Conceptual framework.

To achieve our objectives, we used the Capability, Opportunity, Motivation, and Behavior [COM-B] model, a behavioural change framework that recognizes that behaviour [in this case, PrEP uptake] is influenced by an individual’s knowledge and skills to perform such behaviour, the external and physical factors that either promote or block that behaviour, and the basic drives and reflections that can affect their willingness to perform a certain behaviour [19]. We postulated that factors related to PrEP acceptance among TGW could be mapped into all domains of the COM-B framework. As depicted in Table 1, studies with TGW demonstrated the relevance of various factors on PrEP use that can be mapped in the COM-B. Factors related to the capability domain include HIV prevention knowledge, and skills; factors related to opportunity dimensions include societal influences, resources, interactions with healthcare systems, family, and peers, and HIV stigma; and motivational factors include beliefs, intentions, concerns, mental health states, and habits [8, 9, 20, 21]. The COM-B relies on the delineation of explanatory factors that influence a particular behaviour on multiple levels [i.e., individual, interpersonal, and contextual], which helps us to identify barriers and facilitators, and a structured framework for intervention design [Objective 1]. COM-B lies at the centre of the Behavior Change Wheel [BCW], a toolkit that assists in the selection and design of behavioural interventions and strategies to address identified barriers [19]. By categorizing barriers and facilitators into capability, opportunity, and motivational factors, the COM-B and the BCW will help us to delineate specific areas for intervention [Objective 2].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Examples of how the COM-B model could be applied to the intention of using PrEP in TGW^*.

https://doi.org/10.1371/journal.pgph.0001395.t001

1. Capability.

This domain summarizes the experience of participants concerning HIV prevention knowledge and skills. The themes relate to knowledge and skills that influence their acceptability of PrEP, including continuing condom use, HIV testing, taking pills, and attending PrEP monitoring visits.

1.1. HIV prevention knowledge and skills. Participant narratives demonstrated knowledge about HIV and its prevention, including the effectiveness of consistent condom use, the importance of getting HIV tested routinely, and the risk associated with having sex with partners of unknown serostatus. This knowledge could facilitate PrEP uptake. Mariana [44 years old] mentioned, "Prevention is not only using a condom but also looking at who you are going to be with; in my case, it means not being too promiscuous."

All participants used condoms as their main HIV prevention tool. They know that the efficacy of condoms is high when used correctly and that it is decreased if broken; most of them have high levels of confidence in their effectiveness, as in the case of Fernanda:

I don’t know if I can say 100%, but I feel more confident when I use one. If I didn’t use one, I would be scared, but I always make sure it’s on correctly or that it doesn’t break … the condom has given me a lot of confidence. [Fernanda, 50 years old]

The participants have gained this knowledge through different means: interactions with community organizations and transgender leaders; learning from their own experiences, such as previous sexually transmitted diseases; sexual encounters with partners living with HIV; and sexual education at school.

Participants mentioned their capacity to negotiate condom use with partners, especially commercial partners. Liliana [37 years old], a sex worker, commented, "When they asked me, ’Without a condom?’ I did not accept providing the service." Participants also stated that they were aware that, for example, the use of drugs or alcohol could compromise their skills to use condoms.

Participants identified routine testing for HIV as an additional prevention tool they can use to manage their risk of HIV. For instance, participants mentioned seeking testing to ensure they are negative after a risky encounter or to continue to feel safe in a stable relationship if not using condoms. As Isabel [45 years old] mentioned:

It is something I do every year [HIV testing] after stopping a relationship with my partner because I always have the risk [of contracting HIV], I always have it, and I have lived with this risk. [Isabel, 45 years old]

Among participants seeking femininization, very few in this sample, routine HIV testing was required as part of this process. This was the case for Catalina:

I went to do the tests to get the hormones, I have to go many times to the EPS [the clinic], get seen by a psychologist and a psychiatrist, and I have to go with the HIV test results. The test is done here [a community site]… this has given me a sense of relief. [Catalina, 22 years old]

Few participants reported low knowledge of HIV testing concerning both its importance and accuracy.

