ABSTRACT
Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, uptake among men who have sex with men (MSM) in Upstate South Carolina remains limited. This study investigates barriers to PrEP access and utilization in this population to guide targeted public health strategies. A cross-sectional survey of MSM aged 18 and older was conducted to collect demographic information, perceptions and misconceptions about PrEP, and reported obstacles to accessing it. Pearson correlation tests were used to examine associations between participant characteristics and identified barriers. Social stigma, financial constraints, and limited provider engagement emerged as the most frequently reported barriers. Notably, lower socioeconomic status was significantly associated with perceptions of discrimination in healthcare settings, while racial and ethnic minority participants were more likely to express a desire for proactive discussions about PrEP with their providers. Participants also emphasized the need for clearer pathways to locate PrEP access programs and indicated that reducing wait times for initiation would improve their likelihood of starting PrEP. These results highlight the need for interventions that address both social and structural barriers to PrEP uptake. Expanding financial support, increasing provider involvement, and implementing statewide public awareness efforts are critical to improving access and reducing disparities among MSM in this region.
INTRODUCTION
Preventive efforts to reduce HIV infection rates have illustrated effectiveness over the past few years, however, it remains a noteworthy public health issue across the United States (Center for Disease Control and Prevention, 2024). It is estimated that the Southern region of the United States accounted for 49% of new HIV infections in 2022 (Center for Disease Control and Prevention, 2024), with South Carolina being in the top ten of highest incidence rates in the South that same year (Center for Disease Control and Prevention, n.d.). The federal Ending the HIV Epidemic initiative also lists South Carolina as one of the target states to achieve its eponymous goal (Center for Disease Control and Prevention, n.d.). The funding that this initiative provided has been stated to be useful in promoting PrEP access across the state (Center for Disease Control and Prevention, n.d.). Notably, approximately one in five new HIV infections over a two-year period were reported in the Upstate region of South Carolina in particular, with the largest risk group being men who have sex with men (MSM) (South Carolina Department of Public Health, 2021). The Upstate region consists of eleven counties: Greenville, Spartanburg, Cherokee, Pickens, Oconee, Anderson, Laurens, Union, Abbeville, Greenwood, and McCormick. AIDSVu data on PrEP use among males are available for all of these counties except McCormick. Spartanburg, Greenville, Pickens, and Cherokee counties have some of the lowest rates of PrEP uptake in the Upstate region (AIDSVu, 2024).
The Centers for Disease Control and Prevention (CDC) guidelines emphasize the importance of preexposure prophylaxis (PrEP) for individuals at substantial risk of HIV acquisition, including MSM with recent bacterial STIs or inconsistent condom use (Workowski et al., 2021). Therefore, it is evident that efforts to improve PrEP uptake and adherence among MSM are critical to reducing new HIV infections and achieving public health goals.
PrEP is a safe and effective method of prevention to reduce the risk of HIV transmission (Riddell et al., 2018). Even so, the CDC states that out of 10,390 South Carolinians who are at high risk of HIV and could benefit from PrEP, only 1,701 were prescribed the drug (CDC, 2022). This illustrates the urgent need to explore and address the reasons behind such a discrepancy between the number of those who could benefit from PrEP versus the number of whom actually receive a prescription for it. Despite its proven efficacy, the uptake of PrEP among MSM has been suboptimal. A recent study highlighted that while familiarity with PrEP among gay and bisexual men increased significantly from 2016 to 2018, actual usage remained relatively low, with only 7.8% of eligible participants using PrEP by 2018 (Holloway et al., 2018). This indicates a gap between awareness and utilization that needs to be addressed through targeted interventions.
Previous studies have shown that barriers to PrEP usage and obtainment broadly include the following: awareness/knowledge, HIV risk perception, stigma distrust of the medical system, access to healthcare, lack of financial assistance, and adverse effects (Mayer et al., 2020; Lozano et al., 2023; Watson et al., 2022; Viera et al., 2022). In Upstate South Carolina, specifically, barriers to PrEP use may be linked to the rurality of the county, as most counties are classified as a health profession shortage area (Cicero Institute, 2024). Additionally, the Upstate Region has demonstrated strong support for the Republican Party (which often promotes conservative policies), with every county voting in its favor during the 2024 election (South Carolina Votes, n.d.). Historically, conservative policies have included opposition to certain LGBTQ+ rights, which may contribute to increased social stigma or political barriers to accessing PrEP in this area (Kapadia 2024).
