Introduction

The HIV epidemic in the U.S. disproportionately affects populations at an increased risk of its acquisition and transmission, particularly cisgender sexually minoritized men (SMM), people who inject drugs, and transgender women. In 2021, SMM accounted for approximately 70% of all new HIV diagnoses, constituting 63% of all people with HIV nationwide.

Pre-exposure prophylaxis (PrEP) stands as one of the most effective tools in preventing HIV. Taken daily, it can substantially reduce the risk of acquiring HIV, up to 99% [1]. Despite its effectiveness, PrEP remains severely underutilized, especially among groups who might benefit from it the most, especially racially and sexually minoritized individuals. Disturbingly, 2020 data from the Centers for Disease Control and Prevention (CDC) indicate that less than 25% of the 1.2 million people who could have benefited from PrEP actually received a prescription [2]. Furthermore, racial inequities in PrEP uptake persist, with Black Americans being more than seven times less likely to have obtained a PrEP prescription compared to their White counterparts in 2022 [3]. At the intersection of race and sexuality, studies underscore compounded inequities in PrEP uptake among Black SMM (BSMM), where recent data shows that only 26% were on PrEP as compared to 42% of White SMM [4].

Structural barriers play a critical role in impeding PrEP utilization, notably through inequitable access to PrEP-prescribing facilities and providers [5,6,7]. For example, studies reveal that a considerable proportion of PrEP-eligible SMM reside in areas termed “PrEP deserts,” where the nearest PrEP provider is at least a 30-minute drive away [6]. Harrington and colleagues’ recent geospatial analysis illustrates that areas with the highest HIV incidence rates, particularly in the US Southeast, notably lack PrEP-prescribing clinics [5]. Further, traditional healthcare providers, including many primary care physicians, often lack the awareness and knowledge of PrEP, posing a barrier to prescribing it, especially for populations at increased risk of HIV acquisition such as SMM [8, 9].

To address these access barriers, integrating HIV prevention services such as PrEP screenings into pharmacies emerges as a promising, yet underexplored strategy [10]. Pharmacies boast high accessibility, with most Americans residing within 5 miles of one; people generally visit them about three times a month; and, most have extended operating hours beyond those of traditional healthcare facilities [10]. It has also been documented that pharmacies—particularly community pharmacies—are generally located in areas that experience the highest burden of HIV. Indeed, Harrington and colleagues project that the accessibility of HIV prevention resources, including PrEP, could experience an eightyfold increase if pharmacies were equipped to offer these services [5]. Lastly, many US pharmacy students receive didactic training in HIV prevention services [11]; and, practicing pharmacists exhibit high levels of willingness to provide these services, especially for SMM [12, 13], further positioning pharmacy-based settings as a robust and innovative approach to improve PrEP access and uptake.

While a rapidly growing body of literature has explored the role of pharmacies in enhancing HIV prevention and treatment outcomes [10], extant literature exhibits limitations. Notably, most studies involve small, predominately white community samples, limiting the generalizability of findings. Furthermore, to our knowledge, only one study has assessed willingness to use HIV prevention services in a pharmacy setting among a national sample of SMM, exclusively focused on BSMM [14], Despite its encouraging findings, the study underscores the need for broader data applicable to the wider SMM population. Finally, most studies that have assessed willingness to utilize HIV prevention services in pharmacies, particularly PrEP, lack theoretical frameworks. The use of theoretical frameworks in this field is critical, as it provides a systematic lens through which to analyze the complex interplay of individual, social, and structural factors affecting willingness to engage with healthcare services, informing targeted interventions to optimize PrEP utilization among SMM [15, 16].To address these gaps, this paper aims to examine willingness to obtain PrEP screening in a pharmacy and its associated correlates among a diverse, national sample of SMM in the US.

Methods

Analytical framework

The analysis presented is based on Andersen’s Behavioral Model of Health Service Utilization (hereafter referred to as Andersen’s behavioral model) [17] to provide a comprehensive understanding of factors influencing willingness to screen for PrEP in a pharmacy among SMM. This model considers the impact of distinct structural and social determinants of the utilization of healthcare services. According to this model, three key domains play a crucial role in shaping an individual’s access to and use of health services: predisposing factors, enabling factors, and need factors. Predisposing factors encompass pre-existing sociodemographic characteristics, such as age and race, independent of health behavior. Enabling factors address logistical aspects of obtaining care and may signal social-structural disadvantage, including disparities in health insurance, educational attainment, income levels, and stigma. Finally, need factors encompass an individual’s perceived risks and assessed needs for medical care.

