RESUMO
In this study, we systematically examined the importance of human rights standards and principles for rights-based pre-exposure prophylaxis (PrEP) provision for marginalized adolescents. Nested within a demonstration study of PrEP provision to adolescent men who have sex with men, travestis, and transgender women, we carried out interviews in São Paulo, Brazil with 25 adolescents, eight health providers, and six workers involved in community-based demand creation. Analysis focused on participants' narratives about aspects of human rights within service delivery, including the availability, accessibility, acceptability, and quality of services; informed decision-making; nondiscrimination; and privacy and confidentiality. Clients and service providers highlighted the importance of availing a range of services beyond PrEP and described how community outreach and social media helped promote accessibility. Acceptability centered around clients feeling heard and respected. Health workers appreciated having time to build trusting relationships with clients to ensure quality of care and support informed decision-making. Nondiscrimination was valued by all, including using clients' chosen pronouns. Privacy and confidentiality were primary concerns for clients who were not "out" about their sexuality or PrEP use; to mitigate this, health workers sought to accommodate clients' preferred channels of communication. Rights-based PrEP services can help promote engagement and retention in PrEP services, particularly for marginalized populations.
Assuntos
Confidencialidade , Infecções por HIV , Acessibilidade aos Serviços de Saúde , Direitos Humanos , Profilaxia Pré-Exposição , Pessoas Transgênero , Humanos , Brasil , Adolescente , Masculino , Infecções por HIV/prevenção & controle , Feminino , Homossexualidade Masculina , Pessoal de Saúde/psicologia , Minorias Sexuais e de GêneroRESUMO
PURPOSE: To explore legal and ethical challenges related to adolescents' participation in human immunodeficiency virus (HIV) research that may affect their best interests. METHODS: We analyzed the ethical principles and legal aspects of the participation of 15-17-year-old men who have sex with men and transgender women in the pre-exposure prophylaxis (PrEP) 1519 study, a PrEP demonstration cohort study in three Brazilian cities. The analyses of ethics review committees' (ERCs) evaluations and court decisions followed ethical and human rights principles. An HIV vulnerability score was created, and descriptive statistics and multivariate logistic regression were performed using data from 347 participants. RESULTS: The ERCs evaluated the benefits and risks of research participation, all finding that the benefits outweighed the risks. ERCs deferred responsibility for decisions about waiving parental consent to the judiciary. State courts reached different decisions about waiving parental consent, reflecting variation in recognition of adolescents' evolving capacities and the adolescent as a subject of sexual rights and the primary agent capable of deciding on their health and best interests. The most vulnerable adolescent participants were found in sites where the blanket waiver was in place. DISCUSSION: Judicializing the ethical review process is detrimental to fulfilling the ethical principle of justice and vulnerable adolescents' access to health research. ERCs must be sufficiently independent and autonomous and have the capacity to respect, protect, and help fulfill the rights of participants while ensuring the generation of adequate evidence to inform public health practice.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Pessoas Transgênero , Masculino , Humanos , Adolescente , Feminino , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Brasil , Homossexualidade Masculina , Estudos de Coortes , HIV , Fármacos Anti-HIV/uso terapêuticoRESUMO
This study analyzes how the COVID-19 pandemic affected sexual behavior and use of HIV prevention methods among young transgender women (YTGW) and young gay, bisexual and other men who have sex with men (YGBMSM) participating in an HIV pre-exposure prophylaxis (PrEP) demonstration study in Brazil. Online interviews with 39 participants aged 15-22 years old were conducted between September and November 2020 and analyzed based on social constructionism and human rights-based approaches to health. The pandemic disrupted interviewees' routines, negatively affecting their life conditions. Among those who did not have a steady partner, social distance measures led to temporary interruption of sexual encounters and increased sexting and solo sex. Conversely, for those who had a steady relationship such measures contributed to increasing sexual practices and intimacy. Participants who had sexual encounters during the pandemic reported having continued to use PrEP. However, home confinement with family, lack of privacy, loss of daily routines and changes in housing impaired PrEP adherence and attendance at follow-up consultations. These results highlight the importance of maintaining HIV-service delivery for these groups during a public health crisis, as well as to address the structural drivers of the epidemic with comprehensive HIV prevention policies and by ensuring access of YGBMSM and YTGW to social protection policies.
