Antiretroviral pre-exposure prophylaxis (PrEP) reduces HIV transmission, but barriers to PrEP access limit uptake in the USA. |
Awareness of PrEP remains low in populations at risk and is inadequate in some healthcare provider settings, requiring educational initiatives. |
Low perception of HIV risk among individuals and healthcare providers limits PrEP uptake, alongside lack of access to appropriate, unbiased medical care. |
Financial and social stigma barriers also reduce PrEP uptake, although legal changes to PrEP coverage by insurance providers and social media interventions may provide opportunities to overcome these barriers. |
Introduction
Searches
Key barriers | Potential approaches to removing barriers |
---|---|
Awareness of PrEP | Patient and provider education Better communication between providers |
HIV risk perception | Patient and provider education |
Stigma | Improved cultural humility (via education and advocacy) Improved communication and understanding between patient and provider |
Provider bias and distrust of healthcare system | Patient and provider education Addressing systemic entrenched bias (via education, advocacy, and recruitment of more Black, Latinx, and LGBTQ healthcare professionals) |
Access to medical care | Patient and provider education Extending access to PrEP (e.g., substance use clinics, emergency rooms, pharmacies, correctional institutions, etc.) Leveraging technology to improve access (e.g., telemedicine) Addressing competing priorities (e.g., food, shelter, safety, other healthcare, childcare) |
Lack of access to financial assistance | Help for patients in navigating financial aid options |
Side effects | Patient and provider education |
Awareness and Knowledge as a Barrier to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Survey of Black men and TGW who have sex with men attending Black Gay Pride events in five US cities (N = 1274)a | Only 39% of participants were aware of PrEP. PrEP awareness among TGW was 4.7% | [155] |
Survey of substance-using Black MSM and TGW in New York City (N = 1673)b | Only 18.2% of participants were aware of PrEP | [156] | |
Gendera,b | Survey of women visiting safety net family planning clinics in Atlanta (N = 500), of whom 47% were aged ≤ 28 years, 69% Black, and 12% Hispanic | Only 19% of participants knew about PrEP before their visit | [157] |
Assessment of women enrolled in an HIV study at Southern US sites (N = 225), the majority of whom were Black (83%) | Of the 72 participants who were PrEP-eligible, only 11% had previously heard of PrEP | [158] | |
Focus groups and interview of HIV-negative cis women visiting an STI clinic or emergency department in Chicago (N = 370), the majority of whom were Black (83%)d | Only 30% of participants had heard of PrEP before the survey. The only factor associated with hearing about PrEP was knowing someone on PrEP | [159] | |
Cross-sectional survey of HIV-negative cis women involved in the criminal justice system (N = 125) | Only 25% of participants were aware of PrEP | [37] | |
Survey of individuals attending family planning and sexual health clinics in Arizona, the majority of whom were women (65%) | Women had lower prior awareness of PrEP than men | [19] | |
Survey of TGM who have sex with cis men (N = 857) | 84.1% of participants had heard of PrEP | [160] | |
Race/ethnicityc,d | Survey of a Northern California consortium of individuals with recently acquired HIV (N = 122), the majority of whom were MSM (84%) and of minority racial/ethnic background (64%) | A lack of PrEP awareness was noted in 69% of Black participants | [161] |
Survey of Black individuals in the USA (N = 855) | Only 15% of all participants were aware of PrEP, with awareness of 20% among individuals at high risk | [162] | |
Analysis of PrEP awareness among HIV-negative MSM overall and by race using National HIV Behavioral Surveillance data from 20 cities in the USA | PrEP awareness increased overall from 59% to 90% between 2014 and 2017, but was lower among Black and Hispanic men (both 85%) compared with White men (94%) | [163] | |
History of substance abuseb | Interview of clinical and social service providers from Massachusetts and Rhode Island (N = 18) who work with PWID | Informants expressed concerns relating to low PrEP knowledge among PWID | [83] |
Interview of HIV-negative PWID in Boston and Providence (N = 33) | Low PrEP knowledge was identified as an individual-level barrier to PrEP use | [84] | |
