Barriers, Facilitators, and Action Ideas for PrEP Adoption and Sustainment Among Young Men Who Have Sex with Men and Young Transgender and Nonbinary Individuals in Colorado

Background: Young gay, bisexual, and other men who have sex with men (YMSM) and transgender and nonbinary individuals (YTNB) are disproportionately affected by HIV. Although PrEP is an effective prevention tool, barriers to use adoption and sustainment exist. This academic-community partnership between the University of Denver and Colorado Health Network (CHN) used group model building to answer the following research questions: 1) What feedback processes influence the adoption and sustained use of PrEP by YMSM and YTNB individuals in Colorado? 2) How can we intervene in the system to increase sustained PrEP use?

Methods: Participants were recruited through emails to current and former PrEP users identified through CHN medical records, direct emails to PrEP navigators, prescribers, and program administrators, emails to HIV prevention service provider listservs, and social media posts. First, semi-structured interviews were conducted with 12 YMSM and YTNB PrEP users (ages 18-29) and PrEP navigators, providers, and program administrators to elicit the primary factors associated with PrEP adoption and sustainment. Interview results were used to develop a preliminary causal loop diagram (i.e., seed structure) for use in group model building (GMB) sessions. A total of 28 participants (14 PrEP users and 14 service providers) participated across 4 GMB sessions. During sessions, participants created causal loop diagrams describing the connection between factors associated with PrEP adoption and sustainment and generated action ideas for improving PrEP adoption and uptake based on co-created diagrams. Diagrams were refined by the study modeling team and analysis identified themes within diagrams and action ideas.

Results: Consumers and providers identified pathways of institutional, personally mediated, and internalized stigma and oppression among PrEP users and PrEP prescribers that are associated with PrEP adoption and sustainment. Transgender consumers reported unique experiences of gender-based oppression that prevented them from fully accessing PrEP services. Greater consumer and provider engagement with queer communities was associated with lower levels of stigma and increased access to PrEP through word of mouth and formal outreach, while living in a less populated area of the state was associated with lower levels of engagement in queer communities and greater stigma. Other identified barriers to adoption and sustainment were misconceptions about side effects of PrEP, affordability, lack of knowledge about where to access PrEP, and job/health insurance changes. Action ideas stemming from these findings included provider training on PrEP as well as culturally responsive engagement with sexual and gender minority patients, anti-stigma campaigns targeting primary care physicians, access to PrEP through pharmacists’ prescriptions, expansion of mobile PrEP services units across the state, a centralized resource directory, certification for providers regarding PrEP and sexual and gender minority care, and decreasing cost and insurance complexities.

Conclusions and Implications: Stigma and oppression play a primary role in the system of factors that influence PrEP adoption and sustainment for YMSM and YTNB across Colorado. Social workers can partner with allied health professionals and program administrators involved in prescribing PrEP to decrease provider stigma and bias, as well as to increase access to PrEP resources for current and future consumers.