Community Mobilization
The community mobilization team participated in the ImPrEP CAB Brasil Project Launch Event, involving 34 civil society leaders to disseminate information about the study and engage important stakeholders. It also collaborated in developing the materials for an mHealth intervention to support PrEP-user decision making, participated in study protocol training sessions, and contributed to the planning of peer education activities. The planning meeting for community education activities included discussions on the following points: 1) peer educators' intervention approaches; 2) objectives of project-related graphic materials; 3) ideas for the project's visual identity; and 4) pertinent information to be disseminated.
Process Mapping
From July 2022 to September 2022, three process maps for each site were created to describe the initial visit, follow-up visits and laboratory flow (18 maps total). Figure 1 describes part of the process map of PrEP initiation visit at INI-Fiocruz site. The main challenge identified was the duration of visits due to a high number of laboratory and HIV counseling steps necessary for same-day PrEP delivery. Proposed solutions included point-of-care HIV rapid tests (which sites expressed the need for additional training to perform) instead of laboratory tests and the additional of more staff to perform counseling. Two sites identified the need to expand clinic hours for the project to better serve the study population, also contributing to oral PrEP scale-up.
Qualitative Assessment
A total of 14 focus group discussions were conducted between April 11 and June 14, 2023. Two focus groups with young SGM (aged 18–30 years) were conducted at each of the six study sites. We conducted two focus groups with health professionals (nurses, psychologists and medical doctors) from two sites with prior experience with (CAB-LA). In total, 110 individuals participated in the focus group discussions, 92 SGM and 20 health professionals (Table 1).
Table 1
Characteristics of participants included in Qualitative Assessment.
| | Total (N = 112; %) | SGM (N = 92; %) | Health Professionals (N = 20; %) |
| City | | | |
| Campinas | 13 (11.8) | 13 (14.1) | 0 |
| Florianópolis | 13 (11.8) | 13 (14.1) | 0 |
| Manaus | 13 (11.8) | 13 (14.1) | 0 |
| Rio de Janeiro | 29 (26.5) | 20 (21.7) | 9 (45.5) |
| Salvador | 19 (17.3) | 19 (20.6) | 0 |
| São Paulo | 25 (22.7) | 14 (15.2) | 11 (54.5) |
| Gender | | | |
| Cisgender men | 41 (36.6) | 39 (42.4) | 2 (10.0) |
| Cisgender women | 16 (14.3) | 0 | 16 (80.0) |
| Non-binary | 6 (5.4) | 6 (6.5) | 0 |
| Transgender men | 3 (2.7) | 3 (3.3) | 0 |
| Transgender women | 26 (23.1) | 25 (27.2) | 1 (5.0) |
| Travesti | 20 (17.9) | 19 (20.6) | 1 (5.0) |
| Race | | | |
| Asian | 2 (1.8) | 1 (1.1) | 1 (5.0) |
| Black | 33 (0.3) | 31 (33.7) | 2 (10.0) |
| Indigeneous | 5 (4.5) | 5 (5.4) | 0 |
| Pardo | 31 (28.2) | 25 (27.2) | 6 (30.0) |
| White | 41 (37.3) | 30 (32.6) | 11 (55.0) |
| Education | | | |
| Primary incomplete | 5 (4.5) | 5 (5.4) | 0 |
| Primary complete | 1 (0.9) | 1 (1.1) | 0 |
| Secondary incomplete | 6 (5.5) | 6 (6.5) | 0 |
| Secondary complete | 32 (29.1) | 31 (33.8) | 1 (5.0) |
| Terciary incomplete | 29 (26.5) | 27 (29.3) | 2 (10.0) |
| Terciary complete | 39 (35.5) | 22 (23.9) | 17 (85.0) |
Perceptions about the Implementation of injectable PrEP
Health Care Professionals
The importance of a multidisciplinary team including physicians, nurses, and psychologists for the counseling, screening, administration, and the monitoring of injectable PrEP users for implementation of injectable PrEP into SUS was highlighted by health professionals. Medical care was considered essential at the beginning of the implementation of injectable PrEP, due to the specific requirements of the medication and its administration. The presence of psychologists and peer educators was highlighted to guarantee emotional support and a hospitable and embracing environment. It was reinforced that because young SGM may face more challenges related to HIV and STI prevention, the study team should be prepared to address both clinical and psychosocial aspects.
"What we have seen is that the population we want to access today, both transgender and cis-MSM people, youth 18 to 30 years old, sex workers, have very important psychosocial needs. Most of the people currently coming in for PrEP are young. During HIV diagnoses they always bring a very high emotional load. So, you can't think about not having an approach with a social worker, a psychologist to facilitate linkage and retention. Because if you focus only on the PrEP medication, you will lose that patient or study volunteer. At four, six months, you don't access them anymore."