I said, "I’m going to do it." But in some way, I did not feel anything strange, and I said, "I am going with God." And I did that, and everything was fine. So, I wanted to know if those tests are actually reliable. I think so, right? [Claudia, 32 years old]

1.2. Knowledge and skills for PrEP. Few participants were aware of PrEP or knew about PrEP in any depth. For instance, Isabel, a TGW leader with substantial experience in HIV activism, showed a surprising level of uncertainty in her knowledge:

I’ve heard about it [regarding PrEP] very recently, this is new, right? I heard that it was a medication that allow people to be with a person living with HIV and the person did not get infected, right? I think that was what I’ve heard. [Isabel, 45 years old]

Of the few participants who reported being aware of PrEP, they stated they gained their knowledge through a friend, participation in the demonstration study conducted by the Pan-American Health Organization, or international media and online searches. The latter was the case of Brenda, who found PrEP information 5 years earlier but had not been able to access it yet at the time of the interview:

Well, I remember that the first contact, that is, the first time I read the word "PrEP," was an article from the BBC, I don’t know what I was looking for on the Internet and it was in a headline and it caught my attention … It was talking about how, in England, they were implementing PrEP and that this treatment was for prevention and that you took a pill, …. you took a daily pill, and you could prevent the transmission of the virus, so I was like, "Wow," this is too revolutionary, and I remember that I loved the idea, and I remember that I did discuss it with a couple of friends. This was about 5 years ago. [Brenda, 30 years old]

Concerning skills related to PrEP, most participants mentioned they would maintain the use of condoms if they decided to start PrEP. Their reasons were related to the importance that condoms have had in their prevention of HIV, the high risk of HIV in commercial sex, and because PrEP does not protect against other sexually transmitted diseases.

You know that PrEP is only useful for HIV, but you can also get syphilis or a papilloma [HPV]… Even if I take PrEP, I must continue using a condom. Yes, if I’m going to be with a client or with a man I haven’t met before, with new sexual partners. [Samanta, 30 years old]

For Fernanda, the effectiveness of condoms makes the use of PrEP for prevention less appealing.

I’m not going to say I’m going to take this pill because I’m going to have sex and I’m not going to use a condom. No, I prefer to fuck and use a condom, but if suddenly I have an accident, I take the PrEP. [Fernanda, 50 years old]

Many participants also referred to their own ability to adhere to medications and do the monitoring, including doing HIV tests, and attend medical check-ups, as in this narrative:

I would do anything to get it [referring to PrEP]. … To already have it in my hands and take it daily and go for check-ups every 3 months, as you say, and not stop using condoms, even if I take PrEP. [Liliana, 37 years old]

One participant reported having an aversion to taking pills:

If at a given moment I want to be with someone and I don’t want to put a condom on, it doesn’t matter because I’m sure I’m not going to get it [HIV] because I’m taking some medicine. There would be the cool piece that you’re sure you’re not getting a risk, but the price you have to pay [laughs] would be eating all those pills … like it’s not my thing, it’s not my thing. [Isabel, 45 years old]

Participants mentioned that there is a need to educate TGW in the following areas: PrEP and hormones, the importance of condom use along with PrEP, the inability of PrEP to prevent infections other than HIV, how evidence on PrEP is generated, and the experiences of people using PrEP.

2. Opportunities.

This domain covered aspects related to how the social and physical environments can either enable or hinder the use of HIV prevention tools, including PrEP. The narratives in this domain include themes related to interactions with family, partners, and healthcare professionals and the discrimination and limited social opportunities experienced within these interactions.

2.1. Pressure and support from family. Physical, psychological, and sexual violence perpetrated by family members were narratives frequently reported. Participants also mentioned experiences of sexual abuse and forced sex at early ages as well as discrimination from parents because of their sexual orientation and search for gender transition. One of the most significant narratives came from Pilar, who experienced different types of abuse since childhood.

I lived with my stepmother; my mother abandoned me when I was 4 years old, and the one who raised me was my stepmother until I was 18 years old. After those 18 years, I couldn’t stand them anymore, believe me, I couldn’t stand any more physical and verbal abuse. [Pilar, 29 years old]

For Pilar, those experiences led to social isolation, depression, and suicide attempts. She mentioned that those experiences have prone her to know more about her risk of adquiring HIV and avoid risky situations such as commercial sex. Others described having supportive families with "open minds" as a form of "good luck." For instance, Monica related how her mother taught her to use condoms when she found out her sexual inclination [not disclosed here], and Samanta described how her family approved her use of PrEP.