Age | Survey of a Northern California consortium of individuals with recently acquired HIV (N = 122), the majority of whom were MSM (84%) and of minority racial/ethnic background (64%) | Lack of PrEP awareness was more prominent among individuals aged < 25 years (88%) than those aged 25–34 years (39%) | [161] |
Data from HIV-negative TGW aged 16–29 years enrolled in Project LifeSkills during 2012–2015 (N = 230), the majority of whom were of color (67%) | Younger age (21–25 versus 26–29 years) was associated with lower PrEP acceptability | [164] | |
Survey and interview of young adults experiencing homelessness in Houston (N = 30) or Los Angeles (N = 15) | Low or no prior knowledge of PrEP was reported by 68% of participants | [165] | |
Survey of young (age 18–30 years) HIV-positive minorities in South Texas (N = 92) | Only 45% of participants knew about PrEP at the time of their diagnosis | [166] | |
Geographic location | Focus groups of gay, bisexual, and other MSM in Boston, Massachusetts and Jackson, Mississippi (N = 35) | Boston focus group participants were more likely to be aware of the concept of taking a pill to prevent HIV infection (73%) than Jackson participants (29%) | [167] |
Interview of current and potential PrEP users in Alabama (N = 44) | Participants had a lack of PrEP awareness | [76] |
Study participants | Study methods | Summary of key data | References |
---|---|---|---|
US nurse practitioners (N = 271) | Cross-sectional survey of American annual conference attendees; presented in 2019 | 60.1% reported no prior PrEP training or education; 62.4% reported never starting a conversation about PrEP; Half reported being “confident” in discussing PrEP with an individual, monitoring PrEP side effects, or testing PrEP patients for HIV | [25] |
Physicians (adolescent medicine/family practice/internal medicine/pediatrics/obstetrics and gynecology) providing primary care to adolescents aged 13–21 years (N = 38) | Individual, in-depth, semi-structured interviews | 37% reported being somewhat or very familiar with PrEP; perceived benefits of prescribing PrEP included decreased HIV acquisition, and improved awareness of HIV risk among recipients | [31] |
Internal medicine trainees at a medium-sized internal medicine program (N = 48) | PrEP-focused educational intervention with pre-intervention and post-intervention surveys | Pre-intervention: 22% of trainees were unaware of PrEP, 78% believed PrEP was effective, 66% believed it was safe, and 62% had fair/poor awareness of side effects Post-intervention: 94% believed PrEP was effective and 92% believed PrEP was safe | [98] |
Clinical and social service providers who work with PWID in small cities and towns in Massachusetts and Rhode Island (N = 18) | Semi-structured qualitative interviews; presented in 2019 | Interviewees viewed PrEP as a promising but underutilized HIV prevention strategy. Interviewees also reported limited confidence among staff delivering PrEP | [83] |
First-year health professions students and interdisciplinary care teams at a health department in Illinois (N = 11) | Mixed-methodology assessment of a service-learning project to compile a training module (by health professions students), presented to interdisciplinary care teams | Students and care teams underinformed about PrEP had self-reported increased awareness and confidence in identifying individuals at risk for HIV infection after training intervention | [168] |
Healthcare providers (including infectious disease consultants, family/general practitioners, obstetrics/gynecology specialists, internist, and physician assistant) in Florida (N = 12) | 25-item questionnaire, conducted between January and March 2017 | 66.7% correctly defined PrEP; 58.3% had read the CDC’s PrEP clinical practice guidelines; 41.7% were able to correctly identify PrEP prescribing recommendations | [26] |
Low Perception of HIV Risk as a Barrier to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Survey of a Northern California consortium of individuals with recently acquired HIV (N = 122), the majority of whom were MSM (84%) and of minority racial/ethnic background (64%) | Among participants who were aware of PrEP, a barrier to use was perceived as low risk for HIV by 24% | [161] |
Baseline survey for a randomized controlled trial of MSM (N = 171) | HIV risk was underestimated by 38% of participants; the most common reason for not using PrEP was low perception of own HIV risk | [169] | |
MSM diagnosed with rectal gonorrhea or chlamydia at an STI clinic (N = 410) | Patients who considered themselves to be at medium/high HIV risk were significantly more likely to be interested in PrEP versus those who perceived themselves to be at low/no risk | [170] | |