Numerous reviews of existing literature consistently affirm that Andersen’s behavioral model provides a valuable approach to assessing the social and structural factors influencing healthcare utilization [18, 19]. Consequently, it serves as a strategic analytical framework to identify potential intervention targets to enhance accessibility to and utilization of PrEP-related services in pharmacies.

Data source

Data were obtained from the 2020 American Men’s Internet Survey (AMIS). AMIS is a cross-sectional online behavioral health survey of SMM in the US that has been conducted annually since 2013. The survey collects data on sociodemographic characteristics, sexual behavior, health-related behaviors, and HIV prevention services. The 2020 cycle was conducted from August 2020 to January 2021. Briefly, individuals were recruited through convenience sampling from various websites through banner advertisements and social networking and geospatial networking applications. Additional detail about AMIS are available elsewhere [20].

Study participants

Men were eligible for the AMIS if they reported (1)  ≥ 15 years of age, (2) male sex at birth, (3) cis-gender identity, (4) residing in the US, (5) ever having sex with a man OR a gay/bisexual identity (for those 15–17 years old), and (6) ability to complete the survey in English. Participants were included in the current analysis if they completed the full survey, had oral or anal sex with a man in the past 12 months, and reported being HIV-negative or had an unknown status. Participants who reported being HIV-positive were excluded from this analysis, as PrEP eligibility requires a person to be HIV-negative. Additionally, participants who had taken PrEP in the past 12 months at the time of the survey were not asked about their willingness to obtain PrEP screening in pharmacies, as a function of the skip pattern in the survey [20]. We also excluded participants who had missing data related to their willingness to screen for PrEP in a pharmacy setting (i.e., the outcome variable; n = 273).

Measures

Guided by AHUM domains, we used the following variables to assess willingness to obtain pharmacy-based HIV prevention services among a sample of US SMM.

  • Dependent Variable: To assess willingness to be screened for PrEP in a pharmacy, men were provided with a brief description of what screening for PrEP entailed:

    Screening for PrEP includes answering questions about your sexual behaviors and being tested for HIV and sexually transmitted infections.

    They were subsequently asked, “Would you be willing to be screened for PrEP in a private area in a pharmacy?” and were provided the options: Yes, No, I prefer not to answer, and Don’t Know. The latter two options were excluded from this analysis (n = 1019).

  • Predisposing Factors: Age was treated as a continuous variable in years in descriptive and bivariate analyses. To enhance the interpretation of our findings, age was scaled to five-year increments in multivariable analysis [21]. Race was categorized into four groups: non-Hispanic Black, non-Hispanic White, Hispanic, and Other/Multiple races.

  • Enabling Factors: Employment status was assessed using three categories: Employed, Unemployed, and Retired. Annual household income was categorized into four groups including $0 to 19,999, $20,000 to $39,000, $40,000 to $74,999, and $75,000 or more. Education was defined as the highest level of education completed and categorized as less than (<) a high school (HS) diploma, HS diploma, some college, and college degree or more. Health insurance was assessed as a binary yes/no variable. Lastly, we included a series of questions with binary (yes/no) responses related to health insurance, PrEP awareness, willingness to use PrEP, SMM healthcare stigma (defined as ever feeling afraid of accessing health care services due to someone finding out they have sex with men), and PrEP pharmacy comfort (defined as comfort with speaking to pharmacy staff about PrEP).

  • Need Factors: Need factors were those associated with increased HIV risk and PrEP uptake, particularly among SMM. Participants were asked about the number of male sexual partners they had in the past 12 months (categorized as ‘1’ or ‘2 or more’; no participants reported 0 sexual partners). This item was included as previous studies have found an association between multiple sexual partners and HIV risk [22]. Additionally, participants were asked if they have had condomless anal sex in the past 12 months with another man (yes/no); had any type of sex with a woman in the past 12 months (yes/no); had any STI test in the past 12 months (yes/no); ever been tested for HIV (yes/no); had an HIV test in the past 12 months (yes/no); and if they were worried about becoming infected with HIV (yes/no). Lastly, we categorized participants by their HIV-negative status: HIV negative and never tested/unknown/indeterminate.

