Last month, PrEP Brazil’s team published an article on the magazine The Lancet HIV. The results of one year of PrEP Brazil study were disclosed in the text, comprehending the period from April 1, 2014 to July 8, 2016. The importance of such publication was highlighted by the editorial of the magazine. The editors highlighted the pioneer tradition of Brazil in HIV treatment in Latin America – country that was, for example, the first of the region to offer free antiretroviral treatment to HIV holders, and participated in iPrEx, study that proved the efficacy of PrEP and involved several other countries worldwide.
In 2018, seven countries of Latin America and Caribbean will start demonstration studies with PrEP in their territories; other three countries already started the implementation of PrEP with public funding. Civil society has played an essential role to expand PrEP. Groups like GayLatino and sites like Quiero PrEP declared support to PrEP and help to promote its disclosure, something essential to ground before the government the importance of including PrEP in the public health system.
The article Retenção, engajamento e aderência à PrEP para HSHs e mulheres trans no PrEP Brasil: os resultados de 48 semanas de um estudo de demonstração (Retention, engagement, and adherence to PrEP to HSHs and transgender women in PrEP Brazil: the results of 48 weeks of a demonstration study)
The results of the article presented by the team of PrEP Brazil study correspond to the 450 volunteers followed-up at three reference centers for HIV prevention: one in Rio de Janeiro, Fundação Oswaldo Cruz, and two in São Paulo, USP, and Centro de Referência e Treinamento em DST e AIDS. The volunteers were men that make sex with men (HSHs), transvestites, and transgender women, with negative status to HIV, of age, and resident in any of the participating cities. It was considered eligible to the study the patients that reported to have had one or more sexual episode with risk of HIV infection, anal sex with no condom with one or more partners, one or more episodes of anal sex with HIV-positive partner or partner with history of ISTs (sexually transmitted infections).
Over a year, the participants attended the health center in scheduled visits to receive the drug o PrEP (emtricitabine/tenofovir or FTC/TDF), assess the sexual behavior, and the possible use of drugs, as well as to go through tests for HIV and other ISTs. At every visit, advisory was also provided about the reduction of risk behavior and about the adhesion to PrEP drug. A questionnaire assessed the sexual behavior in the period before each visit. Finally, blood samples were collected to assess the level of FTC/TDF in the organism, so allowing to assess if the volunteer was taking PrEP in the recommended dose (adhesion to PrEP).
Among the 450 participants that started PrEP, 375 appeared in the visit of one year of study (week 48), which denotes a retention or stay in the study of 83%. Out of the total number of 375 volunteers that appeared in week 48, 277 (74%) had satisfactory levels of drug in blood, which also shows a great adhesion to PrEP. In general, such adhesion was higher among participants of São Paulo than in Rio de Janeiro – 183 (82%) out of 222 participants of São Paulo centers, and 94 (63%) out of 150 of Rio de Janeiro capital.
The adhesion still is one of the biggest challenges to implement PrEP. Its success determines that the population to who PrEP is indicated remains protected against the risk of HIV infection. Two groups require special attention in such topic – the one of young HSHs and the one of transvestites and transgender women.
Out of 113 volunteers between 18-34 years old that participated in PrEP Brazil, 7 (6%) did not appear in the visit of week 4 (after one month of study), and 21 (19%) did not appear in the visit of week 48. The percentage of participants with satisfactory quantity of FTC/TDF in blood reduced over the time – from 88 participants (78%) in week 4 to 67 (59%) in week 48. To the young HSHs, to the contrary of the general trend of the study, the receptive anal sex with no condom tended to increase throughout the study – 52% at the start of the participation in PrEP Brazil, and 61% in week 48. However, such difference was not statistically significant.
Among the volunteer transvestites and transgender women (total of 25 participants), 2 (8%) missed the visit in week 4, while 13 of them (52%) did not appear in week 48. However, the concentration of drug detected during the visits was satisfactory in 17 (74% of the total of 23 participants) in the visit of week 4, and 13 volunteers (62% of the total of 21) in week 48.
The authors of the article highlighted the importance of advisory to reinforce the adhesion to PrEP, especially if directed to groups and people that most need incentive. In addition to the advisory during the visits, another important strategy adopted by PrEP Brazil was to send text messages to reinforce the importance of the adhesion to the drugs. Such strategy was relevant to increase the adhesion to PrEP among the youngsters.
Two important relationships were checked by the authors of the article: a higher adhesion to PrEP among those that reported to have made sex with a partner living with HIV in comparison to those that did not report; at the same time, it was observed a higher adhesion among those who reported to use stimulating drugs (for example, cocaine, ecstasy, GHB, etc.) before those that did not use. The proportion of participants reporting receptive sex with no condom (as passive) did not significantly vary over the time. The number of sexual partners in the last 3 months, however, tended to reduce over the time (11.4 partners in the start of the study to 8.3 partners in week 48).
During the study, 2 participants contracted HIV virus – one in week 24 and another in week 36. None of them, however, had levels of FTC/TDF in blood, which indicates that they were not ingesting the drugs when they were infected.
There were no evidences of increase of sexual activity in risk situations over the 48 weeks of participation, something known as risk compensation. Such topic is one of the main questions related to the implementation of PrEP, since the compensation suggests that a higher protection against HIV would have as compensation an increase in the exposure to risk situations. The results of PrEP Brazil, however, evidence that, in Brazilian context, the risk compensation does not reduce the benefits of PrEP.
Finally, the results of PrEP Brazil showed high indexes of retention, commitment, and adhesion, reinforcing the feasibility of PrEP in the context of real world in medium-income countries, such as Brazil. Specially, the data presented reaffirmed the possibility and efficacy of the distribution of PrEP by the public health system. Even groups with higher difficulty in following PrEP (such as, for example, young HSHs) may keep high adhesion rates, if specific strategies to motivate them are adopted.
See the link below for a summary of the article: https://www.ncbi.nlm.nih.gov/pubmed/29467098
 Title in the original “Retention, engagement and adherence to pre-exposure prophylaxis for men who have sex with men and transgender women in PrEP Brasil: 48 week results of a demonstration study”
 The text was written by the authors Beatriz Grinsztejn, Brenda Hoagland, Ronaldo I Moreira, Esper G Kallas, Jose V Madruga, Silvia Goulart, Iuri C Leite, Lucilene Freitas, Luana M S Martins, Thiago S Torres, Ricardo Vasconcelos, Raquel B De Boni, Peter L Anderson, Albert Liu, Paula M Luz, and Valdiléa G Veloso, in name of the Team of PrEP Brazil Study.