Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

Abstract

Antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV transmission was first approved by the US Food and Drug Administration in 2012. Despite correlations of decreases in new HIV infections being greatest where PrEP has been deployed, the uptake of PrEP is lagging, particularly among populations with disproportionate HIV burden. This narrative review seeks to identify individual and systemic barriers to PrEP usage in the USA. A comprehensive search of recent literature uncovered a complex array of structural, social, clinical, and behavioral barriers, including knowledge/awareness of PrEP, perception of HIV risk, stigma from healthcare providers or family/partners/friends, distrust of healthcare providers/systems, access to PrEP, costs of PrEP, and concerns around PrEP side effects/medication interactions. Importantly, these barriers may have different effects on specific populations at risk. The full potential of PrEP for HIV prevention will not be realized until these issues are addressed. Strategies to achieve this goal should include educational interventions, innovative approaches to delivery of HIV care, financial support, and destigmatization of PrEP and PrEP users. Until then, PrEP uptake will continue to be suboptimal, particularly among those who need it most.

PrEP discontinuation among Latino/a and Black MSM and transgender women: A need for PrEP support services

“…At present, many existing PrEP navigation services support individuals in initiating PrEP (e.g., providing information on accessing medication assistance programs, answering questions about using PrEP, disseminating information on where to access PrEP, accompanying individuals to initial PrEP medical visit). This service should be expanded to include PrEP retention efforts after initiation, as some of the barriers or challenges to starting PrEP are the same for remaining on PrEP (e.g., lack or lapse of insurance, cost, side effects) [40][41][42][43]. Case management, which has been shown to be effective in managing HIV care, is another option to support PrEP users [44][45][46].…”

Knowledge needs for implementing HIV pre-exposure prophylaxis among primary care providers in a safety-net health system

“…For example, in an analysis of 2017 prescription data, the lowest PrEP-to-need ratio was seen in US South residents, and less than 10% of the estimated 1.2 million eligible individuals received PrEP ( Siegler et al, 2018 ). Several barriers to PrEP implementation have been identified among PCPs including stigma, lack of knowledge, and inadequate skills to prescribe PrEP ( Mayer et al, 2020 , Pleuhs et al, 2020 ). Nevertheless, limited evidence is available about potential barriers to PrEP implementation among PCPs in safety-net health systems, which may be particularly important in geographic regions where HIV incidence has increased ( CDC, 2019c , Singh et al, 2018 ).…”

Factors Associated With Willingness to Use Oral Pre-exposure Prophylaxis (Prep) Among Fishing Communities in Peri-urban Kampala, Uganda

“…There was a stepwise relationship between educational attainment and willingness to use PrEP: secondary-level was associated with 72% increase in willingness while the tertiary level was associated with 97% increase in willingness. This is likely because those who were more educated had greater access to information and a better understanding of HIV risks, rendering them less prone to misconceptions from peers [24,25].…”