In this study, we aim to identify the most common barriers to PrEP specific to MSM living in the Upstate of South Carolina, in the hopes that local health departments and medical organizations may use this information to optimize their PrEP campaigns and contribute to the ongoing efforts of reducing the number of new HIV infections in the region.
METHODS
Survey Design
An online self-administered survey was distributed to residents aged 18 and older of Upstate South Carolina, USA, including Anderson, Cherokee, Greenville, Greenwood, Laurens, Pickens, Spartanburg, and Union County. Study participants were recruited within a three-month time span between November 2024 and February 2025 using convenience sampling via social media (Instagram and Facebook) and community outreach. Participants were recruited at three community outreach events: (1) a public social gathering hosted by a local queer support center, (2) a fast-track registration event held at a local HIV prevention center, and (3) an informal LGBTQIA+-friendly social event promoted on Instagram. During the public social gathering, flyers containing QR codes were distributed randomly, allowing individuals to participate at their discretion. At the registration and informal events, attendees were randomly approached and invited to complete the survey on a tablet. All survey questions were close-ended and formatted for forced responses to prevent incomplete responses. Survey question development was adapted through peer-reviewed studies (Napper et al., 2012; Pico-Espinosa et al., 2023). Cognitive testing approaches amongst physicians and peers were used to evaluate the proposed questions to ensure survey quality and clarity (Beatty et al., 2007; Presser et al., 2004).
Statistical Analysis
Perceptions of and the use of PrEP was analyzed via Pearson Correlation Test Statistics through R (v. 4.0.2, R Foundation for Statistical Computing, Vienna, Austria), a statistical software package. This allowed for the direct analysis of strength between variables. Descriptive statistics were used to summarize demographic information and PrEP use. Statistical analyses were conducted with significance determined at a threshold of p < 0.05.
Ethical Considerations
This study was approved by an institution’s Internal Review Board. All survey participants gave informed consent to participate and were instructed that they could withdraw at any point. Data obtained was anonymous and personally identifiable information was not collected in the survey and single-blind survey methods were used to countervail any research bias. Qualtrics, a HIPAA compliant software package that uses Transport Layer Security (TLS) encryption for all transmitted data (Kent State University, 2021), was used to collect participant consent and survey data.
RESULTS
Respondents
Of the 35 responses received, 28 participants were used for statistical analysis. Only respondents who listed their biological sex as male were used for analysis. Demographic information obtained included age, sex assigned at birth, gender identity, ethnic background, county of residence, highest level of education, marital status, annual household income, political party, and sexual orientation.
Of the 28 completed male responses, the median age of the respondents was 33 years old, ranging between 22 and 52 years of age. 85.7% (n=24) of respondents were male-identifying and 64.3% (n=18) reported their sexual identity as gay. Underrepresented minorities made up 32.1% (n=9) of respondents which was consistent with state demographics (35.6%). The majority of respondents lived in Greenville County, South Carolina (n=23; 82.1%), reported a democratic political affiliation (n=19; 67.9%), were not currently in a relationship (n=14; 50.0%), and obtained a four-year bachelor's degree (n=14; 50.0%). Further demographic results can be found in Table 1.
Results
Significant correlations were found between several demographic variables and barriers to PrEP use (Tables 2, 3, & 4). These include correlations between socioeconomic status and discriminatory treatment by their primary care physician (p=0.041), individuals not currently taking PrEP wishing for assistance finding a provider in their geographic area (p=0.03), and underrepresented minorities wishing for more physician engagement in discussing their healthcare (p=0.03).
