ABSTRACT

Post-Exposure Prophylaxis (PEP) for HIV is a biomedical technology, offered in cases of sexual violence and occupational accidents since the early 2000s, with its offer expanded to situations of consensual sexual relations after 2010. Despite being classified as biomedical, its offer and execution is mediated by relational technologies, permeated by socially constructed meanings. This study aimed to question the discourses produced on the offer of PEP among health workers. The research is inspired by Michel Foucault’s genealogical perspective, based on the need to problematize power relations in the discourses and knowledge of health professionals who work with the implementation of PEP in a medium-sized city in the central region of Paraná. Twelve interviews were carried out with managers of the HIV/AIDS policy and workers in the services that offer PEP. The discourses about the PEP are discussed, highlighting both the right to access and expansion of preventive possibilities and the prescriptive discourses permeating and constraining its offer. In conclusion, it is pointed out the necessity to qualify the access to PEP, affirming it as a practice of freedom.

KEYWORDS
HIV; Post-Exposure Prophylaxis; Desease prevention

Introduction

In the last decade, tackling HIV/AIDS has gained new characteristics, especially with the emergence of forms of care and technologies. Combined prevention can be characterized as a prevention and care strategy for HIV/AIDS based on the combination of biomedical, structural and behavioral interventions at individual and community level, taking into account specific contexts¹1 Brasil. Ministério da Saúde. Diretrizes para organização do CTA no âmbito da prevenção combinada e nas redes de atenção à saúde. Brasília, DF: MS; 2017..

Therefore, the importance of offering prevention methods on a large scale and in great variety is understood. Combined prevention brings benefits when associated with structural interventions, and this combination of methods may reflect on the way individuals and groups deal with risks and prevention, since it strengthens autonomy in the face of the epidemic and also covers a greater number of people²2 Grangeiro A, Ferraz D, Calazans G, et al. O efeito dos métodos preventivos na redução do risco de infecção pelo HIV nas relações sexuais e seu potencial impacto em âmbito populacional: uma revisão da literatura. Rev Bras. Epidemiol. 2016 [acesso em 2019 abr 2]; 18(1):43-62. Disponível em: http://repositorio.unb.br/handle/10482/23025.
http://repositorio.unb.br/handle/10482/2... ,³3 Brasil. Ministério da Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pós-Exposição (PEP) de Risco à Infecção pelo HIV, IST e Hepatites Virais. Brasília, DF: MS; 2018.. In addition to all prevention methods, knowing that HIV infection is more likely to occur through sex⁴4 Filgueiras SL, Maskud I. Da política à prática da profilaxia pós-exposição sexual ao HIV no SUS: sobre risco, comportamentos e vulnerabilidades. Sexualidad, Salud y Sociedad. 2018 [acesso em 2019 mar 31]; (30):282-304. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1984-64872018000300282&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s... , in 2010, the Ministry of Health added a new possibility of prevention for HIV: Post-Exposure Prophylaxis (PEP). This method is a biomedical technology that has existed since 1999 in the Unified Health System (SUS) and consists of the use of Antiretrovirals (ARVs) for 28 days.

At first, PEP was intended only for health professionals who had suffered accidents with biological materials. In 2000, the technology was made available to victims of sexual violence, and only from 2010 onwards, it began to be offered in cases of consensual sexual intercourse⁵5 Brasil. Ministério da Saúde. Suplemento III - tratamento e prevenção: recomendações para terapia antirretroviral em adultos infectados pelo HIV- 2008. Brasília, DF: MS; 2010. The availability of PEP is considered a significant change in combined prevention technologies and in the recognition, by the Ministry of Health, of people’s sexual rights, especially those belonging to vulnerable populations. Although policies to combat HIV have been involved in the field of sexual diversity since the country’s redemocratization process – seeking a policy based on respect for human rights, including sexual rights – there is great difficulty in transforming this policy into daily action within the SUS⁴4 Filgueiras SL, Maskud I. Da política à prática da profilaxia pós-exposição sexual ao HIV no SUS: sobre risco, comportamentos e vulnerabilidades. Sexualidad, Salud y Sociedad. 2018 [acesso em 2019 mar 31]; (30):282-304. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1984-64872018000300282&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s... ,⁶6 Grangeiro A, Silva LL, Teixeira PR. Resposta à aids no Brasil: Contribuições dos movimentos sociais e da reforma sanitária. Rev. Panam Salud Publica. 2016 [acesso em 2019 abr 2]; 26(1):87-94. Disponível em: http://bvsms.saude.gov.br/bvs/is_digital/is_0409/pdfs/IS29(4)115.pdf.
http://bvsms.saude.gov.br/bvs/is_digital... .

