An Implementation Science Study of a Community-Based PrEP Navigation Intervention for Men in South Florida

Abstract

Preexposure prophylaxis (PrEP) is effective for HIV prevention, yet PrEP-eligible men face structural, social, and cultural barriers to access. In this implementation science study, we evaluated a community-tailored PrEP navigation program to identify modifiable factors influencing adoption and implementation. Using staff interviews and participatory Photovoice with clients, we uncovered multilevel barriers to and facilitators of PrEP uptake. Findings were shared with a community-based organization to inform program improvements. This study highlights the value of participatory, implementation-focused approaches to equitable HIV prevention. (Am J Public Health. 2026;116(S1):S28–S31. https://doi.org/10.2105/AJPH.2025.308344)

The implementation science project described here is designed to understand modifiable factors that influence the adoption and implementation of a community-tailored preexposure prophylaxis (PrEP) navigation program for men.

INTERVENTION AND IMPLEMENTATION

The program includes five expert recommendations for implementing change (ERIC) strategies, as follows.¹

1. Increase demand: The program is offered after screening for HIV and other sexually transmitted infections.

2. Promote adaptability: A personalized navigation program is included that involves client-centered counseling reflective of cultural norms, explanations of PrEP’s efficacy and proper use, sexually transmitted infection screening, assistance with insurance/patient assistance programs, and on-site PrEP, all available in one visit.

3. Alter client fees: Once individuals are enrolled, there is no charge for the initial office visit, any follow-ups, or lab work.

4. Intervene with clients to enhance uptake and adherence: Staff offer PrEP adherence coaching for the first week and then twice monthly for the next three months through telehealth. Clients have an in-person follow-up appointment at three months; if no issues are observed, an advanced nurse practitioner subsequently refills the patient’s prescription as needed.

5. Tailor strategies: The personalized navigation program extends to the delivery of PrEP by offering discreet packaging for mail delivery and client pickup at four community-based sites.

These strategies were selected to modify barriers and enhance facilitators across multiple domains of the Consolidated Framework for Implementation Research (CFIR).² Composed of five domains and subconstructs, the CFIR is a guiding practical framework designed for the identification and assessment of barriers to and facilitators of program success.

PLACE, TIME, AND PERSONS

The program was developed by a community-based organization (CBO) in response to South Florida’s persistently high HIV rates and PrEP needs.³ To evaluate the program, we conducted a study in South Florida from June 2021 to August 2022. We studied multilevel CFIR² factors at two levels: staff (n = 17) and clients (n = 24).⁴ Eligibility criteria required clients and staff to be aged 18 years or older, speak English or Spanish, have access to a smartphone for Photovoice participation, and have an internet-capable device for online meetings; in addition, clients were required to meet PrEP clinical guidelines.⁵ Clients received incentives of $35 for the first session and $40 for the second session.

PURPOSE

Through interviews and an adapted Photovoice approach, we identified CFIR modifiable factors that explained and enhanced the implementation of the program. Photovoice is a technique that uses photos and narratives and provides a safe space for participants to share stories, fears, concerns, and hopes for accessing and using PrEP.⁶

EVALUATION AND ADVERSE EFFECTS

The staff component included qualitative evaluations to identify CFIR modifiable factors that explained and enhanced the implementation of the program. Interviews (45–60 minutes in duration) were conducted in English or Spanish in a private room and were audio-recorded and transcribed. A semistructured interview guide facilitated staff members’ discussions of their experiences with each of the ERIC components and explored challenges and facilitators when implementing each component’s ERIC strategy. We asked staff members about (1) how each strategy was implemented, (2) how implementation functions and workflows supported (or did not support) each strategy, (3) challenges and barriers in implementing each strategy, (4) facilitators to implementing each strategy, and (5) how clients reacted to each strategy.⁷

Two research analysts independently analyzed all interview transcripts. First, they determined which of the five ERIC strategies were discussed and assigned the appropriate operational code. Second, they identified which of the five CFIR domains—“intervention characteristic” (e.g., key attributes of the intervention), “inner setting” (e.g., resources and norms), “outer setting” (e.g., cultural values), “characteristics of individuals” (e.g., organizational staff), or “process” (e.g., implementation strategies)—was reflected in the data; after identifying the domain, they determined which CFIR code within that identified domain was reflected in the data segment.² Third, they ranked the coded text from −2 to +2 to reflect the direction of influence (e.g., positive or negative) on program implementation (as described by Damschroder and Lowery⁴). Finally, they compared their worksheets and discussed discrepancies. Each analyst extracted representative quotes that confirmed or negated the alignment between ERIC strategies and CFIR constructs.

