Understanding PrEP in Brazil: Daily vs. On‑Demand and the Role of Digital Support
Oral HIV pre-exposure prophylaxis (PrEP) is a cornerstone of modern prevention, with daily regimens and event-driven, or on‑demand, dosing options. A qualitative study across five Brazilian cities explored how cisgender men perceive these regimens, what drives their choices, and how a smartphone app could support adherence. The insights come from in‑depth interviews (n=19) and five focus groups (n=47) conducted in diverse health settings under Brazil’s Unified Health System (SUS). The findings illuminate not only regimen preferences but also the privacy, stigma, and digital design considerations that shape real‑world use.
Regimen Preferences and Adherence Realities
The study found that most participants adopted a single PrEP modality, with a notable tilt toward on‑demand PrEP as the preferred option for many. Specifically, 10 of 19 interviewees selected event‑driven PrEP as their first choice, while five subsequently switched from daily to on‑demand. A smaller group—three of 19—started with daily PrEP and later found 2+1+1 dosing impractical for their life, choosing daily use again. A smaller subset deliberately practiced ‘microswitches’ between regimens, depending on travel or life circumstances. This reflects a broader pattern: on‑demand PrEP offers a lighter pill burden and flexibility for sporadic or planned sexual activity, while daily PrEP suits those facing regular or unpredictable sexual routines.
Adherence leaned heavily on familiar digital tools; smartphones alarms and reminders were the mainstay for many participants. However, the 2+1+1 dosing schedule presented practical challenges, especially around initial doses for unplanned encounters and remembering the final dose—situations occasionally leading to adherence errors or, in rare cases, exposure requiring PEP. The concept of a precise, event‑driven timetable placed a cognitive load on users that some described as the main barrier to flawless use.
Perceptions of PrEP and the Potential of a Digital Adherence Tool
participants described PrEP as a powerful HIV prevention measure that reduced anxiety about infection. Older participants recalled the AIDS crisis and spoke about PrEP as a bridge to greater sexual freedom, while younger users framed PrEP as a tool for navigating new, app‑driven dating landscapes. Yet stigma persisted: some viewed PrEP users as promiscuous or as potential carriers of other sexually transmitted infections. Such attitudes underscore the need for stigma‑reduction strategies alongside expanded PrEP options.
When asked about a hypothetical smartphone app designed to support on‑demand PrEP adherence, opinions divided into two groups. One group saw little personal need for additional reminders beyond alarms, while a more enthusiastic group welcomed a feature‑rich app that could integrate dose management with broader sexual health services. A central takeaway: adherence tools should function as cognitive offloading—reducing the mental burden of the 2+1+1 schedule—while respecting privacy and dignity.
Designing for Privacy, Security, and Real‑World Use
Across FG discussions, participants endorsed state management of a PrEP app through SUS (“Meu SUS Digital”) to bolster trust and data protection. Yet concerns about data integration with third‑party platforms (WhatsApp, Grindr) and potential exposure of sexual health information remained salient. Participants urged discreet interfaces, optional LGBTQIA+ symmetry in visuals, and strong access controls (passwords, biometrics) to prevent disclosure in sensitive environments. They also emphasized the value of offline access and simple, intuitive layouts that accommodate varying levels of digital literacy.
From Insight to Action: Implications for Policy and Practice
The study highlights three actionable dimensions for scaling on‑demand PrEP in Brazil. First, technological supports should address the “discipline barrier” by providing adaptive, personalized dosing guidance and predictable reminders that align with individual sexual rhythms. Second, privacy‑first design and state stewardship are essential to build trust and encourage disclosure‑sensitive use, reducing fears of stigma and data misuse. Third, any digital adherence solution should be co‑designed with end users, ensuring features such as appointment calendars, lab results access, stock indicators, and location‑based service finders mesh with real care pathways in SUS settings. A holistic app that integrates PrEP management with broader sexual health care could strengthen engagement and adherence, particularly for on‑demand users balancing work, travel, and dating app‑driven sexual activity.
Conclusion
For cisgender men in Brazil, both daily and on‑demand PrEP are seen as effective HIV prevention tools, with on‑demand PrEP offering flexibility for variable sexual patterns and a lower pill burden. The prospect of a digital adherence tool is broadly acceptable, provided it centers privacy, security, and integration with public health services. These user‑driven insights point to a future wherePrEP scale‑up is coupled with stigma‑reduction efforts and robust, state‑backed digital health solutions that respect diverse sociosexual contexts and privacy needs.
