Why Is Preexposure Prophylaxis So Underused in Brazil?

This article was originally published in Portuguese on Medscape.

In Latin America, Brazil is the leader in the use of preexposure prophylaxis (PrEP) for prevention of infection with HIV. It was the first country in the region to establish free national access to prophylaxis through the Brazilian Public Health System (SUS) for men who have sex with men (MSM) and who are at increased risk of acquiring HIV. However, Brazilians still represent a minimal percentage of PrEP users worldwide.

The Joint United Nations Program on HIV/AIDS (UNAIDS) recommends 50% coverage for MSM and transgender individuals at very high risk of acquiring HIV. Brazil is still far from reaching this goal. Beatriz Grinsztejn, MD, PhD, is an infectious disease specialist and researcher at the Oswaldo Cruz Foundation's Evandro Chagas National Infectious Disease Institute (INI/Fiocruz) and a global expert in HIV. In an interview with Medscape Medical News, she explained, "PrEP use still needs to be expanded to an adequate level in Brazil."

A new study on PrEP use among eligible Brazilian men, according to SUS criteria, found that higher levels of HIV knowledge were associated with increased odds of PrEP use. The investigators also considered the influence of "internalized homonegativity," a phenomenon derived from social prejudice, on adherence to treatment.

"Stigma can impact many things, and internalized homonegativity is an individual's response to societal attitudes. If people experience stigma and discrimination in the world, for example, at work or within their family, it often leads to an internalization of these perceptions. This results in people exposing themselves more instead of protecting themselves," explained Grinsztejn, who is also one of the study's authors. She added that health services need to show more empathy toward these populations to increase engagement with those who are most vulnerable. "In Brazil, health services don't tend to be friendly toward homosexuals and transgender individuals. Stigma and discrimination are seminal issues implicated in the insufficient expansion of PrEP use."

Sexually Active Homosexual Men

The online cross-sectional study was conducted among Brazilian Hornet–Queer Social Network users. Hornet is popular among gay, bisexual, and other MSM in Latin America. Requests to complete a voluntary survey were sent to the approximately 1 million Hornet users in Brazil through the direct message inbox. Only those who described their sexual orientation as gay/homosexual received the questionnaire.

The study authors focused on sexually active cisgender men and thus excluded those who identified as transgender men, transgender women, or gender nonbinary, as well as those who reported having no male sexual partners in the previous 6 months.

Additionally, the study was limited to respondents who were eligible for PrEP in Brazil, in accordance with the following criteria: condomless anal intercourse in the past 6 months, recent history of partner(s) living with HIV, recent history of transactional sex (for money or other types of compensation), and/or recent history of sexually transmitted infection. Only 15.4% of the 2300 eligible respondents reported current PrEP use.

Influential Factors

All eligibility criteria for receiving PrEP were associated with an increased likelihood of current PrEP use. In addition, a high number of male sexual partners was associated with increased odds of PrEP use. Those who reported having 31 or more male sexual partners in the past 6 months had the highest odds of current PrEP in comparison with any other subset.

Another subset that presented higher levels of current PrEP use were those who reported chemsex (illicit substance use before or during sex) or daily use of virtual channels to seek sex. However, the strength of these associations decreased or was lost when adjustment was made for other demographic and sexual behavior variables in the full model.

Internalized homonegativity (ie, the process through which lesbian, gay, and bisexual individuals internalize social messages regarding gender and sex, leading to negative perceptions toward themselves) remained associated with decreased PrEP use.

The Reactions to Homosexuality Scale (RHS), available in Brazilian Portuguese, was used to measure internalized homonegativity. The tool comprises seven statements to which the participant must indicate a degree of agreement. The statements are the following:

I feel comfortable in gay bars.
Social situations with gay men make me feel uncomfortable.
I feel comfortable being seen in public with an obviously gay person.
I feel comfortable discussing homosexuality in public.
I feel comfortable being homosexual.
Homosexuality is as natural as heterosexuality.
Even if it were possible, I would not change my sexual orientation.

Total scores range from 0 to 42. Higher scores indicate higher internalized homonegativity.

The authors recognized that the reason for the inverse association between internalized homonegativity and PrEP use in Brazil is likely multifactorial and feel that further research should explore this relationship in more depth.

In contrast, greater HIV knowledge was associated with increased PrEP use. HIV knowledge was measured via the HIV-KA tool, which contains 12 statements about the transmission and prevention of HIV/AIDS. Participants were asked to respond to the statements by indicating "true," "false," or "I don't know."

As a secondary measure of HIV prevention knowledge, respondents were asked about their perceived accuracy of the following statement: "Undetectable = Untransmissible (U = U), that is, people who live with HIV and are undetectable do not transmit HIV through sex." Response options included "completely accurate," "somewhat accurate," "somewhat inaccurate," "completely inaccurate," or "I don't know what undetectable means."

