The social construction of the PrEP1519 study: conditions of possibility for advances in HIV/AIDS prevention

A construção social do estudo PrEP1519: possíveis condições para os avanços na prevenção do HIV/aids

La construcción social del estudio PrEP1519: posibles condiciones para avances en la prevención del VIH/sida

Abstracts

This paper analyzed the genesis of the PrEP1519 study and feasibility conditions for its construction. A qualitative-approach study was conducted using the Bourdieusian sociology framework to reconstruct the dynamics of the social environment where PrEP1519 emerged during 2015-2018. A document analysis and ten in-depth interviews were carried out to analyze the trajectory of the project. Pre-exposure prophylaxis (PrEP) was introduced in Brazil as a public policy in 2017. The lack of scientific evidence available among the adolescent population led to the development of a demonstrative cohort study, associated with an intervention, aimed at combining the prevention and treatment of sexually transmitted infections at three sites in Brazil. PrEP1519 sought to generate evidence for global use and to help the Brazilian Ministry of Health apply PrEP among adolescents. The articulation of bureaucratic, scientific, and activist stakeholders enabled this study. The feasibility conditions for developing PrEP1519 included a favorable relationship of national organizations with international organizations, the favorable approach that public administrators had at the time towards new technologies and prevention strategies, the researchers’ previous experience in studies with the target population or with PrEP, articulation efforts with social movements, civil society organizations, and other public agencies, and the integration between scientific institutions, which allowed using international resources and developing a response to the problem. Completing this study at a moment when conservatism advances in Brazil demands that the scientific community and activists closely monitor and take stances on PrEP to ensure its availability for adolescents as a public policy.

Keywords:
Pre-Exposure Prophylaxis; Teenagers; Acquired Immunodeficiency Syndrome; Public Health Policies; Medical Sociology

Este trabalho analisou a gênese do estudo PrEP1519 e as condições de possibilidade para sua construção. Um estudo qualitativo foi realizado, utilizando a estrutura sociológica de Bourdieu para reconstruir a dinâmica do ambiente social onde surgiu o estudo PrEP1519, de 2015 a 2018. Foram realizadas uma análise documental e 10 entrevistas aprofundadas, com análise de suas trajetórias. A pofilaxia pré-exposição (PrEP) foi introduzida no Brasil como política pública em 2017. A escassez de evidências científicas disponíveis entre a população adolescente levou ao desenvolvimento de um estudo de coorte demonstrativo, associado a uma intervenção, visando combinar a prevenção e o tratamento de infeccções sexualmente transmissíveis em três localidades no Brasil. O objetivo era gerar evidências para uso global, e apoiar o Ministério da Saúde com a incorporação da PrEP entre adolescentes. Este trabalho resultou da articulação de atores burocráticos, científicos e ativistas. As possibilidades de desenvolvimento deste estudo permearam uma relação favorável com organizações internacionais, a abordagem favorável dos administradores públicos da época para com as novas tecnologias e estratégias de prevenção, a experiência anterior dos pesquisadores em estudos com a população-alvo ou com a PrEP, os esforços de articulação com movimentos sociais, organizações da sociedade civil e outros órgãos públicos, e a integração entre instituições científicas que possibilitaram recursos internacionais e uma resposta ao problema. A conclusão deste estudo em cenário no qual o conservadorismo avança no país, exige que os campos científico e ativista acompanhem de perto e tomem posições, para garantir a disponibilidade da PrEP para adolescentes como política pública.

Palavras-chave:
Profilaxia Pré-Exposição; Adolescente; Síndrome de Imunodeficiência Adquirida; Política de Saúde; Sociologia Médica

Este trabajo analizó la génesis del estudio PrEP1519 y las posibles condiciones para su desarrollo. Se realizó un estudio cualitativo a partir del marco sociológico de Bourdieu para reconstruir la dinámica del entorno social donde surgió el estudio PrEP1519, de 2015 a 2018. Se llevó a cabo un análisis documental y 10 entrevistas en profundidad, con análisis de sus trayectorias. La profilaxis pre-exposición (PrEP) se introdujo en Brasil como política pública en 2017. La escasez de evidencia científica disponible entre la población adolescente llevó al desarrollo de un estudio de cohorte demostrativo, asociado a una intervención, con el objetivo de combinar la prevención y el tratamiento de las enfermedades de transmisión sexual en tres localidades de Brasil. El objetivo fue generar evidencia de uso global y apoyar al Ministerio de Salud con la incorporación de la PrEP entre los adolescentes. Este trabajo resultó de la articulación de actores burocráticos, científicos y activistas. Las posibilidades para desarrollar este estudio permearon una relación favorable con organismos internacionales, el enfoque favorable de los administradores públicos hacia las nuevas tecnologías y estrategias de prevención, la experiencia previa de los investigadores en estudios con la población objetivo o con PrEP, los esfuerzos de articulación con movimientos sociales, organizaciones de la sociedad civil y otros organismos públicos, y la integración entre instituciones científicas que posibilitaron recursos internacionales y una respuesta al problema. La conclusión de este estudio en un escenario en el que avanza el conservadurismo en el país requiere que los campos científicos y activistas vigilen y tomen posiciones para asegurar la disponibilidad de la PrEP para adolescentes como política pública.

Palabras-clave:
Profilaxis Pre-Exposición; Adolescente; Síndrome de Inmunodeficiencia Adquirida; Política de Salud; Sociología Médica

Introduction

In Brazil, the national policy for HIV/AIDS control has historically been based on the articulation of preventive actions, epidemiological surveillance, monitoring, financing efforts by nongovernmental organizations and access to treatment. The law on universal access to antiretroviral drugs resulted from pressure and articulation efforts among social movements, the medical field, and the media, ending the possibility of an AIDS policy without access or with limited access to these drugs in Brazil ¹.

Until 2010, HIV/AIDS prevention actions were organized almost exclusively by encouraging the use of condoms and safe sex, and by recommending the postponement of sexual debut among adolescents ². The effectiveness of new prevention methods, and proposals for an association between different methods (combined prevention) ^3,4,5, expanded the HIV/AIDS prevention and control possibilities. Prevention started to rely on new technologies, not only behavioral methods, including interventions with the use of antiretroviral drugs, adopting the concept of “treatment as prevention”, and recognizing the priority of key populations exposed to situations with high vulnerability towards HIV ^2,6. Pre-exposure prophylaxis (PrEP) has emerged as a safe, effective, and efficient alternative, especially among men who have sex with men (MSM) and transgender people ^6,7,8.

PrEP is a prevention strategy which uses antiretroviral drugs to reduce HIV infection among population segments that are at higher risk, it was introduced in Brazil in 2017, after randomized clinical trials and studies such as PrEP-Brazil showed high efficacy and effectiveness ^9,10,11. Daily oral PrEP consists in the regular use of one tablet containing two antiretroviral drugs: tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). Priority groups for PrEP in Brazil are gays and other MSM, sex workers, transgender people and serodiscordant couples ⁹. Groups with high HIV prevalence such as drug users and adolescents were not included due to lack of scientific evidence on its effectiveness so far, but demonstrative studies with these populations have already been proposed ¹⁰.