The client qualitative component identified modifiable factors influencing success or failure in program implementation by clientele group (Latino men, non-Latino men). An implementation science expert conducted a train-the-trainer session with CBO representatives who then facilitated the Photovoice group sessions.⁶ Training included guidance on selecting and contextualizing the photos to generate themes related to the CFIR factors (e.g., outer setting, inner setting, characteristics of individuals, and environmental and structural features that reflect barriers to and facilitators of intervention uptake). Participants from each group met via Zoom. Participants were trained in the first two-hour session on consent and taking photos; they then took photos with their cell phones in their communities and returned within one week for a second two-hour session to discuss and caption the photos.

Photovoice discussions were guided by the SHOWeD method (See, Happen, Our lives, Why, empowerment, Do), which allowed participants to reflect deeply on their images.⁶ The SHOWeD method uses imagery to elicit what a person sees (S), what is happening (H), how it relates to the person’s life (O), why it exists (W), what about the image is empowering (e), and what can be done about it (D).

In the second session, trainers facilitated discussions with their respective groups to select by consensus up to five photos perceived as the most representative CFIR factors reflective of their community. Participants captioned the photos with sentences that told the story. After that, participants codified themes to synthesize CFIR factors operating for each clientele group. Triangulation approaches were used to explore the extent to which the themes and issues identified by the groups for the selected photos compared across sites and coders’ ratings and to align Photovoice findings with results from the staff component. No adverse effects or unintended consequences were reported.

Results were drawn directly from qualitative assessments incorporating participant and staff perspectives. Photovoice sessions with participants revealed five key themes influencing PrEP access and uptake: (1) the need for normalizing PrEP messaging within and outside the sexual minority community, (2) the need for expanding PrEP knowledge, (3) different motivations for using PrEP, (4) the impact of structural obstacles (e.g., public transportation), and (5) perceptions of stigma related to PrEP use.⁸ Participants emphasized that access to reliable PrEP information was critical, yet misinformation, stigma, and lack of culturally tailored messaging often hindered engagement. Both Latino and non-Latino men reported that public messaging on PrEP needs to be more comprehensive, accessible in multiple languages and present in varied community spaces rather than solely targeting sexual minority men.

Staff perspectives further reinforced these results, identifying specific structural obstacles to PrEP implementation, including financial constraints, health care navigation challenges, and federal policy that limits the amount of funding that can be used for necessary laboratory testing.⁹ Staff also highlighted the importance of nonmedical personnel in facilitating trust and access to PrEP, as many clients felt more comfortable engaging with navigators who shared their cultural background. Furthermore, staff reported that clinics that do not have automated systems for appointment reminders and pharmacy coordination hinder clients’ ability to maintain adherence.

Results indicated that health care providers often lacked adequate training in culturally competent PrEP discussions, contributing to clients’ reluctance to engage with medical professionals about their PrEP options. Participants and staff both identified a need for more community-driven approaches to PrEP education, including peer-led discussions and social media campaigns tailored to younger populations. As a means of addressing these challenges, results were disseminated back to the CBO for incorporation into its outreach strategies.

SUSTAINABILITY

Our findings support the sustainability of the program examined by highlighting points of refinement and areas that should be maintained. For example, the CBO has updated its system to integrate client reminders, addressing concerns raised by staff. Partnerships between academia and local CBOs focused on sexual health ensured ongoing support and resource availability. The intervention was integrated with existing services such as PrEP navigation and education, allowing these services to continue beyond the initial study period. In addition, the adaptability of the program allowed it to evolve in response to participant feedback. The success of this program suggests its scalability to other high-incidence regions with similar demographic and structural obstacles to PrEP uptake.

PUBLIC HEALTH SIGNIFICANCE

This study demonstrates the potential of evaluating community-tailored, community-driven programs using implementation science and participatory methods. The findings contribute to public health by informing best practices for integrating PrEP education and navigation into community settings, ultimately supporting national HIV prevention goals. However, because it was cross-sectional, our study does not provide insight into differences in barriers and facilitators over time. As HIV prevention continues to evolve, this program provides an adaptable framework that can be leveraged to address health needs in other populations at risk for HIV. The emphasis on participant and staff perspectives ensures that barriers to uptake are addressed from multiple angles, strengthening the program’s ability to have a long-lasting impact in reducing HIV transmission in high-incidence communities.