Analysis plan

Sample characteristics were described with medians and interquartile ranges (IQRs) for continuous variables and frequencies for categorical variables. Wilcoxon rank tests were performed to examine differences in median age among those who reported willingness to obtain PrEP in pharmacies versus not. Chi-square and Fisher’s exact (when sample sizes were < 5) tests were performed to explore differences by the included AHUM measures for the main outcome. Bivariate analyses were conducted to explore differences in willingness to be screened for PrEP in pharmacies by the three AHUM domains.

In accordance with AHUM, we also estimated a series of three multivariable models. First, all predisposing variables were included in a model. Second, predisposing and enabling factors were modeled together. Finally, predisposing, enabling, and needs based factors were modeled simultaneously. The use of a hierarchical analytic approach was based on multi-level theory, and to assess the incremental contribution of each variable block group on participants’ willingness to screen for PrEP in pharmacies.[23] To increase parsimony, variables that were not significant in bivariate analyses were removed from multivariable models. We estimated correlates of willingness to use pharmacy-based HIV prevention services using a modified stepwise Poisson regression method suited for common binary outcomes with robust variance estimates [24]. A 95% confidence interval (CI95%) was calculated for each prevalence ratio (PR). Analyses were conducted using SAS version 9.4 (Cary, NC).

Results

Our sample included a total of 10,814 SMM who were not taking PrEP at the time of the survey and responded on their willingness to obtain HIV prevention services in pharmacies. The median age was 26 years, and most men were White (61%) and Hispanic (20%). A large proportion of participants were employed (71%) and college-educated (42%), with household incomes <$75,000/year (63%). Eighty-nine percent of participants reported that they had health insurance. Most participants had heard of PrEP (79%), were willing to use PrEP (56%), and felt comfortable speaking with pharmacy staff about getting PrEP (75%). Overall, risk behaviors were high. In the past 12 months, most participants (70%) had two or more male sexual partners and 68% had condomless anal sex. Most (76%) reported that they were willing to screen for PrEP in a pharmacy.

In bivariate analyses, younger participants were significantly more willing to be screened for PrEP in pharmacies compared to older participants (P < .0001) (Table 1). Among racial and ethnic groups, Hispanic participants (80%) and participants of Other/Multiple races (79%) were significantly more willing to be screened for PrEP in a pharmacy setting compared to Black (75%) and White (75%) participants (P < .0001). Household income was inversely associated with willingness to be screened for PrEP in a pharmacy setting (P < .0001). Similarly, participants with less than a college education were more willing to be screened for PrEP in a pharmacy compared to those with a college degree (P < .0001). Seventy-six percent of participants who had health insurance were willing to screen for PrEP in a pharmacy compared 84% who did not have health insurance. Individuals who reported being afraid of accessing healthcare services because someone may discover that they have sex with men (80%) were significantly more willing to screen for PrEP in pharmacies compared to those who were not fearful (76%) (P < .0001). Participants who reported being worried about becoming infected with HIV (87%) were more willing to screen for PrEP in a pharmacy setting compared to those who were not worried (70%) (P < .0001).

Table 1 Sample Characteristics and Bivariate Associations with Willingness to Screen for PrEP in Pharmacies among SMM in the U.S. (n = 10,816)
Full size table

In adjusted analyses, younger participants were slightly less willing to be screened for PrEP in a pharmacy than older participants (PR = 0.99; CI95%=0.98, 0.99) (Table 2). The race/ethnicity association noted above did not persist after accounting for age. Compared to employed individuals, individuals who reported being retired were less willing to be screened for PrEP in pharmacies (PR = 0.89; CI95%=0.81, 0.98). Participants who had a general willingness to use PrEP, compared to those who were not, were more willing to screen for PrEP in a pharmacy (PR = 1.52; CI 95% = 1.45–1.59). Individuals who reported feeling comfortable speaking with pharmacy staff about PrEP were almost three times as likely to be willing to screen for PrEP in a pharmacy compared to those who did not feel comfortable (PR = 2.71; CI95%=2.47, 2.98). Reported worry around becoming infected with HIV was also associated with willingness to obtain PrEP screening in pharmacies (PR = 1.04; CI95%=1.02, 1.06). Importantly, we observed no differences among those who were willing to be screened for PrEP in pharmacies according to race and ethnicity, education level, household income, nor insurance status.

