Barriers and Facilitators to Pre-exposure Prophylaxis Uptake Among Black Women: A Qualitative Analysis Guided by a Socioecological Model

Age-related factors associated with intention to initiate pre-exposure prophylaxis among cisgender women in Washington D.C

Background

Pre-exposure prophylaxis (PrEP) utilization among cisgender women (subsequently 'women') is low across age groups, relative to their risk of HIV acquisition. We hypothesize that age-related differences in psychosocial factors also influence women's intention to initiate oral PrEP in Washington, D.C.

Methods

A secondary analysis of a cross-sectional survey data was performed to evaluate factors influencing intention to initiate oral PrEP among women seen at a family planning and a sexual health clinic. A bivariate analysis was performed to identify differences by age group in demographic characteristics, indications for PrEP, and attitudes toward PrEP; we then performed additional bivariate analysis to assess these variables in relation to PrEP intention.

Results

Across age groups, perceived risk of HIV acquisition was not significantly different and was not associated with intention to initiate PrEP. Awareness of and attitude toward PrEP, injunctive norms, descriptive norms, and self-efficacy were not different across age, however there were significant age-associated differences in relation to PrEP intention. Specifically, among 18-24-year-olds, intention to start PrEP was associated with support from provider (p = 0.03), main sexual partner (p < 0.01), and peers (p < 0.01). For women 25-34 years old, having multiple sexual partners (p = 0.03) and support from casual sexual partners (p = 0.03) was also important. Among women 35-44 years old, prior awareness of PrEP (p = 0.02) and their children's support of PrEP uptake (p < 0.01) were associated with intention to initiate PrEP. Among 45-55 year-old women intention to initiate PrEP was positively associated with engaging in casual sex (p = 0.03) and negatively associated with stigma (p < 0.01).

Conclusion

Overall, there were more similarities than differences in factors influencing intention to initiate PrEP across age groups. Observed differences offer an opportunity to tailor PrEP delivery and HIV prevention interventions to increase awareness and uptake for cisgender women.

Medical Mistrust and Healthcare Seeking Among Women of Color with Chronic Vulvovaginal Pain

BACKGROUND

Chronic vulvovaginal pain (CVVP), an umbrella term encompassing several gynecological pain conditions (e.g., vulvodynia, vaginismus), has a prevalence rate of 7-8% in the USA and is characterized by considerable diagnostic delay in patient experience research. Furthermore, current research in this area focuses largely on the experiences of white women, while the experiences of women of color are underrepresented.

METHOD

In the present cross-sectional study (N = 488), we surveyed women of color (i.e., Asian, Black, and/or Hispanic/Latinx women) with CVVP about their perceptions and experiences with medical mistrust, healthcare seeking, and healthcare avoidance.

RESULTS

Using the suspicion subscale of the Group-Based Medical Mistrust Scale, we found significant racial and ethnic differences in medical suspicion scores, with non-Black Hispanic/Latinx women reporting the highest suspicion scores and non-Hispanic/Latinx Black women reporting the lowest scores. Racial differences disappeared, however, after examining medical mistrust and perceived discrimination as predictors for various healthcare outcomes related to the journey to diagnosis and healthcare avoidance behaviors. We found that while suspicion was a reliable predictor of increased diagnostic delay and healthcare avoidance in many contexts, the results for perceived discrimination were more varied, suggesting considerable nuance in the relationship between medical mistrust, perceived discrimination, and healthcare seeking outcomes.

CONCLUSION

These findings point to shared experiences of medical mistrust via suspicion that broadly characterize women of color's experiences in seeking CVVP-related care-future research is needed to examine nuances within racial and ethnic groups regarding their healthcare seeking experiences in the CVVP context.

Factors Associated With Willingness to Use Preexposure Prophylaxis Among Black Cisgender Women Residing in Rural and Urban Areas: A Cross-Sectional Study

BACKGROUND

Black cisgender women (CGW) are disproportionately impacted by the human immunodeficiency virus (HIV) epidemic in the United States. Black women account for 57% of the total new diagnoses among CGW. In addition, Black CGW women are 9 times more likely to be diagnosed with HIV than their White counterparts.

METHODS

We conducted surveys (September 2019-March 2020) and collected information on sociodemographics, HIV/preexposure prophylaxis (PrEP) knowledge, HIV/PrEP stigma, sexual practices, and other factors identified as PrEP barriers among Black CGW (n = 795). This cross-sectional study used logistic regression models to assess intrapersonal, interpersonal, and structural factors among individuals willing to use PrEP versus individuals unwilling or unsure to use PrEP.

RESULTS

Our study population had a mean age of 37 years, predominantly lived in urban areas (65%), had stable housing (96.7%), and had private insurance/Medicare (78.2%). Overall, 29.6% reported willingness to use PrEP, 35.6% reported unwillingness to use PrEP, and 34.8% were unsure of PrEP use. The multivariable analysis showed that, compared with individuals reporting unwillingness/unsure to PrEP use, those reporting willingness to PrEP use were younger (adjusted odds ratio [AOR; 95% confidence interval {CI}], 0.97 [0.96-0.99]), had lower odds of intimate partner violence (AOR [95% CI], 0.87 [0.78-0.98), and had higher odds of organizational religiosity (AOR [95% CI], 1.10 [1.01-1.20]), HIV knowledge (AOR [95% CI], 1.08 [1.03-1.13]), and perceived need for PrEP (AOR [95% CI], 6.38 [3.36-12.11]).

