Artigos

Conteúdo (article):

Concepciones de usuarios sobre nuevas vías de administración de profilaxis
pre-exposición para el VIH

Users’ expectations of the new pre-exposure prophylaxis
for the HIV modalities


Resumen
Este artículo tiene como objetivo discutir las concepciones de los Hombres Gay, Hombres Bisexuales y una Mujer Transgénero que usan o quieren usar profilaxis previa a la exposición (PreP) por el virus de la inmunodeficiencia humana sobre nuevas vías de administración. Fueron entrevistados 17 usuarios del BCN Checkpoint. Las entrevistas fueron grabadas en audio, sometidas a análisis categorial temático teniendo en cuenta la perspectiva praxeográfica. Todos están adaptados al uso de la PrEP diaria y a demanda. En relación con las nuevas vías de administración (PrEP inyección intramuscular cada 2 meses; pastilla mensual; inyección subcutánea cada 6 meses) todos son muy receptivos a esas posibilidades, pero les falta información sobre las especificidades de cada una de ellas y una evaluación específica de sus necesidades. Tanto la satisfacción con el uso de PrEP oral, como las expectativas sobre las nuevas vías de administración son positivas. Sin embargo, lo más importante para los/a entrevistados/a es la garantía de que tendrán seguimiento para continuar cuidando de la salud afectivo-sexual, lo que no depende del tipo de vía de administración.
Palabras-claves: Virus de la inmunodeficiencia humana; Profilaxis preexposición; Infecciones de transmisión sexual.

Abstract
This article aims to discuss the expectations of Homosexual Men, Bisexual Men and a Transgender Woman, who use or want to use an oral pre-exposure prophylaxis (PrEP) for the human immunodeficiency virus (HIV) about PrEP modalities. Sixteen PrEP users, who are followed up in the BCN Checkpoint, were interviewed,. The interviews were audio-recorded, subjected to thematic categorical analysis within the theoretical framework from the praxiographic perspective. They are all adapted to the use of daily oral and event-based PrEP. In relation to the new PrEP modalities (monthly pill; intramuscular injection every 2 months; subcutaneous injection every 6 months), they are all very receptive to these possibilities, but they lack information on the specificities of each and specific assessment of their needs. Comments about the use of oral PrEP are positive, and expectations regarding the new PrEP modalities are visibly high. However, the most important thing for the interviewees is the guarantee that they will have follow-up appointments to continue taking care of their affective-sexual health, which is not dependent on the type of PrEP modalities.
Keywords: human immunodeficiency virus (HIV); pre-exposure prophylaxis (PrEP); sexually transmitted diseases (STDs).


