Expanding the Test-to-PrEP Strategy: Including People With HIV in Social Network–Based HIV Testing and PrEP Outreach, Miami, Florida, and San Juan, Puerto Rico, June 2024 to February 2025

Abstract

This study assesses expansion of the “Test-to-PrEP” (T2P) social network strategy to include people with HIV (PWH) as distributors of HIV self-test kits (HIVST) and PrEP/HIV treatment resources, in Miami and a newly introduced site in San Juan. PWH showed strong interest despite perceived barriers such as stigma. Stakeholders found the strategy acceptable and compatible. Findings highlight the potential of PWH-led T2P implementation to advance HIV prevention and treatment, underscoring the need to support scale-up and address barriers. (Am J Public Health. 2026;116(S1):S32–S35. https://doi.org/10.2105/AJPH.2025.308320)

In this study, we assessed expansion of the Test-to-PrEP (T2P) social network strategy to include people with HIV (PWH) as distributors of HIV self-test kits and resources for accessing preexposure prophylaxis (PrEP) or HIV treatment in Miami, Florida, and a newly introduced site in San Juan, Puerto Rico. PWH showed strong interest despite perceived barriers such as stigma. Stakeholders found the strategy acceptable and compatible. Findings highlight the potential of PWH-led T2P implementation to advance HIV prevention and treatment, underscoring the need to support scale-up and address barriers.

T2P is a peer-delivered strategy involving distribution of HIV self-test kits (HIVST) and information regarding PrEP and HIV treatment through social networks of people with lived experience.^1–3

INTERVENTION AND IMPLEMENTATION

The T2P kit contains an OraQuick In-Home oral fluid HIVST (OraSure Technologies Inc, Bethlehem, PA) and bilingual materials with instructions, guidance for positive results, and information on accessing PrEP and postexposure prophylaxis. Using a templated discussion instrument, participants are counseled by trained staff on use of HIVST and included materials. Whereas initial evaluation of the T2P strategy involved PrEP users in Miami as distributors, the current study evaluates inclusion of PWH as distributors and San Juan as a second site.

Mixed-methods data collection evaluated implementation from client, staff, and resource perspectives. Structured qualitative interviews with clinic stakeholders and brief surveys of PWH at two HIV-focused clinics were conducted in Spanish or English on the basis of participant preference. The study was guided by the Consolidated Framework for Implementation Research 2.0,⁴ which identifies key implementation determinants, and social network theory, emphasizing peer influence. Qualitative interview data were transcribed and analyzed using rapid qualitative analysis, shown to be comparable to traditional approaches while allowing faster integration of time-sensitive findings.^5,6 PWH participants were assessed on their willingness, knowledge, and perceived barriers related to distributing HIVST and resources for accessing PrEP and HIV services, whereas stakeholder interviews assessed compatibility and appropriateness across sites.

PLACE, TIME, AND PERSONS

The study took place in Miami and San Juan from June 2024 to February 2025 at two HIV-focused clinics serving primarily Hispanic/Latino clients. Individuals were offered participation at the end of their initial or follow-up HIV care visit. The study population consisted of 57 PWH, with a median age of 40 years (interquartile range = 34.5–53.5; range = 21–85). Participants had been diagnosed with HIV for an average of 15.6 years (SD = 10.1). The majority identified as Hispanic/Latino (77.2%). Most participants identified as White (36.8%) or Black/African American (26.3%) and male (73.7%).

Both Miami‒Dade County and San Juan are priority jurisdictions under the Ending the HIV Epidemic (EHE) initiative, which emphasizes data-driven strategies to allocate resources efficiently and expand access to prevention services for populations at high risk for HIV. Miami‒Dade has an HIV incidence rate of 35.9 per 100 000 people, whereas San Juan has an incidence rate of 31.0 per 100 000—both among the nation’s highest.⁷ These locations are part of EHE’s 50 priority areas, which account for more than 50% of new HIV diagnoses in the United States.⁸

PURPOSE

This intervention aimed to increase HIV testing and prevention by leveraging social networks of PWH, which may include additional individuals who can benefit from HIVST and PrEP information. The success of T2P among PrEP clients led us to consider expansion to PWH, aligning with the EHE goals of improving early diagnosis, prevention, and treatment engagement among priority populations. The expansion of T2P to PWH sought to overcome barriers such as stigma, limited access to health care, and awareness of PrEP and HIV treatment. Unlike previous studies of HIVST distribution to sexual partners of PWH, we addressed potential distribution to social networks more generally.⁹ In addition, our work assessed unique needs of PWH to tailor the strategy. Understanding that determinants of participation, such as stigma, concerns about disclosure and privacy, and social network structure, may differ between PWH and PrEP clients, we sought to establish whether the T2P strategy was acceptable among PWH. In addition, implementation at a new study site in San Juan assessed the generalizability of the strategy. This information is critical to future scale-up.

