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. Pre-exposure prophylaxis (PrEP) is a way of preventing HIV. By taking a daily pill, which contains two medicines, HIV can be stopped before it causes an infection. PrEP is prescribed for people at risk of HIV infection. However, many people who are at risk do not use PrEP. We explored the reasons for this. We found that many individuals at risk had not heard of PrEP, so would be unable to ask their doctors for it. Even among healthcare providers themselves, some were not aware of PrEP or how it should be used. For individuals who have heard of PrEP, unfortunately a stigma remains around HIV that deters some people from seeking the treatment. Furthermore, many individuals at risk have experienced bias at the hands of healthcare providers, deepening distrust of the medical establishment. Many individuals at risk also experience poverty and although there are multiple financial assistance options for PrEP, these can be difficult to access without support. Public education and training of healthcare providers may address many of the barriers we found, but deep-rooted issues such as racism and bias will require significant changes within the healthcare system.