CONCLUSIONS

Preexposure prophylaxis willingness among Black CGW was impacted by individual-level, interpersonal, and structural factors. Improving PrEP willingness and uptake among Black CGW will require multilevel interventions.

Intention to Initiate HIV Pre-exposure Prophylaxis Among Cisgender Women in a High HIV Prevalence U.S. City

OBJECTIVE

Our objective was to identify the individual, interpersonal, community, health-system, and structural factors that influence HIV pre-exposure prophylaxis (PrEP) initiation among cisgender women seeking sexual and reproductive health care in a high HIV prevalence community to inform future clinic-based PrEP interventions.

METHODS

We collected anonymous, tablet-based questionnaires from a convenience sample of cisgender women in family planning and sexual health clinics in the District of Columbia. The survey used the lens of the socio-ecological model to measure individual, interpersonal, community, institutional, and structural factors surrounding intention to initiate PrEP. The survey queried demographics, behavioral exposure to HIV, perceived risk of HIV acquisition, a priori awareness of PrEP, intention to initiate PrEP, and factors influencing intention to initiate PrEP.

RESULTS

A total of 1437 cisgender women completed the survey. By socio-ecological level, intention to initiate PrEP was associated with positive attitudes toward PrEP (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.13-2.15) and higher self-efficacy (OR, 1.32; 95% CI, 1.02-1.72) on the individual level, perceived future utilization of PrEP among peers and low fear of shame/stigma (OR, 1.65; 95% CI, 1.33-2.04) on the community level, and having discussed PrEP with a provider (OR. 2.39; 95% CI, 1.20-4.75) on the institutional level.

CONCLUSION

Our findings highlight the importance of multilevel, clinic-based interventions for cisgender women, which promote sex-positive and preventive PrEP messaging, peer navigation to destigmatize PrEP, and education and support for women's health medical providers in the provision of PrEP services for cisgender women.

Barriers and Facilitators to Acceptability and Uptake of Pre-Exposure Prophylaxis (PrEP) Among Black Women in the United States: a Systematic Review

OBJECTIVES

Pre-exposure prophylaxis (PrEP) provides a salient avenue to address the profound HIV-related health disparities that Black women in the United States face. This systematic review assessed the acceptability of PrEP within this population, and identified barriers and facilitators to its acceptability and uptake.

METHODS

We searched PubMed and Web of Science using 48 search input combinations; this produced 338 unique articles, 16 of which were included in the review.

RESULTS

We analyzed the results using the socio-ecological model (SEM). Findings indicate generally positive attitudes towards PrEP among Black women, although acceptance levels vary widely. Individual-level barriers included inadequate levels of PrEP awareness and knowledge, low HIV-risk perception, and concerns about adherence and side effects; interpersonal-level barriers were the influence of sexual and romantic partners and stigma from family; societal-level barriers included lack of PrEP marketing towards Black women, medical mistrust, cost, and structural violence. The main facilitators at the individual-level were PrEP education and information; at the interpersonal-level, distrust in sexual partners, healthcare provider encouragement, and social support; at the societal-level, PrEP accessibility, and affordability. No community-level barriers or facilitators were identified.

CONCLUSIONS

PrEP should be marketed directly to Black women in the US and campaigns should highlight this medication's effectiveness, accessibility, affordability, and safety. Medical mistrust must also be addressed to enable Black women to feel comfortable following their healthcare providers' advice regarding PrEP.

A survey with interventional components delivered on tablet devices versus usual care to increase pre-exposure prophylaxis uptake among cisgender Black women: a pilot randomized controlled trial

BACKGROUND

Cisgender (cis) Black women in the USA are more likely to become HIV positive during their lifetime than other women. We developed and implemented a behavioral intervention, Increasing PrEP (iPrEP), the first pilot randomized controlled trial (RCT) aimed at motivating cis Black women to be willing to use PrEP for HIV prevention and attend an initial PrEP clinic visit following an emergency department visit.

METHODS

Eligible participants were Black cisgender women ages 18-55 years who acknowledged recent condomless sex and substance use. Participants were randomized to iPrEP or usual care (UC). iPrEP is a survey-based intervention designed to raise awareness and knowledge about PrEP. Participants completed an assessment of knowledge of and willingness to use PrEP before and after the intervention, then received a warm-hand off with referral to a local PrEP clinic. Enrolled participants were followed for 6 months.

RESULTS

Forty enrolled participants were ages 18-54 years. Education levels varied evenly between some high school education and graduate education. Most participants were single (n = 25) or married (n = 7). Twenty-two participants were employed full-time. Pre-test results indicated that 21 of 40 participants had heard of PrEP. All participants identified PrEP as a daily HIV prevention medication. For those randomized to iPrEP, the odds of knowing about PrEP at post-test, when controlling for baseline, were higher relative to UC (OR = 5.22, 95%CrI = 0.50, 94.1]. iPrEP did not have any effect on willingness relative to UC. The estimate for iPrEP on willingness is marginally higher (4.16 vs. 4.04; i.e., 0.12 points higher); however, the posterior probability of 67.9% does not suggest a strong degree of evidence in favor of an effect. During the post-test, those receiving iPrEP were less ready to take PrEP than those receiving UC.

