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Marginalities around gender/sexuality, ethnicity, migration status, and alcohol use tend to coalesce and construct hidden populations which develop their own subcultures. Social science is becoming increasingly aware of the need to better understand the norms and meanings constituting such subcultures, particularly in the era of AIDS and other health risks, if more effective social programs are to be implemented. We report on a qualitative study on the roles of gender and alcohol use in a Latino gay bar with transvestites in a large urban area of the United States. Participant observation and in-depth interviews were carried out. We found that the bar, as a leisure space, provided a social setting where gender and sexuality as social categories are being reconstructed and where alcohol use, besides its legitimized use in so-called social drinking, is part of several rites related to the very disruption and dispersion of the gender/sexuality structure. In terms of other meanings the bar holds for its patrons, it is at the same time a "fantasy island" (i.e., a surrealistic space where "reality" is suspended and other conditions of feasibility and meaning emerge), and a "home away from home," where family-like interaction and care determine a feeling of belongingness and an interest to conserve the privileges of a liberated and safe surrogate home.

«Ciudadanía Sexual» es un concepto en construcción. Ofrece muchas posibilidades, y tal vez también tenga, como algunas y algunos opinan, limitaciones intrínsecas. Esperamos que estas posibilidades sean identificadas e intensificadas, y en tal caso el tiempo permitirá realizar un balance sobre los aportes de este concepto a la lucha por la salud y los derechos sexuales de las personas. En esta línea, estamos seguros de que los ensayos aquí incluidos, que fueran presentados y discutidos en la Primera Reunión Regional «Sexualidades, Salud y Derechos Humanos en América Latina», realizada en mayo de 2003 en Lima, contribuyen a poner el tema en discusión y, de paso, permiten una revisión del trabajo que se realiza en la región en una amplia gama de cuestiones relacionadas a las sexualidades, la salud y los derechos. Este volumen no habría podido materializarse sin la valiosa colaboración de las y los autores de los trabajos, quienes no sólo prepararon versiones iniciales antes de la reunión, sino que enviaron revisiones iniciales luego de ésta, y finalmente absolvieron comentarios editoriales tiempo después, hasta lograrse las versiones aquí incluidas.

IntroductionIt is increasingly clear that the HIV response will not be sustainable if the number of infections is not significantly reduced.DiscussionFor two decades, research has been ongoing to identify new behavioural and biomedical strategies to prevent HIV infection. In the past few years, the efficacy of several new strategies has been demonstrated, including oral pre‐exposure prophylaxis (PrEP; i.e. daily use of tenofovir/emtricitabine). Because several social, political and logistic barriers remain, however, optimal PrEP implementation will require a better dissemination of new evidence in a number of areas and additional implementation research from various disciplinary perspectives (i.e. social science, policy and ethics; health systems; and economics, including cost‐effectiveness studies). Discussion of new evidence on those topics, as well as case studies of potential PrEP implementation in diverse environments, can improve the understanding of the role that PrEP may play in addressing the global HIV/AIDS epidemic.In light of these needs, the Network for Multidisciplinary Studies in ARV‐based HIV Prevention (NEMUS) and the World Health Organization (WHO) were honoured to co‐organize a special issue of JIAS aimed at contributing to a scholarly discussion of current conditions surrounding PrEP implementation, potential impact and efficiency, social science concerns and the study of PrEP implementation in specific country cases. The papers included in this monograph identify and cover many of the main aspects of the complex yet promising discussions around PrEP implementation today.ConclusionsThis is a collection of timely contributions from global leaders in HIV research and policy that addresses geographic diversity, uses a trans‐disciplinary approach and covers a variety of the complex issues raised by PrEP. As this publication will become accessible to all, we hope that it will remain a valuable resource for policy makers, programme managers, researchers and activists around the world at a moment of a paradigm shift of the global response to HIV.

BackgroundIn this article, we present recent evidence from studies focused on the implementation, effectiveness and cost‐effectiveness of pre‐exposure prophylaxis (PrEP) for HIV infection; discuss PrEP scale‐up to date, including the observed levels of access and policy development; and elaborate on key emerging policy and research issues to consider for further scale‐up, with a special focus on lower‐middle income countries.DiscussionThe 2015 WHO Early Release Guidelines for HIV Treatment and Prevention reflect both scientific evidence and new policy perspectives. Those guidelines present a timely challenge to health systems for the scaling up of not only treatment for every person living with HIV infection but also the offer of PrEP to those at substantial risk. Delivery and uptake of both universal antiretroviral therapy (ART) and PrEP will require nation‐wide commitment and could reinvigorate health systems to develop more comprehensive "combination prevention" programmes and support wider testing linked to both treatments and other prevention options for populations at highest risk who are currently not accessing services. Various gaps in current health systems will need to be addressed to achieve strategic scale‐up of PrEP, including developing prioritization strategies, strengthening drug regulations, determining cost and funding sources, training health providers, supporting user adherence and creating demand.ConclusionsThe initial steps in the scale‐up of PrEP globally suggest feasibility, acceptability and likely impact. However, to prevent setbacks in less well‐resourced settings, countries will need to anticipate and address challenges such as operational and health systems barriers, drug cost and regulatory policies, health providers' openness to prescribing PrEP to populations at substantial risk, demand and legal and human rights issues. Emerging problems will require creative solutions and will continue to illustrate the complexity of PrEP implementation.

