Building bridges to care: the experience of peer navigation in enabling linkage to PrEP for adolescent men who have sex with men and transgender women

Vulnerable populations are at increased risk for HIV/AIDS, especially adolescent men who have sex with men (AMSM) and adolescent travestis and transgender women (ATGW). Pre-exposure prophylaxis (PrEP) is one component of combination HIV prevention and is already available for these populations in Brazil. However, ensuring its uptake entails certain challenges since inequality and barriers have traditionally marked access and linkage to the related public health services. Peer navigation could be a way of mediating the linkage process because it involves peers keeping track of others’ care schedules, dynamically fostering linkage to care according to the needs of users and the actors involved in their everyday care contexts. Therefore, this study proposes analyzing peer-navigator-mediated linkage to PrEP care for 15-to 19-year-old MSM and transgender women from the PrEP1519 project in Salvador, Bahia State, Brazil. In total, 15 field notebooks/diaries, written in April-July 2019, by four peer navigators were analyzed, as were the transcripts of one


Introduction
Cad. Saúde Pública 2023; 39 Sup 1:e00176821 As for implementing these practices, linkage is produced in complex, dynamic processes that are constituted and mediated by networks of relationships between heterogeneous actants (human and non-human) 24 . From this perspective, peer navigators, educators, young people, professionals, services, friends, relatives, social media, mainstream media, and medications are some of the actants engaged in the course of actions in which different types of linkage are established in networks of socio-material practices which produce and enact 25 multiple realities. Nonetheless, little is yet known about how to link AMSM and ATGW to PrEP programs 14,26 . A process seldom assessed in the realm of the networks of socio-material practices indicated above. Thus, we aim to analyze the linkage of adolescent MSM and TGW to a PrEP clinic in Salvador, Bahia State, Brazil, via peer navigators mediation.

Methodology
This study analyzes data from the PrEP1519 study, a demonstrative cohort of PrEP use by adolescent MSM and TGW aged 15 to 19 years in three cities in Brazil: Salvador, Belo Horizonte (Minas Gerais State), and São Paulo. Further methodological details can be found in Dourado et al. 27 . In Salvador, this research project is called PrEPara Salvador [a play on words between PrEP and "prepara" -Get ready!], and is organized within an adolescent-friendly space in the historical center of Salvador and has a multi-professional team trained to offer combination HIV prevention, including PrEP.
Potential participants of PrEP1519 were enrolled via educational and community activities, demand-generation and publicity activities on social media, hook-up apps, and direct referrals from health services and adolescents who were already part of the cohort. Further recruitment details can be found in Magno et al. 28 .
Study participants were required to have a negative HIV diagnosis and be at substantial risk of infection and/or of greater vulnerability to HIV. Socio-behavioral questionnaires were answered by participants who then took rapid diagnostic tests for HIV and other STIs, administered by a lab technician. If they got a negative HIV test result, they were referred for clinical check-up with a nurse and doctor. Once they were prescribed PrEP, they were assigned a peer navigator, according to characteristics which may facilitate linkage (e.g., gender identity, sexual orientation, ethnicity, and age) and/or some previous connection between participants and peer navigators.
Peer navigators are supervised by a nurse, who may be consulted for technical information, such as side-effects of PrEP and/or medicine interactions and STIs prevention and testing. Peer navigators act to strengthen their linkage to the PrEP clinic, facilitating participants' uptake, asking questions about their needs and guiding them on issues such as difficulty in using the medication, where to keep it, what time to use it, adverse effects, remember follow-up visit dates, and being responsible for referring such issues to the health team.
The first contact between peer navigators and participants may be in person or by text messages via social media, should the participant give prior authorization for this. In the first month, they make contact once a week, which may then be reduced to fortnightly or monthly appointments, depending on adherence to PrEP; complications during PrEP use; bond between participant and peer navigators; and participant health-related issues.
Peer navigators produce field notebooks which are sent to the team every two weeks and contain information on interactions with participants, which are then discussed in periodic meetings with the supervisor.
The adolescents themselves report their frequency of PrEP use, which their peer navigators classify according to research results that conclude that PrEP is highly effective in preventing HIV when four or more pills are taken each week, as this provides protective levels in the bloodstream 9,29 . PrEP1519 considers high adherence if participants report taking seven pills a week; medium adherence, if they take four to six a week; and low adherence, if they take three or fewer. If an adolescent reports taking four to seven pills a week and a minimum of 16 a month, they are regarded as achieving good adherence. Still, 30 pills are dispensed at the first appointment; 60, at the second; and, after the third, 90, at each follow-up appointment.
Cad. Saúde Pública 2023; 39 Sup 1:e00176821 Follow-up visits take place every three months, in which participants receive counselling, have a medical check-up, do diagnostic tests for HIV and other STIs, and receive prevention materials. Furthermore, adherence to PrEP is evaluated, guidance is given on sexual and general health, and participants are referred to other areas of the public health service if necessary.
A focal group was conducted with three peer navigators about their work of enabling linkage of adolescents to PrEPara Salvador. Also, 15 field notebooks, produced in 2019 by four peer navigators, were analyzed and 20 semi-structured interviews were held with adolescents (17 MSM and 3 TGW) between June and December 2019, conducted by researchers with experience in qualitative research, including the lead author. Topics on recruitment, uptake, and linkage to PrEPara Salvador and experiences of use and adherence to PrEP were included in our interview script.
The focal group and its interviews were recorded and transcribed. Thematic content analysis was conducted based on the categories which emerged from participants' narratives. The material was coded by Nvivo 10 (https://www.qsrinternational.com/nvivo/home).
Analyses of this material were based on the understanding that narratives are ways by which social experience is elaborated, rather than simply sequential descriptions of actions and events 30 . Personal narratives are historically, politically, and culturally situated, which means that their plots are coconstructed and contextually interconnected 31

