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From Noncompliance to Structural Competency in Pre-exposure Prophylaxis Access for a Migrant Man Who Has Sex With Men
Juan M Leyva1,2,3,4,5,6,7,8,9,10, Agustin Marcos1,2,3,4,5,6,7,8,9,10, Rosa Badia1,2,3,4,5,6,7,8,9,10
1Juan M. Leyva is an Associate Professor in the Nursing Department at the Universitat Autònoma de Barcelona (Spain). He is the coordinator of the Nursing Research Group in Vulnerability and Health (GRIVIS). He is also a research collaborator at the Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP).
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.
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