Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients

A mixed-methods evaluation of an HIV pre-exposure prophylaxis educational intervention for healthcare providers in a NYC safety-net hospital-based obstetrics and gynecology clinic

Cisgender women and transgender men are less likely to be assessed for PrEP eligibility, prescribed PrEP, or retained in PrEP care. Thus, this pilot PrEP educational intervention was tailored for healthcare providers (HCPs) in obstetrics/gynecology who provide care to cisgender women and transgender men in an academically-affiliated, public hospital women's health clinic. The three-lecture educational curriculum designed for HCPs focused on PrEP eligibility and counseling, formulations and adherence, and prescription and payment assistance programs. Pre- and post-intervention surveys assessed HCP knowledge and barriers to PrEP counseling and prescription. Among n = 49 participants (mean age = 32.8 years; 85.7% cisgender women, mean years practicing = 4.2 years) pre-intervention, 8.7% had prior PrEP training and 61.2% felt very/somewhat uncomfortable prescribing PrEP. Post-intervention, knowledge of PrEP contraindications, eligibility, follow-up care, and assistance programs all increased. HCPs identified key barriers to PrEP care including lack of a dedicated PrEP navigator, culturally and linguistically appropriate patient materials on PrEP resources/costs, and PrEP-related content integrated into EHRs. Ongoing PrEP educational sessions can provide opportunities to practice PrEP counseling, including information on financial assistance. At the institutional level, incorporating PrEP screening in routine clinical practice via EMR prompts, facilitating PrEP medication monitoring, and enhancing telehealth for follow-up care could enhance PrEP prescription.

PrEPare_Morocco a successful community-based PrEP delivery demonstration program for men who have sex with men and female sex workers in Morocco

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

Applying an Evidence-Based Community Organizing Approach to Strengthen HIV Prevention for Cisgender Women in US South: Protocol for a Mixed Methods Study

BACKGROUND

Most new HIV diagnoses among cisgender women in the United States occur in the South. HIV pre-exposure prophylaxis (PrEP), a cornerstone of the federal Ending the HIV Epidemic (EHE) initiative, remains underused by cisgender women who may benefit. Awareness and access to PrEP remain low among cisgender women. Moreover, improving PrEP reach among cisgender women requires effectively engaging communities in the development of appropriate and acceptable patient-centered PrEP care approaches to support uptake. In a community-clinic-academic collaboration, this protocol applies an evidence-based community organizing approach (COA) to increase PrEP awareness and reach among cisgender women in Atlanta.

OBJECTIVE

The aim of this study is to use and evaluate a COA for engaging community members across 4 Atlanta counties with high-priority EHE designation, to increase PrEP awareness, interest, and connection to PrEP care among cisgender women.

METHODS

The COA, consisting of 6 stages, will systematically develop the skills of community members to become leaders and advocates for HIV prevention inclusive of PrEP for cisgender women in their communities. We will use the evidence-based COA to develop and implement a PrEP-specific action plan to create broader community change by raising awareness and interest in PrEP, reducing stigma associated with HIV or PrEP, and connecting women to sexual health clinics providing PrEP services. In the first 4 stages, to prepare for and develop action plans, we will gather data from one-on-one interviews with up to 100 individuals across Atlanta to capture attitudes, motivations, and influences related to women's sexual health with a focus on HIV prevention and PrEP. Informed by the community interviews, we will revise a sexual health curriculum inclusive of PrEP and community-centered engagement. We will then recruit and train community action team members to develop action plans to implement the curriculum during community-located events. In the last 2 stages, we will implement and evaluate COA's effect on PrEP awareness, interest, HIV or PrEP stigma, and connection to PrEP care among cisgender women community members.

RESULTS

This project was funded by the National Institutes of Health and approved by the Emory University institutional review board in July 2021. Data collection began in December 2021 and is ongoing. COA stage 1 of the study is complete with 70 participants enrolled. Community events commenced in November 2023, and data collection will be completed by November 2025. Stage 1 qualitative data analysis is complete with results to be published in 2024. Full study results are anticipated to be reported in 2026.

CONCLUSIONS

Through a community-clinic-academic collaboration, this protocol proposes to mount a coordinated approach across diverse Atlanta counties to strengthen HIV prevention for cisgender women and to create a sustainable systems approach to move new sexual health innovations more quickly to cisgender women.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56293.