CONCLUSIONS

Findings suggest that iPrEP increased knowledge about the PrEP medication but had a negative impact on readiness to take PrEP relative to UC. It is imperative that future research among cisgender Black women carefully considers the content provided in interventions designed to increase PrEP use, balancing the benefits of PrEP with the side effects and daily pill burden.

TRIAL REGISTRATION

clinicaltrial.gov Identifier: NCT03930654, 29/04/2019.

Experiences of Black Women in the United States Along the PrEP Care Continuum: A Scoping Review

Black women are disproportionately affected by HIV in the U.S. PrEP could decrease the risk of acquiring HIV. This scoping review seeks to understand the experiences of Black women along the PrEP Care Continuum. We searched PubMed, Embase, PsycInfo, and Google Scholar to identify peer-reviewed studies published between July 16, 2012, and December 15, 2021. Articles were included if they discussed PrEP among Black women in the U.S. Two authors screened titles/abstracts and full-text articles. One author extracted and thematically summarized findings (n = 33). Black women reported low levels of PrEP awareness and knowledge, and negative experiences with providers. Women also experienced negative perceptions of PrEP from their social networks, stigma, and mistrust. Future research should focus on helping Black women to overcome PrEP-related barriers. Additionally, future research should further examine barriers to PrEP initiation, adherence, and retention for Black women, as only three studies discussed these aspects of the Continuum.

PrEP Acceptance among Eligible Patients Attending the Largest PrEP Clinic in Jackson, Mississippi

Compared to other states in the United States, Mississippi has the lowest uptake of PrEP relative to the number of people newly diagnosed with HIV in the state. Open Arms Healthcare Center is the largest provider of PrEP in Mississippi, and has systematically documented PrEP eligibility, offers, and acceptance (ie, agreed to undergo a clinical PrEP evaluation) from 2017 to mid-2020. In encounter-based analyses, we examined factors associated with PrEP acceptance. Among 721 encounters where patients were eligible for PrEP, staff offered PrEP at 680 (94%) of encounters (526 unique individuals); individuals accepted a PrEP offer at 58% of encounters. Accepting a PrEP offer was lowest (15.8%) among transgender/non-binary individuals and highest (93.3%) among individuals who reported having sex partners living with HIV. This clinic's model worked to offer PrEP to a highly impacted population, though there is a need to enhance PrEP acceptance for key groups such as transgender/non-binary individuals.

Pre-exposure Prophylaxis (PrEP) Initiation Among Black and Latina Cisgender Women Receiving HIV Prevention Care Coordination Services in New York City

Black and Latina cisgender women are disproportionately impacted by HIV in the US. Although PrEP is effective at preventing HIV infection, uptake in this population remains low. The aim of the study was to examine sociodemographic, behavioral, clinical, and psychosocial factors associated with PrEP initiation (defined as receiving a PrEP prescription) among 565 cisgender women enrolled in an HIV prevention services coordination program in NYC from January 2017 to December 2019 who met HIV risk criteria for PrEP. Of these, 26% initiated PrEP. Latina women were significantly more likely than white women to have initiated PrEP (Latina: 29.7%; Black: 26.1%; White: 16.3%; Other: 7.4%). PrEP initiation was significantly associated with PrEP awareness, an annual income < $20,000, being unstably housed, receiving benefits navigation services, and reporting non-injection drug use and/or a recent sexual relationship with an HIV-positive partner. The relatively low rate of PrEP initiation we observed suggests the need to increase PrEP access and uptake among women, particularly Black and Latina women who continue to be disproportionately at risk for HIV.

Moving toward equity: fostering transdisciplinary research between the social and behavioral sciences and implementation science to end the HIV epidemic

PURPOSE OF REVIEW

Since the beginning of the HIV epidemic, social and behavioral scientists have developed interventions to stem the spread of the virus. The dissemination of these interventions has traditionally been a lengthy process; however, implementation science (IS) offers a route toward hastening delivery of effective interventions. A transdisciplinary approach, wherein IS informs and is informed by social and behavioral sciences (SBS) as well as community participation, offers a strategy for more efficiently moving toward health equity and ending the HIV epidemic.

RECENT FINDINGS

There has been considerable growth in HIV research utilizing IS theories, methods and frameworks. Many of these studies have been multi or interdisciplinary in nature, demonstrating the ways that IS and SBS can strengthen one another. We also find areas for continued progress toward transdisciplinarity.

SUMMARY

We review literature from 2020 to 2021, exploring the ways IS and SBS have been used in tandem to develop, evaluate and disseminate HIV interventions. We highlight the interplay between disciplines and make a case for moving toward transdisciplinarity, which would yield new, integrated frameworks that can improve prevention and treatment efforts, moving us closer to achieving health equity.