Reaching Out to Adolescents at High Risk of HIV Infection in Brazil: Demand Creation Strategies for PrEP and Other HIV Combination Prevention Methods

Abstract

Using baseline data from the PrEP1519 cohort, in this article we aimed to analyze: (i) the effectiveness of demand creation strategies (DCS) to enroll adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW) into an HIV combination prevention study in Brazil; (ii) the predictors of DCS for adolescents’ enrollment; and (iii) the factors associated with DCS by comparing online and face-to-face strategies for enrollment. The DCS included peer recruitment (i.e., online and face-to-face) and referrals from health services and non-governmental organizations (NGOs). AMSM and ATGW who agreed to participate in the study could opt to enroll in either PrEP (PrEP arm) or to use other prevention methods (non-PrEP arm). Bivariate and multivariate analyses were conducted and logistic regression odds ratios were estimated. The DCS reached 4529 AMSM and ATGW, the majority of which were derived online (73.8%). Of this total, 935 (20.6%) enrolled to participate (76.6% in PrEP arm and 23.4% in non-PrEP arm). The effectiveness of enrolling adolescents into both arms was greater via direct referrals (235/382 and 84/382, respectively) and face-to-face peer recruitment (139/670 and 35/670, respectively) than online (328/3342). We found that a combination under DCS was required for successful enrollment in PrEP, with online strategies majorly tending to enroll adolescents of a higher socioeconomic status. Our findings reinforce the need for DCS that actively reaches out to all adolescents at the greatest risk for HIV infection, irrespective of their socioeconomic status.

Important steps for PrEP uptake among adolescent men who have sex with men and transgender women in Brazil

“…There is a need to reach and inform a large number of adolescents from the key population about HIV prevention. Twenty percent of adolescent MSM and TGW reached out by the demand creation strategies of PrEP1519 did reach the PrEP clinics [ 45 , 52 ]. Online interventions can be more cost-effective and easily scaled up to increase service coverage.…”

“…Face-to-face recruitment can reach proportionally more underserved adolescents from key populations. In combination, online and peer-driven face-to-face strategies can provide a critical balance between offering comprehensive coverage and equitable sexual health services for adolescents of key populations from different socioeconomic backgrounds [ 45 ].…”

“…The number of black adolescents who started PrEP in the study was more significant than the number of non-blacks. In addition, among those aged 15 to 17 years, there was a strong association between PrEP initiation and self-reported black skin color, which may be related to the range of racial diversity recruitment strategies implemented in the study [ 45 ]; an important finding, as black MSMs and TGWs have been more exposed to HIV in several countries around the world [ 5 , 55 , 56 ] and in Brazil [ 57 ] due to social inequalities, racial discrimination, and less access to formal education, information, and health services [ 58 , 59 ].Despite this, the rate of PrEP use in Brazil has been higher among white adults than among blacks [ 60 ].…”

“…Therefore, the quarantine and physical isolation measures did not significantly impact on the enrollment of adolescents. The proportion of enrolled participants was similar before and after the COVID-19 pandemic [ 45 ], as we quickly adapt the online strategies for the pandemic using social media and telemonitoring infrastructure.…”

“…During recruitment, the PE guided on the importance of combined HIV prevention, PrEP, scheduled clinical checkups, and guidance on how to get to the service. In addition, adolescents could also spontaneously attend clinics or were referred by other health services, friends, sexual partners, and Non-Governmental Organizations (NGOs) LGBTQIA+ [ 45 ]. Recruited aMSM and aTGW who arrived at PrEP clinics and underwent clinical examination by members of the multidisciplinary team for HIV risk and vulnerability assessments, counseling on combination prevention and clinical follow-up.…”