JMIR Publications

ABSTRACT

Background:

Pre-exposure prophylaxis (PrEP) is a proven effective preventive method in reducing the risk of HIV infection. While daily PrEP is well-established, the on-demand regimen remains less accessible, despite offering advantages such as a reduced pill burden and lower risk of side effects, particularly for those with variable sexual activity patterns.

Objective:

This study explored, from the perspective of PrEP use trajectories, how cisgender men in Brazil choose and adhere to daily or on-demand regimens, and identified key user-informed requirements for designing a digital tool to support on-demand PrEP use.

Methods:

Qualitative study, carried out between July 2022 and December 2023 in five Brazilian cities. Nineteen individual interviews and five in-person focus groups were conducted (n = 47). The sample was diverse by age, education, race/color, time of PrEP use, and experiences of treatment failure. The median age of the interviewees was 34 years (interquartile range 30-36.5); 10/19 (<35 years) and 9/19 (≥35 years). The majority completed higher education (15/19; 79%). The thematic saturation criterion was used and the thematic analysis was conducted by two independent researchers, with periodic consensus.

Results:

Participants perceived oral PrEP as highly effective in reducing HIV-related anxiety. On-demand PrEP was valued for its lower pill burden and a perceived lower risk of adverse effects. However, participants reported that adherence to this regimen demands considerable discipline and organization, posing a significant barrier. In this context, a support app was met not with mere acceptance, but was conceptualized as a "cognitive offloading" tool, capable of transforming the burden of managing the 2+1+1 schedule into a positive and manageable task. Suggested functionalities included pill reminders, appointment scheduling, and geo-location of post-exposure prophylaxis (PEP) services. Nevertheless, significant concerns about data security and privacy were raised, with participants proposing that the State should manage the app to ensure confidentiality.

Conclusions:

Findings highlight clear generational differences in how cisgender men perceive daily and on-demand PrEP: older participants draw on memories of the early AIDS crisis, whereas younger men situate PrEP within app-mediated sexual cultures. Importantly, they agree that the on-demand regimen requires not only greater discipline but also a learning process to incorporate and normalize its episodic dosing into everyday life. The positive reception toward a digital adherence support tool demonstrates potential public health value in such technologies, provided privacy and data security concerns are effectively addressed. Efforts to improve adherence and expand access to on-demand PrEP could significantly benefit from incorporating user-driven insights into digital tool development.