Identifying Implementation Strategies to Enhance HIV Pre-Exposure Prophylaxis Uptake Among Black Cisgender Women in New Orleans, Louisiana

There is an unmet need for HIV prevention among Black cisgender women. From January to November 2020, we conducted formative research to develop locally informed implementation strategies to enhance pre-exposure prophylaxis (PrEP) uptake among Black cisgender women in New Orleans, Louisiana. Following an iterative process, we conducted in-depth interviews (IDIs) with Black women who were not taking PrEP and used those findings to inform IDIs with Black women taking PrEP. We asked about PrEP awareness, social support, PrEP-related norms, medical mistrust, motivation to take PrEP, and potential implementation strategies. Data were analyzed using applied thematic analysis. We established the Black Women and PrEP (BWAP) Task Force-a diverse group of 25 Black female community representatives who reviewed the IDI findings and identified strategies to address these determinants of PrEP uptake. We interviewed 12 Black women who were not taking PrEP and 13 Black women who were taking PrEP. Two main PrEP uptake barriers were identified from the IDI findings and Task Force discussions. First, Black women do not know of other Black women taking PrEP. Women perceived PrEP as a drug for gay men. Most said that testimonials from Black women taking PrEP would make its use more relatable. Second, Black women are not frequently offered PrEP by their providers. Many preferred accessing PrEP through women's health providers. The Task Force identified two strategies to address these barriers: a social media campaign for women and an educational initiative to train providers to discuss and prescribe PrEP. These implementation strategies require further study.

Factors Associated with Planned Future Use of PrEP in the Next 3 Months and Likelihood to Use PrEP Among Black Cisgender HIV-negative Women in Texas

Identifying and then addressing barriers and leveraging facilitators is important to help increase pre-exposure prophylaxis (PrEP) use among Black women vulnerable to HIV acquisition. The present cross-sectional study examined what factors were associated with future plans to use PrEP, and general likelihood to use it among a convenience sample of 152 adult, Black cisgender women from three metropolitan areas in Texas. The final multivariable logistic regression model revealed that relationship status (aOR = 0.20, 95% CI: 0.05-0.73, p < 0.05), PrEP anticipated stigma (aOR = 0.29, 95% CI: 0.10-0.78, p < 0.05), perceived discrimination (aOR = 0.40, 95% CI: 0.21-0.78, p < 0.01) and interest in learning more about PrEP (aOR = 5.32, 95% CI: 2.60-10.9, p < 0.001) were associated with future plans to use PrEP. The final multivariable linear regression model with maximum likelihood estimation identified that perceived discrimination (β=-0.24, SE: -0.38 - -0.10, p < 0.01), perceived HIV risk (β = 0.33, SE: 0.18-0.49, p < 0.001), willingness to use PrEP with condoms (β = 1.26, SE: 0.94-1.60, p < 0.001), and comfort communicating about PrEP with a provider (β = 0.23, SE: 0.06-0.41, p < 0.01) were associated with general likelihood to use PrEP. Findings reveal key factors that warrant further attention and examination toward improving PrEP use within this population.

Understanding Psychosocial Determinants of PrEP Uptake Among Cisgender Women Experiencing Heightened HIV Risk: Implications for Multi-Level Communication Intervention

Pre-exposure prophylaxis (PrEP) is a highly effective daily pill that decreases the likelihood of HIV acquisition by up to 92% among individuals at risk for HIV. PrEP can be discretely used, autonomously controlled, and in place at the time of risk exposure, making it an especially promising method for HIV prevention for cisgender women (CGW). But, PrEP is underutilized by CGW relative to the demonstrable need. We apply the Integrative Model of Behavioral Prediction to identify the critical psychosocial factors that shape CGW's intentions to use PrEP and their relevant underlying beliefs. We surveyed (N = 294) community- and clinic-recruited PrEP eligible CGW to understand the relative importance of attitudes, norms, and efficacy in shaping PrEP intentions. We utilized structural equation modeling to identify the relevant paths. We inspected the summary statistics in relation to three message three selection criteria. We identified beliefs that demonstrated (1) an association with intention, (2) substantial room to move the population, (3) practicality as a target for change through communication intervention. Results show that PrEP awareness was low. When women learned about PrEP, they voiced positive intentions to use it. There were significant and positive direct effects of SE (0.316***), attitudes (0.201**), and subjective norms (0.249***) on intention to initiate PrEP. We illustrate the strategic identification of beliefs within the relevant paths using the 3 belief selection criteria. We also discuss implications for social and structural communication interventions to support women's HIV prevention.

Mapping Implementation Science with Expert Recommendations for Implementing Change (MIS-ERIC): Strategies to Improve PrEP Use among Black Cisgender Women Living in Mississippi

BACKGROUND

Black women are disproportionately affected by the HIV epidemic. Strategies to increase Black women's use of pre-exposure prophylaxis (PrEP) are needed.

METHODS

Interviews were conducted in Mississippi (MS) with Black, cisgender women at risk for HIV, and community healthcare clinic (CHC) staff who work directly with this population. Reflexive thematic analysis was used to identify barriers and select appropriate implementation strategies to increase PrEP care.

RESULTS

Twenty Black women and twelve CHC staff were interviewed. PrEP use barriers resulted from low HIV risk awareness, lack of PrEP knowledge, and structural and stigma-related barriers. Methods for PrEP education and motivation included normalizing PrEP in public communications, providing education at places where women congregate, and tailoring PrEP content with Black women as educators. The Expert Recommendations for Implementing Change (ERIC) project provides a way for implementation scientists to select strategies that are consistent within research and practice across studies. Strategies from the ERIC project were selected to address implementation barriers.

