Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama
Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.
KeywordsPre-exposure prophylaxis (PrEP) Access HIV prevention Continuum of care
This research was supported by the University of Alabama at Birmingham Center for AIDS Research, a National Institutes of Health (NIH) funded program (P30 AI027767) that was made possible by the following institutes: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIDDK, NIGMS, and OAR. K.B.C. and W.S.R. received support through an institutional training grant from the Agency for Healthcare Research and Quality (AHRQ T32HS013852). K.L.S. received support through institutional training grants from the National Institute of Drug Abuse (5T32DA037801 and R25DA037190). Investigator support (B.T.) for this study was also provided by the National Institute of Mental Health (R01MH104114). The contents of this publication are the sole responsibility of the authors and do not represent the official views of the NIH or AHRQ.
This study was funded by the University of Alabama at Birmingham Center for AIDS Research.
Compliance with Ethical Standards
Conflict of interest
Whitney S. Rice declares that she has no conflict of interest. Kristi L. Stringer declares that she has no conflict of interest. Maira Sohail declares that she has no conflict of interest. Kaylee B. Crockett declares that she has no conflict of interest. Ghislaine C. Atkins declares that she has no conflict of interest. Kachina Kudroff declares that she has no conflict of interest. D. Scott Batey declares that he has no conflict of interest. Joshua Hicks declares that he has no conflict of interest. Janet M. Turan declares that she has no conflict of interest. Michael J. Mugavero has served as a scientific advisor for Gilead Sciences, Inc. Bulent Turan declares that he has no conflict of interest.
The human subjects protocol for this study was approved by the Institutional Review Boards at the University of Alabama at Birmingham and at Emory University.
Informed consent was obtained from all individual participants included in the study.
- 1.U.S. Centers for Disease Control and Prevention. HIV in the Southern United States. 2016. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf. Accessed 30 June 2018.
- 3.U.S. Centers for Disease Control and Prevention. HIV among transgender people. 2018. https://www.cdc.gov/hiv/pdf/group/gender/transgender/cdc-hiv-transgender-factsheet.pdf. Accessed 30 June 2018.
- 8.Kramer MR, Black NC, Matthews SA, James SA. The legacy of slavery and contemporary declines in heart disease mortality in the U.S. South. SSM—Popul Health. 2017;3:609–17.Google Scholar
- 10.Roberts D. Killing the black body: race, reproduction, and the meaning of liberty. New York: Knopf Doubleday Publishing Group; 2014.Google Scholar
- 11.Gubrium AC, Mann ES, Borrero S, Dehlendorf C, Fields J, Geronimus AT, et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Washington, DC: American Public Health Association; 2016. p. 18–9.Google Scholar
- 12.U.S. Centers for Disease Control and Prevention. Pre-exposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. Atlanta, GA: U.S. Department of Health and Human Services, U.S. Public Health Service; 2014.Google Scholar
- 41.Mayer KH, Chan PA, Patel RR, Flash CA, Krakower DS. Evolving models and ongoing challenges for HIV preexposure prophylaxis implementation in the United States. J Acquir Immune Defic Syndr. 2018;77(2):119–27.Google Scholar
- 42.Buchbinder SP, Liu AY. CROI 2018: epidemic trends and advances in HIV prevention. Top. Antivir Med. 2018;26(1):1–16.Google Scholar
- 44.U.S. Centers for Disease Control and Prevention. PrEP. 2018. https://www.cdc.gov/hiv/basics/prep.html. Accessed 30 Apr 2018.
- 46.QSR International Pty Ltd. NVivo qualitative data analysis software. Victoria: QSR International Pty Ltd.; 2015.Google Scholar
- 48.Underhill K, Morrow KM, Colleran C, Holcomb R, Calabrese SK, Operario D, et al. A qualitative study of medical mistrust, perceived discrimination, and risk behavior disclosure to clinicians by U.S. Male sex workers and other men who have sex with men: implications for biomedical HIV prevention. J Urban Health. 2015;92(4):667–86.CrossRefGoogle Scholar
- 51.Radley DC, McCarthy D, Hayes SL, Commonwealth Fund. Aiming higher: results from the Commonwealth Fund scorecard on state health system performance, 2017 edition. New York: Commonwealth Fund; 2017. http://www.commonwealthfund.org/interactives/2017/mar/state-scorecard/assets/1933_Radley_aiming_higher_2017_state_scorecard_FINAL.pdf. Accessed 4 Jan 2019.
- 52.Goswami ND, Schmitz MM, Sanchez T, Dasgupta S, Sullivan P, Cooper H, et al. Understanding local spatial variation along the care continuum: the potential impact of transportation vulnerability on HIV linkage to care and viral suppression in high-poverty areas, Atlanta, Georgia. J Acquir Immune Defic Syndr. 2016;72(1):65–72.CrossRefGoogle Scholar
- 53.Fontenot K, Semega J, Kollar M. Income and poverty in the United States: 2017. Suitland: U.S. Census Bureau; 2017.Google Scholar
- 55.Fletcher FE, Fisher C, Buchberg MK, Floyd B, Hotton A, Ehioba A, et al. “Where did this [PrEP] Come From?” African American mother/daughter perceptions related to adolescent preexposure prophylaxis (PrEP) utilization and clinical trial participation. J Empir Res Hum Res Ethics (JERHRE). 2018;13(2):173–84.CrossRefGoogle Scholar
- 62.National Academies of Sciences E, Medicine. Ending discrimination against people with mental and substance use disorders: the evidence for stigma change. Washington, DC: The National Academies Press; 2016.Google Scholar
- 63.Batey DS, Whitfield S, Mulla M, Stringer KL, Durojaiye M, McCormick L, et al. Adaptation and implementation of an intervention to reduce HIV-related stigma among healthcare workers in the United States: piloting of the FRESH workshop. AIDS Patient Care STDS. 2016;30(11):519–27.CrossRefGoogle Scholar
- 65.Zhang HL, Rhea SK, Hurt CB, Mobley VL, Swygard H, Sena AC, et al. HIV preexposure prophylaxis implementation at local health departments: a statewide assessment of activities and barriers. J Acquir Defic Syndr. 2018;77(1):72–7.Google Scholar
- 74.Kaiser Family Foundation. Status of state action on the medicaid expansion decision. Medicaid and Health Reform. 2018. https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act. Accessed 07 Nov 2018.
- 75.Gilead. 2017 year in review. Annual reports. 2018. https://www.gilead.com/-/media/files/pdfs/yir-2017-pdfs/final%20year%20in%20review%20426.pdf. Accessed 06 Jan 2019.