INTRODUCTION
PrEP, a prophylaxis prior to exposure to the human immunodeficiency virus (HIV) is a prevention strategy recently incorporated into Spain’s health system, framed within the measures taken to reduce the number of new HIV cases. This strategy focuses on taking antiretrovirals, and is accompanied by medical follow-up in which aspects related to sexual health and the functioning of the medication are addressed. The Tenofovir Disoproxil fumarate-emricitabine pill, known as PrEP and taken daily or on demand, is the most commonly used worldwide. Oral PrEP reduces the risk of HIV by 99%, as evidenced by studies conducted by Grov et al.1. Other ways of administering it are under study, some in advanced phases, and are considered promising for the control of HIV2-3 transmission. In general, these are not yet available in Spanish public health services. However, conducting studies and advancing the discussion on new ways of administering PrEP is necessary for adequate implementation of combined prevention. According to Zhang et al.4, studies on the use of oral PrEP will be informative and improve its implementation in the future. Some alternative ways of administering it, e.g., long-acting injectable (LAI) cabotegravir PrEP, are already approved in some countries, and others, e.g., implants and patches with microneedles are under development (p. 254-255). The World Health Organization5 (p. X) continues to recommend moderate use of long-acting injectable (LAI) PrEP highlighting that it “can be offered as an additional prevention option for people at substantial risk of HIV infection, as part of combined prevention approaches”.
Mansergh et al.3, in the U.S.A., studied the probability and order of preference of men who have sex with men (HSH) regarding daily use of PrEP and other ways of administering PrEP (injections every one to three months, oral dosage on demand (regime 2-1-1 consists of taking two pills together between 2 and 24 hours before sexual relations), anal or penile gel, or anal suppository). The justification for the study was that understanding this matter could better guide development of HIV prevention. Darrell et al.2, a study in Canada, concluded that the heterogeneity of preferences with respect to emerging HIV prevention technologies suggests the importance of developing a variety of PrEP formulations, since they could attract other HSH at risk. The Torres et al.6 study in Brazil, Peru and Mexico, stated that, in general, injectable PrEP was the modality most preferred among HSH, whereas preference for daily oral PrEP and PrEP based on events varied according to the age, income and education of the interviewees in each country. It concluded that “public health interventions to increase awareness and availability of PrEP modalities in Latin America were urgent, especially among HSH youths with low incomes and educational levels” 6 (p. 8).
This article aims to discuss the expectations of PrEP users, and those who wish to use oral PrEP, daily or on demand, regarding the new ways of administering it. The text is organized in three parts. In the first, we describe the study’s field work, recruitment strategies, the profiles of the participants, and the type of information analysis, while presenting the praxiographic perspective of Mol7 that had led us to consider the use of a pill (object/non-human) and its effects on affective-sexual practices, experienced in the context of the stigma and discrimination of the HIV pandemic. In the second, we discuss the results of the interviewees’ expectations of the ways of administering PrEP based on the remarks they present in relation to the changes in their affective-sex life after the use of PrEP. Finally, in the third, we present the conclusions and contributions of this study regarding this phenomenon.

METHOD
Annemarie Mol was interviewed by Martin et al.8 about her work in the field of health anthropology, in which she defends that the materiality of things is as significant as social interactions, for example, meetings between health professionals and health users, the prescriptions the former give to the latter, and the users’ affective practices in their own socio-cultural contexts. According to Mol, this praxiographic perspective is characterized as resembling a trace or path8 (p. 298). Drawing upon the Actor-Red Theory, Mol7 emphasizes that the reality is made/performed through practices, and thus it is historically, culturally and materially located, which means that “the specificities of the field are very important. A practice always happens somewhere, never in all places ”(p. 298).