Assuntos
COVID-19 , Infecções por HIV , Minorias Sexuais e de Gênero , Pessoas Transgênero , Masculino , Humanos , Feminino , Adolescente , Adulto Jovem , Adulto , Homossexualidade Masculina , Pandemias/prevenção & controle , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Brasil/epidemiologia , Quarentena , COVID-19/prevenção & controle , COVID-19/epidemiologia , Comportamento SexualRESUMO
INTRODUCTION: The COVID-19 pandemic and its control measures have impacted health and healthcare provision in various levels. Physical distancing measures, for instance, may affect sexual health, impacting access to HIV prevention supplies and changing sexual behaviour, as well as mental health, increasing feelings of unsafety and weakening community support ties. These effects can be worsened among socially marginalised groups, such as men who have sex with men (MSM) and transgender women (TGW). Brazil is among the countries most affected by COVID-19 in the world, where control measures have been inconsistently implemented. We aim to investigate the effects of the COVID-19 pandemic on the sexual and mental health of adolescent and adult MSM and TGW in Brazil. METHODS: Convergent mixed-method prospective cohort study, nested in two ongoing HIV pre-exposure prophylaxis (PrEP) cohorts in Brazil, named PrEP1519 and Combina. Participants will be invited to answer, at baseline and after 6 months, a questionnaire about the effects of the COVID-19 pandemic on sexual behaviour, HIV prevention and mental health. Data on HIV infection and sexually transmitted infections (STI) will be collected as part of routine follow-up from the cohorts. Main outcome measures (HIV infection, STI and depression symptoms) will be observed within 12 months after baseline. Sample size is estimated at 426 participants. Complementarily, 50 participants will be invited to in-depth interviews through video calls or interactive voice response, and 20 will be invited to chronicle their lives during the pandemic through digital diaries. Triangulation will be done across qualitative methods and with the quantitative data. ETHICS AND DISSEMINATION: The study was approved by Research Ethics Committees from the Brazilian Universities coordinating the study. Findings will be published in scientific journals and presented at meetings. Informative flyers will be elaborated to communicate study findings to participants and key stakeholders.
Assuntos
COVID-19 , Infecções por HIV/prevenção & controle , Saúde Mental , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero/psicologia , Pessoas Transgênero/psicologia , Adolescente , Adulto , Idoso , Brasil/epidemiologia , Estudos de Coortes , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , Adulto JovemRESUMO
The use of reproductive technologies has expanded beyond cases of infertility, and opportunities for individuals of different sexual orientations to use such technologies for conception have increased. The authors examined the challenges and limitations faced by women in same-sex relationships seeking conception services in São Paulo, Brazil. They interviewed 16 women in same-sex relationships who conceived children using reproductive technologies. Access to public health services for conception remains limited and exclusive to infertile heterosexual couples. Women in same-sex relationships are forced to select between costly medical treatments in the private sector, or self-insemination with sperm from a known donor. In this study, individuals reported that they experienced adverse effects of treatments; were treated with technologies for infertility when they were, in fact, fertile; and were exposed to unnecessary and invasive interventions. Growing political conservatism and the reduction of investment in public health services are factors that can directly affect sexual and reproductive health, including that of lesbians. Public policies that enable same-sex couples to conceive have yet to be developed in many countries, and a clearer articulation of the right to evidence-informed, rights-based care, consistent with national and international guidelines is a much-needed next step.
