key: cord-0956080-lycnuvx7 authors: Dourado, Inês; Magno, Laio; Soares, Fabiane; Massa, Paula; Nunn, Amy; Dalal, Shona; Grangeiro, Alexandre title: Adapting to the COVID-19 Pandemic: Continuing HIV Prevention Services for Adolescents Through Telemonitoring, Brazil date: 2020-05-21 journal: AIDS Behav DOI: 10.1007/s10461-020-02927-w sha: f851cf37d4d147da0f7c42d25ac94b15c5933bbb doc_id: 956080 cord_uid: lycnuvx7 nan . On May 20th, the country had accumulated 271,628 confirmed cases of COVID-19 (129.3 cases/100.000 inhabitants) and 17,971 COVID-19 related deaths, fatality rate of 6.6% [9] . Brazil has one of the highest transmission rates of the virus in the world [10] , but faces an uncoordinated national government response [11, 12] . On the other hand, the existence of a National Health System (SUS) [13] favors state and city governments to adopt their own approaches that range from voluntary social isolation to partial lockdown. PrEP1519 is the first demonstration cohort study in Latin America exploring acceptability, use and PrEP persistence amongst adolescents MSM and TGW age 15-19 years oldadolescent key populations (AKP). While Brazil launched PrEP in its national health system in 2018, PrEP is not yet available for adolescents under age 18 [14] . PrEP1519 is ongoing in three cities in Brazil: Salvador (SSA), São Paulo (SP), and Belo Horizonte. Data collection started in March 2019 (SP); in April 2020 (SSA), 1949 were reached by recruitment strategies; 484 (24.8%) participants have been enrolled: 383 in PrEP and 101 in non-PrEP arm. Of these, 91.5% self-identified as MSM, 8 .5% as TGW, 12.7% were between 15 and 17 years old and 87.3% 18-19 years old; 81.7% reported condomless anal sex at baseline. With launch of this new PrEP demonstration program, customized PrEP clinics began new services and outreach programs tailored to AKP. Participants are recruited by several strategies, including: engaging peer-educators at schools and venues where young people congregate; social media platforms such as Instagram, Facebook, WhatsApp, and hook up apps; word-of-mouth, and by an artificial intelligence chatbot named "Amanda Selfie" conceived as a transgender woman. It is the first Latin America transgender chatbot. Available 24/7 on Facebook Messenger, it emulates chatbased conversations on sensitive subjects: sex, STIs, PrEP and combination prevention. It can identify those in higher risk for HIV, and schedule PrEP arm are PrEP-eligible but chose not to use prophylaxis and receive other HIV combination prevention (counseling, condoms, lubricant, douche, and HIV self-test-HIVST) . After PrEP initiation, participants are assigned a study peer-navigator and are monitored by the health team (Table 1) . These activities take place in person, via smartphone, and on WhatsApp, Instagram, and Facebook messages. All cities where PrEP1519 takes place have adopted quarantine and social isolation guidelines, including reductions in public transportation and suspension of many non-essential health services. Therefore, the difficulty for individuals, and marginalized groups in particular, to reach services is much harder now. The PrEP1519 study decided to continue its work during to the pandemic, and was able to adapt quickly to the new situation due to the social media and telemonitoring infrastructure that was set up to reach AKP beforehand. In this paper, we aim to describe the strategies adopted by PrEP1519-sites of Salvador and São Paulo to continue to provide HIV and sexual and reproductive health services during quarantine periods to contain the COVID-19 pandemic. The contingency plan was adapted from revised protocols from different countries that showed effective telehealth interventions [15] [16] [17] [18] . In order to minimize as much as possible the effect of quarantine measures on PrEP initiation, on PrEP continuation, and access to other sexual health care and prevention needs, we immediately amended our research procedures and care services. Salvador and São Paulo now provides additional telehealth as the default care provision platforms, such as digital participant recruitment and peer support and navigation via smartphone text messages and online social media (Instagram and Facebook), streamlined PrEP initiation and retention procedures. The strategies of navigation online were more intensified as adolescents are eager to have a conversation and ask questions on how to persist with their PrEP use under quarantine. Providers still offer in person visits at their discretion, and reserve care for individuals who do not have respiratory symptoms (Table 1) . PrEP1519 collects all data digitally; this data is fully integrated with electronic medical record platforms (www.sispr ep151 9.org). Even though, the team can monitor the participant's follow-up and can have access to clinical data in real time, it has been essential at this moment for the work from home (home-office). Figure 1 highlights our strategy. We now use e-services and home delivery of condoms, lubricant, douche, HIVST and PrEP medications. HIVST is available for AKP contacted by social media interactions, and for PrEP users. A package with HIVST and guidance is dispensed [19] for those who signed an online consent form, by fast delivery services or mail depending on the participants' preferred address, and has no mention of the content. For those under 18 years old, we ask for parental informed consent whenever necessary for the follow-up of the adolescent in the study. Peer-educators and peer-navigators are responsible for online recruitment, and linkage to the PrEP clinic. Peer-navigators and PrEP1519 health team (doctor, nurse, psychologist, pharmacist, and social worker) offer online support for participants. The strategies of recruitment during the COVID-19 pandemic are described in Table 1 . These interactions aim to identify adolescents searching for socialization, for sexual encounters, and those engaged in private sex parties for sex during quarantine [20] . The monitoring of online social media platforms and hook up apps has shown that, although there is a reduction, the number of AKP who use these platforms during quarantine to interact socially or look for sexual partners is significant. For PrEP initiation, a face to face appointment is scheduled, and follows the routine pre COVID-19 with adjustments described in Table 1 . These adaptations allow AKP who choose to initiate PrEP to reduce in person appointment time at the clinic by approximately 50%. For PrEP continuation, those who the health team identify as