The use of PrEP among adolescents and young people is justified by the growth in the number of HIV-infected people in Brazil and worldwide among this population, especially among minority groups such as MSM, travestis and transgender women (TrTGW) ^12,13. The limited studies on PrEP access, use and effectiveness among adolescents point towards important challenges ranging from legalized access, free of charge and independently, by adolescents under 18, or those who do not have parental consent ^14,15, the obstacles in attracting young people to use PrEP due to lack of knowledge about HIV risks among professionals or adolescents ¹⁵.

The PrEP1519 Study, implemented in three Brazilian capitals, is the first cohort with Latin American adolescents, which aims to assess the effectiveness of the use of PrEP among MSM and TrTGW adolescents, contributing to the reduction of HIV incidence among this population. The study began in 2018 and was expected to be completed by June 2021 but was extended until December. This paper analyzed the genesis of the PrEP1519 Study and the conditions of possibility for its construction.

Methodology

A qualitative approach study was carried out, using the Bourdieusian sociology framework to reconstruct the dynamics of the social environment where the PrEP15-19 Study ¹⁶ emerged, based on the concept of social space, place where agents are distributed according to the different amounts of various capitals forms, especially cultural and economic, but also political, social, symbolic, bureaucratic ¹⁷, or even militant ¹⁸.

The concept of capital is used against an extremely economic view, understanding that others forms of possession or not of riches can influence the benefits each agent are able to obtain in a social space ¹⁹. The political capital is related to the agent’s capacity of mobilizing people, acquired in person or by the delegation of a political party or a union. It’s a capital of recognition, a kind of symbolic capital. To Bourdieu, social movements just can influence the political champ if supported by journalists and the press ²⁰. So, the development of militant capital notion accounts for some aspects of the social engagement for which the political capital is not sufficient. In this sense, the militant capital, developed based on Bourdieu’s theoretical framework, is related to skills like knowing what to do during a meeting, how to talk in public, how to lead people to do something, knowledges and practices that in some cases and situations can be converted or not into political capital if associated with a capital of notoriety ¹⁸.

The study aimed to identify the conditions of possibility within the “Brazilian AIDS space”, considered a social space for organizing the struggle against AIDS, involving stakeholders from different fields and social subspaces ¹, the relationships between different groups and the main representatives involved in Brazil, and in international organizations, from 2015 to 2018.

Thirty-five documents related to the construction of the project were analyzed: 25 from international organizations, 8 from national institutions the original project, as well as agendas, reports and presentations related to the Brazilian National Commission of STIs, AIDS and Viral Hepatitis (CNAIDS) meetings held between 2013 and 2018, available on the Department of Chronic Conditions Diseases and Sexually Transmitted Infections of the Brazilian Ministry of Health (DCCI) website (https://www.gov.br/aids/pt-br) (Box 1).

Box 1
List of the main documents analyzed on the background and construction of the PrEP1519 project, from 2012 to 2019.

