From PrEP-Related Mistrust to Trusted Prevention Ecosystems: Implementation Priorities Following Simon et al. and...

PrEP-related medical mistrust is not simply a lack of trust; it is a relational, historically rooted and continuously reinforced response to perceived institutional betrayal, everyday discrimination, and inequitable prevention systems. Building on recent AIDS and Behavior articles by Simon et al. and Jaiswal et al. describing PrEP-related mistrust, distrust, and misinformation among Black sexual minority men and socioeconomically diverse young sexual minority men from multiple racial and ethnic groups in the United States, we argue that the field must move from documenting mistrust to engineering "trust-ready" prevention ecosystems that can be evaluated, scaled, and sustained. We synthesize converging evidence linking stigma, mistrust, and HIV testing behaviors and situate PrEP mistrust within broader HIV-care experience with antiretroviral therapy adherence and retention. We further highlight that public health narratives that foreground only past abuses can inadvertently obscure ongoing harms that shape lived experience and digital information practices today. We propose three implementation priorities: (1) institutionalize validated trust and fairness metrics within PrEP and HIV programme monitoring; (2) design trust-ready delivery models that embed stigma-reduction, accountability, and rights-based safeguards; and (3) align digital information ecosystems with trust-building by addressing mis- and disinformation, including institutionalized science denialism, while avoiding colonial or paternalistic messaging. These priorities are relevant beyond high-income settings, where overlapping criminalization, under-resourcing, and digital misinformation can compound inequity. Treating mistrust as an implementation outcome-and sometimes a survival-informed response-can accelerate equitable PrEP scale-up.