Prevenção combinada do HIV para homens adolescentes que fazem sexo com homens e mulheres adolescentes transexuais no Brasil: vulnerabilidades, acesso à saúde e expansão da PrEP

Abstract

In Brazil, HIV incidence among cisgender men in the general population has been rising while decreasing among cisgender women 1. Similarly, increasing trends of HIV and AIDS incidence have been reported among adolescents 2,3. This growth is more significant in cisgender men who have sex with men (MSM) and transgender women (TGW). Moreover , surveillance studies have identified an upward trend in HIV prevalence from 14% in 2009 4 to 18% in 2016 5 among MSM older than 18 years; and high HIV prevalence among TGW 6,7. This trend has been observed among adolescent MSM (aMSM) 8 and adolescent TGW (aTGW) 9,10. This surge in the HIV/AIDS epidemic among aMSM and aTGW may be explained by a combination of factors associated with this stage of life, such as sexual practices experimentation and stigma regarding sexual orientation and gender identity 11,12,13,14,15. Moreover, their increased vulnerability is related to social, economic, and organizational inequalities and structural issues 16,17,18. Furthermore, studies report a reduction in dialogue and guidance on sexuality issues in schools, an increase in the rate of sexual initiation without using condoms, and unprotected sex. These issues are more severe in adolescents with greater social vulnerability 19,20,21 ; among younger MSM, for example, studies have shown fewer HIV testing and higher frequency of unprotected anal sex, leading to the increased risk of the worst epidemic scenario in the coming years 22,23. Paradoxically, this is occurring at the same time that an increasing number of HIV control strategies and prevention methods are available in Brazil and globally. One of these strategies is combination HIV prevention, an approach that involves socio-structural and behavioral elements, notably antiretroviral as a prevention tool. In addition, pre-exposure prophylaxis (PrEP) stands out due to its efficacy and effectiveness in preventing HIV infection 24,25,26,27. PrEP became available in the Brazilian Unified National Health System (SUS), free of charge, in 2018 for several key populations aged 18 years or older. Today, it can be prescribed to anyone who needs it from 15 years old or older. An effective response to reducing HIV incidence in adolescents requires a knowledge-based policy, specifically for this population, which presents less access to health services and limited research-based knowledge. For several reasons, such as the inadequate application of regulatory and ethical directives, the approval of research with adolescents younger