BACKGROUND: In the Peruvian Amazon, historical events of colonization and political marginalization intersect with identities of ethnicity, class and geography in the construction of gender and health inequities. Gender-based inequalities can manifest in poor health outcomes via discriminatory practices, healthcare system imbalances, inequities in health research, and differential exposures and vulnerabilities to diseases. Structural violence is a comprehensive framework to explain the mechanisms by which social forces such as poverty, racism and gender inequity become embodied as individual experiences and health outcomes, and thus may be a useful tool in structuring an intersectional analysis of gender and health inequities in Amazonian Peru. OBJECTIVE: The aim of this paper is to explore the intersection of gender inequities with other social inequalities in the production of health and disease in Peru's Amazon using a structural violence approach. DESIGN: Exploratory qualitative research was performed in two Loreto settings - urban Iquitos and the rural Lower Napo River region - between March and November 2015. This included participant observation with prolonged stays in the community, 46 semi-structured individual interviews and three group discussions. Thematic analysis was performed to identify emerging themes related to gender inequalities in health and healthcare and how these intersect with layered social disadvantages in the reproduction of health and illness. We employed a structural violence approach to construct an intersectional analysis of gender and health inequities in Amazonian Peru. RESULTS: Our findings were arranged into five interrelated domains within a gender, structural violence and health model: gender as a symbolic institution, systemic gender-based violence, interpersonal violence, the social determinants of health, and other health outcomes. Each domain represents one aspect of the complex associations between gender, gender inequity and health. Through this model, we were able to explore: gender, health and intersectionality; structural violence; and to highlight particular local gender and health dynamics. Intersecting influences of poverty, ethnicity, geography and gender served as significant barriers to healthcare in both rural and urban settings.

"Christián Larroulet, Juan Andrés Fontaine, Andrés Concha, Patricia Matte, Rosa Camhi, Antonio Sancho, Mercedes Cifuentes, Claudio Osorio, Juan Eduardo Errázuriz, and Rosanna Costa describe the macroeconomic policies, the reforms in education, health and justice, the infrastructure requirements, the new export phase, and the policies to remove poverty and establish an efficient State, which are necessary to advance a free society during the new era of Chilean democracy"--Handbook of Latin American Studies, v. 57

IntroductionDespite progress in scaling up antiretroviral treatment, HIV prevention strategies have not been successful in significantly curbing HIV incidence in Latin America. HIV prevention interventions need to be expanded to target the most affected key populations with a combination approach, including new high impact technologies. Oral pre‐exposure prophylaxis (PrEP) is recommended as additional prevention choice for individuals at higher risk of infection and could become a cost‐effective prevention tool. We discuss the barriers and solutions for a fair consideration of PrEP as part of combination HIV prevention strategies in Latin America.DiscussionAlthough demonstration projects are ongoing or being planned in a number of countries, to date no Latin American country has implemented a public PrEP programme. The knowledge of policymakers about PrEP implementation needs to be strengthened, and programmatic guidance and cost estimate tools need to be developed to support adequate planning. Despite high levels of awareness among health providers, especially if engaged in HIV or key population care, willingness to prescribe PrEP is still low due to the lack of national policies and guidelines. Key populations, especially men who have sex with men, transgender women and sex workers, have been engaged in demonstration projects, and qualitative research shows high awareness and willingness to use PrEP, especially if accessible in the public sector for free or at affordable price. Concerns of safety, adherence, effectiveness and risk compensation need to be addressed through targeted social communication strategies to improve PrEP knowledge and stimulate demand. Alliance among policymakers, civil society and representatives from key populations, healthcare providers and researchers will be critical for the design and successful implementation of PrEP demonstration projects of locally adapted delivery models. The use of mechanisms of joint negotiation and procurement of antiretrovirals could reduce costs and significantly increase the cost‐effectiveness of PrEP.ConclusionsPrEP is an additional prevention tool and should be implemented in combination and synergy with other prevention interventions. PrEP programmes should target high‐risk individuals from key populations for higher cost‐effectiveness. Demonstration projects may generate strategic information for and lead to the implementation of full‐scale PrEP programmes.

