center (COA) called ‘A Hora é Agora (AHA, in English, The Time is Now). The question that motivated the study was whether the AHA project developed at the COA in Curitiba changed MSM access to HIV testing and the linkage of diagnosed HIV+ users to health services to provide the early HIV/Aids treatment.

The AHA aimed to prevent and control HIV among gay men and other MSM, especially among young people aged 14 to 29, which began in December 2014 and ended in December 2017. The project aimed to increase access to testing, offering finger-prick rapid tests at a mobile unit or trailer parked in a strategic location, i.e., near socially interactive areas visited by the target audience; in the Non-Governmental Organization (NGO) Grupo Dignidade, serving lesbians, gays, bisexuals, transvestites and transsexuals (LGBT); at the public health unit (COA); and by incorporating HIV testing into the Curitiba Street Clinic.

Also, with the support of the virtual platform (https://www.ahoraeagora.org/) called e-Testing, the key population of the project (MSM) could receive the oral fluid test at home or collect it at the popular pharmacy of the Ministry of Health to carry out the self-test. The project also aimed to strengthen the link of HIV+ cases with HIV care health services in Curitiba by ‘linkage’, facilitating access to ART and ensuring the monitoring of users through the ‘linker’ – neologism derived from the English word linkage.

The linker was a member of the AHA team that assisted users with HIV+ results to initiate treatment in public health services in primary health care (PHC). The linker is a professional selected and trained to support users when they discovered they were HIV+, facilitating their access to health services, and answering any questions about HIV/Aids, always encouraging their autonomy.

The COA was implemented in Curitiba in 1992 by the state administration. In 1995, it shifted to the municipal administration of Curitiba. When the Ministry of Health changed the name of the COA to Testing and Counseling Center (CTA), Curitiba opted to keep ‘COA’, understanding that its users had already created a service identity. It is currently considered a Specialized Care Service that provides testing for HIV, syphilis, hepatitis B and C, counseling, outpatient medical care for People Living with HIV/Aids (PLWHA), and a Drug Dispensing Unit. The COA is staffed with advising psychologists, nurses, pharmacists, doctors, and administrative assistants.

While the COA is a vital reference for the most vulnerable populations and serving a good number of MSM, this population struggles to access health services due to this social group’s stigma⁶6. Kerr LRFS, Mota RS, Kenadll C, et al. HIV MSM Surveillance Group. HIV among MSM in a large middle-income country. AIDS. 2013; 27(3):427-435.,¹⁸18. Gomes RRFM, Batista JR, Ceccato MGB, et al. HIV Knowledge among men who have sex with men in Brazil: applying the item response theory. Rev. Saúde Pública. 2014; (48):206-215. Most MSM want privacy and secrecy regarding their sexual orientation or activity, which is not always respected. There is also a need for an adequate approach to these groups vulnerable to HIV infection so that there is a more significant link and adherence to treatment, which have been lower.

This is an original study in Brazil because it reveals the barriers and facilitators of users at the time of HIV+ diagnosis at a SUS health service, based on an intervention and research project – the AHA. Given the above, it is fundamental to deepen the understanding of the different barriers of access to HIV prevention, diagnosis, and treatment by young gay men and other MSM at a SUS service in Curitiba, in a context of introducing new technologies for improving care management. In this sense, this paper aims to analyze the main barriers for access to HIV testing at a COA in Curitiba and the linkage of gay men and other MSM to the health service for the early treatment of HIV based on the AHA project.

Material and methods

Primary data was collected following a qualitative method, triangulation of field observation techniques, document analysis, and interviews with users, managers, and health professionals to achieve the objective of the analysis. According to Denzin¹⁹19. Denzin NK. Moments, mixed methods, and paradigm dialogs. Qualitative Inquiry. 2010; 16(6):419-427., triangulation uses different data sources or different data from the same source to examine the same object. This study sought convergence and confirmation through these different techniques used to strengthen the internal validity of the analysis. Such data provided context and depth, providing a denser view of the intervention in the COA.

Field observations were necessary so that the researcher could make a field mapping, that is, previous interaction with the subjects’ reality before the interviews. We observed the busiest times of the research target population (the MSM), service to users, access for people with disabilities, team integration, and waiting time for assistance. The observations were made at three stages from February to April 2018, on all weekdays, during COA’s entire opening hours.

