Structural Barriers to HIV Prevention

California was an early adopter of PrEP, while equitable PrEP uptake remains a major concern in the Southern United States. Florida has not adopted Medicaid expansion, which the protocol links to PrEP coverage and access to substance use treatment. The absence of a comprehensive national standard is a structural barrier to SSB policy development. The Florida site had challenges identifying and randomizing participants. Limited policymaker familiarity with SSB policy options is a major barrier, especially in less developed Chongqing. Florida staff often emphasized privacy, confidentiality, and participant autonomy around social and legal risks. SSB manufacturers raised concerns about profit decline, reformulation costs, technical product challenges, and consumer loss. Uniform national SSB policy implementation is challenging because China has diverse geography, economic development levels, and nutritional burdens. The protocol presents limited public health infrastructure, criminal penalties for substance possession, and structural stigma as possible explanations for Florida recruitment challenges. The protocol identifies legal and policy differences as structural determinants.