Table 1.

Provider and Clinic Level Barriers and Facilitators to PrEP Initiation.

Level	Barriers	Illustrative quotes
Provider	Other care priorities	* “[S]ome of our more high risk populations often just have what feels like a more pressing issue. If your IV drug users are actively withdrawing or they’re actively high or they’re emotionally unstable—which we sometimes see with our transgender populations as well—you feel like you need to address this emergent thing sitting in front of you and then the idea of PrEP gets pushed to the background because it's not something that's urgent.” * “[W]hen that patient got to me, in addition to initiating the PrEP, his blood pressure was out of control and, we need to focus on your blood pressure. We need to do all these labs to make sure that it's safe for us to even initiate the PrEP and all this, that, and the other, so in addition to just initiating PrEP, I felt like I took over the role of his PCP [primary care provider]. They already treated him for the syphilis and so I’m requesting records from the PCP to try to get up-to-date, try to find out what medical problems do you have? What all are you on?” * “From what I see, it doesn’t matter how many reminders you have if the physician or nurse practitioner, whoever, doesn’t think it's important, they’re not gonna do anything about it. They’re gonna ignore it. If it's not something they’re comfortable with, they’re not gonna do it.” * “If someone's in with just their blood pressure, actually asking them about their sexual practices and who they’re having sex with and whether or not they’re protected and whether or not they’re at risk is not somethin’ that I necessarily think to do.”
	Concerns • Side effects of PrEP • Patient adherence • Financial barriers	* “It's not without side effects…. —it's just not water or whatever and so I do still have a barrier in my own mind.” * “I think getting patients to take any medication sometimes is a challenge, either through they forget or perceived side effects and so sometimes that can be a real challenge. I personally have a handful of patients that forget to take their blood pressure medication and then end up in the hospital” * “I had one young man, he was on his parents’ insurance…. He was concerned about them [his parents] knowing and so he refused and did not return for follow-up” * “I had a patient that had bipolar disorder and some high-risk sexual behavior and polysubstance abuse and so definitely needed it [PrEP]. I really had a hard time getting his insurance to cover it.… I had to make a lot of phone calls and stuff just to get it covered and it was difficult enough that the patient ended up stopped taking it….”
	Biases in assessing who is at risk	* “[I]t's like a personal blind spot in the sense that I don’t see that risk the same way [in cisgender women] that I see other populations. I’m not having that conversation because I’m much more concerned about unplanned pregnancy or other issues that I know to be an issue with that, with that specific population.
	Lack of knowledge about how to talk to patients about sexual practices and risk	* “Transgender, I don’t know—I haven’t—that one feels harder ‘cause of the stigma… I think it's also just more awkward to step into their sexual history as well for some other reason for me.”
Clinic	Heavy provider workload	* “I just don’t see it happening in any scale as an add-on to what we’re already doing in those visits because we have so much to do now, especially with all the quality measures at an FQHC. For us in particular, we have so many things we have to get accomplished and check off and do in a visit. With 15 min slots, it's just not doable.”
	Short appointment times	* “I think that just like with anything, drug use or any stigmatized societal issue, I think that stigma plays a big role in a patient's not talking about some of these things. I think someone mentioned having the 15 min appointment slot is problematic because you can’t dig into some of these things I guess in that time period.”
Clinic	Paperwork for financial assistance	* “I had a patient that had bipolar disorder and some high-risk sexual behavior and polysubstance abuse and so definitely needed it [PrEP]. I really had a hard time getting his insurance to cover it. He was on a Medicare—I forget which one—but they gave me a lot of pushback. I had to make a lot of phone calls and stuff just to get it covered.”
Provider	Provider confidence of client risk	* “I think with certain patient populations of it being just big time offering that and just being able to convince them really from my heart, like, 'No. You need to do this.' Where there's [a] couple discordant or MSM, I really feel passionate about that….”
Clinic	Support staff able to provide assistance with PrEP	* “All of our social work case management staff are trained to help with patient assistance with our providers that identify patients who need PrEP, so that's somethin’ we have in the arsenal, is to be able to assist the providers and the patient obtaining the medication for those who are under or uninsured.”
	Provider use of tele-health & mail-in labs	* “[I] have a telemedicine job that I do PrEP in other parts of the country. We tend to have a lot of good follow-up because you don’t have to go in. It's all mailed to you. You mail it in, so we have a lot of compliance.”
	Comprehensive patient education materials about PrEP	* “I think having a large stack of PrEP handouts would be really helpful. I would probably just get it off the CDC or somethin’ website and give it to ‘em if I was—need to give the handout in the clinic, but we don’t have a standardized thing in that that I know of.”