My family knows that I have always worked [as an activist] on sexual health issues. Everyone in my house, even my cat, is sensitized to HIV issues and prevention… . I have tested all my sisters-in-law, and when I told them about PrEP, they said, "That’s so cool!" [Samanta, 30 years old]

The participants indicated that a lack of support from family members would affect the use of PrEP by TGW and increase experiences of discrimination. Participants felt that family members might think that the use of PrEP would lead to a more promiscuous life or that they are already living with HIV.

There are people who hide it from their family so as not to trigger direct discrimination because the family may think that PrEP means HIV treatment, so they would conclude they have HIV. [Margarita, 34 years old]

Similar to Margarita, Brenda also reported that many TGW have difficulties with their families accepting the use of PrEP, and they attributed this to the families’ lack of information and HIV stigma.

If they find out that a member of their family or a friend is taking PrEP and if they ask about it, and they received an explanation about PrEP, they would look at you with their stigma lens… and would think that person has HIV and is going to transmit it to me …. people think that way because they do not know how it is transmitted, they do not know how it works, and so this can increase the prejudices and the discrimination, in the workplace and also in the family. [Brenda, 30 years old]

Brenda also mentioned that this type of problem would not happen with her friends, especially among those who are also transgender.

2.2. Pressure and support from sexual partners. Commercial, regular, and casual partners also exert differential pressures concerning HIV prevention behaviour as described by the participants. In the case of having commercial partners, condom use is the norm; nevertheless, participants mentioned that for many TGW, their poor economic conditions can compromise their ability to persuade their clients to use condoms. Participants who perform sex work consistently reported that commercial partners offer a higher payment for the service in exchange for omitting condom use. In this regard, Margarita said:

In sex work, some clients ask for sexual acts not to be performed with a condom, clients who offer them two, three, or four times the rate [for this]…, and many agree to them not wearing a condom to get a bit more money. Although there are many of us with greater awareness who challenge them [other sex workers] with not doing sex without a condom because there may be something suspicious in a person [client] and that can be risky for them. [Margarita, 34 years old]

Margarita continued her narrative by proposing that when practising condomless sex, TGW may use PrEP as an alternative to prevent HIV infection because other sexually transmitted diseases can be treated and eliminated unlike HIV, which is a lifelong infection.

Participants distinguished between the types of protection and measures taken when they have a regular partner vs a casual or commercial partner. Gabriela, as well as other participants, did not use protection with their stable partners.

There came a time when we stopped using condoms… he was my partner, my husband … there is no possibility of using prevention, one is not able to prevent anything … it’s like, "He’s my partner and so I don’t take care of myself." … in my case, I’ve always lived that way. [Gabriela, 23 years old]

However, participants also described being aware that not using condoms in stable relations is problematic, as they believed that many of the HIV cases among TGW were the result of transmission by their stable partners rather than their commercial partners. As Samanta [30 years old] explained, "Many transgender have had it [HIV], I believe 50% have been infected by their [regular] partners and not by their clients." Given this belief, some participants stated the use of PrEP was an important addition to HIV prevention.

2.3 Peer interactions. Contrary to the largely negative influence of partners and family, participants have established good relationships with peer leaders in their communities. Through their interactions, they have acquired knowledge and skills for HIV prevention.

About 2 years ago, some transgender women and I were invited to an event at the centre… There they taught us a lot of things about HIV, prevention, and all that. They explicitly taught us how to put a condom on a plastic penis. [Catalina, 22 years old]

According to narratives, organizations and transgender peers increase access to HIV testing and condoms and, more importantly, they interact with transgender populations in their places of residence and work. This latter benefit is vitally important to TGW who work in the streets, as they may have fewer economic resources, less time, and difficult schedules that are not compatible with prevention tools offered by the health system. The narratives of Mariana and Denise are examples of these positive interactions:

I have a trans friend in an organization, and she contacts us every time they are going to do these tests or training… she does not hesitate to tell us and so far, I have always been there every single time they do them. [Mariana, 44 years old]

A friend of mine [who works at a community-based organization] sometimes gives them [referring to condoms] to me for free, so I do not need to buy condoms. Although I know using them [condoms] is good for my health … I rather buy Colgate [toothpaste], buy myself something else, because times are tough now. [Denise, 24 years old]

Participants felt that their peers are like their sisters and that they will support them if they take PrEP, as in the case of Catalina:

If I told my friend about it [referring to PrEP], she would say yes, she is a friend who has supported me in many ways; she would tell me, "No, obviously yes, obviously so you can be protected." She always tells me the same, "You know that you can hardly trust these men." That is, if you have a good time, that’s good, but rather you protect yourself more and feel peaceful. She thinks the same as I do. [Catalina 22 years old]

2.4. Health system interactions. Although narratives regarding interactions with the healthcare system were diverse, the majority were related to negative interactions with healthcare professionals. The narratives detail experiences of stigma, discrimination, and lack of knowledge on the part of healthcare providers. For instance, participants described how providers often associated transgender identity with HIV; consequently, any health problems they reported were assumed to be HIV-related.

