Our eligibility criteria followed the population/participants, interventions, comparison, outcome, and study design (PICOS) framework (34). We included empirical studies conducted solely or partly among BMSM in the Midwestern states of the United States. Commentaries, letters to the editor, or expert opinions were not considered. We focused on studies with a primary or secondary focus on PrEP uptake, barriers, or facilitators. We did not limit our search by language or time.

CINAHL Plus, PUBMED, PsycINFO, SCOPUS, and Web of Science were searched in March 2023 using relevant keywords (such as PrEP, barriers, and specific Midwest states), Medical Subject Headings (MeSH) terms, and Boolean operators. For example, we search PubMed with the following terms: (((Barrier* OR problem* OR reluctan* OR concern* OR stigma OR perception OR belief OR attitude OR enabler* OR Motivator* OR facilitator* OR encouragement OR predictor* OR determinant* OR engagement OR uptake OR initiation OR Use OR Utilization OR Utilization OR Compliance OR Adherence) AND (“Pre-Exposure Prophylaxis”[Mesh] OR “pre-exposure prophylaxis” OR PrEP OR Truvada OR Descovy)) AND (“men who have sex with men” OR MSM OR Gay* OR “male couple*” OR homosexual* OR “transgender wom*” OR “trans wom*” OR “bisexual men”)) AND (Iowa OR “Midwest region” OR “Midwestern region” OR “Midwest state*” OR Illinois OR Indiana OR Kansas OR Michigan OR Minnesota OR Missouri OR Nebraska OR “North Dakota” OR Ohio OR “South Dakota” OR Wisconsin). We did not limit our search by date or language. The comprehensive search strategy for other databases is in the Supplementary material. Rayyan, an online article manager (35), was used for the article screening process. Two reviewers (OAB and PA) met to finalize the study eligibility criteria before screening. One reviewer (OAB) removed duplicate articles; two reviewers (OAB and PA) independently performed title and abstract screening. Both reviewers resolved all disagreements through discussions. References of all articles that met our eligibility criteria were manually searched for additional relevant articles.

We extracted the following details from each article that met the set eligibility criteria: author and year of publication, Midwest state, study design, sample size and technique, type of PrEP (pills or injectables), analysis type, BMSM sociodemographic information (i.e., race and age), PrEP uptake, barriers to and facilitators of PrEP use. One reviewer (OAB) extracted all the details, while another reviewer (OAA) checked for accuracy.

All the articles that met the eligibility criteria were subject to methodological rigor assessment using the appropriate Joanna Briggs Institute tools (depending on the study design); one reviewer (OAB) performed this process, which was verified by another reviewer (OAA).

The quantitative findings were summarized descriptively. We synthesized the qualitative data and identified the common factors inhibiting or facilitating PrEP uptake among Black MSM.

Of the 22 studies, 15 (62.5%) were conducted in Chicago (10, 24, 36–46). The remaining studies were conducted in Michigan (47), Missouri (4, 48), and Wisconsin (8, 49–51); two studies focused on four regions: Detroit, Kansas, Milwaukee, and Minneapolis (52, 53).

Twelve (59%) studies were quantitative (10, 24, 38–46, 49), and eight (33%) were strictly qualitative (4, 36, 47, 48, 50–53). Two (8%) studies adopted a mixed methods design (8, 37) but reported either quantitative findings only (8) or qualitative findings only as part of a broader study (37). It is important to stress that seven of the cross-sectional studies analyzed a portion of results from a cohort study (10, 41, 42, 44–46). For studies that conducted qualitative designs, whether qualitative only or from a mixed methods study, five used an in-depth interview approach (4, 37, 47, 48, 51), while four used focus group discussions (36, 50, 52, 53).

Most of the studies (n = 22, 92%) focused only on oral PrEP (i.e., pills), while Biello et al. (36) focused on injectable PrEP and Patel et al. (48) focused on both pills and injectable PrEP. Uptake of PrEP differed across the 12 studies that quantified PrEP uptake, ranging from 3.0 to 32.4% (8, 10, 24, 38, 40–46, 49). However, overall, the findings reveal that most BMSM may not be using PrEP. For instance, 11 studies (79%) reported a PrEP uptake of less than 15% (10, 24, 38–44, 46, 49); and Timmins et al. (45) reported 32.4%. The two studies that reported baseline and follow-up PrEP use recorded little difference between both periods (39, 49).