According to this praxiographic premise, one of the researchers interviewed 17 oral PrEP users at the CheckPoint Community Centre (BCN Checkpoint), run by peers of the LGBTI+ community in Barcelona, Catalonia (https://ww.bccheckpoint.com/ ). During the interviews, there was conversation about their affective-sexual practices with use of the pill and the new ways of administering it. What we produced together (the interviewees, the interviewer and the other researchers) emerged as "a trace" promoting new knowledge on the subject.
With Mol7 we understand that expectations of new ways of administering PrEP can be identified by the description of practices and their interactive networks that enable the co-production of objects/knowledge. In this direction, we are interested in reflecting on the effects of the use of the oral pill and the other ways of administering it in people, assuming that the objects/materials have an impact on our lives, since objects are also actors in social relations7-8.
The users first filled an online questionnaire about the new ways of administering PrEP. It was sent to those who were currently using PrEP or close to initiating its use, which were criteria consistent with the objective of the study. At the end of the questionnaire, participants could decide whether or not to receive a phone call inviting them for a face-to-face interview appointment at the Centre, where we would seek to deepen the theme. The items covered in the interview were: experience with PrEP, affective-sexual practices in the times of PrEP, knowledge about new ways of administering PrEP and possibilities of using it. This article focuses on the expectations the interviewees had about their experiences with oral PrEP and their expectations in relation to the new ways of administering it.
At random, we entered into contact with some of them for the second stage of the investigation, including all those who were already using PrEP or were interested in it. Among the 21 programed appointments, in three consecutive weeks of August 2022, 17 users turned up, and those who did not informed their various reasons. The interviews were completely transcribed with the Transkriptor software and reviewed for the subsequent thematic categorical analysis (TCA) 9 by the first two authors of this article. The TCA was carried out in three consecutive recursive stages (pre-analysis, coding and categorization). The statements were decomposed into units (sentences) and encoded by the similarities depending on the objective of the analysis.
The analysis material resulted from 387 minutes of recording. The most extensive interview was 32 minutes and the shortest 11. The transcription amounted to 160 pages. Below we will present the thematic category, "Expectations of the ways of administering PrEP", which groups together the dialogic fragments about the interviewees’ experiences using their current way of administering it (daily pill or on demand) and the new ways not yet available in Spain (e.g., intramuscular injection every 2 months; monthly pill; subcutaneous injection every 6 months). The analysis also considers the expectations built by the participants of the effects of PrEP on affective-sex life, which we develop in the first section of the results to contextualize the before and after PrEP use. We used the online questionnaire to gather certain information from the 17 participants, for example, age, education, time using PrEP, socio-economic data, sexual orientation, etc.; it should be clarified that these did not constitute selection criteria, but simply aided contextualization of their narratives.
At first, among the interviewees, it appeared that all 17 identified themselves as males, but, during the interview, one declared she was a transgender woman; the latter was not excluded from the group, given that the focus of the study was on PrEP use and not on gender identity (Table 1).
Table 1