Table 2 Stepwise Poisson Regression Examining Factors Associated with Willingness to Screen for PrEP in Pharmacies Among SMM in the U.S. (n = 10,816)
Full size table

Discussion

Guided by Andersen’s behavioral model, this study explored factors associated with willingness to obtain PrEP screenings in pharmacies among a diverse, national sample of SMM in the US. Although there is a general increase in PrEP willingness among MSM [25], our data suggests variations in willingness to obtain PrEP services in pharmacies based on need, enabling, and predisposing factors. Our findings reveal that a substantial proportion of SMM (76%) expressed willingness to undergo PrEP screening in a pharmacy setting. Our study also shows that being of younger age was associated with less willingness to screen for PrEP in a pharmacy setting. Among enabling factors, those who had a general willingness to use PrEP and felt comfortable discussing PrEP with pharmacy staff were more willing to screen for PrEP in pharmacies. Participants who were reported being retired were less willing to screen for PrEP in a pharmacy compared to those who were employed. Finally, being worried about potentially acquiring HIV was the only need factor linked to willingness to screen for PrEP in a pharmacy-based setting.

Notably, we observed no significant differences in willingness to obtain pharmacy-based HIV prevention services based on race/ethnicity, educational level, annual household income, nor insurance status. This finding is promising as it suggests that pharmacies may serve as an accessible and equitable option for individuals, including those most structurally disadvantaged and at-risk for HIV acquisition. Previous studies have highlighted racial inequities in PrEP uptake, often attributed to various barriers faced by minoritized populations, including structural inequities and intersectional stigma and discrimination [26,27,28]. However, contrary to existing research on the relationship between stigma and healthcare utilization among SMM, our findings reveal that stigma may not fully impact willingness to use screen for PrEP in pharmacy settings among a diverse group of SMM. In the context of this study, this might be due to a higher need for HIV prevention services. Similarly, the substantial willingness observed across demographic groups in our study signals a potential avenue for addressing these inequities through innovative service delivery models like pharmacy-based PrEP screening.

Our study highlights the pivotal role of pharmacists and pharmacy staff in facilitating discussions about PrEP and promoting its uptake among SMM. Comfort with speaking to pharmacy staff about PrEP emerged as a significant predictor of willingness to undergo pharmacy-based HIV prevention services. Indeed, in a previous study, Lutz et al. report that approximately 94% of participants felt comfortable discussing PrEP with a pharmacist prior to starting the medication [29]. This underscores the importance of pharmacist training and ensuring patient privacy to foster a supportive environment for discussing sensitive topics related to HIV prevention. Additionally, addressing social stigma and discrimination remains a critical piece in enhancing HIV prevention efforts, particularly among populations like BSMM. Pharmacies, perceived as less stigmatizing and more convenient settings than traditional clinics, [12, 29, 30, 31, 32] hold significant promise in mitigating the impact of stigma on HIV prevention access and uptake.

In this study, we employed Andersen's Behavioral Model of Health Service Utilization as a comprehensive framework for understanding the factors influencing willingness to obtain HIV prevention services in pharmacies among SMM. This model allowed us to consider the impact of various predisposing, enabling, and need factors on individuals' access to and use of pharmacy-based PrEP screening.

