Equity and Access in HIV Prevention: Addressing Global Disparities in PrEP Use Among Men Who Have Sex With Men Population

Abstract

Despite proven efficacy in preventing HIV, the global uptake of pre-exposure prophylaxis (PrEP) remains limited and uneven, particularly among men who have sex with men (MSM). A meta-analysis by Zhao et al. reveals that only 20% of PrEP-eligible MSM have ever used the medication, with stark disparities across regions and income levels. While uptake has increased over time, significant barriers persist, especially in low- and middle-income countries (LMICs). These barriers include financial constraints, limited health care infrastructure, provider knowledge gaps, and pervasive stigma, which together impede equitable access to PrEP. In regions such as sub-Saharan Africa, Asia, and Latin America, MSM face challenges related to health care access, while younger MSM and marginalized groups, including transgender individuals, are particularly underserved. This viewpoint calls for global strategies that address these inequities through targeted, evidence-based interventions that focus on reducing systemic barriers and incorporating intersectional approaches. To scale up PrEP access and ensure equitable HIV prevention, multilevel strategies are necessary, involving policy changes, provider training, community-led initiatives, and youth-centered outreach. Addressing the financial, structural, and social determinants of health is essential for bridging these gaps and ensuring that PrEP fulfills its potential as a global tool for HIV prevention.

Keywords

pre-exposure prophylaxis (PrEP)HIV prevention men who have sex with men (MSM)global disparities low- and middle-income countries (LMICs)equity and access

Introduction

The meta-analysis by Zhao et al. (2025), which synthesized data from 50 studies involving 96,151 participants, underscores a critical gap in global HIV prevention: only about 20% of PrEP-eligible men who have sex with men (MSM) have ever used HIV pre-exposure prophylaxis (PrEP). While uptake has increased over time, it remains uneven across different regions and national income levels. MSM in low- and middle-income countries (LMICs), including China, report particularly low uptake, despite expanding awareness campaigns and policy initiatives. It is important to note that China is considered an LMIC in this analysis.

Moreover, other LMICs in sub-Saharan Africa, Asia, and Latin America face substantial barriers to PrEP access, contributing to slow uptake and uneven coverage (Admassu et al., 2024; Batista et al., 2024; Perez-Urbano et al., 2024; Vega-Ramírez et al., 2022; Were et al., 2021). In sub-Saharan Africa, Admassu et al. identify barriers to PrEP use and adherence among adolescent girls and young women, reflecting structural, funding, and health-system constraints that impede sustained PrEP use (Admassu et al., 2024). In Latin America, Vega-Ramírez et al. show limited PrEP awareness and provider knowledge among physicians in Brazil and Mexico, while PrEP uptake remains uneven across the region (Vega-Ramírez et al., 2022) implementation model demonstrates that rollout remains slow in LMIC health systems due to regulatory, logistics, and supply-chain challenges despite policy endorsement (Were et al., 2021). Research in the Brazilian Amazon by Batista et al. (2024) highlights provider information gaps and the need to decentralize PrEP services, with social media playing a vital role in shaping awareness and demand Batista et al., 2024). Community insights from Tshwane, South Africa, further reveal uptake gaps among transgender people and MSM driven by community-level barriers and health care access issues (Perez-Urbano et al., 2024). Collectively, these studies corroborate regionally diverse yet overlapping barriers to PrEP access in LMICs (Admassu et al., 2024; Batista et al., 2024; Perez-Urbano et al., 2024; Vega-Ramírez et al., 2022; Were et al., 2021). These disparities suggest that PrEP implementation is fragmented, with structural, financial, and systemic barriers hindering equitable access to HIV prevention. This viewpoint emphasizes the need for global strategies that address these inequities, focusing on targeted, evidence-based approaches to ensure effective HIV prevention among MSM worldwide, particularly in resource-constrained settings.

PrEP’s Promise Versus Implementation

The efficacy of PrEP is well established: when taken as prescribed, it can reduce HIV incidence among MSM by up to 97% (Molina et al., 2017). Both on-demand and daily regimens have been shown to be effective in controlled trials. However, global uptake is considerably lower than what would be expected given its proven benefits. Recent pooled estimates suggest that approximately 16.04% of eligible MSM currently use PrEP (Huang et al., 2023). While uptake has grown in recent years, persistent gaps point to challenges in translating clinical effectiveness into widespread public health impact. Barriers such as geographic location, health system structure, and socioeconomic conditions remain key determinants of access and uptake.

Real-world uptake and persistence of PrEP among MSM show significant variability and often fall short of potential, despite strong evidence of efficacy (Wang et al., 2022). This gap persists because systematic reviews highlight that uptake and adherence are shaped by a complex range of individual, interpersonal, and health-system factors, alongside broader social determinants (Wang et al., 2022). For example, studies from West Africa identify socio-behavioral factors like stigma and trauma that adversely affect PrEP use (Eubanks et al., 2022), while experiences in Cameroon and Benin reveal ongoing challenges in scaling PrEP, indicating a need for sustained, targeted support (Diabaté et al., 2023; Ndenkeh et al., 2022). Conversely, Slovenia’s well-resourced healthcare system demonstrates how systemic qualities like coverage can improve outcomes (Ambrožič et al., 2024).

To address these disparities, initiatives such as community-centered mobile PrEP programs in the U.S. target geographic and racial disparities among Black and Latino MSM (Butts et al., 2023). Furthermore, decentralized care models are emerging as viable strategies to enhance engagement for those facing stigma in conventional clinics (Charest et al., 2021). Critically, regional studies show marked differences in modality preferences among MSM in countries like Brazil, Mexico, and Peru, emphasizing the need to offer preferred options (Cameron et al., 2024; Torres et al., 2023). This principle also applies in India, where local preferences significantly shape PrEP adoption (Cameron et al., 2024). Additionally, evidence of risk compensation highlights the need for integrated prevention messaging and STI screening alongside PrEP programs (Dyer, 2022; Manguro et al., 2022).