In addition to taking sexuality into account in the context of biomedical prevention technologies, it is important to detach the risk caused by sexual practice and to connect to one’s Rights. In the first Clinical Protocol and Therapeutic Guidelines (PCDT) for PEP, which was in effect until June 2015, the analysis for recommending or not Antiretroviral Therapy (ART) refers to the context of the exposure. The professional should check three main aspects about the patient/candidate for prophylaxis: the serology of the source patient, the type of sexual practice and the prevalence of HIV infection in the population segment to which the partner belongs³3 Brasil. Ministério da Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pós-Exposição (PEP) de Risco à Infecção pelo HIV, IST e Hepatites Virais. Brasília, DF: MS; 2018..

As of June 2015, the protocol has been simplified. Prophylaxis began to be recommended by assessing the risk of exposure, and no longer by category and context of exposure. Thinking about comprehensive health care for people exposed to Sexually Transmitted Infections (STIs), current guidelines recommend analyzing the answers to four questions asked to all potential users of PEP: the type of material to which the person exposed himself; the type of exposure; the time elapsed between exposure and consultation; and the patient’s serology³3 Brasil. Ministério da Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pós-Exposição (PEP) de Risco à Infecção pelo HIV, IST e Hepatites Virais. Brasília, DF: MS; 2018.. Based on the responses, the professional assesses the need for PEP prescription.

After simplifying the PCDT, the Ministry of Health launched the Guidelines for the Organization of the Post-exposure to HIV Infection Antiretroviral Prophylaxis Network⁷7 Brasil. Ministério da Saúde. Diretrizes para a organização da Rede de Profilaxia Antirretroviral Pós-Exposição de Risco à Infecção. Brasília, DF: MS; 2016. This document aims to standardize some actions for the provision of PEP in the public health network, arguing that, with the simplification of the PCDT, the participation of the specialized professional becomes expendable, making it possible to diversify the places where prophylaxis can be provided⁷7 Brasil. Ministério da Saúde. Diretrizes para a organização da Rede de Profilaxia Antirretroviral Pós-Exposição de Risco à Infecção. Brasília, DF: MS; 2016. In this sense, the experience of municipalities such as Florianópolis (SC) stands out, which initiated the decentralization of HIV/AIDS care, including the provision of PEP in primary care, from 2015⁸8 Pinto VM, Capeletti NM. Reorganização do modelo de atenção às pessoas vivendo com HIV: a experiência do município de Florianópolis/SC. Rev. Bras. Med. Família e Com. 2019 [acesso em 2022 jan 21]; 14(41):1710. Disponível em: https://rbmfc.org.br/rb-mfc/article/view/1710/976.
https://rbmfc.org.br/rb-mfc/article/view... .

PEP is a biomedical technology that consists of the use of controlled drugs, which can be appropriated in different ways, as a political resource with the aim of guaranteeing or detracting sexual rights; what is at stake is whether or not it is understood as the result of a policy based on respect for human rights. To avoid health risks and guide decision-making, it is necessary to analyze the situation of exposure of the user to HIV through a detailed account of the practice that led him/her to seek PEP. However, it is noticed that health workers have difficulty in addressing sexual practices, as well as patients have difficulty in reporting them, which demonstrates that the subject of sex is not natural. In addition, many health professionals, despite working in public programs focused on sexuality, end up acting based on personal values, mixing scientific, religious, moral and other knowledges⁹9 Paiva V. A Psicologia redescobrirá a sexualidade? Psicologia em Estudo. 2008 [acesso em 2019 abr 2]; 13(4):641-651. Disponível em: http://www.scielo.br/pdf/pe/v13n4/v13n4a02.pdf.
http://www.scielo.br/pdf/pe/v13n4/v13n4a... . Another aspect to be analyzed is that, although PEP is considered a biomedical technology, access to it is permeated by relational technologies and various psychosocial aspects. In this sense, PEP can be read not only as a biomedical strategy, but as a strategy in service of different forces, according to the uses of it by the professionals involved.