After the free-floating reading of the available documents of the AHA project, we selected for analysis the project protocol; minutes of meetings between linkers and linkage coordination; the user and linker contact information forms; half-yearly and annual reports on the cooperation agreement; the reports of the supervisory visits at the COA; and the AHA project evaluation report. We identified and organized the type of document, its nature, the number, and characterization of its contents to analyze these documents, as per table 1.

Subsequently, semi-structured interviews were carried out to identify the barriers to MSM access to the COA and other services in Curitiba. The interviews were recorded and later transcribed for analysis. Three categories were created according to each question asked in the interview, grouped according to access barriers: barriers for MSM, MSM testing barriers, and MSM treatment onset barriers (table 2).

The selection of participants for the interviews with the informants was intentional to obtain the specific categories of participants relevant to the research objectives. The linkers played a vital role in the selection, as they were responsible for inviting and scheduling interviews with HIV+ users followed-up or those who had already ended the linkage. Users who went to the COA to test themselves were approached in the waiting room during the days and hours of highest attendance at the service while waiting to take the test. Regarding health professionals and managers, the interviews were previously scheduled by the researcher and carried out at the COA in a private room.

The number of informants was based on the saturation criterion²⁰20. Fontanella BJB, Luchesi BM, Saidel MGB, et al. Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. Cad. Saúde Pública. 2011 [acesso em 2019 out 30]; 27(2):389-94., or the point at which the themes started to be repeated and new information ceased to appear. Twenty-two interviews were conducted per the inclusion and exclusion criteria detailed in table 3, and all managers, health professionals, and users invited for interviews were directly or indirectly involved with the COA.

A thematic content analysis was performed, a data treatment method, which aims to interpret qualitative material, ensuring an objective, systematic description and richness manifested at the time of collection²¹21. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2009.. This analysis included the exploration of the material, which consisted of coding and categorizing, thus building thematic categories according to the barriers, and the treatment of results, which was the phase of reflection and intuition based on empirical materials, comparing accumulated and acquired knowledge²¹21. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2009..

This research was submitted and approved by the Research Ethics Committees of the National School of Public Health Sergio Arouca/Fundação Oswaldo Cruz (Ensp/Fiocruz), under Opinion 2.539.927 of March 12, 2018, and the Municipal Health Department of Curitiba, under Opinion 2.609.994 of April 19, 2018.

Results and discussion

The main barriers of MSM access to the COA, the barriers to reaching the MSM in Curitiba, the barriers that prevent MSM from testing themselves, and MSM diagnosed with HIV+ from starting treatment were analyzed according to the views of users, health professionals, and managers.

The main barrier mentioned by MSM for access to the COA was the opening hours, which is not a specific barrier of the COA but of most public services that operate during business hours. The professionals also mentioned the reduced number of the COA team, which cannot meet the demand and often must ask the user to return the next day.

The barriers to reaching the MSM in Curitiba mentioned by health professionals and managers were access, location, humanization, lack of trained human resources in services, and prejudice.

The COA is located in a central region of Curitiba, with easy access to the bus terminals, although some people have difficulty paying for transportation from the suburbs to downtown.

According to health professionals, there was also a concern about the lack of humanization in the service and people trained to care for MSM and other vulnerable populations, including prejudiced employees. A study conducted with MSM in Brasília revealed that access to public health services is limited, and there is no privacy. As a result, individuals are subjected to stigma, to the very least symbolic violence, or a service geared to the heterosexual public²²22. Pimenta FA, Merchan-Hamann E. Uso dos serviços de saúde por parte de homens que fazem sexo com homens do Distrito Federal. Tempus: Actas de Saúde Colet. 2011; 5(4):35-53.. In other words, these services are less humanized and receptive because they disrespect the social and sexual diversity of the most vulnerable groups.

The interviewed users mentioned the lack of information, fear, shame, and homophobia as barriers to reach MSM in Curitiba. The interviews highlighted the need for communication and information on HIV/Aids for MSM and other key populations, the relevant lack of information materials, and the few existing media campaigns.

Fear, shame, and homophobia arise in all issues, from the idea of a conversation on the topic, lead people to agree with the need to perform the test and start treatment if the result is positive.

Regarding testing barriers, professionals and managers mentioned prejudice, lack of suburban access, reception difficulty in health services, the sexuality acceptance issue, and COA’s opening hours and lack of staff. According to Lippman et al.²³23. Lippman SA, Veloso VG, Buchbinder S, et al. Over-thecounter human immunodeficiency virus self-test kits: time to explore their use for men who have sex with men in Brazil. Braz J Infect Dis. 2014; 18(3):239-44., despite evidence of increased risk among MSM, the coverage of periodic HIV testing in this population subgroup is still low, which is probably due to access barriers that make this social group even more vulnerable.

