From Noncompliance to Structural Competency in Pre-exposure Prophylaxis Access for a Migrant Men Who Have Sex With Men in Spain: A Case Study

ABSTRACT: This case study examines Spain's HIV prevention gap. Although pre-exposure prophylaxis (PrEP) is subsidized, decentralized health care creates a "postcode lottery" for key populations. We present the 5-year trajectory of a 28-year-old Senegalese man who has sex with men who immigrated to Spain. His temporary administrative status, precarious night shifts, and language barriers complicated medical interactions. Using the modified social-ecological model, which operationalizes how macro-level determinants like policy rigidities construct vulnerability, we illustrate how what is frequently mislabeled as patient noncompliance actually stems from institutional barriers. Despite theoretical health care availability, he faced a cascade of missed opportunities. Initial primary care visits yielded only behavioral advice; subsequent PrEP-access attempts were blocked by structural violence, compounded by residential mobility, linguistic isolation, and intersectional stigma. Successful PrEP access was achieved through a nurse-led navigation intervention addressing social determinants. Without structural competency and flexible nurse-led models, universal health rights remain theoretical for marginalized populations.