The best prevention methods will always be those that suit the needs of users and that consider the contexts in which they are inserted, being even more advantageous for providing the means for structural and individual interventions³3 Brasil. Ministério da Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pós-Exposição (PEP) de Risco à Infecção pelo HIV, IST e Hepatites Virais. Brasília, DF: MS; 2018.. When structuring a Pedagogy of Prevention¹⁰10 Gavigan K, Ramirez A, Milnor J, et al. Pedagogia da Prevenção: reinventando a prevenção do HIV no século XXI. Rio de Janeiro: ABIA; 2016. [acesso em 2022 jan 21]. Disponível em: https://abiaids.org.br/pedagogia-da-prevencao/28753.
https://abiaids.org.br/pedagogia-da-prev... , researchers from the Brazilian Interdisciplinary AIDS Association (ABIA) state that, in order to be effective in offering multiple preventive approaches, it is necessary to guarantee access and information about what is available and the effectiveness of each method, allowing that individuals at risk of exposure receive more than pills in their bodies, but that they feel empowered by the decision to prevent themselves in the way that makes the most sense¹⁰10 Gavigan K, Ramirez A, Milnor J, et al. Pedagogia da Prevenção: reinventando a prevenção do HIV no século XXI. Rio de Janeiro: ABIA; 2016. [acesso em 2022 jan 21]. Disponível em: https://abiaids.org.br/pedagogia-da-prevencao/28753.
https://abiaids.org.br/pedagogia-da-prev... .

It should be noted that sexuality continues to be approached hegemonically from the perspective of risk, and not as a right, understanding sexual practices and experiences as a problem that can lead to AIDS; in this logic, a behavior classified as deviant or transgressive can lead the subject to be infected by a virus. Such convictions influence health professionals to seek control over people’s sexual lives, making it impossible to work based on the perspective of sexuality as a right⁴4 Filgueiras SL, Maskud I. Da política à prática da profilaxia pós-exposição sexual ao HIV no SUS: sobre risco, comportamentos e vulnerabilidades. Sexualidad, Salud y Sociedad. 2018 [acesso em 2019 mar 31]; (30):282-304. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1984-64872018000300282&lng=pt&tlng=pt.
http://www.scielo.br/scielo.php?script=s... .

Lima, Almeida and Vieira¹¹11 Lima R, Almeida C, Viana L. A pessoa medicada e o HIV/AIDS: subjetividade, adesão ao tratamento e biopolíticas. Rev. Subjet. 2015 [acesso em 2019 set 2]; 15(3):378-388. Disponível em: http://pepsic.bv-salud.org/scielo.php?script=sci_arttext&pid=S2359-07692015000300006&lng=pt&nrm=iso.
http://pepsic.bv-salud.org/scielo.php?sc... sought to think about AIDS medication and adherence to ART from a biopolitics perspective, criticizing the Brazilian model of care for not welcoming patients or considering their singularities, which leads to the prescription of general conducts and distances the patient from protagonism and from the right to his own body. For the authors, with the emergence of AIDS, the challenge of thinking about public health policies that do not lead to a reduction of human subjectivity and sexuality to biomedical discourses has grown¹¹11 Lima R, Almeida C, Viana L. A pessoa medicada e o HIV/AIDS: subjetividade, adesão ao tratamento e biopolíticas. Rev. Subjet. 2015 [acesso em 2019 set 2]; 15(3):378-388. Disponível em: http://pepsic.bv-salud.org/scielo.php?script=sci_arttext&pid=S2359-07692015000300006&lng=pt&nrm=iso.
http://pepsic.bv-salud.org/scielo.php?sc... .

In view of this, the notion of device¹²12 Defert D, Ewald F, Legrange J. Le jeu de Michel Foucault: (entretien sur l’Histoire de la sexualité), n. 206. In: Defert D, Ewald F, Legrange J. Dits et écrits III: 1976-1979. 9. ed. Paris: Gallimard; 2018. p. 298-329. will be used as a tangle of knowledge-power established between discourses, institutions, decisions, laws, scientific assumptions, between what is said and what is not said, and its understanding is of fundamental importance for the analysis that is intended to be developed in this article. The device is a versatile concept, which will be used to understand sexuality and AIDS intertwined in the power relations between the State as an overseer of the bodies of people who (co) exist or may potentially be exposed to HIV.