The ages of the participants varied from 26 to 60. Two were born at the end of the 60s, four in the 70s, eight in 1980, one in the 90s, and two did not answer the question about age. 70.5% are European, of which 58.3% were born in Catalonia, Spain. As for education, 70.5% of the interviewees had advanced levels, and all finished secondary school except one that had had only attended primary school. All except one had employment at that time. Their salaries varied, most earning over €1,000; one earned less than €1,000, three earned more than €3,000, and one did not want to answer that question. It should be added that the study was approved by the Ethics Committee of Research at the Germans Trias I Pujol University Hospital, Catalonia, as well as by the Ethics Committee of the Nursing School in Salvador, Bahía State, Brazil, thus complying with the current legislation.

RESULTS AND DISCUSSION
EXPECTATIONS OF AFFECTIVE-SEX LIFE AND USE OF ORAL PrEP
The expectations of affective-sex life in times of PrEP allowed contextualization of the analysis of the article’s focus, that is, the new ways of administering it. In this regard, it is to be highlighted that the majority of the interviewees were taking PrEP on a daily basis, and only two on demand. Thus, all were adapted to the presence of the pill in their day-to- day lives:
Look, I’m super strict, so I have my time, at lunch, which is good for me, because at night I do not like to take it, as it could clash with a party or something [. ..] At noon I\'m never partying or drinking alcohol or anything. Also I have an app that gives me a reminder to take it, and, once I’ve taken it, I feel at ease . (E-15, aged 35)
The experience of the interviewees with PrEP was positive, considering the time it had been available in the health services (2019): 60% had used it more than 3 years and 33% for 2 to 3 years. In the interviews it was noticeable that they had no difficulty taking it, whether on a daily basis (13) or on demand (2). One of the participants shared the daily use pills received by his partner. Interviewee E-6 and his partner had autonomously decided to share the pills due to the long waiting list to join the program. However, as E-6 was not carrying out the recommended monitoring, at the end of the interview, he was invited to join the program at the earliest possible date.
It should be added that the above situation can harm those who practice it. Follow-up is essential to evaluate potential side effects derived from PrEP, as well as the importance of performing controls for HIV and other sexually transmitted diseases (STDs). It is especially important to rule out an HIV infection before starting PrEP (and also every 3 months) to prevent the virus from generating resistance to the medicines. The PrEP use information system in Spain (SiPrEP)10 points out that 13.4% of users in the country had taken it prior to entry into the current program. 66.7% had acquired it online, and “almost a quarter without medical supervision” (p. 8). The interviewees suggested that it is necessary for PrEP to reach everyone. E-10, having evaluated his own experience of feeling protected, stated:
It\'s important for everyone to have access. It’d be great, because I know there are people still on the waiting list. [...] As I have been so well since I started protecting myself with it, I’d really like people to have more access to it. (E-10, aged 48).
Among our interviewees, some had also used PrEP before the official implementation by the Spanish health services in 2019. They had bought it on their own online. Two of the interviewees (E-3 and E-4.) did not use PrEP, but wished to do so. Both were included in the PrEP start program after the interview. All 15 participants, who already used PrEP, were satisfied with this combined prevention strategy. Their remarks were mostly positive and they reported changes in their affective-sexual experiences, associating it with freedom, especially the elderly due to their experiences in other stages of the HIV pandemic.
[...] Wow! How well I feel now! Full satisfaction! It’s just unfortunate I’ve had to wait so long. It’s been 40 years, right? I have only really started having full relationships since 55. Other poor fellows are still stuck on the road. (E-17, 60 years). Of course, this is now; Before, if you did something without protection, you always had the fear of whether or not you could be infected not. (E-13, 44 years).
The changes in the affective-sex life of the interviewees can be synthesized by the following aspects: 1) decreased anxiety, guilt and fear of HIV (sexual practices without even thinking of HIV); 2) increased pleasure; 3) greater peace of mind regarding the risk of being infected by other STDs.
The fear is emphasized in the following narratives:
For the next day or two, you suffered a horrible nervousness, that something bad could have happened to you (E1, aged 35).
The main change is that, in my entire life before taking PrEP, I had never been penetrated without a condom. I was always very strict about this as it had always caused me so much fear [...]. (E-15, aged 35).
Among the few negative comments associated with the use of PrEP was the concern about the presence of other STDs, as exemplified by E-8:
The bad part, between inverted commas, of PrEP for me is that, in the end, you relax, on the one hand, but you are exposed to many more things [STDs]. E-8 (no age stated).