Therefore, to bridge promise and practice, programs should diversify delivery modalities and adapt to local preferences. Specifically, evidence supports offering various PrEP options, such as daily oral, on-demand, and long-acting injectable PrEP, to enhance uptake and persistence (Cameron et al., 2024; Torres et al., 2023). However, successful implementation of these flexible options requires attention to supply chain management and provider education (Brink et al., 2022; Doyle et al., 2023). Here, investment in long-acting injectable PrEP is critical for addressing adherence challenges, particularly for individuals who struggle with daily regimens (Rogers et al., 2023; Pilgrim et al., 2022). Concurrently, digital health strategies, including mobile PrEP programs, have shown promise in improving access among underserved populations (Butts et al., 2023; Charest et al., 2021). Ultimately, successful scale-up depends on aligning implementation with local health-system capabilities and equity concerns, ensuring reliable supply chains and targeted outreach to marginalized MSM communities (Ambrožič et al., 2024; Brink et al., 2022; Butts et al., 2023; Diabaté et al., 2023; Ndenkeh et al., 2022).

Financial Barriers

Affordability remains a critical factor influencing PrEP uptake. In high-income countries like the United States, France, and Brazil, the availability of government subsidies, health insurance coverage, and the integration of PrEP into sexual health services has facilitated broader access. However, there are significant differences in how each country’s financial and health care systems impact PrEP access. In the United States, PrEP is often covered under insurance plans, but access can be limited by high out-of-pocket costs for those without adequate insurance or in regions with fewer health care resources (Billioti de Gage et al., 2022). In France, the national health system subsidizes PrEP and integrates it into sexual health services, allowing for more equitable access across diverse populations (Luz et al., 2018). Brazil’s public health system also provides free PrEP to those at high risk, but challenges remain in ensuring distribution to underserved regions, especially in rural areas . By contrast, in many LMICs, PrEP access depends largely on donor-funded pilot programs or self-financed purchases, which limit its reach to at-risk populations. This stark contrast highlights how financial barriers, though surmountable, are deeply intertwined with national health system structures and policies.

Health Care System Factors

Health care systems significantly shape PrEP uptake. Evidence shows that provider training, clinical guidelines, and service delivery structures either facilitate or hinder access to PrEP. In high-income countries, the integration of PrEP into established health care frameworks often leads to improved uptake, but challenges such as inconsistent prescribing practices and gaps in provider knowledge persist (Coukan et al., 2023). In the United States, disparities in health care access due to regional differences, insurance coverage, and provider education can hinder PrEP initiation, particularly in underserved communities (Eubanks et al., 2022). France has made strides by creating clear clinical guidelines for PrEP and training providers on its use, but stigma within health care settings can still affect engagement (Azzi et al., 2024). In Brazil, health care providers face challenges related to training and awareness, especially in remote areas, despite the country’s robust public health system. In LMICs, PrEP access is often constrained by limited health care infrastructure, inadequate provider training, and restrictive eligibility criteria, which can exclude individuals who would benefit most from PrEP (Haines et al., 2021). These disparities illustrate how health care system factors, compounded by broader systemic inequities, shape whether PrEP services are accessible and acceptable to MSM in different global contexts.

Figure 1.

How Health Systems Shape PrEP Access for MSM population.

Stigma and Social Context

Stigma is a consistent barrier identified across studies. Negative perceptions of PrEP sometimes framed as promoting promiscuity can discourage individuals from seeking prescriptions and may affect disclosure of sexual identity in health care encounters. Younger MSM, in particular, may experience overlapping stigma related to age, sexuality, and gender expression, further limiting engagement with PrEP services (Azzi et al., 2024; Miller et al., 2022). Addressing stigma, both within health care and in society more broadly, remains essential to improving uptake and adherence.

Stigma surrounding PrEP among MSM is multidimensional, internal, anticipated, and experienced—and embedded in broader social contexts, consistently undermining PrEP uptake, adherence, and persistence across various settings (Babel et al., 2021; Farley et al., 2024; Nagai et al., 2023; Ort & Bardy, 2024; Zhang & Liu, 2022). Healthcare discrimination and intersecting stigmas based on race and sexual orientation significantly shape access to PrEP information and services; for instance, Black MSM report experiencing discrimination, and disclosure of same-sex behavior to healthcare providers can improve awareness, although stigma remains a barrier in countries such as Ghana and Senegal (Babel et al., 2021; Nagai et al., 2023; Rosen et al., 2023). Social networks can perpetuate PrEP stigma (e.g., associating PrEP with promiscuity) while also facilitating information diffusion and peer support that promote uptake, as observed in contexts like the Philippines and Brazil (Restar et al., 2022; Santos et al., 2022). Interventions that encompass societal campaigns, community-based approaches, and patient-centered delivery models, such as telehealth and mobile PrEP initiatives, have shown potential in mitigating stigma and enhancing PrEP uptake and persistence (Adeagbo, 2024; Assaf et al., 2021; Chamberlin et al., 2023; Nagai et al., 2023; Wang et al., 2022).

The Youth Gap

Zhao et al. (2025) also highlight lower PrEP use among younger MSM, a population disproportionately affected by new HIV infections. Factors such as limited youth-friendly services, underdeveloped digital health platforms, and prevention messaging that does not resonate with younger demographics may contribute to this gap. Tailored strategies that prioritize accessibility, confidentiality, and relevance to young people’s experiences may be needed to address this disparity.

The Youth Gap in PrEP use refers to the persistent underutilization of HIV PrEP among young men who have sex with men (YMSM), despite their willingness and awareness of its benefits. Research consistently reveals a significant mismatch between the willingness to use PrEP and actual uptake, particularly due to barriers such as stigma, financial constraints, and lack of youth-friendly services (Buffel et al., 2021; Liu et al., 2024). Factors such as risk perception, social discrimination, and confidentiality concerns also contribute to the gap, creating a complex interplay of individual and structural barriers to PrEP access for this demographic (Bhatta et al., 2022; Dijk et al., 2021).

The gap is evident across different regions, including Europe, the United States, Asia, and Africa. For example, in China, a study found that although many MSM were willing to use PrEP, uptake remained low due to multi-dimensional barriers (Guan et al., 2023). Similarly, in South Africa, structural and social stigma hindered daily PrEP uptake among MSM (Perez-Urbano et al., 2024). However, regional studies also highlight the potential for addressing these challenges through tailored interventions, such as youth-friendly PrEP services, stigma reduction, and digital health strategies (Charest et al., 2021; Hamilton et al., 2021).

