The COVID-19 pandemic is impacting the delivery of health care services everywhere, and although in the early stages, the results of disruptions are becoming clearer. Infectious disease and sexual health providers may be diverted to care for COVID-19 patients. Closing sexual health services due to COVID-19 quarantine policies will likely have detrimental impacts on health services access and discontinuity of care among marginalized populations in low- and middle-income countries [1]. These challenges may be particularly acute for sexual and gender minorities such as men who have sex with men (MSM) and transgender women (TGW), but also for sexual and reproductive health and family planning services for women [2,3,4,5]. Access to condoms as well as antiretroviral drugs and antibiotics to treat sexually transmitted infections (STIs) and HIV may also be affected, and may ultimately undermine HIV pre-exposure prophylaxis (PrEP) initiation and persistence [3, 6].

On March 20th, 2020 the Brazilian Ministry of Health (MoH) announced that all Brazilian states had coronavirus cases [7], and issued guidelines on social distancing measures, such as voluntary home quarantine, and social isolation [8]. 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 old-adolescent 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 appointments to PrEP1519 clinics. Participants self-select into two arms: a PrEP arm and a non-PrEP arm. Participants in the non-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.

Table 1 Provision of services at PrEP1519 clinics before and after COVID-19
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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.

Contingency Measures Adapted for COVID-19

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.sisprep1519.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).

PrEP1519 Telehealth Strategy: Opportunity to Maintain HIV/STI Prevention and PrEP Delivery Services

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.

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The PrEP1519 telehealth strategy

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Understanding HIV/STI Risk and Creating Demand Virtually in Times of COVID-19 Pandemic

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.

Clinical Follow-up PrEP Initiation and PrEP Continuation

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 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).

Adding of Social and Mental Health Support into Telehealth

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 constraints. Furthermore, mental health support short videos developed by communication team are offered.

Lessons Learned

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.