Perhaps E-8 resorted to the inverted commas to refer to "the bad part of PrEP", because, in a medical follow-up, he discovered he had syphilis, whereas he had thought the "injury" to his penis was not a disease. It was indeed syphilis, and he was treated straight away. Without PrEP follow-up, he might not have realized what it was and discovered it at a more advanced stage. This is surely what was suggested by the ambivalence of his "inverted commas." Some studies attract attention to the fact that PrEP users are frequently asymptomatic for some STDs, as in the case of a study in Germany, where specific actions are suggested to identify and treat them11. This reinforces the importance of the monitoring of PrEP users, which can contribute to an increase in the registration of the incidence of STDs, thus promoting opportune diagnosis for subsequent treatment. A study by Jongen et al.12 in Amsterdam, with 366 participants (364 GBHSH men and 2 trans women), followed up every 3 months for a year, demonstrated that up to 79% of the people diagnosed with STDs were asymptomatic .
Among the important topics in the study of the HIV pandemic and the advances of prevention and treatment biomedicines, the age of those using PrEP is a matter that deserves specific study. Our interviews suggest there operates a subtle difference of emphasis on the effects of PrEP according to age and/or membership of certain generations. The elderly interviewees, in contrast to those born in the 90s, are more emphatic about the impact of PrEP on their affective-sex lives. For some of them, they had never enjoyed an emotional-sex life with freedom. Currently aged 60, E-17 spent all his youth under the threat of HIV infection and lived through the time when prevention was focused on abstinence and use of condoms. Furthermore, the side effects of antiretrovirals were significant. Partners and friends were lost. All of this was in sharp contrast to the experience of taking PrEP. In his own words:
This is why PrEP is synonymous with freedom. I would define it as a great step towards the sexual freedom we had lost with the HIV pandemic, but there is still a long way to go. (E-17, 60).
We found a counterpoint of E-5, currently aged 31, who did not experience the peak of the HIV pandemic:
Of course, I did not pass through the HIV pandemic, in which many people died. That was super bad, but the transition to the situation today has been very strong [...] Back then they did not know how to attend them. Some were not even attended. […] I’m living at a time when a solution is available, but it’s not definitive […] (E-5, aged 31).
The possibility the youngest have to live in a stage of the HIV pandemic aided by significant biomedical advances does not decrease the importance of PrEP in their emotional-sex lives. This is noteworthy. Combined prevention already allows a certain freedom, often conditional upon individual ability to seek means to not be infected by HIV, or to overcome the harm caused by antiretrovirals for prevention, or to be treated for HIV infection. E-4, aged 23, who is on the PrEP waiting list, had his first ever HIV test a little before the Covid-19 pandemic. When he came to know the NGO, he was not much worried about the theme, and, like most interviewees, had had sex without condoms and been infected by STDs. It is plausible that the other STDs with follow-ups are more visible than before the use of PrEP. However, there is a statistically significant correlation between STDs in people who use PrEP and the decrease in condom use. Moreover, in various countries, there is a higher incidence of STDs among HSH that use PrEP13. But the presence of STDs is already a reality in those populations. However, a more recent study by Trager et al.14 demonstrates that the incidence of STDs in PrEP users in Australia tends to decrease throughout the months of use. This is what E-9 illustrates about his experience before and after PrEP:
At first, before taking PrEP, I was always prone to having gonorrhea and chlamydia. I only had fellatio, not risky sex, but now it has changed a little. I don’t know if it has been the PrEP [. ..] I still get those diseases, but their level has dropped a lot. (E-9, aged 37).
In the words of E-4, who was interested in using PrEP and was on the waiting list, appeared to be concerned about catching STDs despite the use of PrEP without condom use:
I’ve been considering it for a few months (using PrEP), because it’s truly something that seems interesting to me, right? Yes, it’s true that I had always had a little interest, not respect, but I think, within the gay community, there is sometimes a slightly erroneous use, because when they take PrEP, they believe they can freely have sex without a condom, without protection, and this should not be so, as, in the end, I don\'t know how to say this, there is always HIV [...], but then, thinking about it well, I think all the advance that can be made to prevent something is positive, and if I can [ …], it would be interesting to benefit from a thing that can be good for me (E-4, aged 23).
The subtle difference in emphasis between generations in relation to PrEP use does not mean that younger persons do not experience anxiety, guilt, fear or complex feelings when it comes to situations of pleasure versus risk of HIV infection. E-4 (aged 23) told us:
"I started crying a lot, as it was like being stripped of everything, Many years ago, I thought I still didn\'t have it. However, in a casual encounter, a boy, living with HIV, told me it was ‘undetectable and non-transmissible’.”
In the same vein, E-5 (aged 31) shared with us his affective-sexual practices:
Once I left on a crazy trip with friends, and then came back the day after for my pill (Prophylaxis Post-exposure/PEP). It was because I was very scared [...]. I had made a fatal mistake, I came crying all the way [...] (E-5, aged 31)
It would not be improbable to assume that many young people make “very crazy trips”, but they do not have their “bodies marked [...] by the institutional discourses of the political, judicial, sanitary, social or economic sphere. These bodies, around the time of the HIV pandemic, were marked through signaling, classification, humiliation, denial of rights, invisibility or disqualification of some needs in relation to others”15 (p. 12).

