Introduction
New qualitative insights from Brazil illuminate how cisgender men perceive daily versus on-demand HIV pre-exposure prophylaxis (PrEP), and what they want from digital tools to support adherence. The study, conducted across five Brazilian cities, interviewed 19 individuals and held five focus groups with 47 participants. It reveals a nuanced landscape where regimen choice, daily life, stigma, and privacy shape prevention strategies in real-world settings.
Regimen Preferences and Adherence Realities
Participants showed broad openness to both PrEP modalities, with a clear tilt toward on-demand PrEP for many due to lower pill burden and flexibility for sporadic or planned sexual activity. Among the 19 interviewees, 12 favored event-driven use as their dominant option, while 4 continued with daily PrEP for practicality and safety in unpredictable contexts. A small group (3) moved from daily to on-demand after finding the 2+1+1 schedule impractical. Interestingly, several participants described a fluid pattern—“microswitches” between regimens depending on life circumstances, such as travel or work demands.
Adherence strategies centered on smartphone alarms and reminders, yet participants flagged the specific challenges of on-demand dosing: remembering the final doses, initiating the 2-dose window before unplanned exposures, and managing the post-exposure +1/+1 period. The data hint at a cognitive load associated with event-driven PrEP, underscoring the need for supporting tools that help people stay on track without forcing a daily routine.
PrEP, Anxiety, and the Social Lens
Across ages, PrEP was consistently framed as an effective HIV-prevention measure that reduces infection-related anxiety. Older participants recalled the AIDS era as a potent motivator to protect themselves and their partners, while younger users described PrEP as enabling new social and sexual experiences increasingly mediated by dating apps. Stigma emerged as a persistent theme: some interviewees faced judgments about promiscuity or the belief that PrEP users are more likely to engage in risky sex. These tensions highlight the social dimensions of PrEP uptake and underscore the need for supportive information-sharing strategies that respect diverse identities and contexts.
Digital Adherence Tools: App Acceptability and Design Needs
Attitudes toward a hypothetical smartphone app to support on-demand PrEP adherence were broadly positive, provided privacy and security were robust. Two user groups emerged in discussions: one that didn’t see itself as the primary beneficiary but supported the idea for others, and another that welcomed a multi-feature app integrated with health services and capable of personalization. Participants emphasized that the app should be flexible to different sociosexual contexts, offer customizable notifications, and respect varying levels of disclosure.
Suggested features clustered into three pillars: functional dose-management and reminders; connections to health services and lab results; and privacy-preserving presentation. Practical elements included a calendar of appointments, dispensing history, latest test results, and location-based access to PEP services for rapid response after any event-driven failure. Importantly, participants argued for offline capability and privacy-first design—options to limit visibility, discreet branding, and user-controlled data sharing. They proposed security measures such as logins, biometrics, or passwords, and even discussed the SUS (Unified Health System) as a potential steward of data to bolster trust. Some warned against excessive data sharing with third-party apps or commercial platforms, urging discretion in integrations with messaging or dating apps.
Implications for Policy and Practice
The findings suggest that scaling on-demand PrEP in Brazil will require more than patient education. Health systems should consider digital adherence tools as cognitive offloading aids—supporting, not replacing, user discipline. Training for providers, equity-focused access, and privacy-first app designs are essential. The study also points to the potential of state-managed digital health integration (for example, Meu SUS Digital) to normalize and safeguard PrEP use while mitigating privacy risks. However, successful implementation must be paired with stigma-reduction efforts and careful governance to avoid unintended exposure of users’ sexual identities.
Conclusion
Brazilian cisgender men view both daily and on-demand PrEP as protective options against HIV, with on-demand PrEP offering distinct advantages for irregular sexual patterns. There is strong appetite for a digital adherence tool, rooted in privacy, security, and adaptability to diverse life contexts. Realizing this potential requires user-centered design, state-backed data protection, and integrated sexual-health services to move beyond reminders toward a holistic, stigma-sensitive prevention ecosystem that supports sustained adherence.