ID	DOCUMENT	INSTITUTION (YEAR)	DOCUMENT TYPE	CONTENT
D1	Guidance on PrEP for serodiscordant couples, men and transgender women who have sex with men at high risk of HIV. Recommendations for use in demonstration projects	WHO (2012)	Guidance	Recommendations specifically developed to address the daily use of antiretrovirals in HIV-uninfected people to block the acquisition of HIV infection (pre-exposure prophylaxis). At that stage evidence was available from studies with two groups: men and transgender women who have sex with men; and serodiscordant heterosexual couples
D2	PrEP demonstration projects: a framework for country level protocol development	WHO (2013)	Guidelines	Recruitment of the priority population for a PrEP program will be defined in each site, as well as the best methods to recruit these populations. In Brazil, adolescents who fit the profile of the population at risk were included
D3	Recommendations for comprehensive care for adolescents and youth living with HIV/AIDS	Brazilian Ministry of Health (2013)	Recommendations	The document aimed to present health professionals with aspects of comprehensive care that promote quality of life and quality of care, with themes related to the epidemiological aspects of HIV infection in this population, considerations about adolescence, diagnostic disclosure, adherence to treatment, sexual and reproductive health, nutritional assessment, and transition
D4	Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations	WHO (2014)	Guidelines	Consolidated guidelines document on HIV prevention, diagnosis, treatment, and care for key populations, the WHO brings together all existing guidance that is relevant to five key populations - MSM, people who inject drugs, people in prisons and other closed settings, sex workers, and transgender people - and updates on selected guidance and recommendations
D5	HIV prevention, treatment, care and support for adolescents and youth	UNAIDS (2014)	Guidance note	Aligns guidance with the HIV investment approach to ensure better coherence of support for HIV programs for adolescents and youth with impact evidence. Emphasizes the need to address and monitor responses for key neglected and vulnerable groups, including adolescents and key affected populations
D6	Update. All in for adolescents	UNAIDS (2014)	News/Update	Meeting held in Geneva (Switzerland), to develop strategies to face the HIV/AIDS situation among adolescents, convened by UNAIDS and UNICEF and partners, who drafted a joint action plan and were committed to fulfilling the “All In Agenda” by February 2015
D7	Update. World leaders unite towards ending the AIDS epidemic among adolescents	UNAIDS (2014)	News/Update	Parallel event to the 69th United Nations General Assembly called All In! Towards Ending the AIDS Epidemic among Adolescents, coorganized by UNICEF, UNAIDS, and the governments of Brazil and Kenya, where representatives of the six regions supported the “All In!” initiative
D8	Update. Treat, reform, educate, love: young people preparing to take the lead at AIDS 2014	UNAIDS (2014)	News/Update	The Youth Pre-Conference, which preceded AIDS 2014 in Melbourne (Australia), addressed various topics of interest to youth and created the Youth Action Plan, demanding youth participation in national, regional, and international discussions on AIDS policy, advocacy, and treatment
D9	All in to #endadolescentaids	UNAIDS (2015)	Call for action document	The “All In” strategic framework is in line with the visions of zero new HIV infections, zero AIDS-related deaths, and zero discrimination, monitoring and assessing efforts of existing national programs and expanding them to focus on results for adolescents
D10	Health blog	Brazilian Ministry of Health (2015)	Blog/Interview	Brazil leads unprecedented PrEP studies scheduled to start in 2016 in the Unitaid action in Brazil; studies on PrEP are carried out with this age group for the first time
D11	Minutes of the 22nd Executive Board Meeting	Unitaid (2015)	Minutes of the Executive Board Meeting	Meeting held in Brazil. Approves several items, including Resolution 5 Enabling Scale-up of PrEP and Linkage to Test as a New Area for Intervention
D12	PrEP - contextualizing a new option/oral PrEP - putting a new choice in context	UNAIDS, WHO, and AVAC (2015)	PrEP reference document	PrEP basic information and implementation issues
D13	WHO technical update on PrEP	WHO (2015)	Guidelines	The role of PrEP as part of a comprehensive HIV prevention package for young women needs urgent consideration and WHO plans to develop this guidance in the first half of 2015
D14	Strengthening the adolescent component of national HIV programs through country assessments and the AADM tool	UNICEF (2015)	Guidelines	All In is an initiative aimed at generating better outcomes for adolescents (10-19 years old) through critical changes in programs and policies that seeks to engage adolescents and unite stakeholders in all sectors to accelerate the reduction in deaths AIDS-related and new HIV infections among adolescents by 2020
D15	Resolution n. 9-2016-e	Unitaid (2016)	Resolution	Presents conditions for Unitaid and UNICEF to conduct the project. It appoints UNICEF as the leading organization, making funding conditional for Unitaid and UNICEF to sign a grant agreement project. Countries involved: Brazil, South Africa, and Thailand
D16	Minutes of the 49th CONITEC meeting	CONITEC (2016)	Minutes	Technical staff from Fiocruz and from the PrEP Brazil Project presented the available scientific evidence on the use of prophylactic antiretroviral (tenofovir + emtricitabine = Truvada) among people at high risk for HIV infection. Discussions on the subject were suspended until Anvisa approved prophylactic indication of the drug. The initial PCDT proposal was not presented
D17	Strengthening HIV programs for adolescents: early lessons from adolescent assessments to guide fast tracking of adolescent responses through All In	UNAIDS and UNICEF (2016)	Guidelines	Tool to help countries identify equity and performance gaps that limit the impact of investments in adolescent programs and direct countries to actions that better target adolescents at greatest risk for infections, illness, and death
D18	Ending the AIDS epidemic for adolescents, with adolescents - a practical guide to meaningfully engage adolescents in the AIDS response	UNAIDS (2016)	Guidelines	Seeks to provide guidance on adolescent involvement in the AIDS response and broader health programs among efforts to end the AIDS epidemic by 2030
D19	All In to end the adolescent aids epidemic: a progress report	UNAIDS and UNICEF (2016)	Report	It seeks to engage adolescents in rapid efforts to end the AIDS epidemic by 2030 and provides targets for 2020
D20	Appropriate medicines: options for PrEP	WHO (2016)	Guidelines	Lack of data for adolescents and transgender people [note: this is also true regarding other PrEP drugs]
D21	Resolution n. 9-2016-e	Unitaid (2016)	Resolution	Enabling scale-up of PrEP and linkage to testing among sexually active older adolescents with substantial HIV risk (Brazil, South Africa, and Thailand)
D22	Resolution n. 21-2017-e	Unitaid (2016)	Resolution	International funding document for PrEP access for adolescent women in South Africa. Integrating PrEP into comprehensive services for adolescent girls and young women in South Africa
D23	Resolution n. 7-2017-e	Unitaid (2017)	Resolution	Release of funds for PrEP project in Brazil, Peru, and Mexico
D24	Resolution n. 2-2021-e	Unitaid (2017)	Resolution	Project term extension “Preparedness for the Rollout of Effective HIV Prevention among Key Affected Populations in Brazil, Peru and Mexico”
D25	Minutes of the 52nd CONITEC meeting	CONITEC (2017)	Minutes	Scientific evidence showed that the use of PrEP reduces the risk of HIV infection with > 70% efficacy, being directly related to adherence. The group decided to submit the topic to public consultation with a favorable preliminary recommendation, with some conditions
D26	Minutes of the 55th CONITEC meeting	CONITEC (2017)	Minutes	Unanimous recommendation to incorporate the use of TDF/FTC 300/200mg as PrEP in SUS for populations at increased risk of contracting HIV. Approval of the HIV PrEP Clinical Protocol and Therapeutic Guidelines
D27	PCDT for PrEP to HIV: report recommendation	CONITEC (2017)	Report	Proposed PCDT for HIV PrEP assessed by the Technical Subcommittee for the PCDT Assessment on CONITEC and CONITEC (52nd regular meeting) that favorably recommended the use of PrEP in writing
D28	Report on the recommendations: TDF/FTC (300/200mg) as PrEP for population at higher risk of acquiring HIV	CONITEC (2017)	Report	Presented scientific and epidemiological evidence to support the analysis for the incorporation of TDF/FTC 300/200mg as PrEP for HIV infection in SUS
D29	PCDT for PrEP of risk for HIV infection	Brazilian Ministry of Health (2017)	PCDT	PCDT for PrEP for HIV infection risks
D30	WHO implementation tool for PrEP of HIV infection - module 9	WHO (2017)	Guidelines	Older adolescents and young people at substantial risk of HIV could also be included in PrEP services. It is important for providers to sensitively and non-judgmentally engage in a discussion with young people about their sexual partners and recognize and minimize risks of intimate partner violence while assessing HIV prevention options
D31	Training workshop for the implementation of PrEP and innovations in HIV testing - Asia and the Pacific	Unitaid, UNAIDS and WHO (2018)	Workshop report	Conducted in Thailand in 2018, the report highlights the challenges for implementing PrEP and using self-testing in the Asia-Pacific region. Indicates actions to be prioritized
D32	UNITAID Annual Report 2016-2017	UNITAID (2018)	Annual Report	Projects and Actions carried out in 2016-2017
D33	WHO implementation tool for PrEP of HIV infection: module 12: adolescents and young adults	WHO (2018)	Guidelines	The limited data available on young key populations suggest that they are even more disproportionately affected by HIV in most settings. Young members of key populations often face tremendous challenges, including legal and sociocultural issues related to societal attitudes about sexuality in youth
D34	Agendas and presentations from CNAIDS meetings (114th to 126th)	CNAIDS (2013 to 2018)	Documents	The website provided no documents of the 116th and 117th meetings. Since it also did not show the minutes of the other meetings, the research group decided to search for information on the discussions about PrEP using other documents
D35	Enabling scale up of PrEP and Linkage to testing among sexually active adolescents who have sex with men, transgender women and their sexual partners with substantial HIV risk in Brazil	2018	Research project	Study project financed by Unitaid, developed in three city capitals of Brazil to (a) reduce HIV incidence among MSM and TrTGW adolescents; (b) assess the effectiveness of PrEP use among MSM and TrTGW adolescents aged 15 to 19 years

• AADM: adolescent assessment and decision-makers; Anvisa: Brazilian Health Regulatory Agency; AVAC: AIDS Vaccine Advocacy Coalition; CNAIDS: Brazilian National Commission of STIs, AIDS and Viral Hepatitis; Fiocruz: Oswaldo Cruz Foundation; MSM: men who have sex with men; PCDT: Clinical Therapeutic Guideline Protocol; PrEP: pre-exposure prophylaxis; SUS: Brazilian Unified National Health System; TDF/FTC: tenofovir plus emtricitabine; TrTGW: travestis and transgender women; UNAIDS: Joint United Nations Programon HIV/AIDS; UNICEF: United Nations Children’s Fund; WHO: World Health Organization.