In ‘The history of sexuality: the will to knowledge’, Foucault¹³13 Foucault M. História da Sexualidade I: a vontade de saber. 7. ed. Rio de Janeiro; São Paulo: Paz e Terra; 2018. seeks to define the Device of Sexuality, which could be described as something that links the stimulation of bodies, the intensification of pleasures, the incitement of discourse, the formation of knowledge, the reinforcement of controls and resistance based on great strategies of power and knowledge and discursive procedures; part of a transformation scheme that needs to be understood as a global strategy that depends on precise and tenuous relationships of support and fixation, articulated in the discourses that convey and produce power, but also undermine it, and in the secrets and silences that, in the same extent, they shelter and prohibit and loosen ties, giving rise to tolerances. There is, in fact, no censorship of sex, but incentives for the production of discourses about it, with an emphasis on the licit-illicit duality¹³13 Foucault M. História da Sexualidade I: a vontade de saber. 7. ed. Rio de Janeiro; São Paulo: Paz e Terra; 2018..

In addition, Michel Foucault allows sex to be denaturalized, showing that no relationship would be – although generally monogamous – just between two people. The State is part of these relationships, seeking to control sex, defining which is good and which is bad, in search of sanitization of practices considered risky to life.

Néstor Perlongher¹⁴14 Perlongher N. O que é Aids. São Paulo: Brasiliense; 1987., based on Foucault’s studies, coined the term AIDS device, which is related to what he calls the ‘old confession’, but now in the office it is time to talk about sex. According to the author, this device refers to

For this regulation to be possible, the AIDS device is exercised when medical councils seek to discipline sexual practices, “especially homosexual ones”¹⁴14 Perlongher N. O que é Aids. São Paulo: Brasiliense; 1987.⁽⁷⁰⁾. The control that the State operates, when it pays attention to the use of the bodies and pleasures, implies that some enjoyments are more legitimate than others, attributing the accusation of irresponsibility to individuals who are part of a ‘risk group’ instituted by convergences, affinities and homogenization of interests, which is the cause of contamination and therefore needs to be sanitized. In view of this, it is necessary to problematize these hygienist and stigmatizing practices that affect not only people living with HIV but also all others considered by the State as part of a more vulnerable population.

That said, it is emphasized that public policies on HIV are advances, from the point of view of asserting the right and access to citizenship, but they must be problematized, especially by the forces of subjection that they can produce: if, on the one hand, they undertake efforts to make positive seropositive identities, on the other hand, the Aids device brings in its memory stigmatization processes that are still strong, acquiring confessional traits¹³13 Foucault M. História da Sexualidade I: a vontade de saber. 7. ed. Rio de Janeiro; São Paulo: Paz e Terra; 2018. and, in a way, disciplinary instruments that the State appropriates.

Therefore, this research aims to question the discourses produced about the offer of sexual PEP among health workers in a municipality in the central region of Paraná.

Material and methods

This study uses data from a larger study entitled ‘Reacting to HIV: post-sexual exposure emergency care in the services of a city in the central region of Paraná’, linked to the master’s thesis defended and supervised respectively by the first and second authors of this article . The research had a qualitative bias, inspired by the genealogical perspective of Michel Foucault: “Foucault’s genealogical period is mentioned to refer to those works dedicated to the analysis of the forms of exercise of power”¹⁵15 Castro E. Vocabulário de Foucault: um percurso pelos seus temas, conceitos e autores. Belo Horizonte: Autêntica Editora; 2009.⁽¹⁸⁴⁾. The choice was justified by the need to problematize power relations based on the speeches and knowledge of professionals who work with the implementation of sexual PEP.

The research had its data produced between July 2019 and November 2020 in a medium-sized municipality, in the range between 150 and 200 thousand inhabitants, in the central region of the state of Paraná. The participants were two professionals representing the management of the Department of Specialized Care, which manages the HIV policy in the municipality, the manager and the health professionals who work at the Specialized Care Service/ Serological Guidance and Support Center (SAE/COAS) and the nurses and the doctor who act as on-duty physicians in the municipal urgency and emergency units and in emergency care related to sexual exposure to HIV. For this article, the sample was made according to table 1:

The research project was approved by the Research Ethics Committee of the State University of the Midwest, Campus Irati, under opinion number 3,417,298, of 06/26/2019. Participation in the interview only occurred after signing the Free and Informed Consent Form.