EVALUATION AND ADVERSE EFFECTS

PWH demonstrated high interest in the strategy. Of PWH participants (n = 57), 47 (82.5%) expressed interest in distributing HIVST kits to their social networks, and 10 declined interest and did not proceed with the remainder of the survey. Interest was similar across sites and between those with longstanding and more recent diagnosis. Of those who expressed interest (n = 47), 38 (80.9%) were already familiar with PrEP, and 42 (89.4%) indicated that they knew a good candidate for HIVST; 20 (47.6%) knew three or more candidates. Participants were encouraged to consider anyone in their social network who may benefit from HIVST. Most identified friends or family members, whereas a smaller proportion named sexual or long-term partners. In addition, 40 (95.2%) said at least one of their contacts would be a good PrEP candidate. When asked why their contacts might be good candidates for HIVST or PrEP, participants commonly cited awareness of those individuals’ engagement in high-risk sexual behaviors or noted that they were sexually active and would value reassurance.

Participants felt “very comfortable” (40.4%) and “comfortable” (29.8%) discussing HIVST and “very comfortable” (46.8%) and “comfortable” (31.9%) discussing PrEP. Participants felt “very capable” (51.1%) and “capable” (34.0%) explaining HIVST and “very capable” (46.8%) and “capable” (44.7%) explaining PrEP. However, 55.3% desired additional training. Although 23 (48.9%) noted no barriers to HIVST distribution, 24 (51.1%) perceived potential barriers including fear of disclosure (62.5%), unwillingness to discuss HIVST (45.8%), and discomfort discussing others’ HIV risk (37.5%). No barriers to distribution of PrEP information were reported by 31 (66.0%), whereas 16 (34.0%) described potential barriers to distribution including fear of disclosure (62.5%), unwillingness of recipient to discuss PrEP (50.0%), and discomfort discussing others’ HIV risk (25.0%).

Clinic staff in Miami and San Juan (n = 4) viewed the intervention as acceptable and compatible with clinic workflow but recognized stigma and insufficient knowledge as potential barriers. No significant adverse effects were reported. Overall, there were strong cultural similarities across sites. However, staff in Puerto Rico noted generational differences in sex education and HIV-related knowledge, which could influence intervention engagement; one stakeholder stated, “The millennial generation, that received all the knowledge when they were in their high school education … are really open to this discussion.”

Across sites, stigma and fear of disclosure were identified as barriers. One Miami staff member cited challenges regarding “stigma, specifically in the Hispanic community,” and a client from Puerto Rico noted, “Stigmatization, it’s going to be a main issue here in Puerto Rico, it’s gotten better … but it’s still really present.” The potential for peer support was noted as a strong positive aspect. As one PWH in Miami stated, “It’s the connection that people have with each other … where one patient says … ‘this worked amazing for me, it could do the same for you.’” A Miami staff member also highlighted the influence of local attitudes, noting that some Latino/Hispanic patients “believe in the power of God to help them in their time of need or through their sickness,” indicating how religious beliefs may impact attitudes toward health and wellness.

Staff across sites agreed that the intervention aligns with existing workflows. One Miami staff member explained, “I think we already have a flow that can take care of it.” However, Miami staff emphasized the need for private space to handle sensitive conversations, requiring, “a little bit more space for patients that do have a couple questions … to have someone answer them on the side.” Across sites, staff stressed the need for additional training to feel confident; one said, “I think the barrier for me would be trying to have enough knowledge to reiterate … what are the proper steps for [the patient].”

SUSTAINABILITY

The T2P strategy demonstrates strong potential for sustainability and adoption. Staff and clients in both San Juan and Miami expressed enthusiasm regarding use of social networks to distribute HIVST kits and PrEP resources. It is important to note that survey participation was voluntary, and, therefore, the sample may overrepresent individuals more engaged in care or interested in HIV prevention. Findings underscore that addressing stigma, delivering culturally tailored education, dedicating resources including adequate space, and ensuring training for staff and peers will be essential for sustainability. PWH expressed interest in further education on PrEP and HIVST, and clinic staff highlighted the need for training to better support and educate peer distributors. This study also considered the local needs and cultural perspectives of a primarily Hispanic/Latino population, a group disproportionately burdened by new HIV infections.⁷ Given the intervention’s alignment with EHE goals and existing infrastructure, and provided that logistical needs such as training and private space are addressed, this approach holds promise for successful and sustained implementation in both jurisdictions.

PUBLIC HEALTH SIGNIFICANCE

This strategy expands access to HIV testing and prevention through trusted social networks of PWH already in care. Leveraging existing social connections and the lived experience of PWH in combination with the accessibility and privacy of HIVST allows extension of evidence-based interventions (HIV testing, treatment, and PrEP) to individuals who otherwise may not seek these services. Locally, we demonstrate applicability of this approach for Miami and San Juan, areas with high HIV prevalence. Through alignment with the EHE initiative, the T2P strategy may have potential for impact in other jurisdictions with similar challenges. Understanding and addressing potential barriers to distribution can improve targeted implementation strategies and promote sustainable adoption and scale-up.