Health Professional, cisgender woman, age 30–35 years
The retention of participants was also underscored as likely to be a major challenge, especially in health facilities in more underprivileged contexts. Thus, it was recommended that services should plan for situations in which people do not return for injection appointments within the appropriate window. The importance of improving follow-up and support services, and developing measures to encourage adherence, was emphasized.
Stigma and resistance to new technologies were the main challenges for implementation of injectable PrEP highlighted by health professionals. The continuous training of professionals necessary to ensure qualified and safe care was also seen as a challenge.
Sexual and Gender Minorities
Challenges pointed out by SGM were diverse, such as the lack of specialized care facilities for SGM populations, which could hinder access to injectable PrEP. In this regard, resistance to the use of their chosen name in health units could also create an uncomfortable and disrespectful environment for people seeking PrEP. Possible stigmatization of PrEP users associated with moral judgement of their sexual behaviors was seen as having a negative impact on SGM privacy and self-esteem.
"It's just that it looks like there's ... a resistance of the professional himself to call the person by the chosen name, when the person doesn´t correct them." (Transgender woman, age 26 years)
"… And when we talk about our sexual practices they come with a huge load of moralism. So that to me is something that just pushes me away and makes me not have that adherence regardless of how good the drug is."
(cis-MSM, age 24 years)
Recommendations were shared about the need for capacity building of these professionals on issues related to gender identity and diversity of SGM populations and to promote a sensitive and friendly environment to ensure respectful and effective care. The importance of a welcoming without judgment or discrimination of those seeking PrEP was strongly emphasized. Health professionals should be empathetic, inclusive, and respectful of the diversity of people's gender identities and sexual orientations.
SGM participants highlighted that infectious disease clinicians, psychologists, and nurses, sensitive to their gender and health issues would be the most appropriate team of professionals for providing injectable PrEP services. The presence of SGM health professionals was also noted as representing an assurance of comprehensive care, and the absence of transgender professionals was identified as a contributing factor to the inadequate treatment of these populations. Finally, transgender, and non-binary people, pointed out the importance of disseminating information about prevention options and services in spaces other than the health environment, such as NGOs to promote more inclusive and welcoming approaches for SGM and sex workers.
Due to the possible long duration of injectable PrEP initiation visit, participants suggested that PrEP users be informed beforehand, so that they have a realistic expectation of the length of time needed. Training that fosters the acceptance and confidence of health professionals in injectable PrEP was considered indispensable to facilitate implementation.
Community education and peer educators were considered important to ensuring a welcoming, comprehensive, and health service adapted to the reality of users. Because of their connection to the SGM community, peer educators and peer navigators are perceived as playing a key role in reaching, approaching, contacting, and maintaining adherence and retention, especially among the most vulnerable.
Transgender and nonbinary participants highlighted aspects related to the actual use of long-acting PrEP as facilitators of acceptance of implementation. The view that injectable PrEP is an alternative to oral PrEP was seen as a more convenient option for people who have difficulty in taking a daily medication or having their pills around the home. They also saw the use of injectable PrEP as an advantage for protection and as an expansion of HIV prevention options for those who do not wish to use oral PrEP.
Evaluation of the mHealth Tool
In general, health professionals thought the mHealth tool would be useful to support the decision making process (oral PrEP or CAB-LA) among eligible PrEP users. Nevertheless, the importance of counseling with a health professional about PrEP choice was asserted. They believed that some technical, clinical and adherence information could be better explained by a professional, and recommended reinforcing the message that PrEP choice can be made by the participant without rush. SGM populations thought the use of digital tools for information and education combined with standard counseling would be very useful for participants to obtain a better understanding of PrEP modalities.
Language
In general, both the verbal and aesthetic languages of the mHealth tool were seen as appealing, accessible, direct, and relevant to reaching the younger SGM. The insertion of subtitles and a sign language interpreter in the videos was highlighted as important for accessibility and inclusivity, especially for people with hearing impairment and in noisy environments. Transgender and nonbinary participants stressed that the videos should use language easily understood by all to ensure comprehension. They emphasized the importance of avoiding stereotypes, using neutral language and inclusive pronouns, and respect for gender identities.
Characters
The choice of characters for the videos was considered correct by health professionals and SGM participants. Health professionals valued character representativeness, for example by the presence of a transgender woman physician and a Black gay man, but suggested the inclusion of additional characters with other genders. Transgender and nonbinary participants suggested adding transgender men and non-binary characters for greater diversity, and to make the messaging more inclusive of trans bodies. Finally, they suggested including credentials for the transgender woman physician character to emphasize her credibility.
