Rights-Based PrEP Delivery and Structural Challenges

Vol 26/2, 2024, pp. 81-82  PDF

LETTER TO THE EDITOR

Haoran Deng

I recently read the article “Are Rights-Based Services Important? An Adolescent PrEP Demonstration Project in Brazil,” by Laura Ferguson et al. published in Health and Human Rights.[1] I want to express my admiration for the authors’ contribution to this increasingly important area of study. This study in particular highlights crucial aspects such as availability, accessibility, and the importance of a supportive, rights-based approach to health care. However, I would like to offer two key areas that I think still deserve further research and discussion. 

First, while the authors advocate for transforming pre-exposure prophylaxis (PrEP) services into centers of holistic youth engagement, this vision presents significant logistical challenges. Specifically, the feasibility of integrating such a wide range of services within existing medical facilities requires further review. The authors rightly note the importance of on-the-ground personnel in developing relationships and an atmosphere that builds trust with groups that are often reticent to approach medical facilities. However, it will be difficult to expand these programs in any way from a policy side when they mainly rely on key personnel. In addition, the authors tend to focus on areas with high population densities. It is unclear how these programs may be able to be created or expanded within rural areas. In these areas, rather than having personnel focused solely on issues of sexual health and HIV prevention, medical personnel will take on multiple roles and it may be more difficult to implement the proper plans or training with those who already have multiple health care roles within communities.

Second, through the United Nations and World Health Organization, all member countries have committed themselves to strive to provide universal access to health care.[2] However, while the constitutional guarantee of health as a right in Brazil provides a solid foundation for these services, there remains a gap between policy and practice. The implementation of these rights will often be hampered by economic barriers. This is especially true for marginalized youth. I believe that addressing these structural barriers through targeted policy interventions should be an integral part of the strategy to improve adolescent PrEP services.

In conclusion, I commend the authors for shedding light on the potential of rights-based PrEP services for adolescents in Brazil. However, I suggest more examination of the practical challenges related to resource allocation for these areas. In addition, the gap between policy and practice still needs to be addressed. However, by addressing these challenges, we can go further in providing effective HIV prevention services for all young people.

Haoran Deng is a master of global health candidate at Duke University, Durham, United States.

Authors’ Response

We are grateful for these comments and agree with the correspondent that providing high-quality, integrated, rights-based care, particularly for marginalized populations, is an immense challenge. Promoting equity may require greater investment, and the right to nondiscrimination requires that resources be channeled to those in greatest need. 

We sought to demonstrate what was feasible within government-run clinics in two cities in Brazil. Our findings have informed training materials and protocols for all government health workers providing PrEP services in Brazil, which is one step to promote implementation. 

Our results are, of course, context-dependent. Each location—rural/urban, more/less conservative—should promote discussions with the community to organize rights-based services appropriately for its context. While no single study can resolve these challenges, we show that this path is feasible and beneficial. We hope that our findings and their incorporation into national guidance will help health workers and managers around the country prioritize rights-based PrEP delivery, including by addressing the structural barriers highlighted in this letter.

Laura Ferguson, Alexandre Grangeiro, Ana Alexandra Natividad, Paula Massa, Ayra Rodrigues, Dulce Ferraz, and Eliana Miura Zucchi

References

[1] L. Ferguson, A. Grangeiro, A. A. Natividad, et al., “Are Rights-Based Services Important? An Adolescent PrEP Demonstration Project in Brazil,” Health and Human Rights 26/1 (2024).

[2] M. Nordentoft, M. F. Krantz, and I. Hageman, “Right-Based Mental Health Care—Advantages of Tax-Financed Universal Mental Health Care: Lessons from Denmark,” JAMA Psychiatry 79/1 (2002).