Table 1.

Summary of barriers to, and interventions to improve, PrEP implementation

Conceptual domain and intervention level	Barriers to PrEP implementation	Interventions matching specific barriers
Individual and Relationships Domains: Provider Level	Knowledge Lack of training in PrEP provision Disagreement/uncertainty about appropriate PrEP patients Concerns/uncertainty about insurance coverage for PrEP Attitudes and beliefs Biases against patients’ race and sexual behaviors Concerns about PrEP efficacy, toxicity, and resistance Concerns about patients’ disinhibition and risk compensation leading to lack of adherence/compliance	Knowledge Improved education of potential PrEP providers Development of trainings and interventions to assist providers in identifying appropriate PrEP candidates Attitudes and beliefs Development and delivery of trainings to increase provider “cultural competency,” including trans- and gender-affirming care Interventions to identify and disrupt provider-held stereotypes about potential PrEP users
Individual and Relationships Domains: Patient Level	Knowledge Low awareness of PrEP and low demand for PrEP Attitudes and beliefs Side effects; effectiveness; toxicities; interaction with feminizing hormones Managing multiple health concerns and PrEP side effects Prioritization of care for current conditions (e.g., pain or stress) above HIV prevention Prioritization of gender-affirming feminizing hormone therapy Distrust of medical system: structural racism, transphobia, and negative experiences Competing priorities during periods of substance use Diminished concern for prevention with intimate partners Concerns about HIV-reporting systems, including potential insurance implications of a positive HIV result Unwillingness to discuss PrEP with primary care providers	Knowledge Increased education and counseling to increase PrEP knowledge Attitudes and beliefs Development of supportive behavioral interventions (e.g., risk-reduction, medication-adherence, and retention counseling) Assistance in navigating the healthcare system, including accessing health insurance and co-pay assistance Referrals of patients with mental-health, substance-use, or “social” issues (e.g., housing insecurity) to social workers or community resources Side-effect monitoring
Community and Policy Domains: Healthcare-System Level	Communication and awareness Lack of effective messaging about PrEP Lack of communication between healthcare providers and community-based organizations Funding Limited health budgets to sustain PrEP programs Lack of insurance coverage and financial-assistance programs Capacity & access Lack of focus on “nonprescribing service providers” Purview paradox: neither HIV specialists nor PCPs consider PrEP implementation within their clinical domain Lack of training, referral systems, or established reimbursement levels for care and drugs Legal constraints to providing PrEP for youth, including mandates to involve parental figures in working with minors Lack of access to care: inadequate transportation; inflexible work schedules; inconvenient locations dispensing PrEP Time constraints on medical appointments Lack of medical insurance and limited insurance networks Lack of patient confidence and perseverance to access care Pharmaceutical barriers Particular constraints of Truvada™ as PrEP (e.g., daily dosing schedule, side effects) Population-specific barriers and stigma Lack of gender-affirming healthcare for transgender women Lack of trans-inclusive marketing of PrEP Low prioritization of PrEP for people who inject drugs Stigma associated with PrEP use and accessing HIV services The intersection of HIV-stigma with transphobia and homophobia	Communication and awareness Community-engagement and community-mobilization strategies Systems to improve interagency/interprofessional collaboration Funding General advocacy for expanded health insurance Funding for medication costs, adherence counseling/monitoring, and support services; referral to medication-assistance programs Capacity and access Expanded PrEP-delivery systems, staff, time, space, expertise Engagement of generalist PCPs in PrEP provision for scale-up (addressing the purview paradox) Expanded/diversified settings providing PrEP (e.g., private practices, mental-health clinics, ERs) and integration of PrEP into primary care Expanded education, screening, referrals to PrEP services Improved methods to identify appropriate PrEP candidates Specific guidelines from “normative bodies” (e.g., CDC, APA) Partnerships between medical and social-service providers Development of systems to monitor and evaluate PrEP use Cross-training of staff (e.g., educators, pharmacists, nurses) Improvements in pharmacists’ PrEP education Pharmaceutical barriers Advancing new PrEP technologies: innovative pharmacologic chemoprophylactic approaches (e.g., on-demand PrEP dosing, injectable, microbicides, rings, films) Pharmacokinetic studies of potential drug–drug interactions, particularly in oral PrEP medications and feminizing hormones Population-specific barriers and stigma Disaggregating transgender women from MSM in research and clinical practice and developing trans-inclusive research strategies Improving access to trans-competent PrEP providers Integrating PrEP care with contraceptive services Focusing resources on vulnerable communities Expanded “youth-friendly” health services, including augmented PrEP visit schedules, adherence clubs and social-support groups