Promising strategies for closing the Youth Gap involve decentralizing PrEP delivery into primary care and community settings, enhancing knowledge through educational programs, and expanding dosing options like long-acting PrEP to address adherence issues (Balasubramanian et al., 2022; Wu et al., 2024). Additionally, peer-led programs and provider education to reduce stigma are critical for increasing acceptance among youth (Pulerwitz et al., 2024; Sevelius et al., 2021). Longitudinal research to track awareness, willingness, and uptake, alongside investments in infrastructure for youth-friendly clinics, is essential for furthering PrEP adoption (Liu et al., 2024; Newman et al., 2023).

Intersectional Approaches to Strengthen PrEP Access and Adherence

Equity-focused HIV prevention requires population-specific, evidence-informed strategies that address the unique needs of groups such as adolescent girls and young women (AGYW), Black women, sex workers, transgender women, and MSM, while also incorporating intersectionality and stigma reduction (Latka et al., 2023; Rousseau et al., 2024). For AGYW, prioritizing PrEP delivery alongside reproductive health services and long-acting products is essential, with an emphasis on youth-friendly and peer-led outreach (Rousseau et al., 2024). Black women benefit from prevention programs addressing social determinants and health care barriers, while sex workers require community-led services that expand access to PrEP and ART (Obioma et al., 2024; Witte et al., 2022). Transgender women need gender-affirming care integrated with HIV prevention, and MSM can benefit from differentiated outreach, including digital tools and community-led models to optimize PrEP uptake (Peng et al., 2022; Rucinski et al., 2022). Across all groups, implementing stigma reduction strategies and legal supports is critical to sustaining equitable access to HIV prevention (Spence et al., 2022; Stangl et al., 2023). These strategies are directly related to PrEP use by addressing the specific barriers and needs of each group, thereby improving uptake and adherence to PrEP and other HIV prevention methods (Claassen et al., 2021; Smith et al., 2023).

Multilevel Strategies for Scaling Global PrEP Uptake

Global PrEP uptake requires explicit, multilevel, and culturally tailored implementation strategies that address barriers at the individual, provider, and clinic levels to improve accessibility and adherence (Estcourt et al., 2023; Johnson et al., 2022; Wang et al., 2022). These strategies align with calls for scalable PrEP delivery models (Bavinton & Grulich, 2021; Rousseau et al., 2021) and evidence suggesting that diverse settings necessitate a comprehensive approach (Estcourt et al., 2023). To broaden PrEP’s reach, delivery models should be diversified by integrating PrEP into family planning, leveraging community-based and mobile delivery, adopting pharmacy-led models, and utilizing telemedicine (Gotsche et al., 2022; Rousseau et al., 2021). Provider training must be culturally sensitive, co-produced, and include guidance on non-daily dosing to address knowledge gaps and support both initiation and persistence (Estcourt et al., 2023; Johnson et al., 2022; Kayesu et al., 2022). In addition, targeted, population-specific strategies for groups such as adolescent girls and young women (AGYW), Black women, sex workers, transgender women, and MSM are essential, with an emphasis on peer networks, stigma reduction, and accessible service delivery (Amogne et al., 2022; D’Angelo et al., 2021; Joshi et al., 2023; Patel et al., 2022). Policy and financing actions, such as reducing costs, enabling diverse prescribers, and integrating PrEP into existing services, are vital for addressing systemic barriers and enabling global scale-up (Bavinton & Grulich, 2021; Comer & Fernández, 2022; Espinosa et al., 2021).

Global Disparities and Equity Considerations

The uneven distribution of PrEP raises questions about equity in HIV prevention. While uptake has increased in high-income countries, MSM in LMICs often report limited access despite high levels of need. As global health institutions set targets for HIV prevention, attention to equity across geography, income, and demographic subgroups will be essential to ensure that PrEP fulfills its potential as a global intervention. Significant global disparities in PrEP uptake and persistence among men who have sex with men (MSM) persist along lines of race/ethnicity, migrant status, language, geography, and stigma. Syntheses confirm that awareness, willingness, and access remain suboptimal and unevenly distributed worldwide, despite evidence of PrEP’s effectiveness (Huang et al., 2023; Sun et al., 2022). These inequities are structurally driven by policy, financing, and health-system factors, which create barriers such as insurance gaps and fragmented service delivery (Coleman et al., 2024; Estcourt et al., 2021). Within care continua, disparities are pronounced for Black, Hispanic/Latino, and migrant MSM, who face lower uptake and retention due to structural racism, discrimination, and cultural or language barriers (Babel et al., 2021; Bonacci et al., 2021; Schumacher et al., 2021).

Conclusion

Although PrEP remains a highly effective tool for HIV prevention, its global uptake among MSM has been modest and uneven. Zhao et al.’s (2025) findings highlight both progress and persistent gaps, especially in LMICs and among younger MSM. Moving forward, addressing cost, health care system barriers, and stigma will be essential for scaling up equitable access. While the statement touches on these challenges, it lacks concrete, evidence-informed solutions to create lasting change. For example, focusing on the licensing of innovative PrEP dosing options could help reduce costs and improve accessibility. In addition, strengthening youth-focused interventions, tackling systemic barriers, and framing PrEP implementation as an equity issue rather than just an efficacy issue can guide more inclusive strategies. Ensuring sustained policy commitment and addressing societal stigma will be crucial for bridging existing disparities and reducing HIV incidence among MSM worldwide.

Footnotes

Acknowledgements

We would like to extend our sincere gratitude to the CDC 2025 HIV Nexus for providing invaluable resources for clinicians, particularly the insights into the clinical guidance for PrEP. We are also deeply thankful to Dr. Antons Mozalevski for his contributions and for sharing the updated WHO guidance on integrated and differentiated PrEP services. Their support and expertise have been crucial to the development of this work.

