Human Enough: Client Experience with Internet-based Access to PrEP and the Mechanics of Satisfaction (Preprint)

BACKGROUND HIV pre-exposure prophylaxis, or PrEP, is a way to prevent acquisition of HIV using antiretroviral medications. However, common barriers to PrEP engagement include lack of access to prescribers; discomfort seeking sexual health services; along with racism, homophobia, and transphobia in medical contexts. Key populations (e.g., communities of color, young men who have sex with men, transgender women) are underrepresented in terms of PrEP uptake in the U.S. Nurx is an innovative company that has offered internet-based access to PrEP since 2016. OBJECTIVE Researchers from the University of California, San Francisco partnered with Nurx to explore clients’ experiences of digital PrEP access—including the difference made by the telehealth format—and understand whether Nurx helped reduce barriers to PrEP. METHODS Electronic chart review and semi-structured interviews were conducted with 31 PrEP requesters from California, Florida, Illinois, and New York. Interviews were recorded, transcribed, and underwent inductive and deductive thematic analysis. RESULTS Clients were effusive about their Nurx experience, despite some initial skepticism about whether such an online service could be legitimate, or how it would work. Many interviewees reported Nurx eased barriers to PrEP access, through availability of knowledgeable, willing prescribers, and minimizing embarrassment and discrimination. Our analysis suggests Nurx produced satisfaction by achieving an acceptable balance between two client desires: “efficiency” and “humanity.” Efficiency encompasses the simplicity, speed, and convenience of obtaining PrEP, both regarding the Nurx process itself and in comparison to in-person encounters. Humanity covers clients’ wish for personalized, responsive interaction, and a feeling of connection or care. Nurx’s messaging platform/function was crucial to manifesting these qualities, and was largely interpreted through the familiar frame of texting. Clients conceived efficiency and humanity as inversely-related in a commercial enterprise, and varied in the particular balance they felt was optimal. Those who wished for slightly more humanity than the service afforded used the concept of a “trade-off” to explain why Nurx remained appealing. CONCLUSIONS Interviewees’ satisfaction with Nurx augments evidence that internet-based PrEP provision can broaden access to this HIV prevention strategy. That important finding notwithstanding, a few provisos merit mention. Telehealth, as practiced by Nurx, was still dependent on culturally-competent medical providers as system “inputs,” and the very technology used to overcome access barriers (i.e., the internet) itself generated new hurdles for some clients. Further, clients did not interpret Nurx in a vacuum: their past experiences and the social and structural context mattered. Finally, only granular inquiry revealed precisely how Nurx satisfied clients whose experiences and preferences fell within a particular range. Extrapolating from this, we urge scholars not to fetishize technological solutions but rather to interrogate the ways any intervention’s design works for certain kinds of patients.