Assuntos
Fertilização/fisiologia , Equidade em Saúde , Acessibilidade aos Serviços de Saúde , Homossexualidade Feminina/psicologia , Técnicas Reprodutivas , Adulto , Brasil , Feminino , Fertilidade , Humanos , Comportamento SexualRESUMO
Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility, and complementary and multidisciplinary care. These principles can foster organization of the health service and care, facilitating linkage and retention in care. Some comments were offered on the relative incompatibility between the existing structure of services and the Brazilian Ministry of Health guidelines for offering PrEP. The conclusion was that the success of PrEP as a public health policy depends on two essential factors: ensuring that health services are culturally diverse settings, free of discrimination, and the intensification of community-based interventions, including social networks, in order to reduce inequalities in access to PrEP and health services as a whole.
A profilaxia pré-exposição sexual (PrEP) tem sido considerada estratégica e promissora no controle da epidemia de HIV globalmente. Contudo, faz-se necessário transpor o conhecimento acumulado pelos estudos de eficácia e demonstrativos à realidade dos serviços e das populações mais vulneráveis à infecção, de forma a alcançar uma ampla cobertura da PrEP. Propõe-se uma reflexão sobre tal desafio enfocando duas dimensões: os usuários da profilaxia, com ênfase nos contextos de práticas e de potencial exposição ao HIV; as vantagens comparativas da profilaxia em relação aos demais métodos e os desafios para um uso protetivo e seguro; e os serviços, considerando os princípios organizativos que poderão conferir maior êxito na oferta e na incorporação da PrEP, no bojo das estratégias de prevenção combinada. Foram analisados como alguns princípios - singularidade no cuidado, autonomia para escolha e não hierarquização dos métodos, gestão de risco sexual e flexibilidade de agendamento e complementaridade de uma equipe multiprofissional - podem favorecer a organização do serviço e do cuidado, facilitando a vinculação e retenção dos usuários. Teceram-se algumas considerações acerca de uma relativa incompatibilidade entre a estrutura existente nos serviços e as diretrizes do Ministério da Saúde para oferta de PrEP. Concluiu-se que o maior êxito da PrEP como política pública de saúde depende de dois aspectos centrais: assegurar que os serviços sejam ambientes culturalmente diversos e livres de discriminação e a intensificação das intervenções comunitárias, incluindo as redes sociais, de forma a reduzir iniquidades no acesso aos serviços e à PrEP.
La profilaxis pre-exposición sexual (PrEP) ha sido considerada una estratégica y prometedora acción en el control de la epidemia de VIH globalmente. No obstante, se hace necesario trasladar el conocimiento acumulado por los estudios de eficacia, que muestren la realidad de los servicios y la población más vulnerable a la infección, de manera que se alcance una amplia cobertura de la PrEP. Se propone una reflexión sobre este desafío centrándose en dos dimensiones: usuarios de profilaxis, con énfasis en contextos de prácticas y potencial exposición al VIH; ventajas comparativas de la profilaxis, respecto a los demás métodos, y los desafíos para un uso con protección y seguro; y los servicios, considerando principios organizativos que podrían otorgar un mayor éxito a la oferta e incorporación de la PrEP, en el seno de estrategias de prevención combinada. Se analizaron como algunos principios: singularidad en el cuidado, autonomía para la elección y no jerarquización de los métodos, gestión del riesgo sexual y flexibilidad de citas y complementariedad de un equipo multiprofesional. Todos ellos pueden favorecer la organización del servicio y del cuidado, facilitando la vinculación y preservación de los usuarios. Se elaboraron algunas consideraciones, acerca de una relativa incompatibilidad entre la estructura existente en los servicios y las directrices del Ministerio de Salud de Brasil para la oferta de PrEP. Se concluyó que el mayor éxito de la PrEP, como política pública de salud, depende de dos aspectos centrales: asegurar que los servicios sean ambientes culturalmente diversos y libres de discriminación y la intensificación de las intervenciones comunitarias, incluyendo redes sociales, de forma que se reduzcan las inequidades en el acceso a los servicios y al PrEP.