Participants' profiles
Peer navigators were representative of the LGBTQI+ community. In total, two were transgender men who identified as heterosexual and two were cis women, one heterosexual and one bisexual. They all identified as black and were aged between 26 and 50 years. Overall, three peer navigators had completed, and one had begun (but not completed), a university degree (Box 1). As for the adolescents interviewed, Box 2 shows most (17) were MSM and identified as black (just two stated they were white); five identified as bisexual, one as pansexual, and the others as gay; their ages at study enrollment ranged from 16 to 19 years old (one was 16 years old; two, 17 years old; the others 18 or 19 years old), and only two youths were 20 years old at the time of the qualitative interview. All three of the TGW interviewed, aged 18 and 19 years, identified as TGW and two were heterosexual and one bisexual. Overall, two identified as white and one as black. The reported adherence to PrEP at the moment of the qualitative interview was good. Figure 1 shows the periods of PrEP use from March 2019 until May 2022, adherence and discontinuation. Ten participants temporarily discontinued PrEP and then resumed it; five discontinued and gave up PrEP use; three have stopped using PrEP, resumed it, and then gave up; and finally, two participants fluctuated between high, medium, and low adherence. STIs such as gonorrhea, syphilis, and condyloma acuminate were diagnosed in ten participants as shown in Box 3.

Figure 1
Periods of pre-exposure prophylaxis (PrEP) use from March 2019 to May 2022: adherence and discontinuation *. PrEP1519 study, Salvador, Bahia State, Brazil.
* Discontinuation is defined in this study as any interruption or decision to stop the use of PrEP.

The importance of representativeness as a mediator of linkage to care
Since navigators are peers, they share certain characteristics with the person who is to receive care, which means they are likely to be accepted as someone "similar". Interventions that focus on linking TGW and MSM to primary HIV and PrEP care stress the importance of using peer navigators who have similar life experiences to the people with whom they work 32,33 . These characteristics, including their sexual orientation, ethnicity, age, culture, relationship status, and local neighborhood -very important for the LGBT population 34 -are considered when pairing them with a new participant. Previous experiences of peer navigators who are MSM, TGW, LGBT, and indigenous describe navigation strategies which are well adapted to the needs of MSM and TGW who live in vulnerable contexts, positively impacting the task of overcoming "trans-specific" (structural and individual) barriers to care, including documentation issues and trouble accessing hormone therapy 22 . The idea behind this horizontal approach is to allow peer navigators to become a point of reference in guiding participants by different support options throughout a particular course of care, especially when dealing with populations regarded as "hard to access" or "hidden", for whom traditional health intervention approaches have proved unsuccessful. The peer navigators at PrEPara Salvador who are transgender men even acknowledged that they see themselves in the adolescent transgender women's narratives because they share similar interactions, experiences, and social contexts, as well as lived experiences relating to being transgender. This representativeness was used as an important dimension to strengthen linkage by all peer navigators and we found this to be important for effective follow-up, listening, and helping participants with their (sexual) health care: " "...saying how much more comfortable she would feel (...) especially because we share the experience of being transgender" (Field notebook -peer navigator 1) In the context of health, professionals and patients take part in a complex socio-material network, a relationship forged in "a context of materially situated historical and cultural practices" 35 (p. 118). Navigators and adolescents are situated in similar socio-material realities which defy hegemonic heteronormative standards. As such, they recognize each other in bodies that diverge from the norm and understand each other as actors whose gender performances are challenged by barriers in all manner of relationships. Pairing gender identity helps foster linkage to care, levels the relationship, opens communication channels, and produces practices of care that resonate with these experiences. However, this identification fails to rule out the distinction between "them and me" in navigators' field notes, often denoted by the age difference between them, not to mention their educational attainment, professional role, and "awareness" of preventive practices.

