Experiences and preferences for HIV prevention modalities among transgender women and <i>travesti</i> sex workers in São Paulo, Brazil: a qualitative study

Transgender women and <i>travesti</i> sex workers in Brazil underutilise HIV prevention services. Understanding preferences and decision-making regarding HIV prevention can help develop new programmes to meet their needs. We conducted semi-structured interviews with 26 transgender women and travesti sex workers in São Paulo, Brazil. Interviews examined experiences with and perceptions of condoms, non-occupational post-exposure prophylaxis (nPEP), daily oral pre-exposure prophylaxis (PrEP), and injectable PrEP. Transcripts were thematically analysed. Participants' median age was 34.5 years and most (80%) were Black or Brown (<i>parda</i>). Sixteen (62%) reported previous or current daily oral PrEP use. Most participants perceived nPEP and PrEP as important given barriers to condom use (eg regular partners, financial incentives by clients, alcohol and drug use, and rape). Initiation of nPEP after condomless sex and rape was described, with many going on to take PrEP after an nPEP course. Injectable PrEP was perceived to facilitate adherence, but there were concerns related to the previous use of industrial liquid silicone. Future interventions should address syndemic barriers to condom and PrEP use and engage regular partners of transgender women and travestis in prevention. Long-acting HIV prevention modalities that do not involve intramuscular injections may help increase PrEP access and use.