Baseline assessment of a subset of HIV-negative MSM indicating a casual sexual partner in the prior 3 months (N = 553) from the “M3” study | Being drunk/buzzed on alcohol during sex was associated with no PrEP use | [171] | |
Gender | Survey of women attending urban obstetrics and gynecology clinics in Louisiana (N = 144), the majority of whom were Black (62%) | Risk of HIV acquisition was estimated to be low by 85% of participants; only 38% of the population were interested in PrEP | [172] |
Focus groups and interview of HIV-negative cis women visiting an STI clinic or emergency department in Chicago (N = 370), the majority of whom were Black (83%) | Participants had low perceived HIV risk (90% low/no risk). Factors associated with starting PrEP included being Latina, recent STI, more concern over HIV, and a higher belief in PrEP effectiveness | [159] | |
Interview of women from six cities in the USA (N = 89) | Few HIV-negative women expressed an interest in PrEP because they did not consider themselves as at risk for HIV | [173] | |
Cross-sectional survey of HIV-negative cis women involved in the criminal justice system (N = 125) | Only 17% of PrEP-eligible participants perceived themselves to be at risk for HIV | [37] | |
Interview of women experiencing intimate partner violence (N = 26) | Potential barriers to PrEP use included low risk perception | [35] | |
Philadelphia residents undergoing rapid HIV testing (90% Black) (N = 5606) | Investigators categorized 71.6% of men and 60% of women as moderate/high risk; only 56.8% of men and 8.3% of women perceived themselves to be high/moderate risk | [34] | |
Race/ethnicity | Survey of Black individuals in the USA (N = 855) | Among individuals at high risk, self-perceived risk was low in 65%, and only 35% would be willing to use PrEP. Those who saw a healthcare provider less frequently were less willing to use PrEP | [162] |
Survey of individuals undergoing rapid HIV testing in Philadelphia (N = 5606), the majority of whom were Black (90%) | A large proportion of individuals at moderate or high risk for HIV infection did not perceive themselves to be at high risk | [34] | |
History of substance abuse | Interview of HIV-negative PWID in Boston and Providence (N = 33) | Individual-level barriers to PrEP use included limited HIV risk perception | [84] |
Interview of clinical and social service providers from Massachusetts and Rhode Island (N = 18) who work with PWID | Informants expressed concerns relating to low HIV risk perception among PWID | [83] | |
Age | Survey and interview of young adults experiencing homelessness in Houston (N = 30) or Los Angeles (N = 15) | Low perceived HIV risk was identified as a barrier to PrEP use | [165] |
Social Stigma as a Barrier to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Interview of HIV-negative MSM who use PrEP (N = 43) | PrEP stigma was experienced as rejection by potential/actual partners, being subject to stereotypes of promiscuity/chemsex, and labeling (both the user and the medication) | [51] |
Interview of incarcerated MSM at the Rhode Island Department of Corrections (N = 26) | Post-release barriers to PrEP uptake and adherence included anticipated partner or family disapproval | [46] | |
Interview of Black MSM PrEP users in Los Angeles (N = 26) | Participants reported multiple experiences of PrEP-related stigma, including the perception of elevated sexual risk behaviors; conflicts in relationships; assumptions that users are HIV-positive; and gay stigma in families | [174] | |
Focus groups of MSM in New York City (N = 24) | Participants thought that stigma against PrEP users was declining as PrEP became more common, but stigma remained for those not using condoms and in relation to suspicions of infidelity with PrEP use | [175] | |
Focus groups of young men and TGM and TGW who have sex with men in Boston, Chicago, and Los Angeles (N = 36) | Stigma and marginalization were highlighted as barriers to PrEP use | [176] | |
Focus groups of gay, bisexual, and other MSM in Boston, Massachusetts and Jackson, Mississippi (N = 35) | Participants from Jackson, in particular, expressed fear that information would be disclosed to family and friends. One person suggested that stigma related to gay sex might be a barrier to people seeking PrEP | [167] | |
Interview of MSM in the USA (N = 3932) and Sub-Saharan Africa (N = 4063) | Individuals in the USA were more likely to avoid healthcare support/intervention if they had not disclosed their sexual behavior to their family | [177] | |