IntroductionAs a group, transwomen in Peru have the highest prevalence of HIV (>20%) in the country, but they have little access to HIV prevention, testing and care services. Until recently, Peru's national HIV programme did not recognize transwomen and had remained essentially static for decades. This changed in December 2014, when the Ministry of Health expressed its commitment to improve programming for transwomen and to involve transwomen organizations by prioritizing the development of a "Targeted Strategy Plan of STIs/HIV/AIDS Prevention and Comprehensive Care for Transwomen."DiscussionA policy dialogue between key stakeholders – Peru's Ministry of Health, academic scientists, civil society, transgender leaders and international agencies – created the conditions for a change in Peru's national HIV policy for transwomen. Supported by the effective engagement of all sectors, the Ministry of Health launched a plan to provide comprehensive HIV prevention and care for transwomen. The five‐year plan includes new national guidelines for HIV prevention, care and support, and country‐level investments in infrastructure and equipment. In addition to new biomedical strategies, the plan also incorporates several strategies to address structural factors that contribute to the vulnerability of transwomen. We identified three key factors that created the right conditions for this change in Peru's HIV policy. These factors include (1) the availability of solid evidence, based on scientific research; (2) ongoing efforts within the transwomen community to become better advocates of their own rights; and (3) a dialogue involving honest discussions between stakeholders about possibilities of changing the nation's HIV policy.ConclusionsThe creation of Peru's national plan for HIV prevention and care for transwomen shows that long‐term processes, focused on human rights for transwomen in Peru, can lead to organizational and public‐policy change.

IntroductionTowards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre‐exposure prophylaxis (PrEP) within the combination HIV prevention framework.DiscussionAfter a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real‐life settings due to stigma, cost, adherence, and potential risk compensation barriers.ConclusionsThe strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.

AbstractIntroductionAmong men who have sex with men (MSM) and transgender women (TW), stimulant use is high and has been associated with an increased risk of HIV infection, suicide and cardiovascular disease (CVD) mortality. We used epidemic modelling to investigate these intersecting health harms among MSM/TW in Lima, Peru and assess whether they could be mitigated by prioritizing HIV pre‐exposure prophylaxis (PrEP) and harm reduction interventions among MSM/TW who use stimulants.MethodsWe adapted a dynamic model of HIV transmission among MSM/TW in Lima to incorporate stimulant use and increased HIV risk, suicide and CVD mortality. Among 6% to 24% of MSM/TW using stimulants (mostly cocaine), we modelled an increased risk of unprotected anal sex (RR = 1.35 [95%CI: 1.17 to 1.57]) obtained from local data, and increased risk of suicide (SMR = 6.26 [95%CI: 2.84 to 13.80]) and CVD (SMR = 1.83 [95%CI: 0.39 to 8.57]) mortality associated with cocaine use based on a global systematic review. We estimated the proportion of health harms occurring among MSM/TW who use stimulants in the next year (01‐2020/01‐2021). We also investigated the 10‐year impact (01‐2020/01‐2030) of: (1) PrEP prioritization for stimulant‐using MSM/TW compared to random allocation, and (2) integrating PrEP with a theoretical intervention halving stimulant‐associated risk.ResultsMSM/TW in Lima will experience high HIV incidence, suicide mortality and CVD mortality (1.6/100 py, and 0.018/100 py, 0.13/100 py respectively) in 2020. Despite stimulant using MSM/TW comprising an estimated 9.5% (95%CI: 7.8 to 11.5) of all MSM/TW, in the next year, 11% 95%CI (i.e. 2.5% to 97.5% percentile) 10% to 13%) of new HIV infections, 39% (95%CI: 18% to 60%) of suicides and 15% (95%CI: 3% to 44%) of CVD deaths could occur among this group. Scaling up PrEP among all stimulant using MSM/TW could prevent 19% (95%CI: 11% to 31%) more HIV infections over 10 years compared to random allocation. Integrating PrEP and an intervention to halve stimulant‐associated risks could reduce new HIV infections by 20% (95%CI: 10% to 37%), suicide deaths by 14% (95%CI: 5% to 27%) and CVD deaths by 3% (95%CI: 0% to 16%) over a decade.ConclusionsMSM/TW who use stimulants experience a disproportionate burden of health harms. Prioritizing PrEP based on stimulant use, in addition to sexual behaviour/gender identity criteria, could increase its impact. Integrated substance use, harm reduction, mental health and HIV care among MSM/TW is needed.