As an analysis method, the study was based on Foucault’s Discourse Analysis. Since it was never one of Foucault’s projects that there was a theory of discourse analysis, the author only considered that his work should be treated as a toolbox: in this box, discourse is a founding concept of his thought, articulating an entire conceptual system that runs through, but is not limited to, language. This means that discourse materializes in the form of text, image, verbal and non-verbal languages, always under historical determinations¹⁶16 Ferreira R, Rajagopalan K. Michel Foucault: Uma teoria crítica que entrelaça o discurso, a verdade e a subjetividade. In: Ferreira R, Rajagopalan K. Um mapa da crítica nos estudos da linguagem e do discurso. Campinas: Pontes; 2016. p. 117-132..

To reach this line of analysis, the interviews were read, first in the order in which they occurred, which made some speeches stand out, and – as they were being related to the research objective – we started treating them as a line of analysis; in a second moment, as the analysis was carried out and the speeches of the interviews were integrated with the theory, we returned to the reading of the interviews, so that the actions complemented each other.

The discursive production on AIDS and sexuality as a device to manage bodies

According to Manager 1’s report, historically, the SAE constitutes a centralized reference for the provision of PEP in the municipality. According to the professional, whenever there was an exposure situation, the SAE was called in to assist the patient. To cover the weekends, there was a shift, in which the professionals were called and carried out all the assistance related to PEP, regardless of the motivation: whether occupational, due to sexual violence or through consensual sex.

Also, according to Manager 1, this on-call system was no longer in use around 2014. Then, in 2015, the PEP PCDT was simplified. This same participant reports the perception that, from 2016/2017, the demand for PEP increased, coinciding with the expansion of its access to municipal emergency services, culminating in the current care configuration.

There are, therefore, two types of service in the municipality where the user can seek the PEP: the SAE/COAS and the Municipal Emergency Units. The SAE service is from Monday to Friday, during business hours; two of the emergency units are open 24 hours a day and 7 days a week, and the third is open from 7 am to midnight, from Monday to Saturday. If the exposure takes place on weekdays, the patient is always advised to seek the SAE/ COAS – even if the exposure occurred during the night or at dawn –, instead of receiving care in the emergency units. It should be noted that the guidelines of the Ministry of Health for PEP recommend that the first dose of the drug should preferably occur two hours after exposure, and cannot exceed 72 hours.

The flow for the PEP, when the patient seeks it at the SAE/COAS, was described by Manager 1 (2019): when the user does not bring the partner, the HIV test is performed and, when the result is ‘no reagent’, the patient goes to the doctor, who prescribes the prophylaxis. When people come together, they are all tested, and efforts are made to avoid prescribing prophylaxis due to possible side effects.

After this contextualization about the offer of PEP in that municipality, we move on to the analysis of some excerpts from the interviews, in which we could observe the experience reports of the health workers mixed with what they heard from the users they attended. Therefore, we intend to analyze the discursive production of care and control of bodies through the research participants’ gaze. The following clipping deals with a service that resulted in the use of sexual PEP and was an experience reported by a nurse on duty at the emergency unit:

These are the facts narrated from the nurse’s point of view; it is possible to verify that the patient felt the need to justify that “at the time she did not think”. Another important detail of the statement is right at the beginning, when the nurse says “we never know the ‘reality’ of the situation”, referring to the impossibility of knowing if the patients are telling the truth. It is important, however, to emphasize the difficulty, in a quick relationship such as emergency care, to make this type of inference, since there is still no link between patient and worker, and a relationship of trust must be built. It is worth highlighting the presence of objective parameters: the PEP PCDT establishes that, when the result of the rapid HIV test is inconclusive, PEP must be prescribed and provided to the patient. Bringing this to the case narrated by Nurse 2, it is perceived the need for a careful listening to the patient’s story, which will establish – together with the criteria contained in the PCDT of the PEP – the bases for the decision on the prescription. Nurse 2 concludes the previous report by saying:

This second part of the worker’s speech can be analyzed from two perspectives: the first concerns fear, and the second, luck. Returning to the research carried out by Paiva⁹9 Paiva V. A Psicologia redescobrirá a sexualidade? Psicologia em Estudo. 2008 [acesso em 2019 abr 2]; 13(4):641-651. Disponível em: http://www.scielo.br/pdf/pe/v13n4/v13n4a02.pdf.
http://www.scielo.br/pdf/pe/v13n4/v13n4a... , the person interviewed, L. (1987) says:

Thus, it is not a universal assumption that a person thinks about HIV, AIDS or other STIs at the time of sex; so, in fact, it is understandable that fear only comes later, being the role of the health professional to address the events of everyday life, including sex. The discourse expressed in the professional’s speech is linked to a normative assumption: when having sex, people should think about illness and, therefore, prevent themselves. What is ‘outside’ this normativity seems surprising. Sexual PEP, however, precisely incorporates the possibility that this ‘taking care of it later’ is embraced by health actions that also enable a form of prevention. The Brazilian HIV prevention policy has been centered, throughout its history, on offering the male condom as the main prevention tool¹⁷17 Pinheiro TF, Calazans GJ, Ayres JR. Uso de Camisinha no Brasil: um olhar sobre a produção acadêmica acerca da prevenção de HIV/Aids (2007-2011). Temas em Psicol. 2013 [acesso em 2022 abr 20]; (21):815-836. Disponível em: http://pepsic.bvsalud.org/pdf/tp/v21n3/v21n3a09.pdf.
http://pepsic.bvsalud.org/pdf/tp/v21n3/v... , shaping a preventive culture. However, in the 2010s, there was an increase in the range of preventive options, represented in the image of the combined prevention mandala¹⁸18 Brasil. Ministério da Saúde. Prevenção Combinada. Brasília, DF: O Ministério; [2010]., which consists of a set of strategies with different combination possibilities, aimed at expanding the autonomy and protagonism of the subjects in the construction of prevention. They require a reconfiguration of the preventive culture: while the condom involves ‘arriving before intercourse’ (it is necessary to have the condom and insert it before penetration) to effect prevention, PEP comprises ‘arriving after intercourse’, but before the infection process occurs. Thus, it requires a twisting of the meaning traditionally attributed to prevention. Perhaps for this reason, many professionals forget about PEP and consider that there is nothing else to do when someone reports unprotected sexual intercourse.

The second discursive aspect is how lucky the patient was not to have been infected with HIV, which is not just a possible assumption to know, since she took the quick test on the day of exposure in the emergency unit and, according to the informed protocol, was not monitored by the emergency unit, but by the SAE or the Basic Health Unit. There are several motivations for people to have sex without a condom, one of which is the imminent possibility of being infected with HIV¹⁹19 Almeida Junior WN. Escolhas conscientes pedem métodos pertinentes: barebacking e a prevenção do HIV. In: Leite V, Terto Junior V, Parker R. Dimensões Sociais e Políticas da Prevenção. Rio de Janeiro: ABIA; 2018. p. 71-75. [acesso em 2020 out 1]. Disponível em: http://abiaids.org.br/dimensoes-sociais-e-politicas-da-prevencao/32257.
http://abiaids.org.br/dimensoes-sociais-... .

Another aspect addressed with the research participants aimed to understand the approach to potential PEP users. According to one of the participants:

The doctor’s speech about how to provide care to a person who has been exposed to HIV and who could use PEP illustrates this:

The worker mentions a tool that until then had not been addressed by other professionals: a mobile application. The Ministry of Health⁷7 Brasil. Ministério da Saúde. Diretrizes para a organização da Rede de Profilaxia Antirretroviral Pós-Exposição de Risco à Infecção. Brasília, DF: MS; 2016 refers to the simplification of the PEP protocol as the institution of a single algorithm for all types of PEP; both the excerpt from the doctor’s speech and the Ministry of Health document denote a rational/administrative implication, with emphasis on the use of tools that enable the objectivity of care, configuring this topic as just another subject to be addressed, like any other, in an aseptic way.

This asepsis is countered by other statements, such as the following:

It is important to consider that, unlike the team at the specialized HIV/AIDS service, the team at the emergency care services is characterized by a greater diversity of professionals, in shift schedules, configuring greater turnover and difficulty in carrying out permanent education processes.

Still, the professional’s speech about the initial resistance of some professionals in relation to the implementation of PEP in emergency services stands out:

The speech of another professional shows that the flows and understandings around PEP in emergency services are not yet settled in the daily life of emergency units:

Complementarily, in the interviews with nursing professionals, it was observed that there is no consensus on the classification of the waiting time of people who access the units in search of the PEP. This shows that, even with the existence of protocols and guidelines, the guarantee of access to PEP in a timely manner and the approach to counseling do not always occur, resulting in patients arriving at the SAE after the possible deadline for prescription of PEP has expired.

In some interviews, more was heard about how the professionals carry out the approach:

This speech has an instituting potential in relation to the processes of permanent education in health, both because it refers to the light technologies involved in care and because of the need for professionals to identify their prejudices or other aspects that interfere with care. If counseling is an intersubjective relationship, the professional’s reactions and approach will also affect the user, allowing greater or lesser openness to dialogue. Thus, it is imperative to include this aspect in the training of health professionals. It is important to emphasize that this speech contrasts with the asepsis denoted in the speech of the physician and Manager 1 previously exposed, which highlighted the more formal dimensions of the process.

