Barriers to Initiating HIV Pre-Exposure Prophylaxis Over Time Among Youth Who are at Higher Risk of Acquiring HIV

Background: Pre-exposure prophylaxis (PrEP) is widely recommended to prevent HIV transmission yet use remains lower among adolescents than older adults. Setting: Youth at higher risk of acquiring HIV, ages 14-24 years, were recruited from 13 community-based and healthcare organizations, social media outreach, and peer referrals in New Orleans and Los Angeles for an HIV prevention trial. Methods: A secondary data analysis examined baseline PrEP initiation barriers and rates over time, among participants who reported never using PrEP. Multiple logistic regressions assessed associations between the four most common barriers reported at baseline, demographics, and risk factors. Results: Participants who responded to initiation barrier questions (n=531) were mostly cisgender men (84%), gay (59%) or bisexual (28%), diverse in race/ethnicity (32% Black, 32% Latinx/Hispanic, 23% non-Hispanic White), and older than 18 years (42% 19-21, 44% 22-24). At baseline, 35% reported “not needing” as their primary barrier, which increased to 69% by 24-months among never PrEP users. Other common baseline barriers were cost (19%), side effect concerns (19%), and difficulty accessing (18%), which declined to about 5%-10% by 24-months. In regression analyses, factors associated with these barriers varied by barrier and direction of association. Reporting no need for PrEP was associated with being White (vs. Latinx; OR=1.95, 95%CI=1.08-3.51), trans-diverse masculine (vs. cisgender; OR=4.17, 95%CI=1.96-8.87), lifetime incarceration (OR=3.76, 95%CI=1.89-7.49), and fewer recent sexual partners (3+ vs. none, OR=0.44, 95%CI=0.21-0.89). Conclusions: Results highlight multiple barriers to PrEP initiation endorsed by youth. The diversity of factors associated with different barriers may inform interventions to improve PrEP uptake.