ORCID iD

Alex Siu Wing Chan

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Adeagbo

(2024). Barriers and facilitators to pre-exposure prophylaxis uptake among black/african american men who have sex with other men in iowa: Com-b model analysis. Therapeutic Advances in Infectious Disease, 11, 20499361241267151. https://doi.org/10.1177/20499361241267151

Admassu

Nöstlinger

Hensen

(2024). Barriers to PrEP use and adherence among adolescent girls and young women in Eastern, Southern, and Western Africa: A scoping review. BMC Women’s Health, 24(1), 665. https://doi.org/10.1186/s12905-024-03516-y

Ambrožič

Adamič

Tomažič

(2024). Slovenia’s national HIV PrEP programme: Evaluation of real-world implementation. International Journal of STD & AIDS, 35(7), 516–520. https://doi.org/10.1177/09564624241233792

Amogne

Sanders

Belihu

Sundewall

Agardh

(2022). Condom failure and pre-exposure prophylaxis use experience among female sex workers in Ethiopia: A qualitative study. BMC Public Health, 22(1), 1079. https://doi.org/10.1186/s12889-022-13468-3

Assaf

Konda

Torres

Vega-Ramírez

Reyes

Elorreaga

O. A.

Diaz-Sosa

Diaz

S. D.

Pimenta

Robles

Medina-Mora

M. E.

Grinsztejn

Caceres

Veloso

V. G.

(2021). Are men who have sex with men at higher risk for HIV in latin america more aware of PrEP? PLOS ONE, 16(8), e0255557. https://doi.org/10.1371/journal.pone.0255557

Azzi

Chartouni

Sakr

Ibrahim

Chebel

Haddad

É.

Saliba

(2024). Addressing pre-exposure prophylaxis awareness and knowledge gaps among Lebanese medical professionals: A cross-sectional study. Journal of Medical Education and Curricular Development, 11, 23821205241307735. https://doi.org/10.1177/23821205241307735

Babel

Wang

Alessi

Raymond

Wei

(2021). Stigma, HIV risk, and access to HIV prevention and treatment services among men who have sex with men (MSM) in the United States: A scoping review. AIDS and Behavior, 25(11), 3574–3604. https://doi.org/10.1007/s10461-021-03262-4

Balasubramanian

Kasaie

Schnure

Dowdy

Shah

Fojo

(2022). Projected impact of expanded long-acting injectable PrEP use among men who have sex with men on local HIV epidemics. JAIDS Journal of Acquired Immune Deficiency Syndromes, 91(2), 144–150. https://doi.org/10.1097/qai.0000000000003029

Batista

Dávila

Santos

Rocha

Araújo

Alencar

Nascimento

L. R.

Araújo

N. D.

Lopes

S. C. P.

Araújo

P. S.

Filgueiras

R. A.

Saraiva

P. F.

Lacerda

M. V. G.

Baía-da-Silva

D. C.

Murta

(2024). Perception and barriers to access pre-exposure prophylaxis for HIV/AIDS (PrEP) among the MSM (men who have sex with men) Brazilian Amazon: A qualitative study. PLOS ONE, 19(9), e0296201. https://doi.org/10.1371/journal.pone.0296201

10.

Bavinton

Grulich

(2021). HIV pre-exposure prophylaxis: Scaling up for impact now and in the future. The Lancet Public Health, 6(7), e528–e533. https://doi.org/10.1016/s2468-2667(21)00112-2

11.

Bhatta

Hecht

Facente

(2022). Factors associated with stigma related to HIV pre-exposure prophylaxis (PrEP) use among men who have sex with men (MSM). Sexually Transmitted Infections, 98(8), 592–594. https://doi.org/10.1136/sextrans-2021-055296

12.

Biello

Valente

Lin

Lodge

Drab

Hightow-Weidman

da Silva

D. T.

Mayer

Bauermeister

(2021). Preparing for nextgen: Cognitive interviews to improve next generation PrEP modality descriptions for young men who have sex with men. AIDS and Behavior, 26(6), 1956–1965. https://doi.org/10.1007/s10461-021-03545-w

13.

Billioti de Gage

Desplas

Dray-Spira

(2022). Roll-out of HIV pre-exposure prophylaxis use in France: A nationwide observational study from 2016 to 2021. The Lancet Regional Health—Europe, 22, 100486. https://doi.org/10.1016/j.lanepe.2022.100486

14.

Bonacci

Smith

Ojikutu

(2021). Toward greater pre-exposure prophylaxis equity: Increasing provision and uptake for Black and Hispanic/Latino individuals in the U.S. American Journal of Preventive Medicine, 61(5), S60–S72. https://doi.org/10.1016/j.amepre.2021.05.027

15.

Brink

Martin-Hughes

Minnery

Osborne

Schmidt

Dalal

Green

K. E.

Ramaurtarsing

Wilson

D. P.

Kelly

(2022). Cost-effectiveness and impact of pre-exposure prophylaxis to prevent HIV among men who have sex with men in Asia: A modelling study. PLOS ONE, 17(5), e0268240. https://doi.org/10.1371/journal.pone.0268240

16.

Buffel

Reyniers

Masquillier

Thunissen

Nöstlinger

Laga

Wouters

Berghe

W. V.

Deblonde

Vuylsteke

(2021). Awareness of, willingness to take PrEP and its actual use among belgian MSM at high risk of HIV infection: Secondary analysis of the belgian european MSM internet survey. AIDS and Behavior, 26(6), 1793–1807. https://doi.org/10.1007/s10461-021-03526-z

17.

Butts

Young

Blackmon

Doblecki-Lewis

(2023). Addressing disparities in pre-exposure prophylaxis (PrEP) access: Implementing a community-centered mobile PrEP program in South Florida. BMC Health Services Research, 23(1), 1311. https://doi.org/10.1186/s12913-023-10277-1

18.

Cameron

Newman

Chakrapani

Shunmugam

Roungprakhon

Rawat

Baruah

Nelson

Tepjan

Scarpa

(2024). Stated preferences for new HIV prevention technologies among men who have sex with men in India: A discrete choice experiment. PLOS ONE, 19(7), e0289396. https://doi.org/10.1371/journal.pone.0289396

19.

Carneiro

Mirzayi

Jones

Rendina

Grov

(2022). Demographic, clinical guideline criteria, medicaid expansion and state of residency: A multilevel analysis of PrEP use on a large us sample. BMJ Open, 12(2), e055487. https://doi.org/10.1136/bmjopen-2021-055487

20.

