Pre-exposure prophylaxis for HIV in Brazil: hopes and moral panic in the social construction of a biomedical technology

Abstract

This paper addresses the role emotions play in the social assemblage of medicines and technical processes in the response to the HIV called pre-exposure prophylaxis (PrEP) for HIV. We describe a series of stages and processes in the social construction of PrEP in Brazil from the run-up to the launch of the initiative by the Ministry of Health to the subsequent implementation of the strategy by public health services. To understand the meanings and symbolism assigned to this biomedical technology, we examined the hopes underpinning scientific, government and non-governmental narratives, clinical processes and health policy. The social trajectory of PrEP was influenced not only by these hopes but also by fears and concerns about the impact of this approach to HIV prevention on lifestyles and modes of sexual governance. The evidence used in this study comes from interviews with health professionals and AIDS activists, anthropological fieldwork, scientific articles and documentary analysis. Our findings provide important insights into how emotions have shaped the meanings assigned to PrEP and shed light on the complex game of negotiation involved in defining responses to the HIV epidemic.

Keywords:

• HIV
• pre exposure prophylaxis
• biopolitics
• pharmaceuticalisation
• emotions

Acknowledgements

An earlier version of this paper was given at the Anthropology of Emotions working group at the 32nd annual meeting of the Brazilian Association of Anthropology held (online) in Rio de Janeiro in November 2020. We are grateful to Maria Claudia Coelho (from the State University of Rio de Janeiro) and Ceres Victora (from the Federal University of Rio Grande do Sul) for their comments on our approach to the topic of hope. We are grateful for the relevant and insightful suggestions of anonymous reviewers.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 Although the expression mulher trans (transgender woman), or simply trans, has gained popularity over the last two decades, especially among younger and more educated individuals, the term travesti remains in current vocabulary. It has been used by many transgender females as a category of self-identification, including as a means of political affirmation. Furthermore, it may be found in the official documents of governmental and non-governmental organisations.

2 Definitions of PrEP vary and make reference to a range of ways of using antiretroviral drugs for the prevention of HIV. In Brazil, PrEP consists of a daily fixed-dose combination of 300 mg tenofovir disoproxil fumarate and 200 mg emtricitabine (TDF/FTC) taken in the form of a pill called Truvada^®.

3 PEP involves the use of antiretroviral drugs to prevent infection soon after a possible exposure to HIV at work (e.g. by health professionals) or through sexual contact (unprotected sex or sexual violence). PEP must be started within 72 hours after possible exposure and continued for 28 days.

4 In this article, we do not address how PrEP connects and, at the same time, shapes the subjectivity of its users. For some interesting reflections on this topic, see Preciado (2015).

5 This study was called Biomedicalização da Resposta à AIDS: O acesso de gays, mulheres trans/travestis e prostitutas às profilaxias pré e pós exposição na região metropolitana do Rio de Janeiro. Using a social studies of science and technology approach, the study examined the implementation of PrEP and PEP in health services, focusing on the gender, sexual and class morality imbued in the social construction of these health technologies. The work was funded by the Fiocruz INOVA Knowledge Generation Program (2019–2020), approved by the institution’s research ethics committee (N^o 45267315.9.0000.5248), and conducted in accordance with the approval.

6 See, for example, http://giv.org.br/publicacoes/Boletim-Vacinas/index.html

7 https://www.youtube.com/c/PoeNaRoda/search?query=PrEP

8 https://www1.folha.uol.com.br/equilibrioesaude/2016/07/1794350-europa-da-sinal-verde-a-tratamento-preventivo-da-aids.shtml

https://g1.globo.com/bemestar/noticia/2013/07/estudo-avaliara-adocao-de-uso-preventivo-de-pilula-anti-hiv-no-pais.html

https://veja.abril.com.br/saude/prep-uma-revolucao-no-combate-ao-hiv/

https://epoca.oglobo.globo.com/vida/noticia/2014/09/um-comprimido-para-bprevenir-aidsb.html

9 The iPrEx trial was the first large-scale trial to show the efficacy and safety of a daily fixed-dose combination of two antiretroviral drugs (later known by the brand name Truvada) for preventing HIV infection among MSMs and travestis/transgender women. The trial started in 2007 in research centres in Peru and Ecuador and was extended to Brazil, Thailand, South Africa and the USA in 2008. It received funding from the US National Institute of Health and the Bill and Melinda Gates Foundation. The medicines used in the trials were donated by the Gilead Sciences. The preliminary findings were widely disseminated by the US media.

10 https://veja.abril.com.br/videos/em-pauta/prep-o-anticoncepcional-do-hiv/

https://www.prefeitura.sp.gov.br/cidade/secretarias/saude/noticias/?p=270004

11 Other authors have already addressed the relationship between PrEP use, condom use, and STI prevalence (Holt et al. 2019; Torres-Cruz and Suárez-Díaz 2020).

12 The Unified Health System was created in 1989 and is the largest non-discriminatory government-run public health care system. It provides free, universal access to medical care to anyone legally living in the country. Paim et al. 2011)

13 https://www.youtube.com/watch?v=O02qhzamw84, accessed on 13 April 2020.

Additional information

Funding

Fiocruz INOVA Knowledge Generation Program (2019-2020).