The barriers to PrEP uptake among BMSM in the Midwest are based on the findings of the included qualitative studies. Several barriers to PrEP uptake emerged, including PrEP unawareness, access, stigma, PrEP side effects, low socioeconomic status, trust in partners, distrust in the health system, and concerns over PrEP adherence (Table 2).

Regarding the PrEP barriers, being unaware of PrEP was common among BMSM in the Midwest. Some BMSM reported that they had never heard of PrEP (51). PrEP side effects were inhibiting factors for those who were aware of PrEP (36). Additionally, we found that low socioeconomic status often prevents access to PrEP. Specifically, some BMSM were uninsured compared to their White counterparts and, as a consequence, do not have money to pay for PrEP-related care when needed, exacerbated by the difficulty in securing jobs (50).

Furthermore, BMSM reported structural-related issues in accessing PrEP. For example, many BMSM reported they could not access PrEP in health facilities for reasons such as health workers not being aware of it or refusing to make it available to them, and even when available, the wait time can be very long (4). Another barrier is distrust of the health system. BMSM continues to refer to historical unethical practices experienced by the Black community, such as the Henrietta Lacks and the Tuskegee experiments, as a reason for not using PrEP (4).

BMSM reported that the fear of others knowing that they are using PrEP is a primary reason they are not interested in PrEP uptake (24, 36). According to some of them, they risk being seen with PrEP if they opt to take it and fear that people will assume they are living with HIV (24, 36). There is evidence that the concern of being labeled “HIV positive” led to the discontinuation of PrEP among some BMSM (24). Interestingly, some BMSM in monogamous relationships trust their partner, and they seem not to be interested in PrEP because they perceive their HIV risk to be low, and they do not want to lose their partner’s trust (24, 53). Moreover, some BMSM did not see a need to be on PrEP because they do not intend to have sexual intercourse with an infected person (24).

We found several factors that made BMSM utilize PrEP, including the safety it provides, having friends who use PrEP, fear of HIV, dislike for condoms, and experience dating men living with HIV. Specifically, some BMSM reported that they adhered to PrEP because they had friends who were on PrEP (37). Furthermore, BMSM were more likely to use PrEP if they had had an experience dating men living with HIV (52), mainly because it protects or provides safety against HIV infection (37, 53).

Another interesting reason for PrEP uptake was the sexual autonomy and power it provides because BMSM on PrEP have more flexibility in sexual decision-making (52). Moreover, they felt that it was better to be on PrEP than use condoms, which they perceived to be “frustrating” and less enjoyable (52). BMSM also alluded that they choose to use PrEP because of fear of contracting HIV (52), and many chose to remain on PrEP until HIV is “eradicated” (47).

One major barrier to PrEP uptake was the lack of PrEP awareness and knowledge among BMSM. Coukan et al. (54) found a similar issue in their review of barriers to PrEP among underserved populations and MSM in the United Kingdom (UK). Knowledge and awareness of PrEP should precede its access and uptake. This calls for more sensitization of PrEP not just for BMSM in the Midwest but also for all key or priority populations globally. Lack of awareness was not limited to BMSM alone; we also found evidence of a lack of knowledge and awareness of PrEP among healthcare providers. Previous US reviews have also reported a similar finding from a pool of studies across several states (30, 55). Lancki et al. (40) reported that the extent to which healthcare providers influence low PrEP awareness and uptake among those who need it might be uncertain, but it is worrisome as it directly impacts counseling and PrEP prescription for BMSM in the US, and could have a negative effect on interventions (30, 56).

Interventions to improve PrEP awareness should be bidirectional, focusing on BMSM (and other priority populations) and healthcare providers; the latter may be more important than the former. An earlier systematic review of healthcare providers’ barriers to PrEP in the US found no intervention tailored toward the improvement of healthcare providers’ knowledge (55); Pleuhs and colleagues also reported the willingness of healthcare providers to prescribe PrEP after an educational intervention; this gap needs urgent attention (55).