Users list the lack of trained professionals, the difficulty of access, time to take the test, the fear of suffering prejudice, exposure, fear of the result, lack of information, stigma, and shame as testing barriers. These barriers can be divided into organizational and subjective, which denotes an overlapping of barriers and, consequently, vulnerabilities.

According to some health professionals interviewed, the need for training the network of professionals in Curitiba was evident in some issues addressed, as was the difficult access to services by people living farther from the center. Concerning working people, the time to take the test was also mentioned by some interviewed users, as the opening hours of public services are limited and coincide with the business hours of most workers. While the location is close, there is not enough time at lunch to perform the test, result, and post-test counseling. Fear emerges through prejudice, exposure, and the test result.

Concerning the lack of information, the need for the media to influence more was answered to try to reduce prejudice and make people have more courage to go and test themselves. Studies carried out with MSM in Germany and Malawi have confirmed shame and fear of stigma as the most daunting barriers for MSM to test themselves²⁴24. Schmidt AJ, Marcus U. Self-reported history of sexually transmissible infections (STIs) and STI-related utilization of the German health care system by men who have sex with men: data from a large convenience sample. BMC Infect Dis. 2011; (11):132.,²⁵25. Wirtz AL, Kamba D, Jumbe V, et al. A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi. BMC Int Health Human Rights. 2014; 14-20.. In Curitiba, stigma, and shame were barriers mentioned by all respondents.

The health professionals interviewed spoke about the barriers that prevent HIV+ users from starting treatment: denial of diagnosis, accepting their sexuality, prejudice, religious issue, lack of financial resources, such as money for transportation.

The widely recognized benefits of the early introduction of ART, according to Marsicano et al.²⁶26. Marsicano E, Dray-Spira R, Lert F, et al. Multiple discriminations experienced by people living with HIV in France: results from the ANRS-Vespa2 study. AIDS Care. 2014; 26(supl):S97-S106., seem to be neglected by the stigma and fear of being positive. The HIV+ users interviewed mentioned fear of medication and its side effects, lack of information, and shame as barriers to starting treatment.

In line with a study by Silva et al.²⁷27. Silva AEP, Nascimento HO, Anjos JGX, et al. Epidemias no Estado do Amazonas: HIV e Aids em destaque. Revista Soc. Cient. 2020 [acesso em 2020 out 12]; 3(4). Disponível em: https://www.scientificsociety.net/2020/06/epidemias-no-estado-do-amazonas-hiv-e-aids-em-destaque/.
https://www.scientificsociety.net/2020/0... , people are usually afraid of what they don’t know; that is why information and communication are so important. All respondents mentioned the fear of medication and side effects as the main barrier, so pharmacists appeared as essential mediators in guaranteeing access to UDMs. “Fear of medication and medication side effects. Some people report suffering from diarrhea all day” (User 1 HIV+).

Despite the significant benefits of early treatment in high- and low-income countries, people continue to test late for HIV infection²⁸28. Maccarthy S, Hoffmann M, Ferguson L, et al. The HIV care cascade: models, measures and moving forward. J Int AIDS Soc. 2015; (18):19395. due to HIV testing barriers, many of which are shared across settings and populations²⁹29. Logie CH, Lacombe-Duncan A, Brien N, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J. Inter. Aids Society. 2017; (20):21385..

All users interviewed were successful in their process to start treatment, but, according to the minutes of the meetings and records forms analyzed, some users faced some barriers during the process even when managing to start treatment:

a) Difficulty in accepting the diagnosis – some users who accepted the linkage did not want to talk about the linkage process right after the quick test; they asked for time to ‘digest’ the diagnosis, which caused some delay in the whole process. One user revealed that he wanted to commit suicide after diagnosis, besides other cases where partners were deemed guilty of transmitting the virus.

b) Registration at the Basic Health Unit (UBS) – users must register at the UBS to start treatment, although this was a significant barrier for users who chose a unit further away from their place of residence. Even decentralizing the public health network in Curitiba to care for people living with HIV/Aids, users’ dwelling territory was an important issue for some UBS, for example, Mãe Curitibana, Vila Guaíra, Campina do Siqueira, and Iperotiga. Thus, users who chose care away from their homes, especially so as not to be recognized by their neighbors in the service or so that the UBS where they were already registered did not know about the diagnosis, were prevented because they lived in a region that did not correspond to the area attended by the health service. Linkers reversed the situation in some cases, and in others, users were directed to the COA, which demotivated some users, requiring more significant intervention by the linkers.

