Provider level bias and prejudice regarding patients’ race and sexual behaviors is a significant barrier to pre-exposure prophylaxis (PrEP) implementation. The finding comes from a literature review published in AIDS and Behavior by University of Michigan (U-M) researchers during the period of January 2007 to June 2017, intended to identify PrEP barriers. 

The final review included 47 peer-reviewed articles that fell under 1 of the following categories: primary data on cognitive variables of providers; data on cognitive variables and perspectives of individuals at risk for HIV infection; literature on PrEP implementation; and case studies of PrEP demonstration and implementation projects. 

On the provider level, the ‘purview paradox’ was noted in many papers; this is the idea that the providers who are best trained and most willing to prescribe PrEP often don’t see HIV-negative patients (Silapaswan A, et al, 2017). Infectious disease specialists rarely see HIV-negative patients whereas primary care physicians may not always be trained to provide PrEP when meeting at-risk patients. Additionally, prejudiced beliefs – judgments concerning risk behaviors based on race – were found to be substantial barriers to implementation (Calabrese SK, et al, 2014); other obstacles included transphobia, homophobia, gender disparities, and racism. 

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For the patient level, many studies cited perceived concerns about toxicities as a barrier to receiving treatment. Other medical conditions and gender-affirming hormone therapy is generally given a higher priority vs high impact prevention (HIP) for HIV. More education and counseling was cited in many studies as a solution to these barriers. 

Effective communication between healthcare providers and community-based organizations was deemed as lacking (Raifman JR, 2017). The most cited system level barrier was a lack of funding, including limited health budgets and an absence of health insurance. Many articles also identified stigma as a barrier for women and black and Latino men, but few proposed actions that would address this. 

In their conclusion, the authors argue for multilevel interventionsthat “do not target providers, patients, or systems inisolation, but rather incorporate each of these levels into new models of implementation.” They acknowledge the difficulty in changing healthcare systems but by recognizing these difficulties and providing concrete solutions, they believe systems can be improved. 

“The key message from this review is that barriers to PrEP implementation cut across patient, provider and health-system levels, and that multiple interventions, mapped onto specific barriers, ought to be used,” said Rogério Pinto, associate professor and associate dean for research at U-M.

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