Minimizing Structural Barriers and Stigma

Navigating insurance and payment options and clinic and lab visits remains one of the most prominent barriers to initiating and sustaining PrEP use. Learn more about barriers to PrEP use and strategies for mitigating those challenges.

Download the Minimizing Structural Barriers and Stigma Key Topic Review as a PDF

WHAT WE KNOW

from the literature

1. Overcoming logistical and financial barriers to PrEP is critical for expanding equitable access.

This paper describes key barriers to PrEP initiation and continuation at a community-based clinic, including: number of doctor visits required, long wait times, distance to clinic, insurance issues, and cost of medication.
- Hojilla, J., Vlahov, D., Crouch, PC. et al. HIV Pre-exposure Prophylaxis (PrEP) Uptake and Retention Among Men Who Have Sex with Men in a Community-Based Sexual Health Clinic. AIDS Behav 22, 1096–1099 (2018). https://doi.org/10.1007/s10461-017-2009-x.1
This paper presents evidence for structural and financial factors driving disparities in PrEP retention in a study with young, majority Black MSM in Mississippi.
- Arnold T, Brinkley-Rubinstein L, Chan PA, Perez-Brumer A, Bologna ES, Beauchamps L, et al. (2017) Social, structural, behavioral and clinical factors influencing retention in Pre-Exposure Prophylaxis (PrEP) care in Mississippi. PLoS ONE 12(2): e0172354. https://doi.org/10.1371/journal.pone.0172354
This paper describes the interaction between syndemic factors (e.g., intimate partner violence, substance use, poverty) and structural factors (e.g., poor access to social services, transport and childcare) as barriers to PrEP adoption for Black women. * Liesl A. Nydegger, Julia Dickson-Gomez & Thant Ko Ko (2021) Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: a qualitative exploration, Culture, Health & Sexuality, 23:5, 659 673, DOI: 10.1080/13691058.2020.1720297

2. Structural barriers can impede PrEP access and exacerbate clients’ alienation from the healthcare system.

This paper provides evidence that when given free, low threshold access to PrEP, patients are more likely to accept and maintain a PrEP prescription.
- Golub, S.A., Fikslin, R.A., Goldberg, M.H. et al. Predictors of PrEP Uptake Among Patients with Equivalent Access. AIDS Behav 23, 1917–1924 (2019). https://doi.org/10.1007/s10461-018-2376-y
This paper reviews the evidence that the way PrEP provision systems are organized make many women in the U.S. feel like biomedical HIV prevention is not “for them.”
- Goparaju, L., Praschan, N. C., Warren-Jeanpiere, L., Experton, L. S., Young, M. A., & Kassaye, S. (2017). Stigma, Partners, Providers and Costs: Potential Barriers to PrEP Uptake among US Women. Journal of AIDS & clinical research, 8(9), 730. https://doi.org/10.4172/2155-6113.1000730

3. Clinic-level protocols and policies can either exacerbate stigma or mitigate against it.

This paper reviews the ways in which HIV stigma manifests in health care settings and provides specific recommendation for reducing stigma at the environmental and policy levels.
- Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: what works?Journal of the international AIDS Society. 2009;12(1):1-7.
This paper explains how practice norms -- such as discussing or offering PrEP only in response to direct patient requests -- favor more privileged groups. Protocols and policies that allow for a high-level of provider discretion in PrEP prescription may limit access and exacerbate inequity.
- Calabrese, S. K., Tekeste, M., Mayer, K. H., Magnus, M., Krakower, D. S., Kershaw, T. S., . . . Hansen, N. B. (2019). Considering Stigma in the Provision of HIV Pre-Exposure Prophylaxis: Reflections from Current Prescribers. AIDS patient care and STDs, 33(2), 79-88.
This paper examines the ways in which complicated protocols for PrEP provision (e.g., requiring multiple follow-up visits prior to full PrEP prescription) can send the message to priority populations that their sexual health does not matter. Improving the ease of these systems makes patients feel that their sexual health actually matters to their providers.
- Cipollina, R., & Sanchez, D. T. (2019). Reducing health care disparities through improving trust: An identity safety cues intervention for stigmatized groups. Translational Issues in Psychological Science, 5(4), 315

This paper provides evidence that PrEP navigation systems that facilitate both financial and logistical aspects of PrEP access (e.g., medication assistance, visit co-pays, appointment scheduling and reminders) increase PrEP uptake and retention across a variety of different patient populations
- Doblecki-Lewis, S., Butts, S., Botero, V., Klose, K., Cardenas, G., & Feaster, D. (2019). A randomized study of passive versus active PrEP patient navigation for a heterogeneous population at risk for HIV in South Florida. Journal of the International Association of Providers of AIDS Care (JIAPAC), 18, 2325958219848848.

WHAT IT MEANS

for policies and programs

Stigma is perpetuated at the structural level within clinics.

PrEP protocols that are burdensome to clients can send the message that PrEP and sexual healthcare in general is “not for them,” since it is so hard to access.

Cultural competency trainings may impact individual biases of providers, but don’t necessarily address structural factors in clinical settings that can perpetuate stigma and disparities in access.

While it is of paramount importance that providers and staff are trained to examine their implicit biases and how these biases can impact their decision making, changing clinical protocols to reduce burden on patients can serve as a structural intervention to reduce stigma.

Patients who feel like their healthcare providers genuinely care about their sexual health and are invested in helping them access health care services are more likely to engage in care. Clinics can help foster this experience for patients by easing the logistical burden of PrEP initiation and retention and creating systems for direct communication when questions or concerns arise.

The introduction of more than one PrEP modality offers an opportunity to reimagine PrEP provision.

Health system and providers should capitalize on lessons learned from oral PrEP as they introduce new forms of PrEP, with particular attention to creating systems of care that minimize burden on clients.

BLUPrInt TOOLS

for this topic area

Resources and tools in these sections of the PrEP Program Builder are informed by and reflect the lessons in this key topic…

Key Topics Navigation:

Reaching Highest Priority Patients | Empowering Choice and Decision-Making | Supporting Adherence and Sustainment | Enhancing Patient-Provider Interactions | Minimizing Structural Barriers and Stigma | Monitoring & Evaluating Programs