Chamberlin

Lopes

Iyer

Psaros

Bassett

Medeiros

O’Connor

Ard

(2023). “that was our afterparty”: A qualitative study of mobile, venue-based PrEP for msm. BMC Health Services Research, 23(1), 504. https://doi.org/10.1186/s12913-023-09475-8

21.

Chapin-Bardales

Haaland

Martin

Holder

Butts

Sionéan

Sey

E. K.

Brady

K. A.

Raymond

H. F.

Opoku

Kuo

Paz-Bailey

Wejnert

(2023). HIV pre-exposure prophylaxis persistence and adherence among men who have sex with men in four us cities. JAIDS Journal of Acquired Immune Deficiency Syndromes, 93(1), 34–41. https://doi.org/10.1097/qai.0000000000003160

22.

Charest

Sharma

Chris

Schnubb

Knox

Wilton

Shahin

Chan

Mishra

Grace

Bayoumi

A. M.

Maxwell

Bogoch II. Tan

DHS

. (2021). Decentralizing PrEP delivery: Implementation and dissemination strategies to increase PrEP uptake among MSM in Toronto, Canada. PLOS ONE, 16(3), e0248626. https://doi.org/10.1371/journal.pone.0248626

23.

Claassen

Mumba

Njelesani

Nyimbili

Mwango

Mwitumwa

Mubanga

Mulenga

L. B.

Chisenga

Nichols

B. E.

Hendrickson

Chitembo

Okuku

O’Bra

(2021). Initial implementation of PrEP in Zambia: Health policy development and service delivery scale-up. BMJ Open, 11(7), e047017. https://doi.org/10.1136/bmjopen-2020-047017

24.

Coleman

Maslen

Foster

(2024). Inequities in PrEP use according to medicare status in a publicly funded sexual health clinic: A retrospective analysis. Sexual Health, 21(2), SH23141. https://doi.org/10.1071/SH23141

25.

Comer

Fernández

(2022). Health departments and PrEP: A missed opportunity for public health. The Journal of Law, Medicine & Ethics, 50(S1), 64–68. https://doi.org/10.1017/jme.2022.39

26.

Coukan

Murray

Papageorgiou

Lound

Saunders

Atchison

Ward

(2023). Barriers and facilitators to HIV pre-exposure prophylaxis (PrEP) in specialist sexual health services in the United Kingdom: A systematic review using the PrEP care continuum. HIV Medicine, 24(8), 893–913. https://doi.org/10.1111/hiv.13492

27.

D’Angelo

Ewart

Koken

Bimbi

Brown

Grov

(2021). Barriers and facilitators to pre-exposure prophylaxis uptake among Black women: A qualitative analysis guided by a socioecological model. Journal of the Association of Nurses in AIDS Care, 32(4), 481–494. https://doi.org/10.1097/jnc.0000000000000241

28.

Diabaté

Béhanzin

Guédou

Goma-Matsétsé

Olodo

Aza-Gnandji

Dossouvo

Akpaka

Chagas

Gangbo

Zannou

D. M.

Alary

(2023). Pre-exposure prophylaxis in real life: Experience from a prospective, observational, and demonstration project among men who have sex with men in Benin, West Africa. Journal of the International AIDS Society, 26(6), e26130. https://doi.org/10.1002/jia2.26130

29.

Dijk

Wit

Guadamuz

Martínez

Jonas

(2021). Slow uptake of PrEP: Behavioral predictors and the influence of price on PrEP uptake among MSM with a high interest in PrEP. AIDS and Behavior, 25(8), 2382–2390. https://doi.org/10.1007/s10461-021-03200-4

30.

Doyle

Milwid

Cox

Xia

Lambert

Tremblay

Otis

Boily

M. C.

Baril

J. G.

Thomas

Blais

A. D.

Trottier

Grace

Moore

D. M.

Mishra

Maheu-Giroux

(2023). Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): A modelling study of surveillance and survey data. Journal of the International AIDS Society, 26(12), e26194. https://doi.org/10.1002/jia2.26194

31.

Dyer

(2022). Syphilis and gonorrhoea cases soar in US. BMJ, 378, o2355. https://doi.org/10.1136/bmj.o2355

32.

Espinosa

Hull

Lachowsky

Hall

Mohammed

Fisher

Grace

Gaspar

Truong

Mitterni

Harding

MacPherson

Woodward

Rayek

Peters

Jollimore

Kilduff

Maxwell

Greene

. . .Tan

. (2021). 850. Reasons for not using PrEP and actions that may facilitate PrEP uptake in Ontario and British Columbia, Canada. Open Forum Infectious Diseases, 8(Supplement_1), S515–S515. https://doi.org/10.1093/ofid/ofab466.1045

33.

Estcourt

MacDonald

Saunders

Nandwani

Young

Frankis

Clutterbuck

Steedman

McDaid

Flowers

(2023). Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: Process evaluation and recommendation development from a national PrEP program. Sexual Health, 20(4), 282–295. https://doi.org/10.1071/sh22170

34.

Estcourt

Yeung

Nandwani

Goldberg

Cullen

Steedman

Wallace

Hutchinson

(2021). Population-level effectiveness of a national HIV preexposure prophylaxis programme in MSM. AIDS, 35(4), 665–673. https://doi.org/10.1097/QAD.0000000000002790

35.

Eubanks

Coulibaly

Keïta

Anoma

Dah

Mensah

Kaba

Lokrou

K. J.

Ouedraogo

F. R.

Badjassim

A. M. F.

Maradan

Bourrelly

Mora

Riegel

Rojas Castro

Yaya

Spire

Laurent

Sagaon-Teyssier

& ; CohMSM-PrEP Study Group. (2022). Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa. BMC Public Health, 22(1), 1832. https://doi.org/10.1186/s12889-022-14211-8

36.

Farley

Beuchamp

Bergman

Hughes

Batey

Rı́o

Raifman

Lowensen

Gamble

Remien

R. H.

Beyrer

(2024). The impact of stigma and sexual identity on PrEP awareness and use among at-risk men who have sex with men in four U.S. cities (hptn 078). Stigma and Health, 9(3), 400–410. https://doi.org/10.1037/sah0000413

37.

