Introduction
Methods
Study design and population
Data collection and instruments
Data analysis
Results
Participants’ profile
Characteristics | N | % |
---|---|---|
Population group | ||
MSM | 39 | 81.3 |
TGW | 9 | 18.8 |
Sexual orientation | ||
Homosexual | 30 | 62.5 |
Bisexual | 10 | 20.8 |
Heterosexual | 7 | 14.6 |
Pansexual | 1 | 2.1 |
Race or skin color | ||
Black | 25 | 52.1 |
Brown | 10 | 20.8 |
Indigenous | 1 | 2.1 |
White | 12 | 25.0 |
Age | ||
16 | 1 | 2.1 |
17 | 6 | 12.5 |
18 | 10 | 20.8 |
19 | 21 | 43.8 |
20 | 10 | 20.8 |
Schooling | ||
High school (complete) | 7 | 14.6 |
High school (attending) | 12 | 25.0 |
High school (incomplete) | 1 | 2.1 |
Middle school (complete) | 14 | 29.2 |
Middle school (attending) | 10 | 20.8 |
Middle school (incomplete) | 1 | 2.1 |
Elementary school (complete) | 3 | 6.3 |
PrEP use and adherence level | ||
High PrEP adherence | 20 | 41.7 |
Low PrEP adherence | 16 | 33.3 |
Non-PrEP user | 11 | 22.9 |
Missing | 1 | 2.1 |
Prior knowledge of LAI-PrEP | ||
Yes | 3 | 6.3 |
No | 45 | 93.8 |
Interest in using LAI-PrEP | ||
Yes, I would use it | 32 | 66.7 |
No, I would not use it | 10 | 20.8 |
Yes, maybe | 1 | 2.1 |
No, maybe not | 3 | 6.3 |
“My family's financial situation is not good... my mother is currently unemployed, it’s my father who works. (...) It ’s not that life where you can go buy the things you feel like, but we manage to support ourselves. (...). I think this has influenced me a lot to try to study and have something in the future.” (#56, White, MSM; # 17, PrEP: non-adherence, SSA)
Knowledge and interest in using LAI-PrEP
Variables | Yes | Maybe, yes | No | Maybe not | Total | ||||
---|---|---|---|---|---|---|---|---|---|
MSM | 30 | 77% | 1 | 3% | 5 | 13% | 3 | 8% | 39 |
TGW | 2 | 22% | 0 | 0% | 7 | 78% | 0 | 0% | 9 |
Advantages | 51 | 81% | 3 | 5% | 8 | 13% | 1 | 2% | 63 |
Disadvantages | 17 | 45% | 3 | 8% | 17 | 45% | 1 | 3% | 38 |
Experience in PrEP use | 25 | 71% | 1 | 3% | 7 | 20% | 2 | 6% | 35 |
No experience in PrEP use | 7 | 64% | 0 | 0% | 3 | 27% | 1 | 9% | 11 |
PrEP Adherence | 11 | 55% | 0 | 0% | 8 | 40% | 1 | 5% | 20 |
PrEP Non-adherence | 14 | 93% | 1 | 7% | 0 | 0% | 0 | 0% | 15 |
Perception of the advantages and facilitators of using LAI-PrEP
“I think there should be a method that (...) the girl takes an injection every month to avoid the risk of having a child. It would be nice to have, like a month-long PrEP injection, instead of having to pill every day.” (#17, White, MSM, # 17, PrEP-adherence, SSA)
Benefits associated with lower frequency of drug use: getting rid of a daily obligation
“Man, injecting (that) would make me more relaxed. Because taking medicine every day … besides forgetting, I hate, it is like punishment, an obligation. I rebel against my obligations. I hear this a lot, and I am rebellious. I do not like obligations.” (#46, black, MSM 19, non-PrEP, SSA).
