Abstract
Background: In Iowa, men who have sex with men (MSM) accounted for 54% of persons with
HIV in 2022 and Non-Hispanic Black/African Americans were over 10 times more likely to be
diagnosed with HIV than Non-Hispanic white Iowans. To address this disparity in HIV incidence
and prevalence, the United States (US) government ending the HIV epidemic (EHE) initiative
seeks to expand pre-exposure prophylaxis (PrEP) coverage across the United States. Recent
data showed that PrEP coverage is suboptimal in Iowa (a rural state), and Black Iowans were
less likely to engage with PrEP services.
Objectives: Using capability, opportunity, motivation and behavior (COM-B) model for behavior
change, this study sought to identify the key barriers and facilitators to PrEP uptake among
Black/African American MSM in small urban areas in Iowa.
Design: This was a phenomenological study aimed to explore subjective views of Black MSM
on PrEP use.
Methods: In-depth semistructured interviews were conducted with 12 Black MSM aged 20–
42 years in two small urban counties. Broad themes identified from the interview transcripts
were analyzed inductively and mapped onto the COM-B constructs deductively.
Results: Results showed that barriers to PrEP uptake were closely associated with five (of
six) COM-B subcomponents: physical capability, psychological capability, social opportunity,
reflective motivation, and automatic motivation. The thematized barriers were (1) lack of
medical insurance; (2) limited PrEP awareness; (3) PrEP stigma; (4) fear of distrust among
partners; (5) anticipated side effects; and (6) doubt about PrEP effectiveness. Similarly,
facilitators to PrEP uptake were aligned with four subcomponents of COM-B model:
physical capability, psychological capability, social opportunity, and physical opportunity.
The thematized facilitators were (1) increased PrEP awareness; (2) PrEP access without
discrimination; (3) state provision of PrEP to uninsured; and (4) physicians buy-in and
recommendation. No motivation-related facilitators were reported.
Conclusion: To reduce the current disparity in HIV incidence and to achieve the EHE goals
of expanding PrEP coverage in Iowa, efforts should be directed toward the provision of
low-cost or free PrEP services, healthcare providers’ training on cultural competence,
and the development of culturally appropriate strategies to deliver PrEP to the Black MSM
community.