Strategies to overcome barriers and enhance PrEP adoption among primary care providers in urban–rural communities outside Canada’s major metropolitan areas

Pre-exposure prophylaxis (PrEP) in Ontario remains concentrated in large cities, leaving smaller urban and rural communities underserved. To inform targeted expansion, we interviewed 28 primary care providers (family physicians, trainees, public health nurses, clinic managers, and practice leads) working outside major metropolitan areas. Recruitment used multiple outreach methods, and interviews were transcribed and thematically analyzed. Half of participants had direct PrEP experience. Providers cited limited training, knowledge gaps, few continuing-education opportunities, staffing shortages, and lack of administrative support as barriers. Structural forces, stigma, high costs, transportation barriers, further limited access, intersecting with poverty, racism, and substance use, and affecting equity-deserving groups beyond gay and bisexual men. Participants recommended province-wide competency-based training, task-sharing through medical directives, normalization of PrEP in clinical discussions, broader awareness campaigns, and nurse-led models. Findings highlight the need to strengthen provider capacity while addressing social determinants to achieve equitable PrEP uptake outside Ontario’s major cities.