The first thing they do is an HIV test because there is still the stigma of HIV since we are trans women and we are classified as sex workers; they will always test us for HIV even if we do not have any symptoms. [Margarita, 34 years old]

Participants also mentioned a lack of knowledge on transgender care and acceptance of gender identity among healthcare workers, as presented in the following narratives.

I would say that most of them [experiences with the healthcare system] have been frustrating because I have encountered medical professionals who do not know enough about the subject [referring to sexual transition], and we would like them to be people who are prepared and who know about such subject, who know how to offer care when a trans person seeks health services. I felt discriminated against. [Brenda 30 years old]

The last time I went to the [hospital], a young man, this happened with men more than with women, the young man treated me as if I were a man, and I said, "I am a trans" and he said, "But you’re still a man." He told me like that, so I felt bad. Do you understand me? [Pilar, 29 years old]

Some of the interactions with healthcare professionals were extremely distressing. This was the situation for Ariana, whose care was refused. She explained, "The doctor who treated me felt disgusted when he saw me, I don’t know, he didn’t want to assess me, he asked few things and that’s it, he took me out of the office." [Ariana, 34 years old]

Of the few participants aware of PrEP, they mentioned that healthcare workers do not know about it. Margarita advances an explanation for this that the lack of knowledge among healthcare workers is related to HIV stigma and likely also a stigma against the use of PrEP.

Yes, I have asked them [about PrEP], but they cannot, well, those that I have asked don’t seem able to address the problem directly and quickly because they also see it as a taboo. After all, they say "no," or there are many who do not work on HIV because they are also afraid of it, or they don’t know about it … Among them, they also have a certain stigma. [Margarita, 34 years old]

Brenda thinks the negative experiences of many TGW with professionals will make it difficult for them to seek access to PrEP through the current healthcare system.

Exactly … like having to constantly face that, I don’t know, that they make you undress, that they ask you questions, that they take blood from you, that they do all that to you. I would say, "Do not do that to me." It doesn’t seem like an obstacle to me, but I know that many people do not like these routines, these types of periodic check-ups. [Brenda, 30 years old]

However, given the importance of monitoring, some participants felt that health services and professionals should be the ones who need to monitor PrEP. This was the experience of Samanta with PrEP.

They could take control of who is taking it; if the patient is reacting positively, if they are taking it as prescribed, or if they are not taking it consistently. Then in the health system, it would be much better because the attending physician is there, and telling them that, "Yes, the treatment is doing a great job for your kidney or liver or [otherwise] stop it immediately." Then it would be better using the [healthcare] system, I think it is better for your health. [Samanta, 30 years old]

In general, participants recommend more education and training for healthcare workers in HIV and transgender care.

2.5. Cost and other types of access. Like the negative interactions with professionals in the health system, participants reported problems with access to care and the need to file an appeal or sue the system to obtain the care they need.

I had to file an appeal… so that they could grant me what I am rightfully entitled to. So, it is a tiring process. I feel that as a trans woman in a country like Colombia and with this system… the laws are not observed, so it is very complicated. [Margarita, 34 years old]

Some participants worry that the medications for PrEP are not consistently supplied, as they have had experiences with other conditions where supply was interrupted. They felt that having access to condoms or asking for an HIV test will take longer and will not be enough, which contrasts with what is provided in community organizations. Given the disadvantageous financial conditions of many of the participants, they also mentioned that PrEP needs to be offered free of cost in sites accessible to them and covered by health insurance plans.

