Knowledge, interest, and anticipated barriers of pre-exposure prophylaxis uptake and adherence among gay, bisexual, and men who have sex with men who are incarcerated

Abstract

Criminal justice (CJ) settings disproportionately include populations at high risk for acquiring HIV, and CJ-involved individuals are often at the intersection of multiple overlapping risk factors. However, few studies have examined attitudes about pre-exposure prophylaxis (PrEP) among incarcerated men who have sex with men (MSM). This study explored interest in, knowledge of, and barriers to PrEP uptake among gay, bisexual, and other men who have sex with men at the Rhode Island Department of Corrections. Using semi-structured interviews, 26 MSM were interviewed about PrEP knowledge, interest, timing preferences for provision (e.g. before or after release), and barriers to uptake and adherence during community re-entry. Interviews were coded and analyzed using a general inductive approach. Participants demonstrated low initial knowledge of PrEP but high interest after being told more about it. Participants self-identified risk factors for HIV acquisition, including condomless sex and substance use. In addition, participants preferred provision of PrEP prior to release. Post-release barriers to PrEP uptake and adherence included 1) concerns about costs of PrEP medications; 2) anticipated partner or family disapproval; 3) lack of access to transportation; 4) unstable housing; 5) compounding impacts of multiple hardships leading to a de-prioritization of PrEP and 6) fears of future re-incarceration. These results point to the need for future PrEP interventions among incarcerated populations that address incarceration and PrEP related barriers during community re-entry via wraparound services that address PrEP and incarceration-related barriers.

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

“…Social factors related to poverty that limit women's access to antiretroviral therapy [44] may also impact PrEP prioritization: a 2017 review noted that ''unemployment, unstable housing, and food insecurity may render accessing PrEP and taking PrEP as unimportant if women are unable to fulfill their basic needs for food and shelter'' [45]. Another setting in which accessing PrEP may be deprioritized is for MSM who are released from incarceration: one study participant stated, ''When you go home you have so much to do… you have to go back to welfare to get food stamps… so much different stuff… you're not really going to be thinking about 'I've got to go to the doctor's [office] right away to get my PrEP''' [46]. Competing priorities have also been identified as major barriers to healthcare in general among homeless adults, for whom meeting basic needs for food, shelter, and safety outweigh healthcare needs [47].…”

“…At the individual level, there are simple logistical constraints to accessing PrEP, exacerbated by socioeconomic inequalities. For example, individuals may experience difficulty in getting to the clinic [74] due to lack of transportation [46] or time constraints [75,76]. A 2016 National Survey on HIV in the Black community found that 38% of 787 participants were more than one hour's drive from a PrEP provider.…”

“…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)…”

Barriers to linking high-risk jail detainees to HIV pre-exposure prophylaxis

“…People who are incarcerated have a prevalence of HIV that is 2.4 times that of the general population [1] and postrelease is known to be a time of increased engagement in high-risk HIV behaviors (e.g. return to drug use and condomless sex) [2,3,4,5,6]. For example, one study found that previously incarcerated men had a higher frequency of condomless sex and sex while under the influence of drugs or alcohol relative to men who had never been incarcerated [7].…”

“…Despite its potential benefit, linkage to and use of PrEP among people who are CJ-involved has been limited and there have been numerous barriers to implementation. For example, knowledge about PrEP among those who are incarcerated remains low [6,15]. Other PrEP related barriers, including medication costs, stigma associated with PrEP, competing needs upon community reentry, concern for side effects and low perceived HIV risk, have also been documented [6; 16-18].…”