Another barrier that impedes on BMSM’s PrEP uptake was low SES. We found that BMSM with low SES were less likely to initiate PrEP and other health services. This perhaps led to complete neglect of the healthcare system and interest in PrEP. Some BMSM prioritized earning a living in the face of unemployment, which is perceived to be more prevalent among Black/African American populations (57).

Furthermore, lack of access to PrEP was a major a barrier. BMSM appeared to have issues accessing health facilities to obtain PrEP, similar to the findings of earlier reviews (30, 54). The lack of access to PrEP may be due to financial difficulties, lack of medical insurance, and limited deliveries of PrEP to Black communities (30). Also, despite the implementation of TelePrEP in Iowa to address access and other barriers, only a few African Americans (17/167) initiated PrEP (58). Innovative strategies are required to overcome PrEP access, especially for BMSM and other priority populations (59).

HIV-related stigma was another barrier identified in this review. HIV-related stigma may have a negative effect on PrEP uptake because there are concerns that being on PrEP may attracts social stigma, particularly enacted stigma, and some BMSM were worried about being perceived to be sexually deviant or promiscuous. Other reviews focused on MSM and transgender persons in the US and UK have established a similar observation (28, 30, 54, 55). Public health experts in the HIV space need to sensitize the larger community about PrEP benefits to reduce the PrEP-related stigma.

Moreover, another important barrier to PrEP uptake among BMSM was their knowledge of previous unethical experiments like the Tuskegee experiment with the Black or African American community Throughout history, the health system has not earned the trust of the Black community following previous unethical experiments (e.g., the Tuskegee experiment), and HIV treatment is a famous example, which unfortunately seems to be playing out with PrEP. Lack of trust in the health system was reported by several PrEP-related reviews (28, 30, 54, 55).

Regarding PrEP facilitators, this review found that BMSM were not interested in using PrEP if they trusted that their partners were faithful to them and if they were in a monogamous relationship. We did not find an earlier review with a similar observation among BMSM. Naturally, trust strengthens the bond between couples. Some may argue that having trust in a partner may not be a barrier to PrEP use as there may not be a need to be on PrEP if there are no risks. Interestingly, we also found that trust did not matter to some BMSM as they were on PrEP to limit their risk of contracting HIV. Also, being in a monogamous relationship does not necessarily mean that one’s partner may not have other sexual partners, which led to regular PrEP use by some BMSM. This result corroborates other primary studies conducted in the US and Vietnam (60, 61).

The present review provides some insights into factors that influence PrEP use among BMSM. BMSM were more likely to use PrEP if they had friends living with HIV, perhaps due to perceived susceptibility to HIV. Not surprisingly, those who have previously dated men living with HIV were motivated to be on PrEP to reduce their chances of contracting HIV (62).

This review found that some BMSM prefer condomless sexual intercourse, claiming that condoms reduce pleasure, and choose to reduce HIV risk by being on PrEP. The debate on the sensitivity of condoms has been long discussed. However, it may be acceptable to choose from the range of HIV preventive strategies available since all the preventive strategies have a similar objective – preventing HIV. Also, some BMSM chose to be on PrEP to minimize HIV risk, irrespective of the level of trust for their partners (63).

This review is not without limitations. This is the first review to report about BMSM in the US Midwest. However, the findings may not generalize to other BMSM outside the Midwest or the US because the context may differ. Our coding of the themes may not have captured the true picture of what individual studies intended, as we cannot access the full transcripts and interview guides. Also, a few studies had a small number of non-BMSM participants in their sample, which may have impacted our findings. Moreover, some studies were conducted by the same authors who may have published these studies using the same data and population, which may influence our conclusions. Additionally, many of the previous reviews that we compare our results to focus mostly on urban areas. Therefore, we are not able to differentiate between urban and rural communities in our paper. Also, we could not perform a meta-analysis for quantitative data due to the heterogeneity of the data obtained from the included studies. For instance, some studies had a few participants who were bisexual (men who have sex with men and women, and others had transgender women who have sex with men). A pooled estimate of the uptakes may be possible with a sub-group meta-analysis; however, because of the variation in population and study designs, we may be committing type 2 error due to fewer studies in each subgroup analysis. It was not advisable to pool estimates with traces of heterogeneity and bias (64).