Gotsche

Steyn

Narasimhan

Rodolph

Baggaley

Kiarie

(2022). Integrating pre-exposure prophylaxis of HIV infection into family planning services: A scoping review. BMJ Sexual & Reproductive Health, 49(3), 210–218. https://doi.org/10.1136/bmjsrh-2021-201356

38.

Guan

Liao

Zhang

Chen

Liu

Shen

Zhu

Tang

(2023). Multi-dimensional mismatch and barriers for promoting PrEP among men who have sex with men in china: A cross sectional survey from the demand-side. AIDS Research and Therapy, 20(1), 11. https://doi.org/10.1186/s12981-022-00497-6

39.

Haines

O’Byrne

MacPherson

(2021). Gay, bisexual, and other men who have sex with men: Barriers and facilitators to healthcare access in Ottawa. The Canadian Journal of Human Sexuality, 30(3), 339–348. https://doi.org/10.3138/cjhs.2021-0002

40.

Hamilton

Rosenberg

Sullivan

Wang

Dunville

Barrios

Aslam

Mustanski

Goodreau

(2021). Modeling the impact of PrEP programs for adolescent sexual minority males based on empirical estimates for the PrEP continuum of care. Journal of Adolescent Health, 68(3), 488–496. https://doi.org/10.1016/j.jadohealth.2020.06.041

41.

Hendrickson

Long

Rensburg

Claassen

Njelesani

Moyo

Mulenga

O’Bra

Russell

C. A.

Nichols

(2022). The early-stage comprehensive costs of routine PrEP implementation and scale-up in zambia. PLOS Global Public Health, 2(11), e0001246. https://doi.org/10.1371/journal.pgph.0001246

42.

Huang

Tian

Zhou

Agins

Zou

Chen

Sun

Zhong

Jiang

(2023). HIV pre-exposure prophylaxis use on a global scale among men who have sex with men: A systematic review and meta-analysis. AIDS Patient Care and STDs, 37(4), 159–191. https://doi.org/10.1089/apc.2022.0198

43.

Johnson

Pyra

Devlin

Uvin

Irby

Blum

Stewart

Masinter

Haider

Hirschhorn

L. R.

Ridgway

(2022). Provider perspectives on factors affecting the PrEP care continuum among Black cisgender women in the Midwest United States: Applying the consolidated framework for implementation research. JAIDS Journal of Acquired Immune Deficiency Syndromes, 90(S1), S141–S148. https://doi.org/10.1097/qai.0000000000002974

44.

Joshi

Namuddu

Kasujja

Mirembe

Homsy

Seeley

King

(2023). PrEP uptake and persistence amongst HIV-negative women who exchange sex for money or commodities in Kampala, Uganda: A qualitative inquiry assessing the influence of pregnancy. PLOS Global Public Health, 3(6), e0000434. https://doi.org/10.1371/journal.pgph.0000434

45.

Kamitani

Wichser

Mizuno

DeLuca

Higa

(2022). What factors are associated with willingness to use HIV pre-exposure prophylaxis (PrEP) among U.S. men who have sex with men not on PrEP? A systematic review and meta-analysis. Journal of the Association of Nurses in AIDS Care, 34(2), 135–145. https://doi.org/10.1097/jnc.0000000000000384

46.

Kayesu

Mayanja

Nakirijja

Machira

Price

Seeley

Siu

(2022). Uptake of and adherence to oral pre-exposure prophylaxis among adolescent girls and young women at high risk of HIV-infection in Kampala, Uganda: A qualitative study of experiences, facilitators, and barriers. BMC Women’s Health, 22(1), 440. https://doi.org/10.1186/s12905-022-02018-z

47.

Latka

Vahle

Gomes

Dam

(2023). Program impact and potential pitfalls of multi-purpose technologies (MPTs) for HIV prevention and contraception. Frontiers in Reproductive Health, 5, 1249979. https://doi.org/10.3389/frph.2023.1249979

48.

Liu

Cheng

Xian

Liu

Wei

Chen

Liu

Yang

Cui

(2024). Cascade analysis of awareness, willingness, uptake and adherence with regard to PrEP among young men who have sex with men (YMSM) in china: A comparison between students and non-students. HIV Medicine, 25(7), 840–851. https://doi.org/10.1111/hiv.13639

49.

Luz

P. M.

Benzaken

Alencar

T. M.

Pimenta

Veloso

V. G.

Grinsztejn

(2018). PrEP adopted by the Brazilian national health system: What is the size of the demand? Medicine, 97(1S Suppl. 1), S75–S77. https://doi.org/10.1097/md.0000000000010602

50.

Madhani

Finlay

(2022). Using the com-b model to characterize the barriers and facilitators of pre-exposure prophylaxis (PrEP) uptake in men who have sex with men. British Journal of Health Psychology, 27(4), 1330–1353. https://doi.org/10.1111/bjhp.12605

51.

Manguro

Musau

Were

Tengah

Wakhutu

Reed

Plotkin

Luchters

Gichangi

Temmerman

(2022). Increased condom use among key populations using oral PrEP in Kenya: Results from large-scale programmatic surveillance. BMC Public Health, 22(1), 304. https://doi.org/10.1186/s12889-022-12639-6

52.

Miller

Mantell

Parmley

Musuka

Chingombe

Mapingure

Harris

(2022). Stigma, social cohesion, and HIV risk among sexual and gender minorities in two cities in Zimbabwe. AIDS and Behavior, 26(9), 2994–3007. https://doi.org/10.1007/s10461-022-03622-8

53.

Molina

J.-M.

Charreau

Spire

Cotte

Chas

Capitant

Tremblay

Rojas-Castro

Cua

Pasquet

Bernaud

Pintado

Delaugerre

Sagaon-Teyssier

Mestre

S. L.

Chidiac

Pialoux

Ponscarme

Fonsart

Rabian

(2017). Efficacy, safety, and effect on sexual behavior of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: An observational cohort study. The Lancet HIV, 4(9), e402–e410. https://doi.org/10.1016/S2352-3018(17)30089-9

54.