Assuntos
Infecções por HIV/prevenção & controle , Programas Nacionais de Saúde , Profilaxia Pré-Exposição/métodos , Populações Vulneráveis , Fármacos Anti-HIV/uso terapêutico , Brasil , Feminino , Humanos , Masculino , Serviços Preventivos de Saúde , Fatores de Risco , Assunção de Riscos , Comportamento SexualRESUMO
Resumo: A profilaxia pré-exposição sexual (PrEP) tem sido considerada estratégica e promissora no controle da epidemia de HIV globalmente. Contudo, faz-se necessário transpor o conhecimento acumulado pelos estudos de eficácia e demonstrativos à realidade dos serviços e das populações mais vulneráveis à infecção, de forma a alcançar uma ampla cobertura da PrEP. Propõe-se uma reflexão sobre tal desafio enfocando duas dimensões: os usuários da profilaxia, com ênfase nos contextos de práticas e de potencial exposição ao HIV; as vantagens comparativas da profilaxia em relação aos demais métodos e os desafios para um uso protetivo e seguro; e os serviços, considerando os princípios organizativos que poderão conferir maior êxito na oferta e na incorporação da PrEP, no bojo das estratégias de prevenção combinada. Foram analisados como alguns princípios - singularidade no cuidado, autonomia para escolha e não hierarquização dos métodos, gestão de risco sexual e flexibilidade de agendamento e complementaridade de uma equipe multiprofissional - podem favorecer a organização do serviço e do cuidado, facilitando a vinculação e retenção dos usuários. Teceram-se algumas considerações acerca de uma relativa incompatibilidade entre a estrutura existente nos serviços e as diretrizes do Ministério da Saúde para oferta de PrEP. Concluiu-se que o maior êxito da PrEP como política pública de saúde depende de dois aspectos centrais: assegurar que os serviços sejam ambientes culturalmente diversos e livres de discriminação e a intensificação das intervenções comunitárias, incluindo as redes sociais, de forma a reduzir iniquidades no acesso aos serviços e à PrEP.
Abstract: Pre-exposure prophylaxis (PrEP) has been considered a promising strategy for controlling the global HIV epidemic. However, it is necessary to translate the knowledge accumulated from clinical trials and demosntration studies to the reality of health services and the groups most vulnerable to infection in order to achieve broad coverage with PrEP. The article proposes a reflection on this challenge, focusing on three dimensions: users of prophylaxis, with an emphasis on the contexts of sexual practices and the potential exposures to HIV; the advantages of prophylaxis as compared to other methods and the challenges for protective and safe use; and health services, considering the organizational principles to ensure greater success in the supply and incorporation of PrEP as part of combination prevention strategies. The following principles were analyzed: uniqueness of care, freedom of choice and non-hierarchization of prevention methods, sexual risk management, scheduling flexibility, and complementary and multidisciplinary care. These principles can foster organization of the health service and care, facilitating linkage and retention in care. Some comments were offered on the relative incompatibility between the existing structure of services and the Brazilian Ministry of Health guidelines for offering PrEP. The conclusion was that the success of PrEP as a public health policy depends on two essential factors: ensuring that health services are culturally diverse settings, free of discrimination, and the intensification of community-based interventions, including social networks, in order to reduce inequalities in access to PrEP and health services as a whole.
