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Same-Day PrEP Popular With Adolescent MSM and TGW in Brazil
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IAS 2023, July 23-26, 2023. Brisbane
Mark Mascolini
Among 1193 adolescent men who have sex with men (aMSM) and adolescent transgender women (aTGW) eligible for preexposure prophylaxis (PrEP) in a big Brazilian demonstration project, 88% agreed to start PrEP at their first study visit [1]. Adolescents who started PrEP reported more frequent HIV risk behaviors than those who declined PrEP but incorrectly perceived themselves to run a low risk of HIV infection.
MSM and TGW account for most HIV infections in Brazil, noted researchers from the Instituto de Saúde Coletiva of the Universidade Federal da Bahia, and HIV incidence among aMSM and aTGW has been on the rise in Brazil. Daily oral PrEP became available to adolescents in Brazil in 2023, but only 0.1% of adolescents use PrEP.
Researchers from the Instituto de Saúde Coletiva conducted this study to explore sociodemographic and behavioral traits of aMSM and aTGW starting or declining PrEP in Brazil’s HIV prevention clinics. They analyzed data from PrEP1519, a demonstration cohort study that offered PrEP to aMSM and aTGW in three Brazilian capitals: Sao Paulo, Salvador, and Belo Horizonte. Baseline data came from people who entered the cohort between February 2019 and August 2021. Follow-up of people who started PrEP continued until February 2022.
The demonstration cohort accepted people 15 to 19 years old who declared themselves an aMSM or aTGW, tested negative for HIV at their enrollment visit, and lived, worked, or studied in one of the three capital cities. Based on HIV vulnerability, standard clinical criteria to start PrEP, and decisions made at the first study visit, researchers placed cohort members into one of four groups—ineligible for PrEP, eligible and started PrEP at the first visit, eligible and started PrEP after the first visit, and eligible but did not start PrEP.
Among 1254 adolescents who visited one of the study clinics, 61 (4.9%) were judged not eligible for PrEP, leaving 1193 eligible PrEP candidates. Of those eligible aMSM and aTGW, 1054 (88.3%) started PrEP on the day of their first clinic visit, 59 (4.9%) started PrEP after their first visit but during the study period, and 80 (6.7%) decided not to try PrEP.
Among the 61 adolescents judged ineligible for PrEP, the most frequent reasons for ineligibility were condom-free anal sex in the past 6 months (44.3%), self-reported sexual intercourse in the last 72 hours that put them at risk for HIV (27.9%), self-reported frequent drug or alcohol use before or during sex (16.4%), and self-reported frequent experience of violence and discrimination related to their sex life (16.4%).
A big majority of adolescents who declined PrEP, 92%, thought they ran a low risk for HIV infection. But in fact, 70% of them had condomless anal sex in the past 6 months and 51% did not use a condom the first time they had sex. PrEP decliners differed from same-day starters and later starters in several ways: higher proportion with 12 or more years of education (59% vs 54% vs 47%, not significant at P = 0.11), lower proportion living in Sao Paulo than the other two cities (31% vs 47% vs 37%, P = 0.01), lower proportion not using condom at first sex (51% vs 55% vs 57%, P = 0.01), lower proportion having condomless sex in past 6 months (70% vs 85% vs 79%, P < 0.00), lower proportion having transactional sex (6% vs 16% vs 22%, P = 0.02), lower proportion with 2 to 5 or 6 or more versus 0 or 1 casual sex partners in the past 3 months (P = 0.00), lower proportion tested for HIV before this study (44% vs 60% vs 59%, P = 0.03), and higher proportion having a low self-perceived risk of HIV infection (92% vs 77% vs 84%, P = 0.02). People who started PrEP at their first visit had the highest proportion with a moderate to high self-perceived risk of HIV (23% vs 16% in later starters and 8% in decliners, P = 0.02).
Notably, big majorities of these aMSM and aTGW considered themselves at low risk for HIV infection yet included high proportions with clear risk factors and usually did decide to start PrEP during the study period, usually at the first visit. The investigators observed that the high proportion of adolescents willing to start PrEP at their first study visit largely explained the high overall rate of PrEP acceptance by these adolescents (93.3%).
Reference
1. Soares F, Magno L, Pinto JA Jr, et al. Same-day initiation of oral pre-exposure prophylaxis is high among adolescent men who have sex with men and transgender women in Brazil. IAS 2023, July 23-26, 2023. Brisbane.
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