Linkage mediated by affection: reciprocity and bonding versus tensions and challenges
As a biomedical intervention that is part of combined prevention, the use of PrEP requires an entire process of continuous and dynamic care that is produced as it is incorporated into user's lives. This is mediated by several actors who are involved in monitoring its use, implementing practices, producing new approaches, and jointly implementing a reality which is not limited to the theme of risk and protection against HIV 36 . From this perspective, peer navigation is dynamically performed or produced according to a series of emerging needs, actors, and situations influencing everyday health. Navigators and adolescents work together, affect each other, and need each other to "do" or produce a bond with care: "I think it's more about empathy and you making the person feel welcomed beyond being a number, a statistic (...) because we're dealing with linkage. We talk to these people, and just as they get linked, we do too, we get concerned, we think about them during the week, talk to them (...) this closeness, making them feel close too" (Focal group -peer navigator 2). "I'll send a really long audio and he'll answer with a really long audio. We chat, we talk about our routine and other stuff, you know? It's really healthy and, despite everything I've said, it's not something professional, you know, it's not like formal, it's more like acquaintances, colleagues helping each other out" (MSM aged 18).
This affective dynamic is an important component of the care practices in which peer navigators engage, producing diverse effects in the involved actors. Generally, it is seen as a sign that the linkage is solid when adolescents show affinity and emotional identification and answer to the contacts from peer navigators. Adolescents show satisfaction at receiving follow-ups from somebody who is interested in their multiple needs: " Another element refers to age difference, which establishes proximity and distance in these interactions. Peer navigators mediate it in the linkage process, with care practices which seek horizontality in the relationships by managing others' identity markers: "So, for me it's a little more difficult because I have a big age difference between them, because I'm a much older person and a lot more mature. (...) I even thought that I would have difficulty with the ones I'm navigating but, thank God, I don't. For me, there's no resemblance to them, but I feel close, I feel like a trailblazer, discovering together with them this whole process of what it means to take care of one's health" (Focal group -peer navigator 3) "...even by the age of participants, we realize that the only way for you to access them it's to become aware and also put yourself as similar to him" (Focal group -peer navigator 2).
Peer navigator perform the care practices with the different objects, actors/actants, and sequences of events involved in shaping the alternate stories in their trajectories of care involving PrEP use. In Cad. Saúde Pública 2023; 39 Sup 1:e00176821 this process, linkage to care is fluid and unstable and its progress is not linear in time. Unpredictability is inherent to the linkage process and that is a challenge to care practices. Contacting these participants spawns conflicting emotions, causing tensions in the care relationships: "Sometimes he is slow to answer my messages and there have been times when he was extremely rude to me during our interactions" (Field notebook -peer navigator 1). "The first participant I didn't link up. (...) we didn't manage to establish a bond. So, it was hard, I don't know (...) there wasn't any dialogue, no sharing, no affinity" (Focal group -peer navigator 3).
When these breaks or hiatuses occur in online interactions, peers navigators are required to continuously invest in managing adolescents' care together with them, to stay in touch and keep the linkage alive, for which they have to manage tensions and plan alternative strategies to remake contact, which intensifies their emotional involvement. As for the adolescents, their communication difficulties with the navigators on virtual platforms stem from a number of actions/events that extend through time, sometimes hindering and sometimes helping communication: These narratives show the role played by cell phones with access to the internet, social media, and related online chat tools. These artifacts and objects are present in the heterogeneous network of relationships of which the participants and navigators partake, taking on a pivotal status in modifying a situation 24 and making a difference in the process of linking to care. They are materialities that set courses of action, becoming indispensable actors/actants in producing care because they mediate emotions, bonds, and navigators' and participants' mutual expectations.
Since virtual technologies are a constant presence in contemporary times, navigation could end up invading a private, intimate sphere, sparking other tensions in these interactions. This could jeopardize linkage to care or even cause discontinuities, depending on the effects produced by the offered practices of care. The limits of such interaction should be considered to determine when and how to gain proximity and give space as part of a strategic and balanced articulation designed to strengthen linkage.