Nagai

Adiibokah

Tagoe

Tun

Pilgrim

Ankomah

Rahman

Y. A. A.

Addo

S. A.

Atuahene

S. K.

Essandoh

Maher

Kowalski

(2023). Policymakers’ and healthcare providers’ perspectives on the introduction of oral pre-exposure prophylaxis for key populations in ghana. BMC Public Health, 23(1), 1065. https://doi.org/10.1186/s12889-023-15871-w

55.

Ndenkeh

Bowring

Njindam

Folem

Fako

Ngueguim

Gayou

O. L.

Lepawa

Minka

C. M.

Batoum

C. M.

Georges

Temgoua

Nzima

Kob

D. A.

Akiy

Z. Z.

Philbrick

Levitt

Curry

Baral

(2022). HIV pre-exposure prophylaxis uptake and continuation among key populations in Cameroon: Lessons learned from the CHAMP program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 91(1), 39–46. https://doi.org/10.1097/qai.0000000000003012

56.

Newman

Tepjan

Fongkaew

Akkakanjanasupar

Wijngaarden

Chonwanarat

(2023). Multilevel factors impacting PrEP engagement among young gay men and young transgender women in thailand: A qualitative analysis.Journal of the International Association of Providers of AIDS Care (JIAPAC), 22, 23259582231188221. https://doi.org/10.1177/23259582231188221

57.

Obioma

Ben-Chioma

(2024). Evidence-based prevalence of HIV infection and associated risk factors among female sex workers in Port Harcourt, Niger Delta, Nigeria. Journal of Microbiology & Experimentation, 12(2), 53–61. https://doi.org/10.15406/jmen.2024.12.00416

58.

Ort

Bardy

(2024). The pre-exposure prophylaxis stigma scale: Measurement properties of an adaptation in german and french. International Journal of Public Health, 69, 1606658. https://doi.org/10.3389/ijph.2024.1606658

59.

Patel

Sato

Bhandari

Kanagasabai

Schelar

Cooney

Eakle

Klucking

Toiv

Saul

(2022). From policy to practice: Uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President’s Emergency Plan for AIDS Relief-supported countries, 2017–2020. AIDS, 36(Supplement 1), S15–S26. https://doi.org/10.1097/qad.0000000000003103

60.

Peng

Wickersham

Altice

Shrestha

Azwa

Zhou

Halim

M. A. A.

Ikhtiaruddin

W. M.

Tee

Kamarulzaman

(2022). Formative evaluation of the acceptance of HIV prevention artificial intelligence chatbots by men who have sex with men in Malaysia: Focus group study. JMIR Formative Research, 6(10), e42055. https://doi.org/10.2196/42055

61.

Perez-Urbano

Dilraj

Pitsi

Hlongwane

Abdelatif

Dietrich

Ahmed

(2024). Strategies to close the PrEP uptake gap among transgender people and men who have sex with men in Tshwane, South Africa: Perspectives from the community. AIDS and Behavior, 28(6), 1999–2014. https://doi.org/10.1007/s10461-024-04300-7

62.

Pilgrim

Evans

Czarnogorski

(2022). A layer plus approach to implementation research and collaboration for long-acting injectable pre-exposure prophylaxis for HIV prevention. Health Promotion Practice, 23(6), 912–915. https://doi.org/10.1177/15248399211053584

63.

Pulerwitz

Gottert

Tun

Eromhonsele

Oladimeji

Shoyemi

Akoro

Ndeloa

Adedimeji

(2024). Reducing stigma and promoting HIV wellness/mental health of sexual and gender minorities: Rct results from a group-based programme in nigeria.Journal of the International AIDS Society, 27(6), e26256. https://doi.org/10.1002/jia2.26256

64.

Restar

Surace

Adia

Goedel

Ogunbajo

Jin

Edeza

Hernandez

Cu-Uvin

Operario

(2022). Characterizing awareness of pre-exposure prophylaxis for HIV prevention in manila and cebu, philippines: Web-based survey of filipino cisgender men who have sex with men. Journal of Medical Internet Research, 24(1), e24126. https://doi.org/10.2196/24126

65.

Rogers

Chan

Sutten-Coats

Zanowick-Marr

Patel

Mena

Goedel

W. C.

Chu

Silva

Galipeau

Arnold

Gomillia

Curoe

Villalobos

Underwood

Sosnowy

Nunn

(2023). Perspectives on long-acting formulations of pre-exposure prophylaxis (PrEP) among men who have sex with men who are non adherent to daily oral PrEP in the United States. BMC Public Health, 23(1), 1643. https://doi.org/10.1186/s12889-023-16382-4

66.

Rosen

Wickersham

Altice

Khati

Azwa

Shen

Tee

Jeri-Wahrhaftig

Luces

J. R.

Kamarulzaman

Saifi

Shrestha

(2023). Barriers and facilitators to pre-exposure prophylaxis by men who have sex with men and community stakeholders in malaysia. International Journal of Environmental Research and Public Health, 20(9), 5669. https://doi.org/10.3390/ijerph20095669

67.

Rousseau

Bennin

Bekker

(2024). Effective pre-exposure prophylaxis in young women and girls, a key population for HIV prevention. Current Opinion in HIV and AIDS, 19(6), 287–292. https://doi.org/10.1097/coh.0000000000000885

68.

Rousseau

Julies

Madubela

Kassim

(2021). Novel platforms for biomedical HIV prevention delivery to key populations—Community mobile clinics, peer-supported, pharmacy-led PrEP delivery, and the use of telemedicine. Current HIV/AIDS Reports, 18(6), 500–507. https://doi.org/10.1007/s11904-021-00578-7

69.

Roy

Himelfarb

Karrah

Porterfield

Paremoer

Serag

Lee

(2022). The social, behavioral, and ethical modalities of COVID-19 on HIV care in South Africa: A systematic review. International Journal of Environmental Research and Public Health, 19(15), 9766. https://doi.org/10.3390/ijerph19159766

70.

Rucinski

Banda

Olawore

Akolo

Zakaliya

Chilongozi

Schwartz

Wilcher

Persaud

Ruberintwari

Baral

(2022). HIV testing approaches to optimize prevention and treatment for key and priority populations in Malawi. Open Forum Infectious Diseases, 9(4), ofac038. https://doi.org/10.1093/ofid/ofac038

71.

