Understanding PrEP in Brazil: Daily vs. On‑Demand and the Promise of Digital Support
Oral HIV pre-exposure prophylaxis (PrEP) shields sexually active individuals from HIV infection using two antiretroviral drugs. In Brazil, as in many places, PrEP is most commonly taken daily, while an event‑driven or on‑demand regimen (2+1+1 dosing) offers an alternative for those with episodic sexual activity. A qualitative study across five Brazilian cities examined how cisgender men perceive these regimens, what drives their choice, how they manage adherence, and how a smartphone app might support on‑demand PrEP use while honoring privacy and security concerns.
Regimen Choice: Why Some Prefer On‑Demand PrEP
Researchers analyzed 19 in‑depth interviews and five focus groups with gay, bisexual, and other men who have sex with men (MSM). They found a clear tilt toward on‑demand PrEP among many participants: the regimen was favored for its lighter pill burden and flexibility to match irregular sexual patterns. Some participants initially started with daily PrEP but switched to on‑demand as their routines evolved; others remained with the daily option due to life circumstances that made unpredictable sexual activity or travel challenging for event‑driven use. A small subset experimented with a fluid approach, toggling between regimens to fit life moments.
Across ages, the sense of empowerment and reduced anxiety about HIV infection emerged as a common thread. For many, PrEP represented a bridge from the fear and stigma of the AIDS era to a modern model of sexual health control. Yet the perceived discipline required for on‑demand dosing—timing the initial double dose, waiting for the window before intercourse, and the subsequent +1+1 doses—also surfaced as a practical concern that could hinder sustained use.
Adherence Realities: Strategies and Barriers
Most participants relied on cellphone alarms to cue doses, but forgetting the final doses or managing early or late sexual encounters proved difficult for event‑driven users. In one case, improper timing contributed to a post‑exposure prophylaxis (PEP) need, underscoring the real‑world risks of imperfect adherence. The findings highlight a “discipline barrier”—a cognitive and behavioral load that can deter long‑term use of on‑demand PrEP—and explain why many see digital tools as essential companions rather than optional add‑ons.
Digital Adherence Tools: What Users Want and Worry About
Participants were asked to imagine a hypothetical smartphone app designed to support on‑demand PrEP adherence. There was broad openness to a digital tool, contingent on strong privacy protections and trustworthy governance. Two user profiles emerged: a group content with existing reminders and services and another that welcomed a feature‑rich app capable of coordinating PrEP with broader sexual health care. For the latter group, the app was envisioned as a “cognitive offloading” platform—more than a reminder, it could help plan dosing around anticipated exposures, track lab tests, and connect with health services.
Proposed functionalities included a calendar of medical appointments aligned with PrEP supply, a history of dispensed pills, access to latest test results, reminders for retesting, and geolocation to nearest PrEP/PEP services. A key feature: seamless online/offline use, privacy‑minded design, and integration options with health systems such as Brazil’s SUS (Sistema Único de Saúde). Participants stressed that privacy controls should permit discreet design (e.g., non‑prominent PrEP branding) and secure login. Security concerns extended to the potential cross‑linking of health data with other apps (WhatsApp, Grindr) or external databases, underscoring the demand for state‑managed, privacy‑first architectures, potentially via Meu SUS Digital.
Designing for Diversity: Layout, Customization, and Stigma Reduction
Respondents urged flexible presentation and easy accessibility for people with varying levels of digital literacy. Customizable interfaces—such as choosing discreet color schemes or hiding PrEP symbolism—could mitigate stigma in shared spaces and protect users’ privacy. A practical learning was that the app’s success hinges not only on dose management but also on stigma reduction and trustworthy data stewardship. Co‑design with end‑users, clinicians, and public health authorities was repeatedly championed as essential for creating a tool that respects users’ diverse sociosexual contexts while improving adherence.
Implications for Policy and Practice
The study suggests that scaling on‑demand PrEP in Brazil will require more than making the regimen available; it demands integrated digital supports that address practical dosing, stigma, and data security. State involvement—potentially through SUS oversight—was seen as central to building user trust and ensuring privacy protections. Training for providers, plus ongoing monitoring of stigma and privacy risks, will be critical as on‑demand PrEP and digital adherence tools become more common in sexual health services.
Limitations and Outlook
Limitations include convenience sampling and a predominantly urban, well‑educated cohort, which may limit generalizability to rural or less‑educated populations. Future work should expand demographic reach and quantify how digital features influence adherence across regimens, while continuing to center user voices in the design of digital health interventions.
Conclusion
Overall, cisgender men in Brazil view both daily and on‑demand PrEP as valuable HIV prevention options, with on‑demand PrEP offering flexibility for variable sexual activity. A digital adherence tool, thoughtfully designed with privacy and state oversight, could transform adherence to PrEP by reducing cognitive load and supporting stigma‑aware care. The path to broader uptake lies in co‑designed, privacy‑centric solutions that align with users’ real‑world routines and concerns.
