Abstract
Methodological limitations in PrEP implementation studies may explain why PrEP implementation is lagging. This methodological review provides a description and critique of the methods used to identify barriers to PrEP implementation in the United States (2007–18). For each selected article, we provide: (1) research questions; (2) measures; (3) design; (4) sample (size and type); and (5) theoretical orientation. Among 79 articles which identified knowledge, attitudes, and behavioral and social/structural barriers to PrEP implementation, 51 (65%) were quantitative; 25 (32%) qualitative; and 3 (4%) were mixed-methods; overall, just one-half described a conceptual approach. About two-thirds of articles were conducted with patients and one-third with healthcare providers. Our review reveals a paucity of longitudinal, mixed-methods, and ethnographic/observational research and guiding theoretical frameworks; thus, the applicability of results are limited. We recommend that interventions aimed at PrEP implementation address barriers situated at multiple ecological domains, and thus improve PrEP access, uptake, and adherence.
Highlights
At the end of 2015, the United States Centers for Disease Control and Prevention (CDC) estimated that 1,122,900 persons in the United States (US) were living with HIV; of these, 38,500 new infections occurred in 2015 alone [1]
We describe how methods to study pre-exposure prophylaxis (PrEP) implementation have evolved over time, and we make recommendations about how to build on these methods to better capture PrEP implementation barriers and corresponding solutions as we move forward
We selected articles published between January 2007 and December 2018, a time period that included the development of the HIV continuum of care and high-impact prevention approach, the surge of evidence of PrEP effectiveness from large-scale clinical trials [2, 13, 14], the subsequent Food and Drug Administration (FDA) approval of PrEP for service settings [15], and, more recently, the confirmation that daily PrEP use is safe [16, 17]
Summary
At the end of 2015, the United States Centers for Disease Control and Prevention (CDC) estimated that 1,122,900 persons in the United States (US) were living with HIV; of these, 38,500 new infections occurred in 2015 alone [1]. In a comprehensive review of the literature, our team identified 30 barriers to PrEP implementation—steps patients and health providers must take in order to navigate healthcare systems and to ascertain access, delivery, and adherence to PrEP [7]. As from our original review, the steps patients and providers must take to follow policies governing access to PrEP and to navigate healthcare systems are referred to as “PrEP implementation.”. We identified barriers across four ecological domains individual (patient), relationship (patient-service provider), community, and policy [9]. Among cognitive barriers, those affecting patients and providers included lack of knowledge about, and negative attitudes toward PrEP. Healthcare-level barriers included lack of communication about, funding for, and
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