Santos

Grangeiro

Couto

(2022). HIV pre-exposure prophylaxis (PrEP) among men who have sex with men: Peer communication, engagement and social networks. Ciência & Saúde Coletiva, 27(10), 3923–3937. https://doi.org/10.1590/1413-812320222710.06542022en

72.

Schumacher

Tao

Chandran

Fields

Price

Greenbaum

Jennings

; IMPACT Partner Collaborative. (2021). Reaching those most at risk for HIV acquisition: Evaluating racial/ethnic disparities in the preexposure prophylaxis care continuum in Baltimore City, Maryland. JAIDS Journal of Acquired Immune Deficiency Syndromes, 87(5), 1145–1153. https://doi.org/10.1097/QAI.0000000000002712

73.

Sevelius

Glidden

Deutsch

Welborn

Contreras

Salinas

Venegas

Grant

(2021). Uptake, retention, and adherence to pre-exposure prophylaxis (PrEP) in triumph: A peer-led PrEP demonstration project for transgender communities in oakland and sacramento, california. JAIDS Journal of Acquired Immune Deficiency Syndromes, 88(S1), S27–S38. https://doi.org/10.1097/qai.0000000000002808

74.

Smith

Graham

Harripersaud

Zhu

Lan

Shen

Tang

(2023). Sexual mixing patterns in men who have sex with men: Network approaches for smart resource allocation. Sexual Health, 20(2), 126–133. https://doi.org/10.1071/sh22163

75.

Spence

Wang

Michel

Merenstein

Kharfen

Goparaju

Kassaye

(2022). Unprepared for HIV prevention services: Hesitancy among US primary care providers. Medicine, 101(43), e31242. https://doi.org/10.1097/md.0000000000031242

76.

Stangl

Atkins

Leddy

Sievwright

Sevelius

Lippman

Veras

M. A.

Zamudio-Haas

Smith

M. K.

Pachankis

J. E.

Logie

C. H.

Rao

Weiser

Nyblade

(2023). What do we know about interventions to reduce intersectional stigma and discrimination in the context of HIV? A systematic review. Stigma and Health, 8(3), 393–408. https://doi.org/10.1037/sah0000414

77.

Sun

Dai

Zou

Agins

Chen

Shen

Yang

Jiang

(2022). Increasing awareness of HIV pre-exposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: A systematic review and meta-analysis of global data. Journal of the International AIDS Society, 25(3), e25883. https://doi.org/10.1002/jia2.25883

78.

Torres

Nascimento

Coelho

Konda

Vega-Ramírez

Reyes

Elorreaga

O. A.

Diaz-Sosa

Hoagland

Guanira

J. V.

Pimenta

Benedetti

Caceres

C. F.

Veloso

V. G.

Grinsztejn

(2023). Preferences for PrEP modalities among gay, bisexual, and other men who have sex with men from Brazil, Mexico, and Peru: A cross-sectional study. Therapeutic Advances in Infectious Disease, 10, 20499361231153548. https://doi.org/10.1177/20499361231153548

79.

Vega-Ramírez

Torres

Guillén-Díaz-Barriga

Pimenta

Díaz-Sosa

Konda

da Cunha

A. R. C.

Robles-Garcia

Benedetti

Hoagland

Bezerra

D. R. B.

Caceres

C. F.

Grinsztejn

Veloso

V. G.

& ImPrEP Study Group. (2022). Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: Cross-sectional web-based survey. BMC Health Services Research, 22(1), 532. https://doi.org/10.1186/s12913-022-07900-y

80.

Wang

Mitchell

Zhang

Liu

(2022). Evidence and implication of interventions across various socioecological levels to address pre-exposure prophylaxis uptake and adherence among men who have sex with men in the United States: A systematic review. AIDS Research and Therapy, 19(1), 28. https://doi.org/10.1186/s12981-022-00456-1

81.

Were

Musau

Mugambi

Plotkin

Kabue

Manguro

Reed

(2021). An implementation model for scaling up oral pre-exposure prophylaxis in Kenya: Jilinde Project. Gates Open Research, 5, 113. https://doi.org/10.12688/gatesopenres.13342.1

82.

Witte

Yang

McCrimmon

Aira

Batsukh

Terlikbayeva

Primbetova

Mergenova

Cordisco Tsai

Carlson

Vélez-Grau

Ssewamala

El-Bassel

(2022). Combination microfinance and HIV risk reduction among women engaged in sex work. Research on Social Work Practice, 33(2), 213–229. https://doi.org/10.1177/10497315221119992

83.

Chang

Strong

(2021). Imperfect adherence in real life: A prevention-effective perspective on adherence to daily and event-driven HIV pre-exposure prophylaxis among men who have sex with men – a prospective cohort study in taiwan.Journal of the International AIDS Society, 24(5), e25733. https://doi.org/10.1002/jia2.25733

84.

Saina

Brown

Chege

Donnell

Glidden

Ngure

Mugo

N. R.

Akelo

Schaafsma

Anderson

P. L.

Mugwanya

(2024). Establishing adherence–concentration–efficacy thresholds of TDF-FTC pre-exposure prophylaxis for HIV prevention in african women: A protocol for the women TDF-FTC benchmark study. Frontiers in Reproductive Health, 6, 1325257. https://doi.org/10.3389/frph.2024.1325257

85.

Zhang

Liu

(2022). Understanding the association between PrEP stigma and PrEP cascade moderated by the intensity of HIV testing. Tropical Medicine and Infectious Disease, 7(5), 74. https://doi.org/10.3390/tropicalmed7050074

86.

Zhao

Huang

Zhou

Agins

Ong

J. J.

Zou

She

Jiang

(2025). HIV pre-exposure prophylaxis (PrEP) use among PrEP-eligible men who have sex with men: A systematic review and meta-analysis. International Journal of Infectious Diseases, 154, 107874. https://doi.org/10.1016/j.ijid.2025.107874

87.

Zimmermann

Davidovich

Bilsen

Coyer

Matser

Prins

Harreveld

(2023). A psychosocial network approach studying biomedical HIV prevention uptake between 2017 and 2019. Scientific Reports, 13(1), 16168. https://doi.org/10.1038/s41598-023-42762-2