The obstacle is that they are a little expensive… because there are people who do not have the means, that would be an obstacle. Another [obstacle] would be that the EPS [the healthcare provider institution] would not provide them because they [TGW] are not affiliated [with their institution] or do not pay the co-payment. They should provide them for free. [Liliana, 37 years old]

In a nearby place, because we often don’t have access to money to pay for transportation, a bus, a motorcycle, a taxi. Many times we don’t have that money … because we have [other] responsibilities, such as paying rent, buying food, pay bills, and often we don’t have it. [Gabriela 23 years old]

Regarding these obstacles, participants suggested different options for PrEP delivery, such as having PrEP available in a nearby pharmacy, community organizations, or even home delivery. Samanta, who takes PrEP, recognizes that once the demonstration project finishes, she will have difficulties accessing PrEP.

I wish that would happen, that I would go to my health system and request the PrEP and continue taking it because I know that once this project ends [referring to the demonstration project], that will be it, and that is bad. [Samanta, 30 years old]

2.6 Community interactions and opportunities. TGW experience different forms of discrimination: against their identities as TGW, their occupation as sex workers, their HIV-positive status, or their poor socioeconomic condition. For instance, Margarita mentioned increased levels of violence toward TGW perpetrated by different community actors:

I don’t do sex work, but if I’m with girls and I approach girls who do sex work, many of them are raped, raped with a knife, raped because they live on the street, raped because they expose themselves to certain social problems. Even with the police and with the environment where they live, and in certain types of situations, there have been, let’s say, injuries. [Margarita, 34 years old]

Participants also mentioned how those experiences become obstacles to education, employment, housing, appropriate access to care, and the use of preventive measures.

That is very true, many people, especially trans girls, often do not have the chance to study and end up choosing prostitution because it is the path that society offered us. Or [there are] some [transgender] girls who have studied because they received support and they were able to move on. But many of us have a hard life, and we don’t have a way to do that [referring to study and work]. [Gabriela, 23 years old]

Participants mentioned that within the TGW population, some groups are more vulnerable to discrimination than others. The participants cited those with lower socioeconomic status, those who do sex work, and Afrodescendants.

There are different problems that a single person would need to handle, the burden is 10 times heavier than that I have to bear. I live in a stratum-3 or -4 house [socioeconomic stratum], I am White, I’m not Black, and, basically, I live with all the privileges that those girls don’t have, and they have to fight day by day, stealing, trying to earn their daily living whoring in the streets, in order to survive … and trying to have a level of life that they would never reach because they wanted to be happy but their families do not accept them. [Margarita, 34 years old]

Participants consider that the HIV stigma that persists in society may become a barrier to accessing PrEP, as taking PrEP may be perceived as them having HIV.

Well, it will make me feel a little bit ashamed… if you go somewhere and there are people … associated with having HIV and they realize that [and say], "Look, she is coming here to get that." You know how people are here in Colombia. They are going to think that I have HIV, I mean, people will think that if you are taking a pill that is for HIV, they will think that you have it. [Liliana, 37 years old]

Participants felt that the fact that TGW have always been at high risk of HIV has perpetuated the stigma against them. They suggest that PrEP-related messages should also be focused on the non-LGTB population, as heterosexual men and women are also at risk of transmission and acquisition of HIV.

3. Motivation.

This domain summarizes the narratives of the participants related to their perceptions about PrEP, their intentions to use it, the reasons to use it, and the possible psychosocial barriers to their use. The narratives of the TGW demonstrated their keen interest in using PrEP.

3.1. Reduce the risk and fear of HIV. Most of the participants perceived themselves as having a high risk of contracting HIV. They also recognized that their sexual behaviours increase their risk. Many reported being aware that TGW are at higher risk of HIV in general either because they know the statistics or because they have family and friends with HIV. For participants, this is translated into constant fear of becoming HIV-infected and suffering the consequences of the severe stigma they anticipated they would face.

It is something hard for a person having to take pills from the time they get up to the time they go to bed, knowing that if they live with their family, they have to have everything separate, and they will always be named as having it do it like [unintelligible word] … you know, like saying, "No, he has HIV, he has to stay separate from us." "No, he’s like a plague." "Use the gloves, he has HIV." It’s something very hard, I think. [Gabriella, 23 years old]

For most participants, their primary motivation to use PrEP was related to the possibility of reducing HIV risk, either personally or in their communities. Monica’s and Gabriela’s narratives covered both the personal and community benefits of PrEP, such as less fear of being infected, gaining confidence in being capable of preventing HIV infections, gaining control of decisions on prevention, and reducing the mental health consequences of a diagnosis of HIV in a context of significant discrimination.