There were found to be weak negative correlations between respondents’ annual household income and education levels with their experienced/perceived barriers of “My family would think less of me” and “The people in my doctor’s office would treat me differently if they found out that I used PrEP”, -0.388 and -0.389, respectively (Table 2). In addition, there was a strong positive correlation between the responses of the aforementioned barriers to PrEP use (0.77) (Table 3). This suggests that respondents who have personally experienced or perceived familial bias also experienced or believed they would be discriminated against in the healthcare setting.
Whilst the majority of respondents have reportedly never seen the barriers listed in the survey, two barriers were seen in approximately one third of respondents, which were either experienced personally, perceived in friends/family, or perceived through social media
Figure 1 Experienced or Perceived Barriers to PrEP Use (%)
Finally, when analyzing factors attributing to the barriers of PrEP use, it was found that most respondents wish for assistance in finding a public PrEP access program (n=27; 96.4%), a guide to providers who prescribe PrEP within their area (n=25; 89.3%), and a shorter wait time when going to obtain PrEP (n=25; 89.3%).
Figure 2 Factors That Would Increase PrEP Use (%)
DISCUSSION
Across the United States, barriers to PrEP usage are not only prevalent but also reflect similar challenges to those observed in Upstate South Carolina. These barriers often stem from deeply rooted social and financial factors, which can significantly influence an individual's decision to start or continue PrEP (Eichenwald et al., 2024). In both urban and rural areas, stigma remains a key issue, with many individuals expressing concerns about how their families, friends, or communities might perceive them if they were to use PrEP. This fear of social judgment can prevent individuals from accessing vital health resources, as they may prioritize maintaining social acceptance over seeking out preventive care (Arnold et al., 2024).
A recent study explored the relationship between socioeconomic status (SES) and perceived control over health, particularly in the context of HIV PrEP usage. The study found that lower SES was associated with higher perceived barriers to PrEP, such as stigma and discrimination in healthcare settings. These findings suggest that individuals with lower SES may feel less empowered to manage their health, which can negatively impact their willingness and ability to use PrEP (Petsnik & Vorauer, 2023).
Our findings highlight that a majority of participants desired support mechanisms, such as assistance in identifying publicly funded PrEP programs and providers in their area, as well as shorter wait times to initiate PrEP. These intervention preferences underscore the need for streamlined referral systems and localized provider directories. Furthermore, participants expressed interest in risk assessment tools and public testimonials, suggesting that digital tools and community storytelling campaigns could serve as valuable adjuncts to traditional public health messaging (Figure 2). According to the National Alliance of State & Territorial AIDS Directors (NASTAD), only 12 states/districts offer a State PrEP/PEP Assistance Program for financial support to cover the costs associated with PrEP (CA, CO, IL, IN, IA, MA, NM, NY, OK, VA, WA, and the District of Columbia) (NASTAD 2025). As of 2025, South Carolina does not offer a state-funded assistance program for PrEP, creating a significant barrier to access, particularly in the Upstate, where financial constraints may further limit its use. However, local organizations such as AID Upstate (serving Greenville and Anderson Counties) and Piedmont Care (serving Spartanburg County) have stepped in to provide vital resources for PrEP access in the region (AID Upstate 2025; Piedmont Care, 2025). It remains to be seen whether increasing awareness of these local organizations and their services would lead to greater PrEP utilization among MSM in the area.
Beyond financial and broad social stigma, our data revealed that familial perceptions play a role in deterring PrEP use. Many respondents believed their families would think less of them if they used PrEP, reflecting internalized stigma that extends beyond community norms. Additionally, perceived discrimination by healthcare providers, especially among lower-income participants, points to a need for cultural competency training to reduce bias in clinical settings. Only a small percentage of respondents believe that simpler alternatives exist to prevent HIV (~7%) or that believe that others would avoid them if they use PrEP (~10%) (Figure 1). However, further nuanced education addressing the accuracy of these beliefs could be part of the comprehensive effort to promote PrEP use and reduce associated misperceptions.