Ten in-depth interviews were conducted with individuals related to the project coordination, who occupied leadership positions, participated in the genesis of PrEP1519 in three sites: the Brazilian Ministry of Health, the Pan American Health Organization (PAHO), and the World Health Organization (WHO). The script addressed the academic, professional, and political-institutional trajectories of the representatives, as well as issues around the process of creating and developing the project, and stages for study implementation. The snowball sampling technique was used to establish the sample with key informants from the Brazilian Ministry of Health and international organizations, beginning with I3 as the first key informant. The interviews were transcribed, revised, edited, coded, and analyzed using the NVivo 11 software (https://www.qsrinternational.com/nvivo/home).

The social and professional trajectories of the coordinators, understood as the positions occupied in different spaces and social fields, and their positions in “Brazilian AIDS Space” were analyzed based on their Lattes Curriculum and interviews. The position was characterized by the volume and composition of the different types of capital: school, scientific, political, bureaucratic, university bureaucratic, and militant (Box 2), adapted from previous studies ^1,21,22.

Box 2
Analysis criteria for different types of capital * used.

TYPE OF CAPITAL	CAPITAL VOLUME
	VERY HIGH	HIGH	MEDIUM	LOW
Scientific	Research productivity scholarship 1A, 1B, 1C, 1D (CNPq - Public Health and Nutrition or Medicine) or compatible profile: Obtained Doctorate at least 8 years ago; Supervised at least 10 stricto sensu graduate students in the last 10 years, at least 2 at a doctorate level (PGP with a Doctorate for at least 5 years); Published 30 scientific papers in the last 10 years; Is active in a PGP with score 3 or higher	Research productivity scholarship 2 (CNPq - Public Health and Nutrition or Medicine) or compatible profile: Obtained Doctorate at least 3 years ago; Supervised at least 1 main stricto sensu graduate student in the last 5 years; Published 10 papers in the last 5 years; Is active in a PGP with score 3 or higher	Doctorate; Permanent staff in a PGP and supervising 1 main student in progress/completed. Coordinates research project with funding	Doctorate; Is part of a research project team
Bureaucratic **
Occupation of technical positions at different levels of management in the health system and international organizations	Management positions in international organization (UNAIDS, PAHO, WHO); Leaders of the National STI/AIDS Program or in senior positions involved in AIDS policy	Leading state programs; National STI/AIDS Program technical staff; Participation in meetings to define the Ministry of Health policy	Intermediate management positions in Municipal Health Departments (municipal programs); State program technical staff	Technical positions (advisor, consultant)
University bureaucratic	President	Unit director	Department head; GP coordinator	Deputy head of department; GP vice-coordination
Political
Occupation of administrative positions that result in specific political articulations	Minister of Health; Chairmen of the health agencies	State health secretaries	Municipal health secretaries	Other technical positions with a political appointment
Participation in political parties	National leader	State political party leader	Municipal political party leader	Affiliated to a political party
Participation in elective positions	Senator; Federal representative	State representative	City councilor
Militant
Professional and popular leaders	Leader with charismatic leadership skills capable of engaging and gathering people (high symbolic capital)	Director of NGOs or social movements	Intermediate positions in NGOs or social movements	Activists in NGOs or social movements

• CNPq: Brazilian National Research Council; GP: graduate program; NGO: nongovernmental organization; PAHO: Pan American Health Organization; PGP: postgraduate program; STI: sexually transmitted infections; UNAIDS: Joint United Nations Programon HIV/AIDS; WHO: World Health Organization.
• * Adapted from Barros 1, Vieira-da-Silva & Pinell 21, and Costa et al. 22.
• ** Measured based on stances taken, considering that occupying a technical position requires titles (acquired cultural capital) appropriate for the related position.

A multiple correspondence analysis (MCA) was performed using the R software, version 4.0.4 (http://www.r-project.org), to understand the characteristics of the teams that were part of the project at each site during its genesis. MCA is a multivariate method that analyzes the relationship between two or more variables within the context of a phenomenon of interest ²³. The following active variables were considered: undergraduate course, highest degree, and area of expertise; as well as the following supplementary variables: research site and area of the graduate program (GP) with the highest degree.

The research followed the recommendations in Resolutions n. 466/2012 and n. 510/2016 of the Brazilian National Health Council regarding ethics in research involving human beings and was approved by the Research Ethics Committee at the Collective Health Institute in the Federal University of Bahia (n. 3,224,384).

In the Results, the documents are identified by the letter “D” (Box 1) as the interviewees are identified by the letter “I” (Box 3).

Box 3
Analysis of the interviewees’ professional trajectories and volume of scientific, bureaucratic, university bureaucratic, political, and militant capital.

INTERVIEWEES	PLACE OF BIRTH	AGE (YEARS)	UNDERGRADUATE DEGREE	CAPITAL VOLUME
				SCIENTIFIC	BUREAUCRATIC	UNIVERSITY BUREAUCRATIC	POLITICAL	MILITANT
I1	Brazil	52	Biological Sciences (UNICAMP, Brazil, 1986-1989)	Medium	Very high	-	-	Medium
I2	São Paulo (Brazil)	41	Psychology (USP, Brazil, 2001-2005)	Medium	-	-	-	-
I3	Salvador (Bahia State, Brazil)	62	Medical Sciences (EBMSP, Brazil, 1976-1981)	Very high	Medium	Medium	-	-
I4	Manaus (Amazonas State, Brazil)	65	Medicine (UFAM, Brazil, 1973-1978)	Very high	Very high	-	-	High
I5	NI	74	Medical Sciences (UFMG, Brazil, 1965-1969)	Very high	Very high	Medium	-	-
I6	Bragança Paulista (São Paulo State, Brazil)	55	Social Sciences (PUC-SP, Brazil, 1987-1992)	Medium	Very high	-	-	Medium
I7	NI	31	Nursing (UFBA, Brazil, 2007-2011)	Medium	-	Low	-	High
I8	NI	NI	Psychology (University of Maryland at College Park, United States, 1974-1978)	Medium	High	-	-	Medium
I9	Baltimore (Maryland, United States)	44	Health Services Administration (Auburn, United States, N/I)	-	Very high	-	-	-
I10	Itápolis (São Paulo State, Brazil)	63	Medicine (UEL, Brazil, 1975-1982)	Medium	Very high	-	Medium	High

• EBMSP: Bahian School of Medicine and Public Health; N/I: no information; PUC-SP: Catholic University of São Paulo; UEL: Londrina State University; UFAM: Federal University of Amazonas; UFBA: Federal University of Bahia; UFMG: Federal University of Minas Gerais; UNICAMP: Campinas State University; USP: University of São Paulo.