EXPECTATIONS OF THE NEW WAYS OF ADMINISTERING PrEP
All the interviewees were well adapted to the use of oral PrEP, whether daily or on demand, and narrated some strategies so as not to forget to take it: association with other medicines for chronic diseases, use of alarms, or always carrying an extra pill in case they did not return home, etc. Below is what the interviewees shared about their routine daily use of PrEP:
“It does not bother me, as, after breakfast, the pill is right there.” (E-10, age 48);
"Yeah. It’s a pill every night. I just set the alarm. I put 10:00-10:30. Easy! (E-5, aged 31).
In this same sense, E-7 told us the process of adapting to the daily oral PrEP. He had begun to take it at night, but it was incompatible with his routine, so he switched to taking it in the morning:
What I did so as not forget it again was to adapt it to my work schedule, that is, by starting to take it in the morning as soon as I woke up. With this routine it has been much better. I never miss a day now. (E-7, no age stated).
According to SiPrEP10, there is a low treatment interruption index and high adhesion, since they indicate that, among the 1,398 registered users, “PrEP interruptions were identified in 126 of them (9.0%). In 101 cases (79.5% of the total interruptions) the participant subsequently returned to PrEP consultations ”(p. 13). Bekker et al. (2022) pointed out that use of the daily pill can be a challenge for the youngest group of users “due in part to side effects, the risk of shortage and the lack of pill storage options” (p. 1 ). Thus, these authors highlighted the importance of evaluating other alternatives for PrEP use to respond to these demands. Contrary to the results of Bekker et al.16, the study by Torres et al.6 in Latin America stated that the preference for daily PrEP was associated with younger age and lower income in Brazil and Mexico, and also, in Brazil only, with a lower educational level .
Regarding the monthly tablet, the interviewees, with greater spontaneity, explained their routine experiences of the challenges to maintaining the discipline of daily pill use:
Well, if they offered it to me, I would say yes, because a monthly PrEP can be forgotten some day. No, you have to take it every day, and it\'s a chore. You\'re partying with friends, and the alarm sounds “10, Wednesday”. So you then need to go home (E-5, aged 31).
In general, doubts and concerns about the new ways of administering PrEP have to do with the uncertainties and lack of information on the subject, but everyone trusts that they can adapt to having something even more compatible with their personal and psycho-social needs. Among the concerns, we were told the following: 1) doubts about efficacy; 2) the monthly pill has good receptivity, but some think it is more difficult to control than the daily version, because the latter is more evident in the routine; 3) injection is also an option that attracts interest, but there are some concerns about the loss of autonomy to administer it; 4) as for implants, some care about having some permanent material in their bodies. However, it is clear in the statements that there is receptivity in relation to the ways under study, provided that they fulfil the same function, and if they are compatible with the need of each person:
So, if everything that is developed is better, in the end, it’s better for me too. I see no problem in changing (E-13, aged 44).
Injectable is also interesting, an implant too. As cream, I don\'t know. It seems less attractive, more for sensations, I don\'t know. On balance, it’s probably better to have a jab or take it orally. Nevertheless, these seem very interesting (E-3, aged 53).
Even though once a month would make me afraid, the monthly pill would be more practical. However, it has the same effectiveness as taking it every day. I feel that every day you would be protecting yourself (...) I believe that the main thing is that I would not be encouraged to do something that had just begun, but I know it is validated and I know it works. It seems practical, because, if it were once a month, I would have to remember. So I really find the daily dose more practical. (E-15, aged 35).
These challenges that suppose the use of new objects exemplify what the praxiographic perspective7 explains. In this case, PrEP is part of a network of relationships and practices (of the health professional, the user, sexual acts, infections, etc.), and, as an actor, has the capacity to influence the actions of other actors .
It should be noted that, in the case of our transgender participant, more medications and various ways of administering them could present a major challenge. However, she seems to have an open disposition to this precisely for having had previous experience of using other biotechnologies. Referring to injection, she said:
(...) for a long time, the hormone I used was a blister that I would buy in Argentina, was intramuscular, and I had to take it once a month. It was something that I had also undergone at another time in my life. So, injections are no problem for me. (E-14, aged 36)
In a study similar to ours, Manserg et al.3 analyzed the preference for using various prevention technologies including the daily pill, prolonged action injection, the pill for occasional sex, penile gel and anal suppository. They concluded that beyond preferences, what stood out was the type of behavior, these being divided into those based on products dictated by sexual events and those not dictated by sexual events. In the study by Manserg et al., when questioned about their preferences, PrEP users tended to choose the injection taken monthly or every three months, compared to those who use it on demand or who do not use it, which explains the concern about the stress that can be caused by taking it daily or the effect of a minimum dose. This differs from our results, since our participants do not indicate the reasons for interruption of oral PrEP synthesized by SiPrEP10: “Absence of risk perception (20%), followed by personal reasons (17.1%); a small number of cases due to side effects, for example, alteration of the renal function; cessation of sexual activity due to isolation derived from a situation of pandemic such as Covid-19, stable couple relationships, appearance of diseases unrelated to the treatment”(p. 13).
While the interviewees described some concerns and expectations regarding the use of PrEP irrespective of how it is administered, these do not interfere with adhesion or interest in using the new modes. In particular, their condition for any new use was "real patient tracking", as a step towards "a more feasible solution to make HIV disappear" (E-9, aged 37). This is also stated by E-7 (no age stated) indicating with respect to injection that "This would be a great advantage provided that the analyses were maintained. I really see this as very positive." On the other hand, E-8 (no age stated) insisted on the matter of “how checking is conducted”, showing that there is a posture more interested in continuous monitoring than in the type of biotechnology that prevents HIV.