It is necessary to consider that, although PEP is configured as a biomedical technology, the access and approach to it are characterized as a light, relational technology²⁰20 Merhy EE. Ver a si no ato de cuidar: educação permanente na saúde. In: Ferla AA, Ramos AS, Leal MB, et al. Caderno de Textos do VER-SUS/Brasil. Porto Alegre: Rede Unida; 2013. p. 58-71. [acesso em 2020 nov 4]. Disponível em: https://edisciplinas.usp.br/.pluginfile.php/4447985/mod_resource/content/1/FINANCIAMENTO%201_VERSUS.pdf.
https://edisciplinas.usp.br/.pluginfile.... . Thus, the application can indicate the biomedical perspective, but the relationship must be produced in the meeting, in a unique way, taking into account the complexity surrounding issues involving sexuality and its multiple meanings.

Continuing with the analysis and understanding of the aspects that permeate the PEP offer, it is observed that several professionals reported a common attitude among patients: the request for privacy since the reception. According to Nurse 2 (2019),

Nurse 1 also shows concern about exposing the patient:

These situations and requests express a discourse that relates sex and sexuality with intimacy and privacy. Therefore, they need to be spoken behind closed doors, or in a lower voice. It is understood, therefore, that this is not discussed as any other subject, constituting forms of expression of the device of sexuality.

Within the aspects discussed so far, it can be said that health practices are part of a game of captures and resistances. By problematizing these discourses from the forms that have been observed so far, we seek to make a statement about the need to create or expand conditions of resistance, opportunities for identities and behaviors to be legitimized, and not judged. One might think that health workers prescribe, in addition to condoms and ARVs, a sexual diet, but it is recalled that the existence of a power relationship is inseparable from the possibility of resistance. A speech that drew attention is expressed as illustrative of what this prescriptive discourse is:

This speech is crossed by a prescriptive and normative perspective: ‘if you drink, don’t have sex’. It starts with prescriptions, rather than with attempts to understand or seek to construct, with the subject, what is the best and/or possible for him, understanding that the aforementioned prescriptive discourse could be inscribed:

Thus, it is understood that

It would be possible, then, to associate this with the statement of freedom for Foucault, which only exists based on power relations. Castro¹⁵15 Castro E. Vocabulário de Foucault: um percurso pelos seus temas, conceitos e autores. Belo Horizonte: Autêntica Editora; 2009. compiles and explains how freedom works for Foucault:

The prescriptive speech, present in the worker’s instruction, can be heard by several subjects, that are free to follow or not, that can be captured or resist. It is important to emphasize that, in the relationships that are conceived by processes of freedom, one places oneself next to the other, not in the place or on top of the other, seeking to build relationships of dialogue, that help to think about oneself (not to prescribe to the other), recognizing the leading role in the production of health. This perspective dialogues with the reduction of harm and risk, envisaged as one of the approaches expressed in the prevention mandala¹⁸18 Brasil. Ministério da Saúde. Prevenção Combinada. Brasília, DF: O Ministério; [2010].. From this perspective, it is possible to expand possibilities that protect the subject, based on what is within their reach, their conditions and needs.

Final considerations

The study found that the PEP was implemented in the municipality, expanding the possibilities of HIV preventive strategies for the population. Despite this, there are still aspects that constrain the offer of PEP, highlighting controversies around its classification within the risk classification criteria and situations in which users did not obtain care in emergency services, resorting to the SAE/COAS after the end of the deadline for prescription of PEP.

Public policies are crossed by a game of socially constructed forces and discourses. Just as many of these discourses convey acceptance, not judgment, participatory bias, there are also prescriptive discourses: ‘if you drink, don’t have sex’, forging a sexual dietetics and insinuating itself on the bodies of health professionals and users of health services, opening a field of possible experiences in this game of forces.

The need for a reconfiguration of the preventive culture is indicated, incorporating the notion of combined prevention, in which the condom is just one of the prevention strategies among several available, with emphasis on PEP. It is defended that it be offered as a way to expand the relations of freedom, allowing the subjects to maximize their degrees of autonomy and protagonism in the effectiveness of prevention.

References

Publication Dates

History