Results and discussion

Background and incorporation of the youth population into the agenda

In July 2012, the WHO pointed out the effectiveness of PrEP based on clinical trials and encouraged countries to carry out demonstrative studies to better understand the safety, effectiveness and sustainability of its daily use for serodiscordant couples, MSM and TrTGW (D1). In 2013, the WHO carried out a call for demonstration studies as an important step prior to full implementation in countries (D2) and, as of 2014, the WHO began recommending the offer of oral PrEP as one of the prevention possibilities for people that have high risks of having HIV, based on a combined prevention perspective (D4). There was not a referral for use among the adolescent population (D4) (Figure 1; Box 1).

Figure 1
Timeline with the main projects, documents, and formalized actions by the State or international organizations for pre-exposure prophylaxis (PrEP) accessibility among the adult and/or youth population, from 2012 to 2019.

In 2015, WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS) and the AIDS Vaccine Advocacy Coalition (AVAC) identified daily oral PrEP as the only option available for HIV-negative people to use outside of sexual experiences. The document highlighted its use by women, including adolescent girls, and among stable partners. Other populations at risk for HIV were not mentioned (D12). In 2016, the WHO reinforced the importance of PrEP as a strategy with strong scientific evidence towards HIV prevention ⁴. Subsequently, PrEP implementation strategies were published in different countries, with a specific module for adolescents and young adults (D30)(Figure 1). Figure 1 illustrates a timeline with the historical construction of this strategies in the international context and in Brazil.

While deaths caused by AIDS were rapidly decreasing in other age groups, this did not occur in the adolescent population aged 15-19 (D12). Then, the prioritization of the fight against the HIV/AIDS epidemic among adolescents began, highlighted in the agenda for several events held (D6, D7, D8) and documents published independently or jointly, especially by UNAIDS (D5, D9, D12, D17, D18, D19, D31), United Nations Children’s Fund (UNICEF) (D14, D17, D19), and WHO (D12, D20, D30). Studies that analyzed the emergence of a PrEP policy in Brazil also highlighted the debate among international organizations defending its offer as a HIV prevention strategy ^24,25.

The Youth Pre-Conference, which preceded the International AIDS Conference in 2014, addressed topics of interest to youth and developed the Youth Action Plan, demanding their participation in discussions on HIV/AIDS policies, advocacy, and treatment (D8).

Also in 2014, along with the 69th General Assembly of the United Nations (UN), the All In! Towards Ending the AIDS Epidemic among Adolescents event happened, co-organized by UNICEF, UNAIDS and the Brazilian and Kenyan governments. In this event, representatives from six regions joined the movement to advance the response to HIV among adolescents, supporting “All In!”, which sought to reduce new HIV infections among adolescents by at least 75%, and reach treatment for at least 80% of the adolescents living with the virus, through prevention, testing, care and treatment strategies for this population (D7).

In Brazil, this theme was discussed during the CNAIDS meetings, as of 2014. Although most CNAIDS meetings between 2013 and 2018 (114th to 126th) do not have their minutes published on the Committee’s website, the meeting agendas, presentations, and documents available made it possible to identify which themes were discussed and when, as well as the positions taken by some agents. At the 119th meeting (August 26, 2014), during a presentation by the International Cooperation Office of the Department for Sexually Transmitted Diseases, HIV/AIDS and Viral Hepatitis (DDAHV), PrEP was mentioned as one of the new prevention technologies. The 120th meeting (March 30, 2015) discussed the topic of AIDS and youth; followed by representatives of the National Network for Adolescents and Youth Living with HIV/AIDS/Youth Coalition for Post-2015, and the General Coordination for Prevention and Social Articulation at the DDAHV (D34).

DDAHV management promoted changes in the technical staff and supported technological innovations related to the use of antiretroviral drugs as a preventive measure. The recruitment of gay boys and trans girls helped to reorganize the actions and a training for youth empowerment (Box 4). These evidence shows that the Brazilian Ministry of Health, its director in person but also his collaborators, was predisposed to adopt PrEP, and brought the youth to the agenda, in consonance with international bodies guidelines.

Box 4
Analysis category, social agent, and interview fragments.

THEME	AGENT (HIGHER CAPITAL)	INTERVIEW FRAGMENTS
Background and conditions of feasibility: national and international cooperation	I9 (Bureaucratic)	“...what Unitaid does as part of product introduction, and what they wanted to do for PrEP, we knew that PrEP was effective, but we didn’t know how to deliver it effectively, so the ideas of the projects were to see what demand-generation activities, what type of service delivery, what type of messaging, what type of support tools would users need, you know, you’re trying to reach a particular population and concentrated epidemics, who don’t access services...”
	I10 (Bureaucratic)	“...the department even had an LGBT population working there, but (...) it had nothing to do with youth (...) three gay boys and a trans girl (...) young people, very energetic who knew how to deal with youth, communicate [were recruited] And they helped (...) to organize a training (...) for youth empowerment...”
	I7 (Scientific and Militant)	“...there was a whole international and Brazilian context that brought PrEP to a leading role. Not a leading role as the only technology, but as an effective prevention technology. So, all the AIDS and HIV congresses with many studies, as a promising technology, so this whole background pushed us to study this topic. It has a favorable context, a scientific, financial, technological, favorable context for that... and social too, right? So PrEP was the focus of the study”
	I7 (Scientific and Militant)	“So, the studies (...) show the great effectiveness of PrEP for prevention and this technology stands as a promising technology for prevention. So it turns out that the governments of different countries, the international agencies have a super important role in this process, the agencies specifically the WHO or UNAIDS also have an important role in the diffusion of these prevention technologies...”
PrEP and scientific evidence	I3 (Scientific)	“...the PrEP Brazil project was fundamental in providing CONITEC with scientific evidence on the importance of evaluations to demonstrate the effectiveness of PrEP for these two key populations, men who have sex with men, travestis, and trans women...”
PrEP in Brazil - initial challenges	I1 (Bureaucratic)	“...civil society in Latin America has a lot of resistance to everything that resembles medicalization, capitalism, so it’s always received with ‘no’. So, PrEP took some time to convince civil society that this was a good thing (...) [We also] have all the councils involved and supporting and finally manage to approve antiretrovirals as prevention, etc. and the whole regulatory issue...”
The delay in the Brazilian response	I1 (Bureaucratic)	“...it was absurdly slow (...) because what happens is that, in general, any recommendation takes a long time to enter Latin America and the Caribbean (...) One is because you don't have a financing agent pushing and determining things (...) Latin America doesn’t receive many external resources (...) in Brazil, you don’t bring in a new product overnight, you have a whole bureaucratic process...”
PREP1519: strategies and innovations	I9 (Bureaucratic)	“...the creativity that these folks have, I think I’ve never seen anything like it. (...) I think [it] will turn the tide for services to the younger population. (...) how they design the different digital technologies, or the services (...), you know, you don’t see that very often, but I do think Brazil is a very special place when it comes to key populations (...). So, to do those types of services might be harder in other places, but I do think that what digital tools have been created in PrEP1519 will help in those places where these populations are more marginalized”
Choosing the research sites	I3 (Scientific)	“São Paulo has always been the epicenter of the HIV/AIDS epidemic in Brazil, and it has accumulated experience like no other municipality. (...) Belo Horizonte has [had] a tradition of [conducting] cohort studies on men who have sex with men for a long time, very concentrated in the department of infectious diseases at UFMG, where the coordinator (...) has a more clinical profile (...) [Salvador had a research project on the acceptability of PrEP between TrTGW called PopTrans]”
	I1 (Bureaucratic)	“So, in terms of choosing cities, I think honestly it was a political decision. I think this combination of meeting people who can play and play well...”