Resumen: La profilaxis pre-exposición sexual (PrEP) ha sido considerada una estratégica y prometedora acción en el control de la epidemia de VIH globalmente. No obstante, se hace necesario trasladar el conocimiento acumulado por los estudios de eficacia, que muestren la realidad de los servicios y la población más vulnerable a la infección, de manera que se alcance una amplia cobertura de la PrEP. Se propone una reflexión sobre este desafío centrándose en dos dimensiones: usuarios de profilaxis, con énfasis en contextos de prácticas y potencial exposición al VIH; ventajas comparativas de la profilaxis, respecto a los demás métodos, y los desafíos para un uso con protección y seguro; y los servicios, considerando principios organizativos que podrían otorgar un mayor éxito a la oferta e incorporación de la PrEP, en el seno de estrategias de prevención combinada. Se analizaron como algunos principios: singularidad en el cuidado, autonomía para la elección y no jerarquización de los métodos, gestión del riesgo sexual y flexibilidad de citas y complementariedad de un equipo multiprofesional. Todos ellos pueden favorecer la organización del servicio y del cuidado, facilitando la vinculación y preservación de los usuarios. Se elaboraron algunas consideraciones, acerca de una relativa incompatibilidad entre la estructura existente en los servicios y las directrices del Ministerio de Salud de Brasil para la oferta de PrEP. Se concluyó que el mayor éxito de la PrEP, como política pública de salud, depende de dos aspectos centrales: asegurar que los servicios sean ambientes culturalmente diversos y libres de discriminación y la intensificación de las intervenciones comunitarias, incluyendo redes sociales, de forma que se reduzcan las inequidades en el acceso a los servicios y al PrEP.
Assuntos
Humanos , Masculino , Feminino , Infecções por HIV/prevenção & controle , Populações Vulneráveis , Profilaxia Pré-Exposição/métodos , Programas Nacionais de Saúde , Serviços Preventivos de Saúde , Assunção de Riscos , Comportamento Sexual , Brasil , Fatores de Risco , Fármacos Anti-HIV/uso terapêuticoRESUMO
This paper offers a critical overview of social science research presented at the 2014 International AIDS Conference in Melbourne, Australia. In an era of major biomedical advance, the political nature of HIV remains of fundamental importance. No new development can be rolled out successfully without taking into account its social and political context, and consequences. Four main themes ran throughout the conference track on social and political research, law, policy and human rights: first, the importance of work with socially vulnerable groups, now increasingly referred to as "key populations"; second, continued recognition that actions and programs need to be tailored locally and contextually; third, the need for an urgent response to a rapidly growing epidemic of HIV among young people; and fourth, the negative effects of the growing criminalization of minority sexualities and people living with HIV. Lack of stress on human rights and community participation is resulting in poorer policy globally. A new research agenda is needed to respond to these challenges.
Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Pesquisa Biomédica/organização & administração , Política de Saúde , Ciências Sociais/instrumentação , Síndrome da Imunodeficiência Adquirida/prevenção & controle , Síndrome da Imunodeficiência Adquirida/psicologia , Adolescente , Comportamento do Adolescente/psicologia , Atitude Frente a Saúde , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Política de Saúde/legislação & jurisprudência , Direitos Humanos , Humanos , Preconceito , Fatores Socioeconômicos , Terminologia como Assunto , Populações VulneráveisRESUMO
This paper offers a critical overview of social science research presented at the 2014 International AIDS Conference in Melbourne, Australia. In an era of major biomedical advance, the political nature of HIV remains of fundamental importance. No new development can be rolled out successfully without taking into account its social and political context, and consequences. Four main themes ran throughout the conference track on social and political research, law, policy and human rights: first, the importance of work with socially vulnerable groups, now increasingly referred to as "key populations"; second, continued recognition that actions and programs need to be tailored locally and contextually; third, the need for an urgent response to a rapidly growing epidemic of HIV among young people; and fourth, the negative effects of the growing criminalization of minority sexualities and people living with HIV. Lack of stress on human rights and community participation is resulting in poorer policy globally. A new research agenda is needed to respond to these challenges.
Este artigo oferece uma perspectiva crítica da pesquisa em ciências sociais apresentada na Confe-rência Internacional de AIDS de Melbourne, Aus-trália, em 2014. Em tempos de grandes avanços no campo biomédico, a natureza política do HIV permanece de importância fundamental. Nenhuma inovação será bem-sucedida na prática se desconsiderar o contexto sociopolítico e suas consequências. Quatro temas emergiram da Conferência nos campos do direito, dos direitos humanos e da pesquisa social e política: (1) a importância do trabalho com grupos socialmente vulneráveis, crescentemente chamado de "populações chaves"; (2) o reconhecimento de que ações e programas devem ser sob medida para cada local e contexto; (3) a urgência da resposta a uma epidemia crescendo muito rapidamente entre adolescentes; (4) o efeito negativo da crescente criminalização de minorias sexuais e pessoas vivendo com HIV. Globalmente, a falta de ênfase nos direitos humanos e da participação comunitária tem como resultado políticas públicas de pior qualidade. Precisamos de uma nova agenda de pesquisa para responder a esses desafios.