These results align with prior work and are not unique to the Upstate region of South Carolina; rather, they are reflective of broader trends observed nationwide. In many parts of the country, the combination of social stigma and financial hardship creates significant barriers to accessing PrEP, limiting its potential impact as a preventive measure (Antonini et al., 2023; Smit et al., 2024). Addressing these barriers requires a multifaceted approach, including greater public education to combat stigma, improved access to financial resources, and enhanced healthcare policies to ensure that PrEP is accessible to everyone who could benefit from it. By tackling these social and financial hurdles, we can work toward making PrEP a more widely accepted and accessible tool in the fight against HIV.
Strengths and Limitations
Data collection for our study was limited amongst the residents of Upstate South Carolina which resulted in a small sample size for statistical analysis. While we recognize this as a limitation, we present statistically significant findings that, despite the sample size, were appropriately tailored for our analysis. A majority of respondents reported that they reside in Greenville County. Further efforts should emphasize increased recruitment from more sparsely-populated and rural counties for more diverse representation of MSM perspectives on PrEP in the Upstate overall. In conducting this study, our goal was to identify barriers to PrEP access and uptake within this often marginalized population. Due to the limited sample size, the scope of statistical analysis was constrained. Future research with a larger cohort and more respondents from rural areas, along with more targeted hypotheses, would enable more rigorous and comprehensive statistical evaluation. Along with recall bias and the self-report nature of the survey, the validation of survey responses could not be confirmed. Additionally, despite extensive efforts to recruit a diverse group, our participants were predominantly white and cisgender male. Although this demographic may reflect a significant part of the LGBTQ+ population of Upstate South Carolina, we acknowledge that it does not fully represent the entire general population of the area. Despite these limitations, to our knowledge, this is a first of its kind analysis looking into the various barriers that individuals encounter when attempting to access or educate themselves about PrEP in this particular population.
Conclusion
In conclusion, this study explored the perceptions surrounding PrEP use among men who have sex with men in upstate South Carolina. Our findings revealed several barriers to PrEP usage, including inaccessibility, biases, and fear of judgment from others. These insights highlight the need to address these obstacles in order to improve PrEP uptake in the region. Future research should involve a larger and more diverse sample, including cisgender and transgender women, to gain a more comprehensive understanding of PrEP perceptions across different groups. This research is crucial, as it sheds light on the reasons behind the disengagement with PrEP use in South Carolina and provides a foundation for developing targeted education strategies, referral programs, and other public health initiatives aimed at combating prevalent misconceptions and increasing PrEP accessibility and acceptance.
Conflicts of Interest
The authors have no conflicts of interest to declare.
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Table 1: Characteristics of study participants (n=28)
Characteristic | N (%) |
|---|---|
Age (median) | 33 |
Sex Assigned at Birth | |
Male | 28 (100%) |
Gender Identity | |
Male | 24 (85.7%) |
Nonbinary | 3 (10.7%) |
Transgender | 1 (3.57%) |
Ethnic Background | |
White/Caucasian | 19 (67.9%) |
African American or Black | 5 (17.9%) |
Asian | 2 (3.6%) |
Hispanic or Latino | 2 (3.6%) |
County of Residence | |
Greenville | 23 (82.1%) |
Spartanburg | 3 (10.7%) |
Pickens | 2 (3.6%) |
Highest Level of Education | |
Less Than High School | 1 (3.57%) |
High School (including GED) | 1 (3.57%) |
Some College | 4 (14.3%) |
Associated Degree (2-year) | 1 (3.57%) |
Bachelor’s Degree (4-year) | 14 (50.0%) |