• CONITEC: Commission for Incorporation of Technologies in the SUS; PrEP: pre-exposure prophylaxis; TrTGW: travestis and transgender women; UFMG: Federal University of Minas Gerais; UNAIDS: Joint United Nations Programon HIV/AIDS; WHO: World Health Organization.

In December 2014, during a meeting in Geneva (Switzerland), led by UNAIDS and UNICEF, with the support of other organizations, a strategy to face the HIV/AIDS situation among adolescents was created. A commitment was made to work towards the fulfillment of the “All in!” agenda by February 2015 (D6). Subsequently, the All In to End Adolescent AIDS (D6, D9) initiative was launched, involving 25 countries that account for more than 80% of the HIV/AIDS cases among adolescents in the world.

As part of the agenda for this initiative, a document with guidelines was prepared (D14) to promote changes in national programs and policies, to engage adolescents and stakeholders from different sectors to accelerate the reduction in infections and deaths by HIV/AIDS among adolescents (D14), through the assessment and reorganization of national programs and prioritization of interventions among this group.

This international context supported the incorporation of PrEP in Brazil, with an emphasis on the following documents: Recommendations for Comprehensive Care for Adolescents and Youth Living with HIV/AIDS (D3), Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections²⁶ and the Clinical Protocol and Therapeutic Guidelines for Post-Exposure Prophylaxis (PEP) for Populations at Risk for HIV Infection, STIs and Viral Hepatitis²⁷.

Developing the strategy for PrEP use in Brazil

PrEP use was approved for oral and daily use in the Brazilian Unified National Health System (SUS) for populations that are highly vulnerable and have an increased risk for HIV infection in May 2017 (PrEP-SUS Program) (D24), effectively made available in December 2017 ²⁸. Specific criteria were considered: having anal or vaginal sex without a condom in the last six months; having frequent episodes of sexually transmitted infections (STIs); repeated use of PEP; having many sexual partners, and the commitment to medication adherence (D29) ⁹. The delay of the Brazilian response towards the incorporation of PrEP as a public policy was highlighted by two interviewees (I1,I9).

A study on the use of PrEP on a social network, between 2015/2016, pointed out that some Brazilian participants reported buying Truvada (PrEP’s trade name) on pharmacy websites in other countries, and using it without medical supervision. Defending universal access to PrEP in Brazil is also mentioned along with the discussion on government responsibilities ²⁹.

The process towards PrEP accessibility in Brazil involved the DDAHV directors and technical team, university researchers and professors, and civil society organizations (CSOs).

The Commission for Incorporation of Technologies in the SUS (CONITEC) meeting, in October 2016 (D16), integrated dolutegravir into therapeutic guidelines, and expanded the use of darunavir as a second-line treatment ³⁰ (I4), it also discussed the approval of the TDF/FTC-300/200mg co-formulation as PrEP, but its use for populations at higher risk for HIV was only recommended in May 2017 by CONITEC (D25). CONITEC analyzes the effectiveness of the technology, comparing it to treatments already incorporated into the SUS.

The Oswaldo Cruz Foundation (Fiocruz) technical team and PrEP-Brasil research coordinators presented scientific evidence on the use of TDF/FTC-300/200mg among people at a high risk for HIV (D16). The drug was not authorized by the Brazilian Health Regulatory Agency (Anvisa), that has the responsibility to evaluate the safety of a medicine or health product with a view to marketing authorization in Brazil, however, the agency’s representative said that the analysis towards possibly including the package insert would be prioritized. Members in the plenary, with a more conservative point of view (I4), requested the discussions regarding this topic be suspended until approval of the prophylactic indication by Anvisa ³⁰⁰ (I4), and thus, there was no presentation of the initial proposal on the Clinical Therapeutic Guideline Protocol for Pre-Exposure Prophylaxis for HIV Infection Risk (PCDT). It is noteworthy that CONITEC could have declared public health interest in the use of Truvada for prevention, despite it being approved by Anvisa for treatment purposes ³⁰.

A new assessment of the PrEP drug took place at the 52nd CONITEC meeting. The members discussed a public consultation with a preliminary favorable recommendation for PrEP, subject to the registration approval by Anvisa for this indication, and the presentation of an annual follow-up plan for the people who would receive prophylaxis (D25).

Evidence from demonstration studies and international studies supported the presentation to CONITEC and PCDT on the effectiveness of PrEP for populations such as MSM and TrTGW ³¹ (I3). At the 55th CONITEC meeting, the results of the public consultation on the incorporation of PrEP were presented, with unanimous approval by all who were present at the meeting (D26). Users and health professionals with experience in the field participated in the public consultation. The CONITEC report highlighted the contribution of the Brazilian Society of Infectious Diseases (SBI), UNAIDS, the Brazilian Interdisciplinary AIDS Association (ABIA), and the Public Defender’s Office in the State of São Paulo (D27). The use among adolescents was suggested, questioning the lack of discussion regarding this population (D28), however, this group was not included due to lack of scientific evidence to support the approval for its use (D27) (I3, I10). Studies highlight the absence of adolescents in the PCDT (10,20).

CSOs played an important role in the debate within the CNAIDS, especially ABIA (I3). The failure to publish the minutes of CNAIDS meetings from 2013 to 2018 did not allow us to identify the positions taken by different members. ABIA’s position was identified through the presentation made by the coordinator of the Working Group on Intellectual Property (GTPI) in the Association, who pointed out the patent system as an inequality generator, “used to promote profit and prolong monopoly”, increasing the costs for purchasing medication. At that time, the purchase of antiretroviral drugs represented approximately 73% of DDAHV expenses. Several publications on their website (https://abiaids.org.br) reinforce that the entity considered PrEP a cutting-edge prevention strategy, questioned the delay ³² and lack of political will ³³ towards its adoption, and, after its approval, the high cost of using a patented drug ^34,35.

Silva ²⁵ also highlights ABIA’s role towards the development of the PrEP policy in Brazil, with support from other social movements and the Public Defender’s Office in São Paulo. The entity also criticized the smaller than expected number of people who would have access to prophylaxis, and the absence of the adolescent population in the approved PCDT, an age group with growing numbers in the epidemic ³⁶.

