Why So Many New HIV Infections in US, Despite PrEP Availability?

MedicalResearch.com Interview with:

Rogério M. Pinto, LCSW, Ph.D. Associate Professor Associate Dean for Research School of Social Work University of Michigan Ann Arbor, USA

Dr. Pinto

Rogério M. Pinto, LCSW, Ph.D.
Associate Professor
Associate Dean for Research
School of Social Work
University of Michigan
Ann Arbor, USA

MedicalResearch.com: What is the background for this study?

Response: This integrative review, published in the journal AIDS and Behavior, includes content from 47 peer-reviewed scholarly articles reporting multiple barriers to high-risk individuals trying to access pre-exposure prophylaxis (PrEP), the HIV drugs that reduce subsequent risk of infection. We found 31 potential solutions to 30 barriers at the patient, provider and health-system levels. In synthesizing this research from a multi-level perspective, based upon a socioecological model, our report contributes much-needed analysis to the rapidly expanding field of PrEP implementation research.

At this stage in the scale-up of U.S. PrEP programs, it is important to systematically and comprehensively analyze and integrate knowledge about the successes of and the barriers to PrEP implementation. Our review provides a comprehensive analysis and informs the direction of PrEP implementation across a variety of settings.

MedicalResearch.com: What are the main findings?

Response: In the 47 articles that we examined, we found key barriers to PrEP implementation and we found proposed interventions to address them. These barriers and interventions were present on patient, provider and health-system levels. We identified cognitive barriers and interventionsinvolving patient and provider knowledge, attitudes, and beliefs about PrEP. For example, low awareness of PrEP and low demand for PrEP among patients can be helped by increasing PrEP education and counseling.

We also identified the “purview paradox” as a key barrier – HIV specialists often do not see HIV-negative patients, while primary care physicians, who often see uninfected patients, are not trained to provide PrEP. Moreover, healthcare systems barriers included lack of communication about, funding for, and access to PrEP. Population-specific barriers—including structural obstacles like homophobia, transphobia and racism—may be addressed by interventions that disrupt stereotypes about PrEP users and provide assistance to patients in navigating the health care system. 

MedicalResearch.com: What should readers take away from your report?

Response: Nearly four decades into the HIV pandemic, thousands of people are infected with HIV each year in the United States. Pre-exposure prophylaxis (PrEP), a drug available in the United States can reduce the subsequent risk of infection, when taken consistently. Therefore, it is recommended that individuals at risk – for example, uninfected individuals in relationships with HIV-infected persons–be tested for HIV and seek medical counseling on the whether or not to take PrEP. However, we should be aware that multiple barriers may stop high-risk individuals from accessing PrEP, and these barriers must be addressed. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: This review identifies solutions that will help patients overcome barriers that make it harder for historically underserved populations to access PrEP. Research to develop and test interventions that address the needs of underserved populations, such as transgender women, men who have sex with men, and people of color, are most needed. Interventions to lessen providers’ biases and to fix breakdowns in the health system are important, but these often target the behavior of individual patients instead of targeting providers and health systems. In order to improve access to PrEP, researchers must test the effects of multiple interventions, mapped to specific barriers, on patient, provider and health-system levels. 

MedicalResearch.com: Is there anything else you would like to add?

Response: The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups must be acknowledged and resolved, but few interventions identified in our review actually address these barriers. Attending to these issues in research and in practice will not only help improve PrEP implementation but will also decrease HIV transmission. This social justice matter needs attention from the scientific community, and also from stakeholders and policy makers who are poised to address structural barriers.


Rogério M. Pinto et al. Improving PrEP Implementation Through Multilevel Interventions: A Synthesis of the Literature, AIDS and Behavior (2018). DOI: 10.1007/s10461-018-2184-4


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