Barriers to and Facilitators of Heterosexual Men's Engagement with the PrEP Care Continuum in Sub-Saharan Africa: A Scoping Review.

The HIV epidemic in sub-Saharan Africa (SSA) continues to spread primarily through heterosexual contact, and in many countries, heterosexual men continue to exhibit a high HIV incidence with resultant morbidity and mortality. While there is a growing recognition of the importance of engaging men in the pre-exposure prophylaxis (PrEP) care continuum, there remains a significant gap in our understanding of the multilevel influences that modulate heterosexual's men ability to utilize PrEP. We conducted a scoping review to explore emerging research examining the individual-, interpersonal-dyadic, and social-structural barriers and facilitators to PrEP awareness/willingness, uptake, adherence, and persistence in this population. Sixty-two articles were selected for inclusion in this review. We identified several multilevel influences on PrEP engagement for heterosexual men that were similar to those affecting other key populations, including doubts about PrEP safety and efficacy, difficulties communicating with partners, peers, and family members, as well as PrEP-related stigma, and costs associated with accessing PrEP. In addition, we found that heterosexual men's engagement with the PrEP care continuum was influenced by the interaction of individual-level characteristics and beliefs about PrEP and a distinct set of masculine norms governing men's personal, sexual, and economic lives. Results from this review can help guide future research and interventional approaches seeking to improve PrEP engagement among heterosexual men in the SSA context.