Castro ³⁷ highlights participation from other movements and CSOs, in addition to ABIA, for their entry into the PrEP agenda and construction of the PrEP policy for SUS, such as the Forum for AIDS Nongovernmental Organizations in the State of São Paulo (FOAESP), Gestos, Grupo de Incentivo à Vida (GIV), Grupo Arco-Íris, and the National Network of People Living with HIV (RNP+Brasil). These organizations were active during public consultations, articulated to support the DDAHV management, contributing/monitoring the clinical research and government actions, through debates and campaigns, sharing information, and activities to pressure the government ³⁷.

A commission produces symbolic effects, develops a (new) definition of a public problem and its solution, which becomes an authority discourse ¹⁶. Until 1990, CNAIDS was established as a group of experts from different social subspaces and had an important technical and political role in the development of official discourse ¹. In the first 15 years (1986 to 2001) 63 meetings were held ^38,39. Over the next 18 years, there were 64 meetings, reaching the 127th meeting in 2019 (D34). The reduction in the frequency of meetings is probably related to the specialization and complexity of the “AIDS space”, with the emergence of new opportunities for participation and specific articulation. This expansion fragmented power, previously concentrated at CNAIDS, which started to be characterized more as an informative and debate environment than an actual decision-making space ¹, which is also evidenced by the non-disclosure of its minutes and attendee lists. Within the PrEP discussion, however, ABIA’s taking of a stance within CNAIDS, but also through its communication channels with society, and representative spaces, demonstrated the possibility for actual social participation.

It is noted that the composition of the DDAHV, with a director with experience in international institutions and favorable to the use the PrEP to HIV/AIDS prevention, the approval of TDF/FTC-300/200mg use to PrEP by CONITEC and Anvisa associated with CSOs demand, were the conditions of possibility to PrEP incorporation to SUS.

PrEP1519

PrEP1519 was proposed based on the issue with the large number of youth aged 15-24 infected with HIV in the world (D25) ¹³, and the increase in deaths related to HIV/AIDS within this population between 2005/2012 ⁴⁰. Upon recognizing the increase in the incidence of HIV among adolescents and the lack of sufficient scientific studies to include this group in the protocol approved by CONITEC, and associated with the Unitaid proposal, a demonstration cohort study with combined HIV prevention, including PrEP, was proposed for the population aged 15-19 years, at three sites, in order to support CONITEC in expanding the supply of PrEP in SUS for this age group (I4, I10).

At the 123rd CNAIDS meeting (May 9, 2017), the proposal for the implementation of PrEP among the population at increased risk for HIV was presented, highlighting five demonstration studies on the acceptability and feasibility of PrEP carried out in the country: PrEP Brazil (Fiocruz), Project Combina! (Faculty of Medicine, University of São Paulo - FMUSP), “PreParadas” (Fiocruz), Horizonte Project (Federal University of Minas Gerais - UFMG), Project PopTrans (Federal University of Bahia - UFBA), generating evidence for the development of national policy, and two implementation studies, cofinanced by Unitaid (PrEP Adult and PrEP Youth and Adolescents), which began in 2017 (D34).

The statement of an interviewee reinforces the favorable conditions towards international organizations such as WHO and Unitaid, with funding opportunities (Box 4).

What is it?

PrEP1519 was developed between 2017/2018, after PrEP was approved as a combined prevention strategy for key populations. The main researchers in the study are a medical epidemiologist, head professor of the GP on Public Health, in a Federal University in Northeast Brazil with a research focus on Epidemiology and HIV/AIDS prevention; a sociologist, researcher in a very recognized university in the Southeast Brazil, and former director of the National STI and AIDS Program, and an immunologist and infectious disease physician, professor emeritus in a Federal University in Southeast Brazil, with research/performance in the field of Infectious and Parasitic Diseases, Clinical Immunology and Ethics, also a former director at DDAHV.

Funding was provided by Unitaid and the Brazilian Ministry of Health, which contributes with medication and supplies. Each site has ways of raising funds jointly and counts on the provision of supplies/inputs for the prevention and treatment of STIs by the state and municipal departments of health, in addition to institutional financial support from Brazilian universities.

The conditions of possibility also involved cooperation with Unitaid for PrEP1519 which was enabled through the settlement of payments due by Brazil to the international organization. Furthermore, a new director of the DDAHV, a medical doctor with a specialization, and a PhD in Public Health, with a long history of HIV/AIDS work, and responsible for proposing the first legislation in the country that advocated the free distribution of medication by the public network, with extensive experience in management positions, as well as in international organizations, contributed to this process (I10).

UNICEF was part of the international management of the project, but since it was not possible to transfer funds within the UN and there were many requirements in exchange for participation, the organization did not remain in the study. While the organization was part of the project for international management, the three sites had already been merged and there was a more focused design on the assessment of the offer and effectiveness of PrEP (I6), with greater importance for the services component. This position taken by Unitaid provided more autonomy to Brazilian researchers to redesign the project according to the current settings. Based on this perspective, the management of resources of the PrEP1519 is done by Fiocruz Support Foundation (FIOTEC), the same for the study on PrEP among adults (I4, I3, I6). This possibility ensured that PrEP1519 could generate evidence for global use and then contribute to making PrEP available to adolescents (I1, I3, I6, I10). It is noteworthy that Brazil started its PrEP public policy after other middle and high-income countries, even if it is one of the most advanced countries in Latin America, somehow it has loosed its vanguard position (I3).

The main objectives for PrEP1519 are (i) assess the effectiveness of the use of PrEP among adolescent MSM and TrTGW, between 2018 and 2020, at three sites, and (ii) to contribute to the reduction of HIV incidence among this population. To achieve the objectives, six components were outlined, namely: (1) qualitative formative research; (2) demand-building strategies for recruiting, enrolling, and attachment to PrEP clinics; (3) HIV incidence to be estimated from prevalence data on the population accessed through demand creation strategies; (4) study demonstrating the effectiveness of PrEP; (5) assessment of the distribution and use of HIV self-tests (HIVST); and (6) cost-effectiveness of PrEP among adolescents. Components 2, 3, 4 and 5 involved mixed method research projects. The study components were development at the three sites, adapting aspects related to the specificities in each municipality, and articulating the development of indicators along with the Brazilian Ministry of Health and state/municipal health departments.

PrEP1519 also provides health care and prevention actions such as quick testing for HIV and other STIs, and laboratory tests for confirmation, as well as distributing self-tests and enabling greater access. The project also offers educational materials and counseling on HIV and other STIs, in addition to other prevention strategies: condoms, lubricating gel, HIV PEP, and referral for vaccination in the municipal network against viral hepatitis (A and B) and HPV.

Choosing the research sites

The choice of sites came from the DDAHV board, between 2015/2016, based on the trajectory of “AIDS space” agents, especially in the scientific and/or bureaucratic fields, and previous experience with research projects with adolescents and about PrEP. In São Paulo, the researcher coordinated Project Combina!, aimed at analyzing the use of PrEP by MSM and TrTGW at high HIV exposure and vulnerability, and participated in the committee that structured the PrEP PCDT. In Belo Horizonte (Minas Gerais State), the Horizonte Project presented objectives related to increasing the use of PrEP and testing the population, among others. In Salvador, there was the Project PopTrans initiated in 2013, on the acceptability of PrEP among TrTGW.

