2.1 Study Design and Theoretical Framework

We used a phenomenological approach for this semi-structured interview study of people living in Wales who currently, previously or may in the future access PrEP.

We drew on Levesque's conceptual framework of access to healthcare (2013) and defined access as ‘the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care’ [17]. Within this framework, there are five dimensions of accessibility (approachability, acceptability, availability and accommodation, affordability, and appropriateness) and five dimensions of abilities that potential service users require (ability to perceive, seek, reach, pay and engage).

The study was reviewed and approved by the Cardiff University School of Medicine Research Ethics Committee (Reference Number: 23/91).

2.2 Participant Selection

Drawing on the 2023 PrEP need framework, which identifies eight different forms of need associated with PrEP [18], we interviewed individuals who: (i) currently access PrEP through a sexual health clinic in Wales (Group 1); (ii) have previously accessed PrEP through a sexual health clinic in Wales (Group 2); (iii) are resident in Wales, aware that they might benefit from PrEP (through awareness that it is an HIV prevention option and their own self-assessment of risk and/or need), but had not accessed it through a sexual health clinic in Wales (Group 3). Inclusion criteria were those who were over 18 years old, belonged to one of the three target populations above, were able to communicate fluently in English (though English did not need to be their first language) and gave consent.

2.3 Setting and Data Collection

Participants were recruited from the community via social media advertising and other social networks (e.g., Fast Track Cymru [19], THT Cymru [20], PrEPster [21], local councils and networks of PrEP users from associated research). We advertised the study in NHS settings (e.g., sexual health clinics, GP practices and community pharmacies) using posters, but we did not recruit directly from these services. To acknowledge their time, participants were offered a £20 digital gift voucher.

The lead researcher (D.G.) sent an information sheet and consent form to prospective participants. With consent, online interviews were conducted by either D.G. or A.W. using a topic guide that covered PrEP access history and acceptability of PrEP services delivered via community pharmacy and other potential community settings. The topic guide can be viewed in Appendix 1.

We interviewed 24 individuals but planned for 45 (15 per target population group), based on the information power model proposed by Malterud (2016) [22]. We used maximum variation sampling to incorporate views from individuals of different genders, ethnic groups, ages and individuals from different parts of Wales.

2.4 Data Analysis

All transcripts were checked against the recording for accuracy and anonymised. We conducted a reflexive thematic analysis to analyse our interview data [23]. Following familiarisation with the data, codes were developed by inspecting transcripts line by line, with an initial coding framework developed. Double coding was supported by F.W. and R.M. for the first five interviews to agree on the initial coding framework, accounting for alternative perspectives. Subsequently, a further five interviews were double coded to assess coding consistency. Themes were developed using the ‘One Sheet of Paper’ or ‘OSOP’ technique and were reviewed, refined and subsequently named.

During our recruitment process, we suspected that we may be prone to so-called imposter participants (i.e., participants pretending to meet eligibility criteria) [24]. We (D.G., A.W. and F.W.) therefore reviewed the timing of expressions of interest, consent forms, audio from interviews and interview transcripts. If concerns were present across all four of these elements (e.g., the expression of interest was sent near in time to others, consent forms were completed almost identically, cameras would not or could not be used for the interview and answers were vague), participants were considered imposters and excluded from the analysis. Where there were concerns around some but not all elements, these were discussed, and a consensus was reached about how their data would be handled.

2.5 Research Team and Reflexivity

All four researchers directly involved in data collection and analysis are experienced in research around PrEP. The team was supported by others with expertise in community pharmacy practice, public health policy and lived experience of accessing PrEP in Wales. Our core data collection and analysis team consisted of males and females, straight and gay, clinicians and non-clinicians, and those with an age range of 27–55. Our team-based approach to developing the topic guide and codes encouraged alternative views and perspectives. This study was conducted in response to both stakeholder engagement work, which highlighted the role that community pharmacies could play in expanding access to PrEP, and an action within the Wales HIV Action Plan, which indicated that access to PrEP would be expanded beyond sexual health clinics in Wales.

3.1 Participants

We interviewed 24 participants between February and June 2024. Four participants were deemed imposters by the research team and were discarded from our analysis. The remaining five participants were considered potential imposters but retained following agreement that the guarded nature of their responses could be explained by the nature of the research. Data from these five interviewees were given less weight in our analysis. We therefore included 20 participants in our analysis. Our sample included people with varying levels of experience of accessing PrEP as well as diversity in terms of age, gender identity, ethnic group and area of residence in Wales (Table 1).

We generated four themes, the most pertinent capturing the experiences of accessing PrEP via sexual health clinics, the perceived influences on and acceptability around accessing PrEP via a community pharmacy, as well as other community-based settings. However, an additional theme was identified covering the integration of health services and associated data. Figure 1 illustrates the generated themes and their conceptual links. Thematic matrices can be viewed in Appendix 2.