Format
The mHealth tool was considered visual appealing. The use of images, colors and drawings was praised as a joyful and simplified way to convey information and facilitate understanding in the videos. The use of electronic sounds was perceived as unpleasant for most, although some found the voice effects different and flashy, and thought this could gain the viewer’s attention.
Regarding length, health professionals noted the videos on oral and injectable PrEP were shorter and more objective than the subsequent ones dealing with the PrEP choice itself, were more detailed and longer. They emphasized the importance of keeping videos concise and focused on the essential information to users' choice. Complementing this thought, the idea of an interactive format was valued by a few, including short videos with PrEP modalities in a summarized form, to allow the viewer to obtain more information about specific topics of interest.
SGM considered the length of the videos appropriate, although some suggested making them shorter. They suggested a clearer division of the contents into introductory and other specific videos, emphasized the importance of a linear and organized approach. Different opinions about the order of the videos were expressed, with some people suggesting that the last video on combination prevention appear first.
SGM and health professionals provided different suggestions about the design, colors, and dynamism of the videos. Cis-MSM participants recommended making the animations and colors more attractive, with a more dynamic and less "professorial" appearance, and including of keywords or summaries to reinforce the main information. The animated illustration of a PrEP user timeline for those in the study was praised, as it explains step by step what the person will do after choosing the PrEP modality (injectable or oral PrEP) and includes the reading the informed consent. Health professionals also agreed that the illustration would support participant understanding of the process.
Content
Though health professionals considered the content of the videos to be very good, they recommended including additional information to manage the expectations of the participants, such as: the amount of time required for clinical visits; the need for other tests besides HIV, such as for other STIs, kidney and liver functioning; and the periodicity of injectable PrEP appointments. All groups suggested including information on the possibility of switching prevention modalities from CAB-LA to oral PrEP and vice-versa.
SGM had similar views to health professionals, but they highlighted additional information needs. They requested information about injectable PrEP for people with silicone implants and the impact and interaction of CAB-LA PrEP with hormone therapy. They also recommended the inclusion of more information about the difference of daily PrEP and on demand PrEP, and on the advantages and possible side effects of each. Regarding information on the duration of PrEP protection, it was suggested to clarify the reason for the interval between injectable PrEP applications and its safety. Also, what to do when forgetting to take daily oral PrEP, importance of daily oral PrEP adherence, and the possible consequences of switching between PrEP modalities, emphasizing the intervals needed to make this change and the waiting time for the new PrEP choice to provide protection.
A recurrent observation was made by all groups regarding combination prevention in general, emphasizing that information on the use of condoms, lubricants, and regular testing in conjunction with PrEP should be addressed more thoroughly in the videos. Condom promotion was seen as needing to be reinforced, even for those using PrEP, for other STI prevention. SGM and health professionals both also highlighted the need for information on post-exposure prophylaxis (PEP). Health professionals suggested the inclusion of information about other situations in which PEP can be used, such as sexual violence or work accidents, allowing the viewer a more comprehensive understanding.
Specifically on injectable PrEP, the need to present possible side effects of this prevention modality in more detail and the necessary care after application were underscored, as well as the possibility of interruption of cabotegravir injections due to adverse event. The importance of having trained health professionals clarify and reassure potential users regarding possible side effects was reinforced.
Health professionals raised doubts about the efficacy, duration of protection of both PrEP modalities. They suggested to adding information about the efficacy of the CAB-LA PrEP and the duration and initiation of protection against HIV.
Finally, transgender participants suggested the inclusion of information about services and centers specialized in transgender care and people living with HIV.
Acceptability of WhatsApp Messages
All SGM agreed that receiving WhatsApp messages to confirm appointments is helpful and facilitates communication with the health service. They emphasized the importance of providing relevant information such as date, time, and purpose of the visit. Furthermore, they raised concerns about privacy and suggested that the messages should be generic to avoid revealing personal information. They proposed that the message include an icon or symbol associated with the health service, such as the ImPrEP logo, so that recipients could easily identify the source of the message.
There were different opinions on which messages would be most appropriate. In the context of the study, participants expressed preference for reminder messages ("Don't forget your return visit on that date"). They stressed the importance of using more discreet, general messages, avoiding keywords such as PrEP, injection, HIV-related consultations to protect privacy. They also emphasized the importance of personalizing reminder messages to increase effectiveness. They suggested sending more intimate messages, including the name of the receiver, and adding a greeting, such as "Hello, so-and-so, don't forget your visit, we are waiting for you." They believed these types of messages would create a stronger connection and help people feel more valued.
There was consensus that text messages are more practical and efficient than phone calls. Many participants mentioned that they prefer short and direct messages, easier to read and remember, considering the needs and preferences of the different population groups. There was concern that transgender populations from underserved settings may have less patience with reading long messages or that illiteracy may be an issue. Thus, they emphasized the need to approach communication in a careful and inclusive way.