Previous intervention studies have demonstrated the feasibility of implementing HIV testing and PrEP access in pharmacies, effectively reaching populations with increased needs [10, 33]. For instance, one study found that pharmacy-based point-of-care HIV testing, including pretest counseling, test processing, and posttest counseling, was feasible within a 30-minute period in 21 pharmacies across both rural and urban areas in the U.S. [34]. Another study, addressed the stigma usually associated with HIV and HIV testing by utilizing a comprehensive health screening approach, which improved HIV testing uptake among individuals at increased risk in disadvantaged neighborhoods [35]. This intervention found that individuals that participants who received HIV testing, holistic chronic disease screening, and a healthy lifestyle video—aimed at normalizing all screenings and destigmatizing HIV—were more likely to undergo HIV testing in a pharmacy compared to those who only received HIV testing services [35]. Regarding PrEP screenings specifically, Sawkin and Shah’s study trained clinical pharmacists to provide PrEP education and medication management, enabling PrEP providers through a collaborative practice agreement (CPA) [36]. They employed a destigmatizing approach similar to Crawford et al. [35], offering PrEP screening alongside other health condition screenings [36]. Despite growing evidence and advocation for integrating HIV prevention services in pharmacies, very few interventions have specifically focused on enhancing pharmacy-based HIV testing and PrEP screening among SMM, particularly racially and SMM living in disadvantaged neighborhoods. This is particularly notable given their demonstrated willingness to utilized such services, as evidenced by this study’s findings and others [12, 14, 32]. HIV prevention services in pharmacies, particularly PrEP screenings, may currently be limited due to restrictions around pharmacists’ ability to initiate PrEP for clients without a CPA with a partnering PrEP-prescribing physician [37]. Efforts to address these limitations and barriers are critically needed.

Building upon the findings of this study, future studies may focus on integrating and testing culturally appropriate strategies within pharmacy-based settings to assess if willingness to undergo PrEP screening translates into true uptake and sustained engagement with preventive care. Moreover, further research is needed to explore the mechanisms by which stigma, including intersectional stigma and discrimination, influences HIV risk and PrEP utilization among SMM, particularly BSMM, in pharmacy settings. To advance PrEP equity, further investigation is warranted to comprehensively understand and address the underlying reasons behind certain men's willingness and unwillingness to access such services. By addressing these challenges and leveraging the potential of pharmacies as accessible and inclusive platforms for HIV prevention, we can make advancements towards the goal of reducing HIV disparities and ending the epidemic.

Limitations

Several limitations should be considered in the interpretation of our findings. First, AMIS relies on a convenience sample of internet-using SMM, which may introduce selection bias. Caution should be exercised when generalizing these results to the broader population of SMM in the US. Notably, Notably, while a significant portion of our sample consisted of non-Hispanic white men, which does not fully represent the diversity within the SMM community. Second, the data collection period during the Fall of 2020 coincided with the COVID-10 pandemic, which may have influenced men’s perceptions of healthcare and their access to it, including through pharmacies. The evolving landscape of healthcare delivery during this time may have affected participants’ willingness to engage with pharmacy-based HIV prevention services. Third, the categorization of race/ethnicity data, particularly to the grouping of individuals under ‘Other/Multiple Races’, limits the ability to address specific prevention needs of communities disproportionately affected by HIV. For instance, the CDC reports a notable increase (24%) in HIV diagnoses among American Indian/Alaska Native individuals between 2015 and 2019 [38]. Future research efforts should prioritize strategic recruitment of racially and ethnically diverse SMM cohorts, enabling a nuanced analysis able to consider unique prevention strategies tailored to different communities. Finally, the cross-sectional design of our study precludes establishing causality or assessing temporality. While our findings indicate willingness among SMM to access pharmacy-based HIV prevention services, longitudinal studies are needed to ascertain whether this willingness translates into true uptake of services such as PrEP over time.

Conclusion

Integrating HIV prevention services within pharmacy-based settings is a promising strategy in the comprehensive initiative to end the HIV epidemic in the US, including inequities experienced by priority populations. The receptivity of a diverse, nationwide sample of SMM to undergo PrEP screening in pharmacies, even in the face of potential sexuality-based stigma, underscore the viability of this approach. Recognizing pharmacies as inherently conducive and accessible environments for such services further strengthens the case for their pivotal role in advancing HIV prevention efforts.

The next crucial step involves the implementation of demonstration studies aimed at assessing the impact of pharmacy-based PrEP delivery models on both the uptake and adherence of PrEP among SMM. These studies will contribute invaluable insights to inform and enhance the effectiveness of future strategies, ultimately bringing us closer to the goal of eradicating HIV.