Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis

  • Avy A. SkolnikEmail author
  • Barbara G. Bokhour
  • Allen L. Gifford
  • Brigid M. Wilson
  • Puja Van Epps
Original Research



Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP.


We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records.


Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA.


One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates.


We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers.

Key Results

Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP.


Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.


HIV/AIDS prevention pre-exposure prophylaxis patient-provider communication primary care 


Funding Information

Dr. Van Epps is supported by the Geriatric Research Education and Clinical Center (GRECC). Additionally, Dr. Skolnik was funded by a VHA post-doctoral research fellowship.

Compliance with Ethical Standards

Conflict of Interest

No conflict of interest, financial or other, exists for any of the authors of this manuscript.


  1. 1.
    Pre-Exposure Prophylaxis (PrEP) | HIV Risk and Prevention | HIV/AIDS | CDC. Published August 23, 2018. Accessed September 30, 2018.
  2. 2.
    Baeten JM, Donnell D, Ndase P, et al. Antiretroviral Prophylaxis for HIV-1 Prevention among Heterosexual Men and Women. N Engl J Med. 2012;367(5):399-410. Scholar
  3. 3.
    Grant RM, Lama JR, Anderson PL, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010;363(27):2587-2599. Scholar
  4. 4.
    Fonner VA, Dalglish SL, Kennedy CE, et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016;30(12):1973-1983. Scholar
  5. 5.
    Kirby T, Thornber-Dunwell M. Uptake of PrEP for HIV slow among MSM. Lancet. 2014;383(9915):399-400. Scholar
  6. 6.
    Krakower DS, Mimiaga MJ, Rosenberger JG, et al. Limited Awareness and Low Immediate Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex with Men Using an Internet Social Networking Site. PLoS ONE. 2012;7(3):e33119. Scholar
  7. 7.
    Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Lancet Infect Dis. 2014;14(9):820-829. Scholar
  8. 8.
    Tellalian D, Maznavi K, Bredeek UF, Hardy WD. Pre-Exposure Prophylaxis (PrEP) for HIV Infection: Results of a Survey of HIV Healthcare Providers Evaluating Their Knowledge, Attitudes, and Prescribing Practices. AIDS Patient Care STDs. 2013;27(10):553-559. Scholar
  9. 9.
    Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition — United States, 2015. Accessed September 30, 2018.
  10. 10.
    US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. Washington, DC: US Public Health Service; 2014.Google Scholar
  11. 11.
    Maier MM, Gylys-Colwell I, Lowy E, et al. Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran’s Health Administration. AIDS Behav. 2018. Scholar
  12. 12.
    Garner W, Wilson BM, Beste L, Maier M, Ohl ME, Van Epps P. Gaps in Preexposure Prophylaxis Uptake for HIV Prevention in the Veterans Health Administration. Am J Public Health. 2018;108(S4):S305-S310. Scholar
  13. 13.
    Sun CJ, Anderson KM, Bangsberg D, et al. Access to HIV Pre-exposure Prophylaxis in Practice Settings: a Qualitative Study of Sexual and Gender Minority Adults’ Perspectives. J Gen Intern Med. 2019;34(4):535-543. Scholar
  14. 14.
    Adams LM, Balderson BH. HIV Providers’ Likelihood to Prescribe Pre-exposure Prophylaxis (PrEP) for HIV Prevention Differs By Patient Type: A Short Report. AIDS Care. 2016;28(9):1154-1158. Scholar
  15. 15.
    Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV Providers’ Perceived Barriers and Facilitators to Implementing Pre-Exposure Prophylaxis in Care Settings: A Qualitative Study. AIDS Behav. 2014;18(9):1712-1721. Scholar
  16. 16.
    Blumenthal J, Jain S, Krakower D, et al. Knowledge is Power! Increased Provider Knowledge Scores regarding Pre-exposure Prophylaxis (PrEP) are Associated with Higher Rates of PrEP Prescription and Future Intent to Prescribe PrEP. AIDS Behav. 2015;19(5):802-810. Scholar