4.1 Summary of Main Findings

This is the first study from Wales, and one of the first across the United Kingdom, to explore prospective user views of a PrEP service in community pharmacies before implementation. We found broad acceptance of the idea of a PrEP service being delivered in community pharmacies. The key appealing features of such a service would be improvements in access—both in terms of the varied operating hours of community-based services (e.g., evenings and weekends) and the broad use of such services reducing the stigma attached to attending. These were important barriers to access highlighted when descriptions were given of PrEP access via sexual health clinics. Thus, ‘access’ to PrEP services, regardless of setting, comprised two aspects—logistical challenges of gaining access to a health service (e.g., location and opening hours) and the psychological challenges associated with accessing a service (e.g., varying components of stigma, including anticipated, enacted and self-stigma) (see Figure 2). Important positive aspects were noted regarding PrEP services delivered via sexual health clinics. These included well-trained staff experienced in having sexual health discussions, the holistic nature of the sexual health service (e.g., PrEP prescription, STI testing, blood tests, other STI prevention or treatment services) and a sense of comparative anonymity when attending a sexual health clinic due to its location (e.g., out of a person's local area). Participants expressed uncertainty around the capacity and capability of community pharmacies and pharmacists to conduct certain aspects of healthcare (e.g., blood sampling) necessary for a full PrEP service and wondered whether the convenience of a local PrEP service may be offset by the entirety of their sexual healthcare (and accompanying data) becoming fragmented. Therefore, while considered acceptable, there were several uncertainties and concerns expressed by participants which may need addressing before the successful rollout of any service.

4.2 Strengths and Limitations

Globally, there are ambitions to widen access to PrEP to increase uptake and reach, particularly in traditionally underserved groups [25]. Differences in policy decisions regarding ways in which PrEP has been rolled out (e.g., universally vs. through a programme of research) may have led to differences in access. Our community-based sampling approach has allowed us to include a diverse sample, incorporating views and experiences from individuals across Wales, different age groups, gender identities, sexualities and ethnic groups. We incorporated established frameworks to both include views of individuals at different stages of PrEP need and provide a structure around the study of access to healthcare. These informed the interviews and analysis and supported the justification for including individuals who have a self-identified PrEP need but have not yet accessed it. Views from these individuals were important to incorporate if this study is to inform service provision for new as well as established PrEP users.

An important drawback to our community-based sampling strategy was that it attracted so-called ‘imposter participants’. The phenomenon of imposter participants has received increasing attention in qualitative research recently and seems to have coincided with an increase in the normalisation of remote interviews.

4.3 Comparisons to Existing Literature

Our findings are largely in line with a recent publication of community members' views of the barriers and facilitators of community pharmacy PrEP delivery conducted in England, the United Kingdom, and a wider scoping review of barriers and facilitators of community pharmacy PrEP delivery [26, 27]. Key differences include the choice of models/framework used (COM-B [28] vs. PrEP need framework and Levesque framework for healthcare access [17]), geographical variation (e.g., healthcare is devolved in Wales) and policy contexts within which studies were conducted both in terms of how PrEP was rolled out and how community pharmacies operate. For example, PrEP was initially made available in England as part of a research study with a cap on the numbers of those who could access it, whereas, in Wales, it was available without any cap on numbers to those who met initial clinical indications. Additionally, community pharmacies in Wales have offered clinical services for more than a decade, whereas the structure underpinning this across is more of a recent initiative in England [14, 29]. Additional differences are present in the respective topic guides, with the work by Harrison et al. [26] including more direct questions and fewer questions about interviewees' experiences of PrEP access via sexual health clinics and broader experiences of healthcare access via community pharmacy. Importantly, in our findings, we found that the acceptability of a community pharmacy PrEP service is likely to be differential and depend on both an individual's wider healthcare needs and psychological concerns regarding sexual healthcare access. Thus, these studies are likely to be complementary and give some understanding of the role of context (particularly around PrEP rollout and community pharmacy set-up) on influencing factors around any new PrEP services.

4.4 Implications

There is a need for an ongoing understanding of the acceptability of the expansion of healthcare services to community pharmacies. As new services are rolled out, they need to be subject to ongoing training, monitoring and evaluation (including economic evaluation), which also captures the experiences of those accessing services. Furthermore, the nature of community pharmacies as both a healthcare setting and a business may have implications with regard to client/customer expectations and trust. As the focus of this paper is on the prospective users' influencing factors, we did not consider the structural context of service delivery such as commissioning and primary care drug delivery costs. Additionally, the deployment of remote community-based qualitative research requires safeguards against imposter participants. This is particularly problematic for topics such as sexual health, as participants particularly value anonymity and may be more guarded (or unwilling to participate) if verification of inclusion criteria is seen to be overly intrusive. Care is required for the use of data collection methods which do not limit the inclusion of underserved populations. For practice, any rollout of a PrEP service via a community pharmacy, or any other setting outside of a specialist sexual healthcare service, must be twinned with a communication strategy which informs people what PrEP is, where it can be accessed and what to expect as part of any access (including how data are communicated to relevant parties). Furthermore, staff delivering the PrEP service must be trained to engage in sexual health discussions in a non-judgemental manner, displaying cultural competency, sensitivity and inclusivity across a range of gender identities and ethnic groups. A rollout that does not include the type of communication and training outlined here will have limited impact and likely only lead to a partial displacement of PrEP users from current services.