Interview of current and potential PrEP users in Alabama (N = 44), the majority of whom were gay or lesbian (66%)a | Sexuality-related stigma was raised as a perceived barrier to PrEP access | [76] | |
Gender | Focus groups of TGW living in New York City (N = 18) | Stigma and exclusion of TGW from advertising were identified as barriers to PrEP use | [50] |
Online survey of HIV-negative, heterosexually active PrEP-inexperienced women in Connecticut who were planning parenthood (N = 597) | PrEP-user stereotypes were commonly experienced, with many believing others would regard them as promiscuous (37%), HIV-positive (32%), bad (14%), or gay (11%). Thirty percent reported they would feel ashamed to disclose PrEP use; many expected disapproval from family (36%), sexual partners (34%), and friends (25%) | [178] | |
Group discussions among cis and TGW of color at the “Empowering Women’s Health Summit” in 2018 (N = 279) | Participants identified cultural gender norms and roles as an overarching barrier to PrEP use; other barriers included lack of effective communication with healthcare providers, structural racism, and stigmatization | [179] | |
Race/ethnicity | Survey of HIV-negative cis women who completed enrollment for a PrEP clinical trial in Southern California (N = 136) | Black women were less likely to know if their partner was HIV-positive, compared with White and Latina women | [180] |
History of substance abuse | Interview of HIV-negative PWID in Boston and Providence (N = 33) | HIV-related stigma within social networks was identified as a barrier to PrEP use | [84] |
Survey of PWID recruited to a mobile syringe exchange program in New Jersey (N = 138) | Participants reported substantial barriers to PrEP, including feeling embarrassed (45%) or anxious (52%) about taking PrEP, and nondisclosure to partners (51%) | [78] | |
Age | Survey of young (age 18–30 years) HIV-positive minorities in South Texas (N = 92) | A total of 43% of participants reported that they would be embarrassed to ask for PrEP | [166] |
Survey and interview of young adults experiencing homelessness in Houston (N = 30) or Los Angeles (N = 15) | Identified barriers to PrEP use included perceived stigma of PrEP use | [165] | |
Interview of physicians providing care to 13–21-year-old adolescents (N = 38) | Participants reported lack of acceptability to parents as a barrier to PrEP use | [31] | |
Survey of young MSM in California using geosocial networking apps (N = 687) | Stigma was identified as a factor in low willingness to take PrEP, e.g., concern around family members or friends finding out about PrEP use | [181] | |
Survey of PrEP-indicated emerging MSM aged 18–25 years (N = 194) | Only approx. 20% of participants reported moderate or high comfort with parent sex communication. Odds of current PrEP use increased with age, parent sex communication, and increased family disclosure of sexual identity. Participants who reported being in a relationship were less likely to be using PrEP than single participants | [182] | |
Survey of MSM aged 18–25 years (N = 236) | Participants were less likely to use PrEP if they were in a relationship | [183] | |
Online surveys and focus groups of adolescents (N = 56), most of whom were cis male (95%) and identified as gay (79%) | A frequently reported barrier was homophobia in the form of disapproving parents and healthcare providers | [74] | |
Online focus groups of HIV-negative sexual and gender minority adolescents (aged 14–18 years) recruited from across the USA | Participants asked a variety of questions about PrEP, including how or where to get PrEP without parents finding out | [184] | |
Geographic locationa | Focus groups of individuals at high risk of HIV in the Deep South (N = 54), primarily Black MSM and women participating in substance use treatment | Participants described substantial levels of stigma, including HIV-related stigma and discrimination from family, church, and community | [185] |
Provider Bias and Distrust of Healthcare Providers/Systems as a Barrier to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Survey of MSM at two Atlanta-based Gay Pride events in 2018 (N = 381) | More than half of participants were willing to be screened for PrEP in pharmacy (with Black MSM being significantly less willing than White MSM) and one-third were unwilling to discuss PrEP with pharmacy staff | [186] |