  17. 17.
    Silapaswan A, Krakower D, Mayer KH. Pre-Exposure Prophylaxis: A Narrative Review of Provider Behavior and Interventions to Increase PrEP Implementation in Primary Care. J Gen Intern Med. 2017;32(2):192-198. Scholar
  18. 18.
    Puro V, Palummieri A, De Carli G, Piselli P, Ippolito G. Attitude towards antiretroviral pre-exposure prophylaxis (PrEP) prescription among HIV specialists. BMC Infect Dis. 2013;13(1):217. Scholar
  19. 19.
    Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Admin Pol Ment Health. 2015;42(5):533-544. Scholar
  20. 20.
    Smith DK, Van Handel M, Grey J. Estimates of adults with indications for HIV pre-exposure prophylaxis by jurisdiction, transmission risk group, and race/ethnicity, United States, 2015. Ann Epidemiol. 2018;28(12):850-857.e9. Scholar
  21. 21.
    Siegler AJ, Mouhanna F, Giler RM, et al. The prevalence of pre-exposure prophylaxis use and the pre-exposure prophylaxis–to-need ratio in the fourth quarter of 2017, United States. Ann Epidemiol. 2018;28(12):841-849. Scholar
  22. 22.
    Hsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15(9):1277-1288. Scholar
  23. 23.
    Eaton LA, Driffin DD, Bauermeister J, Smith H, Conway-Washington C. Minimal Awareness and Stalled Uptake of Pre-Exposure Prophylaxis (PrEP) Among at Risk, HIV-Negative, Black Men Who Have Sex with Men. AIDS Patient Care STDs. 2015;29(8):423-430. Scholar
  24. 24.
    Turner L, Roepke A, Wardell E, Teitelman AM. Do You PrEP? A Review of Primary Care Provider Knowledge of PrEP and Attitudes on Prescribing PrEP. J Assoc Nurses AIDS Care. 2018;29(1):83-92. Scholar
  25. 25.
    Fix GM, Hyde JK, Bolton RE, et al. The moral discourse of HIV providers within their organizational context: An ethnographic case study. Patient Educ Couns. 2018. Scholar
  26. 26.
    Karasz A. The Visit Before the Morning After: Barriers to Preprescribing Emergency Contraception. Ann Fam Med. 2004;2(4):345-350. Scholar
  27. 27.
    Wallace JL, Wu J, Weinstein J, Gorenflo DW, Fetters MD. Emergency contraception: knowledge and attitudes of family medicine providers. Fam Med. 2004;36(6):417-422.PubMedGoogle Scholar
  28. 28.
    Mimiaga MJ, White JM, Krakower DS, Biello KB, Mayer KH. Suboptimal awareness and comprehension of published pre-exposure prophylaxis efficacy results among physicians in Massachusetts. AIDS Care. 2014;26(6):684-693. Scholar
  29. 29.
    Wimberly YH, Hogben M, Moore-Ruffin J, Moore SE, Fry-Johnson Y. Sexual history-taking among primary care physicians. J Natl Med Assoc. 2006;98(12):1924-1929.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Calabrese SK, Earnshaw VA, Underhill K, Hansen NB, Dovidio JF. The Impact of Patient Race on Clinical Decisions Related to Prescribing HIV Pre-Exposure Prophylaxis (PrEP): Assumptions About Sexual Risk Compensation and Implications for Access. AIDS Behav. 2014;18(2):226-240. Scholar
  31. 31.
    Sabin JA, Riskind RG, Nosek BA. Health Care Providers’ Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men. Am J Public Health. 2015;105(9):1831-1841. Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  1. 1.Center for Healthcare Organization and Implementation Research (CHOIR)ENRM Veterans Affairs Medical Center BedfordBedfordUSA
  2. 2.University Health ServicesUniversity of MassachusettsAmherstUSA
  3. 3.Department of Health Law, Policy, and ManagementBoston University School of Public HealthBostonUSA
  4. 4.Section of General Internal Medicine, Department of MedicineBoston University School of MedicineBostonUSA
  5. 5.Center for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare SystemBostonUSA
  6. 6.Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCVAMC)ClevelandUSA
  7. 7.Department of Internal MedicineCase Western School of MedicineClevelandUSA

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