eligible (participant with high PrEP adherence, no suspicion of acute HIV infection and no severe side effects), a telehealth appointment is scheduled, and PrEP medication and HIVST delivered to their preferred addresses. Those who are not eligible, or participant does After an AKP is identified, PrEP and other sexual health services are offered If they are interested in the provision of services, a telehealth appointment is scheduled to conduct an eligibility assessment for PrEP use; and a face to face appointment is scheduled at PrEP1519 clinics If they are not interested in the provision of services during the quarantine, the contact information is collected in order to create a list of potential PrEP users to be contacted after the quarantine And we offer a prevention kit with an HIVST, condoms, lubricants, PrEP flyer, anal douche and hand sanitizer to be delivered to their preferred address after online signed informed consent Navigation After PrEP initiation, a peer-navigator is assigned to follow-up the needs of each participant. The follow-up is mostly online, through social media platforms and smartphone text messages. They emphasizes and monitors PrEP adherence at PrEP initiation, and PrEP continuation biweekly and monthly. The nurse and the doctor supervise this work. not want telehealth, a face to face appointment is scheduled, and follows the same routine as for PrEP initiators. In cases of suspecting COVID-19 infection, we follow the telehealth routine for eligible participants (Table 1) . Telehealth appointments are conducted according to the adolescent's availability and based on health providers' evaluation, through a video or voice connection, including general health screening, PrEP and other strategies of HIV prevention such as counseling, HIVST and COVID-19 prevention guidance. Telehealth is the main intervention for PrEP follow-up visits to eligible participants but exceptionally in person for new PrEP initiators (30 days follow up). Because social distancing can exacerbate or precipitate the symptoms of depression and anxiety [21] and participants may also be at risk for domestic violence because of potential disclosure of their gender identity, social and mental health support service is now available via telehealth, and conducted by a member of the health team depending on the severity of the situation. So far, participants in need of support, have switched to the e-service modality without If participant's choice is a face-to-face appointment, we conduct HIV rapid tests, collect a blood sample to STI serological tests such as HIV, syphilis, viral hepatitis and HTLV, and safety tests for PrEP use that assess kidney and liver function, collect DBS for future for future PK sub-studies; and dispensation of PrEP for 1 or 2 months. Site staff conducts a phone call the day before their appointment to confirm their intention to attend the visit, and evaluates if s/he lives with someone at a higher risk of COVID-19 (e.g. the elderly or people with comorbidities) and offers guidance on COVID-19 protection for in person appointments. Also to inquire about COVID-19 symptoms: fever (> 37.7 °C), cough, runny nose, shortness of breath or difficulty breathing, muscle pain, or anosmia. If any of these symptoms are reported, his/her visit is postponed and s/he receives guidance on COVID-19 management and resources, and the clinical team evaluates the possibility of sending PrEP and HIVST to their preferred addresses No worries with temperature measurements of participants on arrival The temperature of all participants is measured on arrival constraints. Furthermore, mental health support short videos developed by communication team are offered. Because of the investments already made in demand creation, and online social media platforms for marginalized adolescents by the PrEP1519 project, the rapid shift to more complete telehealth services due to COVID-19 was possible. This adaptation has allowed PrEP initiation and PrEP continuation for AKP. Nevertheless, some reduction in recruitment of new participants for the study is observed. An added benefit is that project staff have been able to be retained and continue to provide services. Keen demand for PrEP and other HIV prevention services continues among AKP in Brazil. The adoption of wraparound telehealth platforms has simplified and streamlined procedures for PrEP initiation, and has facilitated and enabled continuity in PrEP services during quarantine. These changes have been well-received by our participants and providers and will likely be sustained even after quarantine restrictions are lifted. These experiences offer important lessons for other middle income countries, as well as other countries scaling up PrEP. Centring sexual and reproductive health and justice in the global COVID-19 response Characterizing the Impact of COVID-19 on men who have sex with men across the United States in COVID-19: What implications for sexual and reproductive health and rights globally? Sex Reprod Health Matters Sexual and reproductive health (SRH): a key issue in the emergency response to the coronavirus disease (COVID-19) outbreak COVID-19 policies can perpetuate violence against transgender communities: insights from Peru The COVID-19 outbreak: potential fallout for sexual and reproductive health and rights. Guttmacher: Guttmacher Institute No 454, de 20 de Março de 2020. Brasília: Ministério da Saúde No 356, de 11 de Março de 2020. Brasília: Ministério da Saúde Painel de casos de doença pelo coronavírus 2019 (COVID-19) no Brasil. Ministério da Saúde Informação e Solidariedade. Painel Coronavírus COVID-19 in Brazil A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada Brazil's unified health system: the first 30 years and prospects for the future Protocol and Therapeutic Guidelines for Pre-Exposure Prophylaxis (PrEP) for Risk of HIV Infection. Secretaria de Vigilância em Saúde Departamento de IST e HIV: Ministério da Saúde It is time to include Telehealth in our measure of patient retention in HIV CARE From HIV to coronavirus: AIDS service organizations adaptative responses to COVID-19 Rapid to implementation of service delivery changes mitigate COVID-19 and maintain access to methadone among persons with and at high-risk for HIV in an opioid treatment program Development of telemedicine infrastructure at an LGBTQ+ clinic to support HIV prevention and care in response to COVID-19 Pandemia, sexualidade e percepção do risco: algumas notas sobre quarentena e desejo Social distancing in covid-19: what are the mental health implications?