Focus groups of MSM in New York City (N = 24) | Many participants reported mistrust of medical providers | [175] | |
Interview of gay, bisexual, and other MSM involved in the criminal justice system (N = 26) | Participants noted the following reasons for mistrust: feelings of dehumanization; lack of privacy leading to belief that medical care is not confidential; and belief that status as an incarcerated person influences care received | [187] | |
Survey of Black MSM in Southeastern USA (N = 147) | Perceived healthcare-related discrimination was negatively associated with PrEP awareness | [188] | |
Focus groups of Black MSM aged 16–25 years in Milwaukee (N = 44) | Previous/anticipated negative interactions (perceived racism/homophobia) with physicians and skepticism about the healthcare system were reported to have alienated young Black MSM from the healthcare system and created barriers to PrEP use | [189] | |
Interview of Black MSM PrEP users (N = 26) | Participants reported judgement from medical providers, and discomfort with medical providers | [174] | |
Focus groups of gay, bisexual, and other MSM in Boston, Massachusetts and Jackson, Mississippi (N = 35) | Participants from Jackson had a palpable and emphatic degree of medical mistrust, and described a strong aversion to medical care in Black communities; they also expressed skepticism about the effectiveness of PrEP | [167] | |
Gender | Data from HIV-negative TGW aged 16–29 years enrolled in Project LifeSkills during 2012–2015 (N = 230), the majority of whom were of color (67%) | Having a medical provider who meets health needs was associated with higher PrEP acceptability scores | [164] |
Group discussions among cis and TGW of color at the “Empowering Women’s Health Summit” in 2018 (N = 279) | Distrust of medical providers was identified as a barrier to PrEP use | [179] | |
2017 cross-sectional survey of HIV-negative, PrEP-inexperienced and heterosexually active adult women (N = 501) | Black women expressed higher levels of medical mistrust than White women, which was also associated with lower comfort discussing PrEP | [190] | |
Focus groups and interviews with TGW in San Francisco (N = 30) | Transgender-specific barriers included medical mistrust due to transphobia | [89] | |
Race/ethnicity | a,b,c | ||
History of substance abuse | Interview of HIV-negative PWID in Boston and Providence (N = 33) | Negative experiences with healthcare providers was identified as a barrier to PrEP use | [84] |
Ageb | Cross-sectional data from an ongoing cohort study of young sexual-minority men in New York City (N = 492) | Participants with greater concerns around talking with their provider about their sexual behaviors were less likely to use PrEP | |
[191] | |||
Online surveys and focus groups of adolescents (N = 56), most of whom were cis male (95%) and identified as gay (79%) | A frequent barrier to PrEP use was homophobia in the form of disapproving healthcare providers | [74] | |
Survey of young MSM in California using geosocial networking apps (N = 687) | Greater medical mistrust was associated with lower willingness to take PrEP | [181] |
Lack of Access to Medical Care as a Barrier to PrEP Uptake
Financial Barriers to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Qualitative phone interviews with attendees at a sexual health clinic in New York City (N = 1208) | 58 of 1208 patients who initiated PrEP reported barriers stemming from insurance issues | [20] |
Patients with recently diagnosed HIV (N = 268, mainly MSM) | Cost/insurance concerns were reported as barriers in 36% of patients | [161] | |
Interviews with MSM at Rhode Island Department of Corrections (N = 26) | Most participants were interested in taking PrEP, but were concerned that access to health insurance may be necessary to help with the cost | [46] | |
A large survey of young MSM (N = 2297) | PrEP use was associated with having health insurance | [10] | |
Mixed-methods study of 14–18-year old MSM (N = 56) | Paying for PrEP was frequently cited as a barrier | [74] | |
Gender | Interviews with women attendees at an urban sexual health clinic (N = 14) | Lack of insurance coverage was a concern | [81] |
Race/ethnicity | Group discussions with cis and transgender women of color in South Florida (N = 279) | Insurance coverage and lack of economic independence were cited as barriers | [179] |
Age | a | ||
History of substance abuse | A survey of PWID in New Jersey (N = 138) | 33% reported lack of insurance as a barrier to PrEP use | [78] |