Yes, there would give me peace of mind, with PrEP yes. So, I wouldn’t go with so much fear to take the test, you know, that being positive is something that will be difficult to hear, that somebody tells you, "You are positive." Although we cannot rule out it can happen. [Monica, 22 years old]

I think we are going to see more self-confidence, that we are going to be able to prevent this issue of HIV, spreading it … and the negative part of PrEP would be like not knowing what adverse effects can have on the body, to our health. [Monica, 22 years old]

Well, I think the positive thing is that it would prevent the disease, and it would stop many deaths and many suicides because most of the suicides of homosexuals or trans girls come from this disease. [Gabriela, 23 years old]

Of course, for me, yes, some girls are afraid of that [HIV infection]. But for me, that is essential [prevention of HIV]. I think that, as a trans woman, one is exposed to many things; one is exposed to sex, one is exposed to sleeping with men you do not know. Yes, I can tell you … that I would do it [use PrEP], of course, I would do it. For me, it would be a control, a check-up, to know that I am healthy. [Gabriela, 23 years old]

3.2. Concerns about the use of PrEP. Side effects, unknown efficacy, interference with hormone treatment, and how the use of PrEP medications may affect other medical conditions were among the concerns reported. However, none of those concerns seem to disfavour its use among the participants.

Negative points would be the side effects… that may arise, for example, I don’t know if there are enough studies that show what the implications are of taking this medication for ’x’ time. [Brenda, 30 years old]

What happens in your body? Has that been studied or not? What happens if I start taking PrEP and I see that it’s affecting my hormone treatment in some way… that would be a reason for people to say, "Oh no!" [Margarita, 34 years old]

One participant expressed concern about the possibility that people could counterfeit PrEP pills and sell them and that the counterfeit pills would not effective or they could be combined with illicit drugs. Regarding the first point, Margarita mentioned, "Colombia is practically the country that counterfeits most things in the world, and this type of pill or treatment may also be easy to fake, and that could be a problem."

3.3. Mental health and emotional states. Narratives of participants mentioned how following the hormonal transformation of their bodies and the various expressions of social discrimination affect them physically and emotionally. Participants mentioned suffering from depression and anxiety and having suicidal thoughts. Pilar commented on her experience with mental health issues as follows:

It has been a very strong process [acceptance of her transsexuality], too strong, they are very strong processes. If I had chosen that life would have not been like this, I would have preferred to have died because it is a very hard process, where you see it is a very hard process because now I have had anxiety, depression, very strong obsessive disorders. So, I think so. [Pilar, 29 years old]

Drug and alcohol use and abuse among TGW was also identified as a consequence of the persistent fear and discrimination TGW living with HIV experience. As mentioned by Gabriela:

Many times, suicide, other times, they began to consume more drugs than usual. They began to consume more alcohol than usual, and that makes death accelerate faster because, well, you know that the defences get affected and, then they accelerated death faster. [Gabriela, 23 years old]

The participants indicated that substance use and abuse would influence the intention of TGW to use PrEP negatively, such as decreased adherence or interest in taking additional pills when not sick. Gabriela and Samanta explained:

To calm my sadness, I used to take everything [drugs]. Then I became so unhealthy because I neglected my hormones and my thyroid. I suffered from insomnia, and I began to attend a drug addiction program. There, they recommend us not to take anything, so we don’t get addicted. [Gabriela, 23 years old]

Other people could be discouraged about taking PrEP because of a state of mind, such as the girl does suffer from depression or psychiatric problems … sentimental issues would be what would suddenly lead a trans woman to turn on not taking it. [Samanta, 30 years old]

Other participants’ narratives reflect high self-esteem and resilience among TGW, aspects that could favour their use of preventive strategies, including PrEP. As Samanta, who uses PrEP, described:

The motivation came from ourselves too, of wanting to do it, because I don’t need someone else to support me to do something I want, right? Let’s say if my family would have opposed me taking it, I do it anyway. [Samanta, 30 years old]

The importance of having a good mindset to be willing to use PrEP was also mentioned by Catalina:

So, it is more a self-commitment, a commitment to you, to what you are doing and your health. That is, if you do not take care of your health, nobody is going to take care of it. That is the reality. Unless it is your mother, well, that is reality. [Catalina, 22 years old]