“There are people who give up on PrEP because it has to be used every day, at the same time, and it requires a certain type of discipline, right? For you to keep taking it, and many people are not willing to do that (...) although I have this discipline, to be able to take it every day like that, (with LAI-PrEP) it would be less of a concern, for example, one less task a day, not having to take PrEP.” (#49, Black, MSM, # 19, PrEP non-adherence, SSA)
“For example, on long trips, you sometimes kind of disconnect from obligations (...), from chores, a PrEP (...), that you do not need to take every day and then I will go back again to having it injected, that would be interesting.” (#49, Black, MSM, # 19, PrEP non-adherence SSA)
Solution against forgetting to take the medication
One of the participants pointed out the possibility of unpredictable and/or everyday situations in which adolescents could be involved in, such as participating in long parties or even organizing social events such as going to the beach on Sundays, which could interrupt the daily regimen.“I would use it because it would be good (avoiding) having to use the medicine every day, (so) this form of injection would be great. Not to have an excuse like: “Oh, I forgot to take the medicine,” I did not take it, that's why it happened without a condom, and I got HIV. Got it?” (#43, Black, MSM, # 19, PrEP non-adherence, SSA)
Among participants who were not adherent to the PrEP regimen and were only interested in using the LAI-PrEP, forgetfulness and difficulty in incorporating this new habit into their usual routine were among the main reasons for discontinuing PrEP.“If I go out somewhere, for example, if I go to the beach on Sunday, and I have to take the medicine at night and I am not back in time, or if I go out and go somewhere else, understand? Or the party goes on overnight and I forget to take it and such.” (#46, black, MSM; # 19, non-PrEP user, SSA)
There was a time when I was not working out; I resumed working out, and every day I was taking it when I arrived at the gym. I was in doubt about whether I had taken it. Because I took it and I was in doubt afterwards, did I take it? Did I or did I not?”. (#45, White, MSM, # 20, PrEP non-adherence, SSA)
“Sometimes I go out and forget it at home. I go out with my backpack a lot, sleep over at my aunt's house, take my clothes, take my backpack, and sometimes forget to take my PrEP. I once took an empty vial because I had two small vials, for two months, and I took the empty vial with me and left the full one at home’ (#45, Brown, MSM, 20, PrEP-Non-adherence, SSA)
Perceived practicality of LAI-PrEP: greater independence from the health center and lower costs
Some participants with low adherence to PrEP reported that the displacement to pick up the medication monthly was considered a barrier, possibly related to their socioeconomic vulnerability and the change in residence, which were shown in the interviews’ undertones.“I thought it was cool and since I live far away it is even better. Like, I go there, do the exam and such, and then I take it, then after months I go back there again, it’s even better, you know? (...). And like, it's not every time I have the money, right?” (#21, Brown, MSM, # 17, PrEP adherence, SP)
Other participants with low adherence to PrEP reported having difficulty swallowing PrEP pills and found LAI-PrEP to be a better option despite having concerns about receiving an injection.“I stopped using it because I stopped living downtown [the same location of the PrEP clinic], so it was a bit difficult, you know? Like, finding the time to go to the place where I used to pick up [PrEP].” (#49, Black, MSM, # 19, PrEP non-adherence, SSA)
“Needles, those things... I don't know... I don't know... So, maybe, maybe, I would use it... It's bad, even, to swallow that pill. I have a hard time swallowing that thing, you know?” (#49, Black, MSM, # 19, PrEP non-adherence, SSA)
LAI-PrEP–others–target populations: “crazy friends,” “sex workers,” and “always forgetful”
“[LAI-PrEP] It is more suited for people who forget a lot, are very busy, work in the world, sex work too, because they sleep a lot outside the home and forget to take their medicine [...]. I have a friend who is a sex worker. [...]. She is very forgetful and understands?”. (#83, white, TGW, 18, PrEP adherence, SSA)
“Oh yes, I would advise it. There are some friends of mine, for Heaven’s sake, for God's sake, they are up to no good. My trans friends, the ones who are married.”. (#89, indigenous, TGW, 19, PrEP-non-adherence, SP)