Based on the decision of the sites and the principal investigators (PIs), the development of the proposal began. The PIs have relevant contributions to the fields of HIV/AIDS and are leaders of several projects financed by national and international organizations. They are professors and/or researchers at public universities. Two of them work with Public Health, while the other, works in the Medical Clinic context. He was a director at DDAHV (Box 3). The other PI was also a director of DDAHV and presented a long trajectory in the bureaucratic field (Box 3).

These differences enabled different arrangements of the research team at the three sites. The MCA (Figure 2) shows this relationship. In Belo Horizonte, the high scientific capital was related to conducting cohort studies and clinical trials in the HIV/AIDS field the team mainly includes physicians and other health professionals, with a more clinical background and postgraduate training at the master and doctoral level, in Medical GPs.

Figure 2
Multiple correspondence analysis with the characteristics of the professional trajectory (highest degree, undergraduate course, area of expertise, graduate area of the course with the highest degree) of the PrEP1519 project team.

The group in São Paulo gathers a large number of individuals in the Humanities (Psychology, Sociology, or Social Sciences), with a lower number of postgraduates than in the other two sites, and, when present, it is in a Public Health GP. In Salvador, there appeared to be greater diversity in the team profile regarding undergraduate and graduate education levels, despite its proximity to the Public Health GP.

The development of the PrEP1519 project demonstrated recognition of the problem with the large youth population aged 15 to 19 infected and the increase in deaths related to HIV/AIDS for this population. The dynamics of the social environment where the problem definition was developed resulted from the interpenetration of the strategies among stakeholders interested in constructing the problem as a social problem. According to Bourdieu ⁴¹, the reconstruction of a social construction process is not reduced to a pure and simple set of coincidences. It implies the search for visual logical elucidations in that environment, as intended through this study.

Final considerations

PrEP was introduced in Brazil as a public policy in 2017, after proving its effectiveness through scientific studies, although international organizations recommended access through health systems since 2014. The scarcity of scientific evidence available among the adolescent population led to the development of a demonstrative cohort study, associated with an intervention, aimed at combining the prevention and treatment of STIs in three sites in Brazil. The goal was to generate evidence for global use, and to support the Brazilian Ministry of Health with the incorporation of PrEP among the 15-19-year-old population. This work resulted from the articulation of bureaucratic, scientific, and activist stakeholders. The articulation of agents from different fields, with diverse dispositions and point of views at the three sites contributes to the formulation of broader strategies and an inclusive policy, based on clinical, collective health and social sciences knowledge. The differences on the accumulation of distinct capitals during the agents’ trajectories could be evidenced through the different composition of the research team in the different sites.

The possibilities for developing this study permeated a favorable relationship with international organizations, the favorable approach that public administrators had at the time towards new technologies and prevention strategies, the researchers’ previous experience in studies with the target population or with PrEP, articulation efforts with social movements, civil society organizations and other public bodies, and the integration between scientific institutions that enabled international resources and a response to the problem. Completing this study at a moment where conservatism advances in the country, demands that the scientific field and militant space closely monitor and take positions to ensure the availability of PrEP for adolescents as a public policy. This study had not the objective of the implementation analysis, which must be investigated in another studies.

Acknowledgments

To Unitaid and Brazilian Ministry of Health for providing financial support.

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  » http://abiaids.org.br/abia-critica-atraso-brasileiro-na-adocao-do-truvada-para-a-prevencao-do-hiv-no-sus/28802
• ³³
  Associação Brasileira Interdisciplinar de AIDS. ABIA: falta de vontade política para adotar PrEP na resposta à epidemia de AIDS no Brasil. http://abiaids.org.br/abia-falta-vontade-politica-para-adotar-prep-na-resposta-epidemia-de-aids-no-brasil/29269 (accessed on 08/Feb/2021).
  » http://abiaids.org.br/abia-falta-vontade-politica-para-adotar-prep-na-resposta-epidemia-de-aids-no-brasil/29269
• ³⁴
  Associação Brasileira Interdisciplinar de AIDS. Truvada® livre! Boletim ABIA 2018; (63). http://abiaids.org.br/wp-content/uploads/2018/10/BOLETIM_ABIA_63_PrEP_completo.pdf
  » http://abiaids.org.br/wp-content/uploads/2018/10/BOLETIM_ABIA_63_PrEP_completo.pdf
• ³⁵
  Associação Brasileira Interdisciplinar de AIDS. ABIA diz que Brasil precisa ir além das “promessas” e questiona alto custo anunciado para entrada da PrEP no país. http://abiaids.org.br/abia-diz-que-brasil-precisa-ir-alem-das-promessas-e-questiona-alto-custo-anunciado-para-entrada-da-prep-no-pais/30192 (accessed on 08/Feb/2021).
  » http://abiaids.org.br/abia-diz-que-brasil-precisa-ir-alem-das-promessas-e-questiona-alto-custo-anunciado-para-entrada-da-prep-no-pais/30192
• ³⁶
  Buscato M. CONITEC recomenda terapia que previne aids no SUS, mas restringe oferta do medicamento. Época 2017; 17 mar. https://epoca.oglobo.globo.com/saude/noticia/2017/03/comissao-recomenda-terapia-que-previne-aids-no-sus-mas-restringe-oferta-do-medicamento.html
  » https://epoca.oglobo.globo.com/saude/noticia/2017/03/comissao-recomenda-terapia-que-previne-aids-no-sus-mas-restringe-oferta-do-medicamento.html
• ³⁷
  Castro CG. Sociedade civil e a política da profilaxia pré-exposição ao HIV no Brasil [Masters Thesis]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020.
• ³⁸
  Ministério da Saúde. Comissão Nacional de Aids: 1986-1994. Brasília: Ministério da Saúde; 1994.
• ³⁹
  Ministério da Saúde. Comissão Nacional de Aids: a presença do passado na construção do futuro. https://bvsms.saude.gov.br/bvs/publicacoes/cd03_06.pdf (accessed on 08/Feb/2021).
  » https://bvsms.saude.gov.br/bvs/publicacoes/cd03_06.pdf
• ⁴⁰
  United Nations Children’s Fund. Towards an AIDS-free generation - children and AIDS. Stocktaking Report, 2013. https://data.unicef.org/resources/towards-an-aids-free-generation-children-and-aids-stocktaking-report-2013/ (accessed on 08/Feb/2021).
  » https://data.unicef.org/resources/towards-an-aids-free-generation-children-and-aids-stocktaking-report-2013/
• ⁴¹
  Bourdieu P. Meditações pascalianas. Rio de Janeiro: Bertrand Brasil; 2007.

Publication Dates

• Publication in this collection
  27 Mar 2023
• Date of issue
  2023

History

• Received
  17 Aug 2021
• Reviewed
  25 Apr 2022
• Accepted
  10 June 2022