CONCLUSIONS
Among our interviewees, there was satisfaction regarding the use of PrEP, both on a daily basis and on demand, when there are outstanding positive repercussions for their emotional-sexual lives, characterizing that there is greater freedom and decreased fear and anxiety about HIV infection; according to their responses, there were also positive expectations about the new ways of administering PrEP. The male interviewees and the female interviewee manifested their interest, expressing their hope to be able to use them in the near future, according to their needs. This reaction coincided with the HSH in some other studies2-3-6. This study takes into account Mol\'s praxiographic perspective that prioritizes the interaction of people with objects and institutions. However, as its objective was to understand the expectations about these new ways, not yet offered or well established in Spain, future studies are expected to investigate relationships with these new objects. These studies could also describe in more detail the ways these technologies, in interaction with other actors, will produce multiple realities.
In our study, this availability of new ways of administering PrEP is accompanied by the perception that the users will feel safe and protected if they have the follow-up in the context of the Community Centre and in public health services, which is similar to what is raised in a study by Brooke et al.17 on the positive monitoring effects carried out with medical care for the LGBTQ collective. Systematic monitoring, which has a fundamental function at this time of implementation, is necessary to reduce new HIV infections and head toward their eradication, at least until PrEP coverage reaches all of this population group, and also has the capacity to provide protection against other STDs.
In conclusion, it follows that the most important thing for those who use PrEP, or are interested in it, is the guarantee that they will have follow-up to continue taking care of their emotional-sexual health, that is, the type of follow-up implemented by the PrEP program, both in the public health services and in the community center that monitored it. This important aspect does not depend on the way of administering it in the sense that the different ways will be made available and will be determined by specific evaluation of the requirements of each of them. This suggests that expansion of the supply of daily pills and those on demand, reduction of waiting lists and new ways of administering it, will be important for the success of this combination. As this aspect of monitoring was not emphasized in the scarce psycho-social studies of reference found on the subject, it constitutes one of the main contributions made by this article.

Financial sponsorship
National Minister of Scientific and Technological Development (CNPQ).

Thanks

Acknowledgments: We wish to express our gratitude to the colleagues of our research groups, the Laboratorio de Estudos Es Mental (Lev) of Bahia Federal University, LAICOS/IAPSE of the Barcelona Autonomous University (UAB) for the critical readings of the text’s initial versions, and Bahia Federal University for granting leave to the first author from the UAB to pursue a post-doctorate.

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