Optimizing health system readiness for long-acting injectable PrEP implementation in adolescent care through a narrative review of organizational barriers and facilitators

Despite an expanding portfolio of HIV Pre-Exposure Prophylaxis (PrEP), from daily oral pills to newer long-acting injectables (LAI-PrEP), a significant implementation gap persists for youth. The introduction of these complex therapeutics challenges existing health system models. This narrative review examines the literature on oral PrEP implementation to identify systems-level barriers and inform proactive health policy and capacity-building strategies for the LAI-PrEP era. Analysis of 12 U.S.-based empirical studies reveals systemic fractures impeding youth PrEP access. A primary obstacle is the "purview paradox," a lack of care coordination where primary care providers feel unequipped and view PrEP as a specialist's role, creating significant care gaps. This is exacerbated by profound workforce capacity deficits, with providers across specialties unfamiliar with prescribing guidelines and uncomfortable discussing sexual health. Furthermore, structural barriers to confidential service delivery, including uncertainty over minor consent laws and insurance-based confidentiality breaches, create powerful deterrents. These legacy issues are poised to worsen with the increased logistical and financial demands of LAI-PrEP. A reactive approach to implementing newer PrEP options risks amplifying these documented failures and widening health disparities. To ensure system readiness, this review offers coordinated, systems-level recommendations, including developing innovative shared-care organizational models, investing in national training for healthcare professionals, and establishing policies that guarantee sustainable and equitable access for adolescents.