“Oh, I don't know anyone, but for people who do porn, in the porn industry, people who have relationships with several partners, sex workers...”. (#62, White, MSM 19, Non-PrEP users, SSA)
Perception of disadvantages and barriers to LAI-PrEP use
Fear of injection, doubts about handling and storage of LAI-PrEP
“I would think it's bad because there are a lot of people who don't like to take injections. I would rather take it. I prefer to take a pill every day.”. (#17, White, MSM, # 17, PrEP adherence, SSA)
A young MSM also expressed concerns on the storage conditions of the medication used in LAI-PrEP, regarding it as more “complicated.”“The disadvantage I think would be the handling, someone handled it wrongly, someone applied it wrongly, jabbed wrong, you know? Sometimes, I think about the contraceptive that sometimes women take at home or at the pharmacy, and it can happen that they are wrongly applied and I think that it can also happen in this model.” (#62, White, MSM 19, Non-PrEP users, SSA)
“And the means also, like, for preserving it, it's not, like, all-encompassing. As I do not know, an injection is a liquid, it will have to reach a certain temperature, and it will have to be kept in a given environment. Therefore, this process is complicated. So, I think it's complicated.”. (#16, Black, MSM; # 17, PrEP adherence, SP)
Little confidence in the efficacy, doubts about dosage, and fear of side effects
“Maybe, I don't know, the side effects, all of a sudden. You sum up the 60 days in one go. Sixty pills at once.” (#46, black, MSM; # 19, non-PrEP user, SSA)
“It's very good, but it's scary because it's a huge dose of medicine you are taking, right? As we do not, we are not at the mercy of knowing if you are going to have an allergic reaction. It's like the injectable contraceptive, like it's a very large dose that you are taking, so it varies from body to body. [...]. Therefore, there is the insecurity of not knowing if this high drug dose will cause something to your body, because when you take it assiduously, at least it will be something in the long term. If you take a very high dose, once, every two months, you are at the mercy of some kind of side effect, it comes faster.”. (#22, Brown, MSM, # 20, non-PrEP user, SP)
Fear of forgetting and worry of discontinuation
“Ah, I think the daily PrEP, because, for example, you're going to go there [health service], sometimes you forget too, sometimes you forget... Then you forget, now not anymore, PrEP daily, the small vial of medicine is already in your house, for you to take.” (#21, brown, MSM; 17, PrEP adherence, SP).
“Because it could be that I had the injection today, but I did not schedule anything, but I do not know, a month and a few days, I do not know, a month and twenty days from today I have to travel somewhere and I will be gone for 30 days. So, I was past the deadline for taking the medicine. Then, I did not take my medicine and it happens that … for example … I was on this trip and it happened that I ended up having sex with someone there. So, I am not going to be “protected” if I am using a condom, yes, I am. However, if you do not have it at the moment, how does it happen? So, I think it is cool, but not cool. Because the medicine's facility is that you can take it everywhere, right.” (#27, black; MSM, 17; PrEP adherence, SP)
Dependence on the PrEP clinic and health professional
“So, if you see that thinking broadly now, if you see that every time it requires you to go there every two months, it requires a certain periodicity, for example, for you to do that, I think it would be a little complicated.” (#21, brown; MSM, 17; PrEP adherence, SP)
Safety and comfort of taking daily oral PrEP
“It's that comfort zone issue, right? I will not complain about the pill. Injection is something like... the needle, this thing... I do not know... I do not know... I am still fixed on this issue with the needle, right?”. (#39, black, MSM; # 18, PrEP-nonadherence, SSA)
“Well, as I like to take medicine... it's not that I like it, but I have the habit of taking it, so it does not make any difference to me, taking an injection or a pill.” (#83, white, TGW, 18, PrEP adherence, SSA)
Interference with feminizing hormone therapy
“And I also know that there are other types of PrEP, such as injectable PrEP. However, even when talking to the infectologist, she said there is a risk of the injectable part, which is not recommended for trans women, precisely because it conflicts with hormone therapy.” (#37, white, TGW, 19, PrEP adherence, SP)