El artículo ofrece una perspectiva crítica de la investigación en ciencias sociales, presentada en la Conferencia Internacional de SIDA en Melbourne (Australia), 2014. En tiempos de enormes avances biomédicos, la naturaleza política del VIH sigue siendo muy importante. Ninguna innovación será exitosa sin considerar el contexto sociopolítico y sus consecuencias. Cuatro temas surgieron de la conferencia en el campo legal y derechos humanos, además de investigación social y política: (1) la importancia del trabajo con grupos socialmente vulnerables, crecientemente denominados "poblaciones claves"; (2) el reconocimiento de que las acciones y programas deben ser adaptados a un contexto local; (3) la urgencia de una respuesta a una epidemia con crecimiento rápido entre adolescentes; (4) el efecto negativo de la creciente criminalización de las minorías sexuales y personas viviendo con VIH. Globalmente, un limitado énfasis en los derechos humanos y la participación comunitaria tiene como consecuencia peores políticas públicas. Necesitamos una nueva agenda de investigación para responder a estos desafíos.
Assuntos
Animais , Humanos , Camundongos , Inativação Gênica/fisiologia , Doença de Huntington/terapia , Proteínas do Tecido Nervoso/genética , Proteínas do Tecido Nervoso/metabolismo , Northern Blotting , Western Blotting , Linhagem Celular , Regulação da Expressão Gênica/genética , Doença de Huntington/genética , Doença de Huntington/metabolismo , Imuno-Histoquímica , MicroRNAs/genética , MicroRNAs/fisiologia , Proteínas Nucleares/genética , Proteínas Nucleares/metabolismo , Análise de Sequência com Séries de Oligonucleotídeos , Plasmídeos , Reação em Cadeia da Polimerase , RNA Interferente Pequeno/genética , RNA Interferente Pequeno/fisiologiaRESUMO
Wing pattern evolution in Heliconius butterflies provides some of the most striking examples of adaptation by natural selection. The genes controlling pattern variation are classic examples of Mendelian loci of large effect, where allelic variation causes large and discrete phenotypic changes and is responsible for both convergent and highly divergent wing pattern evolution across the genus. We characterize nucleotide variation, genotype-by-phenotype associations, linkage disequilibrium (LD), and candidate gene expression patterns across two unlinked genomic intervals that control yellow and red wing pattern variation among mimetic forms of Heliconius erato. Despite very strong natural selection on color pattern, we see neither a strong reduction in genetic diversity nor evidence for extended LD across either patterning interval. This observation highlights the extent that recombination can erase the signature of selection in natural populations and is consistent with the hypothesis that either the adaptive radiation or the alleles controlling it are quite old. However, across both patterning intervals we identified SNPs clustered in several coding regions that were strongly associated with color pattern phenotype. Interestingly, coding regions with associated SNPs were widely separated, suggesting that color pattern alleles may be composed of multiple functional sites, conforming to previous descriptions of these loci as "supergenes." Examination of gene expression levels of genes flanking these regions in both H. erato and its co-mimic, H. melpomene, implicate a gene with high sequence similarity to a kinesin as playing a key role in modulating pattern and provides convincing evidence for parallel changes in gene regulation across co-mimetic lineages. The complex genetic architecture at these color pattern loci stands in marked contrast to the single casual mutations often identified in genetic studies of adaptation, but may be more indicative of the type of genetic changes responsible for much of the adaptive variation found in natural populations.