Expanding Knowledge about HIV Pre-Exposure Prophylaxis (PrEP) Implementation: A Methodological Review to Inform Social Work Research and Practice

Background and Purpose: HIV pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention intervention. A comprehensive review of the PrEP implementation literature (2010-2018) identified 30 barriers to PrEP implementation at multiple social-ecological levels, many of which disproportionately affect people living in poverty and racial, ethnic, and sexual minority persons (Pinto et al., 2018). However, the translation of these findings into ‘real world’ improvements in PrEP prescriptions and access have been limited by the methods used to study access barriers. This review details the methods used to identify barriers to PrEP implementation, highlights limitations, and makes methodological recommendations for future social work research and practice, particularly with clients who can benefit from but are not accessing PrEP.

Methods: Grounded in Whittemore et al.’s (2005) model for integrative reviews and Munn et al.’s (2018) typology for systematic reviews in the medical and health sciences, the current methodological review used a theoretically-driven set of inclusion and exclusion criteria. Based on a comprehensive search of published articles, we summarized chronologically: (1) key elements of research questions; (2) measures; (3) research design; (4) sample (size and type); and (5) theoretical orientation for each of 64 papers included.

Results: 42 articles (66%) were quantitative, 19 (30%) qualitative, and three (4%) mixed-methods. Research questions focused on: (1) patient and provider preferred modes of PrEP delivery, (2) patient engagement with PrEP, including experiences of discontinuation, (3) patient and provider knowledge about and/or attitudes toward recommending and/or prescribing PrEP, (4) behavioral and psychosocial factors influencing PrEP engagement, and (5) structural disparities (e.g., race) in PrEP access. Only five studies focused on racial and ethnic minority populations; all focused explicitly on the African American community. The majority of quantitative studies were cross-sectional (n=31/42, 73.8%); qualitative studies included  semi-structured interviews (n=8/19, 42.1%) or focus groups alone (n=9/19, 47.4%). The majority of quantitative (n=31/42, 73.8%), qualitative (n=11/19, 57.9%) and mixed-methods studies (n=2/3, 66.7%) did not explicitly identify theoretical orientations. 

Conclusions and Implications: The PrEP implementation literature shows limited longitudinal and mixed-methods studies, which may best highlight social work practice and health policy solutions for PrEP implementation over time. Additionally, the populations in the US who are most disproportionately affected by HIV (Latino and African American men and trans women) are under-represented in this literature. The majority of studies lacked explicit theoretical frameworks, and the applicability of results is limited. Addressing these concerns may better equip social work researchers and policy makers to improve practices aimed at reducing barriers to PrEP implementation. These practices need to address multiple social-ecological needs, particularly those inhibiting access for under-serviced groups (e.g., stigmatization of racial and/or ethnic minority people).