Prevents, but does not eliminate: stigma and the use of preexposure and post-exposure prophylaxis in the context of sex work among cisgender women in São Paulo

Abstract

Over the past four decades, research and activism have shown that reducing stigma must be a central focus of prevention policies. However, stigma remains both a barrier and a driving force behind the acceptability and use of biomedical technologies among cisgender sex workers. This article explores that paradox by questioning the effectiveness of pre- and postexposure prophylaxis in a context shaped by stigma around prostitution and HIV/AIDS. Our analysis is based on in-depth interviews with cisgender sex workers who use these prophylaxes, conducted in 2015 and 2018/2019. We apply thematic analysis to four categories drawn from the Health Stigma and Discrimination Framework: prevention negotiations, representations of HIV/AIDS, motivations for use, and perceptions of PEP and/or PrEP. The findings show that the pursuit of greater autonomy in selfcare drives interest in these technologies. This motivation, however, often aims to navigate stigma and power imbalances within prevention practices. By situating the discussion within Brazil’s STI/AIDS programs over the past decade, we advocate for a renewed focus on structural factors – particularly stigma – as the “first barriers” to prevention in the context of sex work.