“There's No Superhighway to PrEP: Illuminating the Roles and Challenges Facing CBOs in the Biomedical HIV Prevention Era

Background and Purpose
Pre-Exposure Prophylaxis (PrEP) presents unprecedented opportunities for stemming the HIV epidemic in the U.S. However, current racial/ethnic disparities in the PrEP Continuum of Care point to significant implementation problems and gaps in the diffusion and uptake of this novel intervention. Community-based organizations (CBOs) that offer HIV prevention services are uniquely positioned to help the most vulnerable populations (e.g., African Americans, Latinos, and men who have sex with men) access PrEP. However, PrEP expands the institutional logics of HIV prevention, presenting unique challenges and opportunities for CBOs. Institutional logics are the socially constructed organizing principles that guide service delivery in an organizational field. For HIV/AIDS focused CBOs, institutional logics encompass debates over how prevention has been perceived over time and the appropriateness of various intervention strategies. The primary purpose of this study was to explore how CBOs are modifying their organizational infrastructures to accommodate expanding prevention logics. The specific aims were to: 1) describe the expansion of institutional logics that has resulted from the emergence of PrEP, 2) examine how CBOs respond to expanding institutional logics to integrate PrEP into their existing service portfolio, and 3) explore how various organizational attributes (e.g., size, structure, and identity) influence CBO responses to expanding institutional logics and to differing ACA implementation strategies within their respective regions.

Methods
This study employed formative qualitative research that included in-depth interviews with over 50 key stakeholders (e.g. local public health administrators and prevention program directors/ frontline staff from CBOs) in four cities heavily impacted by HIV/AIDS and with differing Affordable Care Act (ACA) implementation strategies: Atlanta, Baltimore, Memphis, and New Orleans. Thematic analysis was conducted to identify common insights and experiences.

Results
The field of HIV prevention and the CBOs operating within it have historically been guided by “behavioral logics”, which focus on reducing “high-risk” sexual behaviors and increasing HIV status awareness among vulnerable populations. “Biomedical logics” emerged as the notion of Treatment as Prevention (TasP) gained empirical support, offering that viral suppression among people living with HIV significantly reduces the likelihood of transmission to HIV-negative partners. PrEP expands biomedical prevention logics by prioritizing the engagement of “high-risk”, HIV-negative individuals into primary medical care, while also extending previously unavailable wrap-around services such as housing and transportation to these individuals. CBOs have adjusted to these expanding logics by 1) diversifying their funding streams, 2) hiring “PrEP navigators”, 3) broadening their relationships with primary care providers, and/or 4) transitioning to Federally Qualified Health Centers.

Conclusions and Implications
Although CBOs are adapting their organizational infrastructures to broaden access to PrEP for vulnerable populations, substantial challenges remain with regards to increasing uptake. These challenges include a general lack of interest in PrEP among priority populations and limited ability to address more pressing social determinants of health. Specifically, the social safety net that provides temporary housing and other basic needs to vulnerable citizens has not been designed or funded to support those who are at highest risk for acquiring HIV, particularly those individuals who have been labeled as “able-bodied”.