Variable Availability

Individuals who had never taken or had stopped taking PrEP reported having difficulty accessing the prophylaxis. This issue is important because the availability of PrEP at SUS facilities varies across the country. Two thirds of the country's 270 facilities that provide PrEP are in the south or southeast region of the country. The state of São Paulo, for example, has 100 of these facilities, while eight states in the north and northeast regions of the country have two or fewer facilities.

"São Paulo has a series of municipal and state services that provide PrEP, while in Rio de Janeiro, for example, these services are precarious," said Grinsztejn.

The study also found that in comparison with White or Asian persons who were MSM, Black persons who were MSM had significantly lower odds of current PrEP use, even when controlling for income and education level. In addition, the number of young adults aged 18 to 24 years who used PrEP was lower in comparison with those older than 40 years.

The study had several limitations. The authors recognize that it is impossible to establish causality when using cross-sectional data from a convenience sample (ie, using a sample collection from a part of a similar population rather than a randomized sample). There are also deviations in the responses given on the self-report questionnaires and demographic characteristics, which may influence results.

How Many Have Benefited?

As of September 2021, there were 270 healthcare centers across all Brazilian states that provided PrEP to approximately 23,000 individuals. An additional 3000 or more received PrEP through research studies, such as the Implementation PrEP Project (ImPrEP). Recent studies estimate an HIV prevalence among Brazilian MSM as high as 23.0%, but it is impossible to know how many Brazilians who do not have HIV would benefit from PrEP.

"There is no evaluation of the size of the MSM population, nor the size of the population of transgender women, to calculate how many of these individuals would be eligible for PrEP in Brazil. It is a very complex calculation," said Grinsztejn.

Grinsztejn participated in the mathematical modeling study that evaluated the size of the population eligible to receive PrEP in Brazil, with the aim of supporting public policy. The study estimated that in 2018, this population would include approximately 66,000 men aged 15 to 64 years.

In Latin America, several countries have recorded a growing incidence of HIV infection among MSM. The situation differs from that in Africa, where the epidemic is widespread and where, as a result, PrEP is broadly indicated. "PrEP is a medication used solely by persons at increased risk of contracting HIV. The issue is completely epidemiologic," said Grinsztejn.

Oral and Injectable

Emtricitabine and tenofovir together in a single tablet is the PrEP administered by mouth and made available through the SUS. It is estimated that the drug reduces the risk of HIV infection by up to 99% when taken by MSM once per day or before and after sexual activity using the 2 + 1 + 1 PrEP regimen. "Brazilian guidance indicates daily use; however, the WHO [World Health Organization] guidance already includes on-demand PrEP," Grinsztejn added.

Long-acting injectable cabotegravir has been approved by the US Food and Drug Administration (FDA) and has been submitted for approval to the Brazilian National Health Surveillance Agency. This drug provides 8 weeks of continuous protection against HIV infection through a single intramuscular injection. FDA approval was based on two extensive studies conducted with MSM and transgender women in seven countries, including Brazil, Argentina, and Peru. One study indicated that cabotegravir was superior over oral therapy. The other study was conducted with young women in Africa.

Brazil will pioneer injectable PrEP use. Unitaid, the global health initiative, will finance the implementation of the project, whose target population is MSM and transgender women aged 18 to 30 years. Grinsztejn will coordinate the project at Fiocruz, and it will be conducted in partnership with the Brazilian Ministry of Health.

Demedicalization of PrEP

Grinsztejn emphasized that healthcare professionals need more access to information and a greater understanding that PrEP can bring better quality of life to those at greater risk of HIV infection.

"In fact, I think this could eventually change physicians' expectations regarding prescriptions. There is also a lot of false information, which leads to a lack of sensitivity in the medical profession regarding prescriptions. On top of this, we have structural issues, stigma, and discrimination toward the most affected populations," she stated.

"Therefore, if there is one message to get out there, it's that we need healthcare professionals who are more empathetic toward the populations under their care. Stigma and discrimination are significant issues in the process of this disease, because they discourage people from seeking care."

Grinsztejn believes that PrEP should be prescribed not only by doctors but also by other healthcare professionals, such as nurses. "I believe it is crucial to demedicalize PrEP. This would have an enormously positive impact."

Grinsztejn reported no relevant financial relationships.

Roxana Tabakman is a biologist, freelance reporter, and writer who resides in São Paulo, Brazil. She is the author of the books A Saúde na Mídia, Medicina para Jornalistas, Jornalismo para Médicos (in Portuguese), and Biovigilados (in Spanish). Follow her on Twitter: @roxanatabakman.

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