Linkage and comprehensive health care
This study problematized the notion of care on the basis of a praxiographic approach 36,37 , highlighting the practices in which the care and follow-up of these young people take place, with the potential to spawn multiple effects/results and itineraries. Thus, care -as a continuous fluid, open, and collective process 37 -is an effect of the practices that perform it, being produced via the practical actions and interactions established between different actors and actants (human and non-human), i.e., it can be shaped and reformulated depending on its results. Such practices are situated and also change in space and time.
Peer navigators' role is to intervene with practices of care produced from the necessities that stem from interactions and liaisons between the several actors/actants involved in young people's relationship with health services, according to the following narrative: "...they come into contact with other professionals and end up creating this bond but afterwards it's practically just you. And you think it's going to be mechanical, that you're going to ask, ' Peer navigators set about employing care strategies in an ongoing quest for equilibrium, which, in practice, is always provisional and unstable because tensions and conflicts are an integral part of the courses of action taken to attain a healthy life. It aims to encourage self-care without necessarily feeding the illusion of control and without disregarding the unforeseen. And, given the context of vulnerability in which project participants live, adversity is ever-present and significant in decisions pertaining to how care is offered. Navigators offer what support they can, situated in the social and material context in which both they and the adolescents find themselves. They can propose alternate routes, lending a sense of fluidity to care, enabling adolescents to actively take part in their care practices, and becoming adaptable and resilient in overcoming the obstacles they face in their quest for health. Such is the case of the trans adolescents in the project, who share certain vulnerabilities with navigators because of their transgender status: "Socioeconomic issues that also end up affecting emotional issues (...) have a strong impact in erecting these barriers to access and adherence. (...) I've managed to devise some strategic actions to get around them and ensure participants' adherence" (Field notebook -peer navigator 1).
"She told me she was well physically but revealed to me that she was emotionally depressed because of lack of employment and income. Financial difficulties have made her worried and sad because she has to depend on her father, who helps with what little he can at the moment" (Field notebook -peer navigator 4).
Each person's needs are different and practices of care must thus consider these differences and specificities 33 . The focus turns to the relationship between individuals in specific contexts. In the work of navigators, paying attention to such specificities is crucial for successfully following up and receiving each participant and enabling uptake and linkage to the service: "...one thing that makes this project different is precisely that it has LGBT people in the team, and I think that's necessary to construct new values and perspectives inside this care setting, because we have to exist in places like this to make projects like this last longer..." (Focal group -peer navigator 2).
"Of course, we have to take the social aspects, the political aspects, into consideration, particularly because it's the population that suffers most in this country [in terms of just existing] for being LGBT (...) The prospect of not getting work, the barrier that's the family, so lots of these people don't come out to their families that they're LGBT and all that causes a load of emotional and psychological suffering" (Focal group -peer navigator 1).
These specificities appears in the discontinuities in follow-up adherence to PrEP. As shown in Figure 1, there were oscillations in the level of adherence of the participants, in addition to interruptions and resumptions in the use of PrEP and those who gave up its use. Adolescents reported some of these reasons: conflicts in family relationships and/or with sexual partners, mental suffering, and material and financial difficulties. In these situations, peer navigator face the tensions emerging from different logics underlying their care practices, oscillating between pre-determined and biomedicalbased guidelines and those produced from dilemmas, challenges, and conflicts. These adversities socially and materially place them in their networks of relationships and trace fluid paths open to the trajectory of the offered care. This viscosity of care 37 produces different forms of action and creates other scripts for the use of PrEP, with a perspective to produce comprehensive care which is sensitive to specific realities and life conditions. The trajectories of LGBT people, especially when they are adolescents, are ridden with vulnerabilities and risks, which impair their relationships, make their trajectories invisible, and foster processes of social exclusion, making it harder for them to get access to the care offered by navigators. However, a study by Reback et al. 22 on a peer navigation intervention for MSM and TGW experiencing multiple syndemic health disparities found that even the most vulnerable social groups can successfully achieve linkage and retention to PrEP. Despite daily tensions, the inclusion of this strategy to the PrEP1519 project constitutes an offer of care whose practices are shaped toward greater comprehensiveness and inclusion, considering the health inequities these vulnerable populations face, which implies forging bonds which may be consistent and lasting.

Concluding remarks
This study brings an expanded look at a care strategy with a prescriptive and preventive tradition, based on its ability to choose care practices to achieve good care 37 , with a series of informed actions and decisions pre-determined by a structure of different actors and actants who, if engaged, perform biomedical care strategies. However, peer navigator in practice is richer than what is expected, and the production of care is not restricted to its actions. Practices are multiple and perform realities that coexist within the PrEP1519, bringing together a network of relationships of heterogeneous elements and the occurrence of several things within such micro-relationships. The tension between these logics is set, instituting, an actor which, in the network of associations, has a specific place in the project, producing effects that impact the various links between human and non-human actors. This certainly generates these or other possibilities for the undertaken care practices.
We find definite methodological limitations related to the participants' profile regarding adherence to PrEP, as well as the period in which they were interviewed. We conducted our fieldwork in 2019, the first year in which the PrEPara Salvador clinic was operating, in which most of the youth in good adherence to PrEP had been with the project for one to six months. This follow-up time and use of PrEP could have been instrumental in adolescents' positive appraisal of the peer navigator work. Therefore, studies which assess the problems and challenges that come up in the longer-term engagement with care of young adolescents and caregivers in the scope of STIs prevention, including potential discontinuities in PrEP use, would be opportune.