Description
Background: Despite the availability of effective HIV prevention strategies, including pre-exposure prophylaxis (PrEP), gaps in prevention delivery persist across healthcare settings. Missed opportunities for HIV prevention remain common, yet multilevel factors driving these gaps are not fully understood. Understanding these drivers is essential to inform effective interventions at the individual, interpersonal, provider, and system levels. Objectives: To identify and synthesize multilevel determinants of missed opportunities for HIV prevention and PrEP delivery. Methods: We conducted a qualitative synthesis within a systematic review of U.S.-based studies (2012-2025) on missed opportunities for HIV prevention. Articles were identified through database searches (PubMed, Embase, and Scopus). Following systematic screening and eligibility assessment based on predefined criteria, 10 studies were included. Data analysis was conducted in 2026 using thematic coding in ATLAS.ti (version 26.0.1.33961), applying inductive and deductive approaches. Coding was conducted iteratively to identify recurring patterns and develop higher-order themes. Emergent themes were organized within a socio-ecological framework to capture patient-, provider, and system-level influences. To enhance analytic rigor, two independent coders conducted the analysis, with discrepancies resolved through discussion to ensure consistency. Results: Thematic analysis revealed consistent, interrelated multi-level barriers. At the patient level, low perceived HIV risk, stigma, and competing social priorities, including housing instability and substance use, limited engagement in prevention services. Provider-level barriers included limited PrEP knowledge, discomfort with sexual health discussions, and inconsistent sexual history screening. At the health system level, time constraints, inadequate documentation, and poor integration of PrEP into routine workflows contributed to missed opportunities, even when clinical indications were clear. Across studies, missed opportunities occurred during routine clinical encounters, including STI testing, reproductive health visits, and primary care interactions. A substantial decline in engagement was observed along the PrEP care continuum, particularly between patient interest and initiation. These barriers were highly interconnected, with structural and system-level constraints influencing provider behaviors and patient engagement. Conclusions: Missed opportunities for HIV prevention are driven by interconnected multilevel barriers rather than isolated patient-level factors. Interventions integrating provider training, clinical decision support, workflow redesign, and pharmacist engagement may improve the identification of eligible individuals, facilitate PrEP uptake, and advance equitable preventive care
Publication Info
2026.