c) Waiting time to schedule appointments and exams – in some of the reported cases, the first appointment was difficult to schedule, taking up to two months and generating the transfer of UBS. Also, a linker was prevented from entering the medical visit with the user in one UBS, and, in another UBS, the unpreparedness of one of the teams to observe PLWHA was observed. There was also a delay in scheduling necessary tests for ART prescription, such as CD4, viral load, and chest x-ray exams for users with suspected tuberculosis. According to the final report of the linkage, 22 users had difficulty scheduling the visit, and 30 found difficulties with laboratory tests.

d) Prejudice and discrimination – some of these cases are reported in the minutes of the meetings, such as the referral of a user to another service, given that PLWHA can be assisted in any health unit; stigma/discrimination during medical visits at the UBS of Bacacheri, Ouvidor Pardinho, and Mãe Curitibana; a user was kicked out of his home after the father found out he was infected with HIV; a user reported the number of a friend to the linker, fearing that the family would discover his diagnosis.

The study carried out in Brasília (DF) by Pimenta and Merchan-Hamann²²22. Pimenta FA, Merchan-Hamann E. Uso dos serviços de saúde por parte de homens que fazem sexo com homens do Distrito Federal. Tempus: Actas de Saúde Colet. 2011; 5(4):35-53. draws attention to the need for reformulation in the education and teaching of health professionals to reduce the vulnerabilities of homosexual citizens. Also, Gomes et al.¹⁸18. Gomes RRFM, Batista JR, Ceccato MGB, et al. HIV Knowledge among men who have sex with men in Brazil: applying the item response theory. Rev. Saúde Pública. 2014; (48):206-215 show how fundamental the role of civil society is in occupying social control spaces to eliminate barriers that compromise access to health services.

Finally, we register aspects that arise as guiding questions for improving access and quality of care for MSM and other vulnerable groups to provide a synthesis of the access barriers (table 4) announced by the different subjects.

Final considerations

This research addressed the access of Men who have Sex with Men, one of the most vulnerable populations to HIV infection, in an intervention that aimed to expand access to early diagnosis and treatment for HIV to prioritize this population.

The results revealed that the AHA strategies converged to increase the visibility of the COA among MSM and that the entry of the AHA project also provided increased testing at the COA, a more appropriate approach to counseling and care.

The COA’s opening hours were the main barrier found and the most easily perceived access barrier. Moreover, the need to expand the COA team became evident as the AHA project changed MSM access in the COA, but the demand was only absorbed due to the team recruited by the project. It is worth emphasizing the importance of this team of trained professionals who helped reduce the time between diagnosis and treatment and introduce a new organizational culture.

The barriers mentioned to reach MSM, test them and start their treatment immediately led us to conclude that there is a need for more information on HIV/Aids and prevention for the entire population, not just for the key populations. Information about treatment is also essential for people even before a possible diagnosis. We recommend that the Ministry of Health and health departments develop more actions in this area for the general population without focusing on key populations to reduce stigma. Actions with the Ministry of Education, such as the extinct School Health and Prevention project, could affect, as they will focus precisely on the young population, where the epidemic predominates.

This study brought the need for greater depth on stigma, given an overlap found. Stigma is found in the disease, MSM categories, transgender/transvestite people, and the individual vulnerable situation of MSM, such as their socioeconomic condition and the barriers to access and treatment brought about by these conditions. It is important to have continuing education and conversation circles with the primary care network, including sex, sexuality, gender, and vulnerabilities. Also, better mediation and interaction with civil society organizations and communication channels are required to address sensitive issues for young gay men and other MSM who need to improve access and care for healthier sex life.

Finally, it should be emphasized that most respondents and users of this research have completed high school or above and are therefore privileged concerning access, given that access is directly linked to the individual level of knowledge and education. In this sense, expanding access to ensure the rights of those who effectively have more difficulty entering SUS health services is still a significant challenge.

Acknowledgment

Juliane Cardoso, Tereza Kindra, Teresio de Freitas, Guilherme Passos, Carlos Henrique Gonçalves and José Henrique Vacillotto. A special thanks to Solange Kanso, Suely Deslandes and to the Public Health Postgraduate Progam at Ensp.

References

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