Master’s Degree | 5 (17.9%) |
Doctoral Degree | 2 (3.6%) |
Marital Status | |
Divorced | 1 (3.57%) |
In a Relationship | 8 (28.6%) |
Married | 5 (17.9%) |
Single | 14 (50.0%) |
Annual Household Income | |
$0-$29,999 | 9 (32.1%) |
$30,000-$59,999 | 6 (21.4%) |
$60,000-$99,999 | 3 (10.7%) |
$100,000-$129,999 | 4 (14.3%) |
$120,000+ | 6 (21.4%) |
Political Party | |
Democratic | 19 (67.9%) |
Independent | 4 (14.3%) |
Other | 2 (3.6%) |
Republican | 3 (10.7%) |
Sexual Orientation | |
Bisexual | 4 (14.3%) |
Gay | 18 (64.3%) |
Other | 1 (3.6%) |
Pansexual | 2 (7.1%) |
Queer | 2 (7.1%) |
Straight | 1 (3.6%) |
Table 2: Correlations found between study variables
Barrier | Variable | Correlation | P-Value |
|---|---|---|---|
If I were to use PrEP, people would think that I have HIV | How many men (cis or trans) have you had anal sex within the past 6 months? | 0.432 | 0.020 |
If I were to use PrEP, people would think that I have HIV | Information I could bring to my doctor to help them learn about PrEP | -0.404 | 0.033 |
If I were to use PrEP, people would think that I have HIV | In which county do you currently live? | -0.384 | 0.044 |
There are easier ways to keep from getting HIV than taking PrEP | A written step-by-step guide to going onto PrEP | 0.403 | 0.034 |
People would avoid me if they found out that I used PrEP | How many men (cis or trans) have you had anal sex within the past 6 months? | 0.386 | 0.042 |
My family would think less of me if they found out I was using PrEP | What is your level of education? | -0.388 | 0.041 |
My family would think less of me if they found out I was using PrEP | Information I could bring to my doctor to help them learn about PrEP | -0.397 | 0.036 |
The people in my doctor’s office would treat me differently if they found out that I used PrEP | What is your annual household income? | -0.389 | 0.041 |
Table 3: Correlations found between study variables
If I were to use PreP, people would think that I have HIV | 1.00 | 0.68 | 0.57 | 0.38 | 0.62 | 0.24 | 0.20 |
|---|---|---|---|---|---|---|---|
My friends would think less of me if they found out I was using PrEP | 0.68 | 1.00 | 0.31 | 0.15 | 0.60 | -0.07 | -0.09 |
My family would think less of me if they found out I was using PrEP | 0.57 | 0.31 | 1.00 | 0.77 | 0.20 | 0.52 | 0.26 |
The people in my doctor’s office would treat me differently if they found out that I used PrEP | 0.38 | 0.15 | 0.77 | 1.00 | 0.13 | 0.40 | 0.32 |
People would avoid me if they found out that I used PrEP | 0.62 | 0.60 | 0.20 | 0.13 | 1.00 | -0.03 | 0.23 |
I cannot afford to be on PrEP | 0.24 | -0.07 | 0.52 | 0.40 | -0.03 | 1.00 | 0.01 |
There are easier ways to keep from getting HIV than taking PrEP | 0.20 | -0.09 | 0.26 | 0.32 | 0.23 | 0.01 | 1.00 |
If I were to use PreP, people would think that I have HIV | My friends would think less of me if they found out I was using PrEP | My family would think less of me if they found out I was using PrEP | The people in my doctor’s office would treat me differently if they found out that I used PrEP | People would avoid me if they found out that I used PrEP | I cannot afford to be on PrEP | There are easier ways to keep from getting HIV than taking PrEP |
Table 4: Correlations found between study variables & interventions
Intervention | Variable | Correlation | P-Value |
|---|---|---|---|
An online program that allows me to calculate my risk of HIV | County | -0.49 | 0.008 |
Ethnicity | 0.464 | 0.013 | |
A short waiting time for my first PrEP appointment | Age | 0.423 | 0.025 |
A list of other providers in my area that prescribe PrEP | Marital Status | 0.419 | 0.026 |
PrEP Use | 0.404 | 0.033 | |
Information I could bring to my doctor to help them learn about PrEP | Ethnicity | 0.419 | 0.029 |
Perception of HIV Status | -0.404 | 0.033 | |
A healthcare provider telling me that my risk for HIV is higher than I thought | Gender | -0.398 | 0.036 |
A healthcare provider counselling me in detail about how well PrEP works | Ethnicity | 0.389 | 0.041 |
More people in my community speaking publicly about their experiences taking PrEP | PCP status | 0.377 | 0.048 |
Someone working with me to access the publicly funded PrEP program in my county | Gender | -0.375 | 0.049 |