Equitable expansion of PrEP Choice for transgender women and travestis in Brazil: Community and other stakeholder perspectives on implementation opportunities

Abstract Expanding prevention programs to incorporate new PrEP modalities could offer important benefits to transgender women and travestis (TWT) in Brazil, who are underserved by current approaches. Long-acting injectable (LAI) products are not yet available through the national health system, and episodic PrEP was recently approved for some TWT, providing a critical window for formative research to guide equitable rollout. Engaging the Consolidated Framework for Implementation Research, we interviewed TWT PrEP consumers (8), PrEP providers (8), and program/policy advisors (4) in São Paulo. Participants expressed enthusiasm for offering all modalities as a cohesive ‘PrEP choice’ intervention– despite consensus on advantages of LAI-products (increased ease, freedom, protection) and limitations of episodic PrEP (complicated dosing, limited eligibility). We differentiated implementation opportunities related to culture, learning climate, and readiness in neighborhood primary care clinics, referral centers, and community-based programs. Findings coalesced around the need to center community in planning and executing implementation processes, by incorporating adjunctive interventions (pain management, peer navigation, food and transportation assistance) and peer staff. By interviewing stakeholders who participated in LAI-PrEP research, we elicited informed perspectives grounded in lived experience, before widespread availability. Findings provide a foundation for future studies comparing implementation and outcomes for TWT in different delivery settings.