In the past decade, powerful tools to prevent HIV have become available. Two of the most important are:
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Pre-exposure prophylaxis (PrEP): A daily pill taken by people who do not have HIV to greatly reduce their chances of getting it.
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Treatment as prevention (TasP): When a person living with HIV takes medication consistently and keeps the virus at an “undetectable” level in their blood, they do not transmit HIV to their sexual partners. This is often summarized as "Undetectable = Untransmittable" (U=U).
These approaches are especially important for communities that continue to be hardest hit by HIV, including men who have sex with men (MSM) and transgender women, particularly those who are Black, Latino, or living in areas with fewer health resources.
Dr. Matacotta and his team conducted a systematic review of 24 studies published between 2010 and 2019 to understand what MSM and transgender women believe about PrEP and TasP, and what gets in the way of using them.
What Did the Study Look At?
The researchers searched several medical and psychology databases for U.S.-based studies focused on:
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MSM and transgender women
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Knowledge, attitudes, and beliefs about PrEP and TasP
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Real-world barriers to getting and using PrEP
They then looked across all the studies to identify common themes and patterns.
Key Finding 1: Many People Still Don’t Know Enough
A major finding was limited awareness and understanding of PrEP and TasP:
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Many MSM and transgender women had never heard of PrEP or were unsure how it worked.
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Knowledge gaps were especially common among younger people, Black and Latino MSM, transgender women, and people with lower income or less access to health information.
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Even when people had heard of PrEP, they often had misconceptions, such as:
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Fears of serious long-term side effects
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Worries that HIV medications used for PrEP would stop working if they later got HIV
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Belief that PrEP was only for certain groups
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For TasP and U=U, many people did not fully understand what “undetectable” means or felt unsure whether the message could really be trusted.
Key Finding 2: Cost, Location, and Systems Get in the Way
Even when people were interested in PrEP, practical barriers often blocked access:
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Cost and insurance: Concerns about paying for visits, lab tests, and prescriptions were common, especially among people without stable insurance or those on Medicaid.
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Geography: People in rural areas or regions with few LGBTQ+ or HIV-focused services struggled to find providers who knew about or felt comfortable prescribing PrEP.
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Clinic access: Transportation problems, long distances, and limited clinic hours also made it harder to start and stay on PrEP.
These issues were especially pronounced in communities of color in the Southern United States, where HIV rates are high, but services are often limited.
Key Finding 3: Stigma and Mistrust Are Powerful Barriers
The review found that stigma—shame and negative attitudes related to HIV, sexuality, and gender identity—strongly affects whether people use prevention tools:
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Some worried that taking PrEP would lead others to label them as “promiscuous” or assume they had HIV.
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Fear of judgment from partners, family, or community members led some to avoid asking about PrEP or seeking care from clinics known for HIV services.
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Many Black and Latino MSM described mistrust of the health care system and pharmaceutical industry, shaped by racism, homophobia, and past discrimination.
These experiences make it harder to believe that HIV prevention campaigns and health systems truly have their best interests in mind.
Key Finding 4: Health Care Providers Play a Critical Role
Health care providers can be trusted guides in HIV prevention, but the studies showed this potential is not always realized:
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Many patients said their doctors never mentioned PrEP, even when their HIV risk was high.
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Some reported dismissive or judgmental reactions when they asked about sex, partners, or prevention options.
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Some providers themselves lacked training on PrEP or assumed only HIV specialists should prescribe it.
When patients feel judged or misunderstood, they are less likely to return, ask questions, or start medicines that could protect them.
What Needs to Change?
Dr. Matacotta and his team concluded that PrEP and TasP are highly effective but underused. To unlock their full potential, efforts must go beyond simply making the medicines available. Key steps include:
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Better education and public information about what PrEP and TasP are, how well they work, and who can benefit.
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Targeted outreach to communities most affected by HIV, using culturally relevant, affirming messages.
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Reducing financial and structural barriers, including cost, insurance challenges, and lack of local knowledgeable providers.
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Training and supporting health care providers to offer respectful, informed care to sexual and gender minority patients.
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Directly addressing stigma, including HIV stigma, homophobia, and transphobia.
Bottom Line
PrEP and TasP give us the tools to dramatically reduce new HIV infections—even to move toward a future with zero new transmissions. But to get there, people must:
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Know about these options
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Trust the information and the system providing it
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Have real, affordable access to respectful, judgment-free care
This research highlights that HIV prevention is not only about medication; it is also about information, trust, and equity.
The original article can be found on PubMed.