Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature

Our review revealed a lack of effective messaging about PrEP and communication between healthcare providers and community-based organizations [52]. Proposed solutions in this domain included community engagement and mobilization strategies [62] as well as systems to improve interagency and interprofessional collaboration.

Lack of funding is the most consistently cited system-level barrier, including limited health budgets to sustain PrEP programs and lack of insurance coverage [9, 46, 47, 54, 56]. The latter has been framed as both a systems-level barrier to access and care, with studies showing that patients without access to insurance are less likely to successfully obtain PrEP [54]; and as a provider-level barrier, with insurance barriers affecting providers’ attitudes and behaviors about prescribing PrEP [9]. The cost of PrEP is covered by many health insurance plans [70]. Gilead Advancing Access^® program, a commercial medication assistance program, provides free PrEP to eligible HIV-negative adults in the US with limited income and no insurance covering PrEP [71]. However, individuals enrolled in government programs (e.g., Medicare Part D, Medicaid, TRICARE, or VA) are not eligible for this program. Adolescents under 18-years-old and young people covered by their parents’ insurance, and who may wish to seek PrEP independently to avoid disclosure through their parents’ Explanation of Benefits, are also excluded from this program [65, 66, 72]. Private insurers’ policies concerning medications, including PrEP, are insurance-specific and thus outside the scope of this review. However, it is important to mention that insurers have enacted policies that may exacerbate existing barriers to PrEP implementation, such as prior authorization paperwork requirements, and strict requirements regarding completion of test results prior to authorizations and prescription renewals. In addition to suggesting help for patients in navigating healthcare systems to access insurance and co-pay assistance programs, articles proposed general advocacy for expanded health insurance [46], coverage of medication costs, PrEP adherence counseling, and support services [56].

Barriers included a lack of focus on non-prescribing providers [10]; the purview paradox; lack of referral systems, and lack of training on, for example, when to initiate PrEP; legal constraints to providing PrEP for youth [65]; lack of access to care caused by inadequate transportation, inflexible work schedules, time constraints during medical appointments [56], and inconvenience of locations dispensing PrEP; and lack of medical insurance. Solutions to these barriers included expanded space, time, and expertise for PrEP-delivery systems [67]; engagement of generalist PCPs in PrEP provision (to address the purview paradox); diversification of settings providing PrEP (e.g., mental-health clinics and criminal-justice settings) [46]; integration of PrEP into primary care; education, screening, and referrals to PrEP; improved methods to identify appropriate PrEP candidates [56]; stronger guidelines and policies for providers [34]; partnerships between medical and social-service providers; cross-training of staffers (e.g., social workers, educators, pharmacists, and nurses); leadership support of increased staff time to address financial barriers [12]; and improving pharmacists’ PrEP education [45].

We identified barriers specific to Truvada™ and its oral daily dosing schedule and potential side effects. Proposed solutions included advancing new PrEP technologies, such as pursuing innovative pharmacologic chemoprophylactic approaches (e.g., on-demand PrEP dosing, injectables, microbicides, rings, and films), and pharmacokinetic studies of potential drug–drug interactions, particularly involving those with feminizing hormones [11, 62].

Several papers focused on transgender women [49, 53, 62], Black and Latina women [48], Black and Latino MSM [51], adolescents [65, 66], men who engage in street-based sex work [46], heterosexual couples [69], and people who inject drugs [43, 63]. These papers point to stigma associated with PrEP use and the intersection of HIV-stigma with transphobia and homophobia [48, 49]. Despite the number of articles that identify stigma as a barrier to PrEP, few interventions were proposed that would directly address the effects of stigma.

Barriers specific to transgender women included non-inclusive marketing of PrEP; perceived interactions with feminizing hormones and prioritization of hormone care; managing multiple medical appointments and medications; mistrust arising from transphobia in the medical system; and life instabilities and substance use. Proposed gender-affirming healthcare initiatives included prioritizing hormones and gender-affirming medical care, exclusively using patients’ preferred names and pronouns, and creating safe spaces for trans clients [62]. Studies also proposed pharmacokinetic studies of potential drug–drug interactions between oral PrEP medications and gender-affirming hormones in transgender women [11, 62]. Sevelius et al. [49] argue that current deficits in the provision of gender-affirming care for transgender women are connected to the conflation of transgender women with MSM, which serves to conceal transgender women’s unique social and behavioral vulnerabilities.

Like transgender women, cisgender Black women and Latinas face particular barriers to engaging with messages often designed for MSM [48]. PrEP implementation among women may be helped by addressing the burden of frequent medical visits; the stigma associated with accessing HIV services; and the burden of pill-taking, including concerns about adding to an existing pill burden. Increasing the availability of PrEP in settings where women receive services may also improve PrEP uptake, for example by integrating PrEP care with provision of contraceptives and screening for sexually transmitted infections [48].

Barriers for Black and Latino men include decreased access to private health insurance and more access through public clinics, as well as frequently endorsed stigma-related concerns about PrEP [47, 51]. Healthcare is a problematic area for MSM of color, who are more likely than other men to view talking about their sex lives to their doctors as a barrier to PrEP [51]. Moreover, research included in this review indicates that medical providers in training exhibit prejudicial assessments of Black patients based on stereotypes about risk compensation (e.g., increased condomless sex associated with PrEP use) [38]. While this study was limited to current medical students, exploratory research surveying medical providers (primarily HIV specialists) suggests that providers’ likelihood to prescribe PrEP varies widely across patient groups, making the potential consequences of prejudicial assessments particularly troubling [73]. These barriers underscore the limitations and potentially severe consequences of considering seemingly individual-level interventions (such as provider knowledge or individual behavior) in isolation from larger systemic factors, such as structural racism.