Geographic location | Strengths-based case management intervention in Florida (N = 30, mostly male, Hispanic, and Black) | Financial barriers to PrEP were encountered by 67% (20/30) of adults | [80] |
Marginalized populations | Behavioral intervention trial in female sex workers in the Mexico–US border region (N = 295) | 18.7% of individuals cited perceived financial barriers to PrEP | [192] |
Mixed methods study of young adults experiencing homelessness in Houston and Los Angeles (N = 45) | Cost was identified as a barrier to PrEP use | [165] |
Side Effects/Medication Interaction Concerns as a Barrier to PrEP Uptake
Demographic variable | Study design | Summary of data | References |
---|---|---|---|
Sexual orientation | Focus groups of MSM in New York City (N = 24) | Concerns were raised about side effects of PrEP, and this was particularly the case among Black participants | [175] |
Focus groups of gay, bisexual, and other MSM in Boston, Massachusetts and Jackson, Mississippi (N = 35) | Participants concerns about side effects and safety | [167] | |
Gender | Survey of Black and Latina TGW in Baltimore and Washington (N = 201) | The most commonly reported barrier to PrEP uptake was worries about drug interactions with hormone therapy | [91] |
Focus group of TGW in New York City (N = 18) | Participants raised the barriers of uncomfortable side effects, difficulty taking pills, and lack of research in TGW | [50] | |
Focus groups and interview of HIV-negative cis women visiting an STI clinic or emergency department in Chicago (N = 370), the majority of whom were Black (83%) | Most participants (81%) had concerns about taking PrEP, the most common being side effects (68%) and incomplete protection (25%) | [159] | |
Interview of women experiencing intimate partner violence (N = 26) | Participants raised fear of side effects and long-term health concerns as potential barriers to PrEP | [35] | |
Interview of women at an urban sexual health clinic (N = 14) | Participants raised concerns about PrEP safety as a key barrier | [81] | |
Interviews with TGW (N = 60) and TGM (N = 90) | About half were extremely or somewhat worried about the possibility of negative medical side effects of PrEP and 23% did not want to add another medication to their health regimen | [38] | |
History of substance abuse | Interview of HIV-negative PWID in Boston and Providence (N = 33) | Participants raised concerns about PrEP side effects | [84] |
Age | Survey of young MSM in California using geosocial networking apps (N = 687) | Concern about side effects was associated with reduced willingness to take PrEP | [181] |
Barriers to PrEP Persistence
Potential Solutions to Barriers
Identify individuals at risk |
Routinely assess sexual and injection drug use history for all patients in an open and nonjudgmental manner |
Identify behaviors that make a person an appropriate candidate for PrEP |
Complete baseline assessments in PrEP candidates |
HIV testing and medical history to exclude persons with acute or chronic HIV infection |
Kidney function testing |
Serologic testing for hepatitis B |
Serologic testing for hepatitis C |
Testing for other STIs |
Pregnancy testing (if applicable) |
Consider vaccination for hepatitis A and hepatitis B in unvaccinated individuals |
Patient counseling |
Counseling points should include |
The importance of adherence and its correlation to effectiveness |
That PrEP does not reduce the risk of other STIs |
Use condoms consistently to prevent other STIs |
The importance of regular screening of STIs and the need to test once patient notices signs and symptoms of STIs |
On-going follow-up and monitoring |
HIV testing every 3 months |
Regular screening for STIs |
Continue to assess HIV risk |
Other considerations |
Identifying persons at risk of HIV can be challenging because of stigma and discrimination against gay, bisexual, transgender, and nonbinary persons, or the lack of a trusting relationship between patient and clinician |
Recognize that adherence support is a key component of providing PrEP and includes establishing trust and open communication with patients, patient education, reminder systems for taking medication, and attention to medication adverse effects |
Recognize the barriers to PrEP implementation and uptake; these barriers and disparities need to be addressed to achieve the full benefit of PrEP |
Patients may discontinue PrEP for several reasons, including personal preference, decreased risk of HIV acquisition, or adverse medication effects |
Consult the CDC guidelines for a complete discussion of implementations considerations for PrEP [33] |