Exploring the Indigenous and Western determinants of health and PrEP continuum of care among Native Americans across Indian Country (United States of America): a systematic review

Introduction The burden of HIV among Native American communities is significant and rising across Indian Country, yet little is known about the PrEP continuum of care or the factors that influence PrEP engagement among these resilient communities.Theory This review examines the determinants of health shaping the PrEP continuum of care among Native American communities through the lens of both Indigenous and Western frameworks. Barriers and facilitators emerging across the literature are organized within the five levels of the Socio-Ecological Model.Method A systematic search across six academic and two grey literature databases identified 2,949 studies, of which 31 were included; qualitative and quantitative associations between determinants of health and PrEP outcomes were synthesized descriptively, and barriers and facilitators were identified thematically.Results Only three studies had entirely Native American study populations; across the remaining 28, Native Americans were underrepresented or aggregated with other racial-ethnic groups, demonstrating evidence of data genocide. Findings revealed mixed or non-statistically significant associations between Western determinants of health and PrEP outcomes, while Indigenous determinants were rarely examined. Thirty-six barrier and 26 facilitator themes emerged across the five levels of the Socio-Ecological Model.Discussion Results underscore the limited understanding of the determinants of health influencing the PrEP continuum of care among Native American communities. Recognizing both Indigenous and Western determinants as integral to the PrEP continuum of care may transform how researchers, practitioners, and Native American communities collectively conceptualize and implement PrEP initiatives.