Overcoming Barriers in the Use of HIV PrEP


Although PrEP is highly effective, few appropriate patients with HIV currently use it.

The CDC has recommended pre-exposure prophylaxis (PrEP) for patients at high-risk of HIV infection since Truvada’s approval in 2012. Although PrEP is highly effective, few appropriate patients currently use PrEP. Cost, awareness, adverse effect concerns, stigma, lack of provider access, and poor patient—provider communication are barriers to wider PrEP usage.

A team of researchers from the City University of New York found fewer than 1 in 10 suitable PrEP candidates are currently taking PrEP, in a new article published in Journal of Acquired Immune Deficiency Syndrome.

The study proposes a 5-level model called the Motivational PrEP Cascade: awareness, willingness, access, ability to obtain, and maintaining adherence. The Transtheoretical Model of Change was the inspiration for this model.

The researchers reviewed data from the “One Thousand Strong” longitudinal study of HIV-negative gay and bisexual men across the United States. The study excluded former PrEP users, participants lost to follow-up, and those infected with HIV in the study’s first 12 months.

Two of 3 participants met modified criteria to initiate PrEP, but only 9.1% were using PrEP at follow-up. Encouragingly, almost all PrEP users (80%) took at least 4 doses per week and 72% visited their providers quarterly.

Some patients were willing to use PrEP, but lacked intention. Lack of intention is a significant barrier to uptake and points to an area where counseling can make a difference. Helping patients identify and verbalize short- and long-term benefits and drawbacks of behavior change (in this case, PrEP uptake) seems to increase behavioral intentions and changes, including HIV medication adherence.

Some patients who had access to a PrEP provider had not discussed the topic with their providers. In fact, half of eligible participants were still in the first (“pre-contemplation” or unwilling) phase of the motivational cascade.

The data showed no racial, ethnic, or geographic trends. Previous studies found that black men who have sex with men may face greater barriers to PrEP access, and Hispanic men who have sex with men are less aware of PrEP’s availability. These trends may be locally pronounced or too subtle to find on a representative (largely white population) nationwide level.

The researchers concluded that appropriate PrEP candidates are often unwilling to use PrEP, lack intent, or have never discussed PrEP with their providers. Providers should screen and use motivational interviewing skills to encourage PrEP use among high-risk patients. Public health measures should target both providers and patients to increase PrEP use.


Parsons JT, Rendina HJ, Lassiter JM, Whitfield TH, Starks TJ, Grov C. Uptake of HIV pre-exposure prophylaxis (PrEP) in a national cohort of gay and bisexual men in the United States. J Acquir Immune Defic Syndr. 2017;74(3):285-292.

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