Rapid review of drivers, barriers, and facilitators to pre-exposure prophylaxis uptake among indigenous peoples for improved HIV prevention outcomes

Abstract

Indigenous peoples experience disproportionately high rates of HIV, highlighting a gap in access to biomedical prevention tools like Pre-Exposure Prophylaxis (PrEP). This rapid review synthesizes evidence on socio-cultural, structural, and systemic drivers of HIV disparities among Indigenous populations, alongside the barriers and facilitators of PrEP initiation and sustained use. Differences and commonalities in PrEP needs, perceptions, and implementation strategies across Indigenous communities worldwide were also examined, with a focus on identifying successful Indigenous-led interventions that improved HIV prevention outcomes. We conducted a rapid review of publications in PubMed/MEDLINE, without date or language restrictions. Searches combined terms for Indigenous populations, HIV/PrEP, and their determinants. Eligible studies included Indigenous populations and focused on barriers, facilitators, or interventions related to PrEP. Data were extracted and narratively synthesized using the SEM-Cultural Safety framework. Findings identified underfunding of Indigenous health services, geographic isolation, poverty, and culturally unsafe healthcare environments as contributors to HIV acquisition. These structural inequities were compounded by intersecting substance use, sexuality, and HIV stigma, as well as medical mistrust, which hindered PrEP access and uptake. Facilitators were Indigenous leadership and community-controlled models, which fostered trust, cultural safety, and program relevance. Successful interventions integrated structural investment in Indigenous-led services, community-based stigma reduction, support from trusted providers and peers, and individual-level education tailored to local contexts. Bridging gaps in PrEP access for indigenous people requires a paradigm shift towards decolonized, community-led interventions that dismantle structural barriers and embody Cultural Safety. Future efforts must prioritize implementing and evaluating Indigenous-governed programs to achieve health equity.