Needs and Opportunities for Anal Cancer Prevention in Patients Engaged With PrEP Care: Development of Conceptual Model

Abstract

Introduction: Populations at risk for HIV infection—including gay, bisexual, and other men who have sex with men (GBM) and transgender/gender diverse people (TGD)—are at disproportionate risk for anal cancer. Most anal cancers are caused by human papillomavirus (HPV) and are preventable with HPV vaccination and screening. Engaging at-risk populations who are already receiving HIV preventive care (eg, pre-exposure prophylaxis [PrEP]) may be an effective implementation strategy. The purpose of this study was to (1) identify the information, motivation, and behavioral skills that influence decisions about anal cancer prevention and to (2) describe the healthcare utilization patterns among PrEP users that impact their engagement in anal cancer prevention. Methods: Using purposive sampling in the United States, we ensured diverse representation among PrEP users aged 18 to 45 across gender and ethnoracial identities. Recruitment sources included primary healthcare clinics, social media, and community venues. Semi-structured interviews were recorded, transcribed, and coded using structural, pattern, and theoretical approaches. Results: Participants (N = 36) were mostly cisgender gay ethnoracial minority men. We identified 29 unique codes that were nested within 3 categories: individual decision-making, healthcare utilization patterns, and healthcare system influences. Participants commonly lacked essential information about HPV and anal cancer, often holding misconceptions about risks and prevention. Motivation for anal cancer prevention was driven by healthcare interactions and perceived risks, while fragmented healthcare and reliance on telemedicine were potential barriers. Many participants used telehealth services to access PrEP, described it as convenience, cost-effective, and liked the lack of provider interaction. Some participants used telehealth for PrEP and did not have a primary care provider. The importance of access to LGBTQ+-affirmative healthcare services was highlighted. Conclusions: Integrating patient education and prevention services into ongoing PrEP management can enhance the reach and equity of anal cancer prevention. Our model underscores critical areas of misinformation, necessary systems-level changes, and unmet needs.