CONCLUSIONS

Tailoring PrEP implementation protocols to increase Black women's access, engagement, and adherence to PrEP is needed. This is one of the first implementation studies to incorporate these four implementation concepts into a single study: (1) implementation outcomes, (2) i-PARIHS, (3) ERIC's strategy list, and (4) operationalizing the strategies using the Proctor et al., guidelines. Results provide an in-depth comprehensive list of implementation strategies to increase PrEP uptake for Black women in MS.

Sexual and Reproductive Health Care Visits as a Venue for Preexposure Prophylaxis Service Delivery Among Women in the United States: Results From a Nationally Representative Survey

BACKGROUND

Preexposure prophylaxis (PrEP) for HIV is disproportionately underprescribed to women. Centers for Disease Control and Prevention guidelines identify a group of women at risk of HIV acquisition who should be offered PrEP, but opportunities remain to improve patient awareness of and provider counseling about PrEP and to expand service delivery of PrEP.

METHODS

Using nationally representative data from the 2017-2019 National Survey of Family Growth, we compared women with (n = 689) and without (n = 5,452) Centers for Disease Control and Prevention indications for PrEP on measures of PrEP awareness, counseling by a provider, and interaction with the health care system.

RESULTS

Women with PrEP indications were no more likely to report awareness of PrEP (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.82-1.29) or PrEP counseling by a provider (OR, 1.32; 95% CI, 0.77-2.27), compared with those without PrEP indications. However, women with PrEP indications were more likely than those without to report a birth control visit (OR, 1.82; 95% CI, 1.39-2.38) or an abortion within the last 12 months (OR, 5.93; 95% CI, 1.48-23.73), and to currently use prescription contraception (OR, 1.45; 95% CI, 1.19-1.78). A majority of both groups reported accessing prenatal care within the last 12 months.

CONCLUSIONS

There remains a gap in PrEP awareness and counseling among women at highest risk for HIV acquisition. Sexual and reproductive health visits represent a logical and feasible venue for PrEP provision. Obstetrician-gynecologists and other family planning providers may be able to aid in service delivery innovations by providing PrEP alongside other sexual and reproductive health care.

Integrating pre-exposure prophylaxis of HIV infection into family planning services: a scoping review

INTRODUCTION

The aim of this review was to map evidence of integrating pre-exposure prophylaxis (PrEP) for HIV prevention into family planning services. A comprehensive package, using a combination of PrEP and contraceptive delivery, could reduce the number of new HIV infections and/or unintended pregnancies for at-risk women and adolescent girls.

METHODS

A scoping literature search was conducted between August 2020 and October 2020. After developing the review question, electronic databases (MEDLINE, Embase, Cochrane Library, Global Health, Web of Science) were systematically reviewed. All types of articles published from 2012 to August 2020 in English were included. The intended outcome was to identify barriers and enablers of integrating services at the client-level and provider-level.

RESULTS

38 articles met inclusion criteria, with 16 from low-and middle-income countries and 22 from high-income countries. Barriers at the client-level included a lack of risk perception associated with low uptake and continuation of PrEP and pill burden; and at the provider-level, barriers included a lack of studies on cost-effectiveness of integrating services and provider training and knowledge. Facilitators included the initiation of PrEP and contraception at the same time and by the same provider or HIV self-testing.

CONCLUSION

Mapping and synthesising current evidence, this review identified key barriers and facilitators for the integration of PrEP into family planning services for women and adolescent girls. In order to address these factors, more implementation research in a variety of settings is needed to meet women's sexual and reproductive health needs globally.

Using qualitative comparative analysis to understand the conditions that produce successful PrEP implementation in family planning clinics

BACKGROUND

Title X-funded family planning clinics have been identified as optimal sites for delivery of pre-exposure prophylaxis (PrEP) for HIV prevention to U.S. women. However, PrEP has not been widely integrated into family planning services, especially in the Southern U.S., and data suggest there may be significant implementation challenges in this setting.

METHODS

To understand contextual factors that are key to successful PrEP implementation in family planning clinics, we conducted in-depth qualitative interviews with key informants from 38 family planning clinics (11 clinics prescribed PrEP and 27 did not). Interviews were guided by constructs from the Consolidated Framework for Implementation Research (CFIR), and qualitative comparative analysis (QCA) was used to uncover the configurations of CFIR factors that led to PrEP implementation.

RESULTS

We identified 3 distinct construct configurations, or pathways, that led to successful PrEP implementation: (1) high "Leadership Engagement" AND high "Available Resources"; OR (2) high "Leadership Engagement" AND NOT located in the Southeast region; OR (3) high "Access to Knowledge and Information" AND NOT located in the Southeast region. Additionally, there were 2 solution paths that led to absence of PrEP implementation: (1) low "Access to Knowledge and Information" AND low "Leadership Engagement"; OR (2) low "Available Resources" AND high "External Partnerships".

DISCUSSION

We identified the most salient combinations of co-occurring organizational barriers or facilitators associated with PrEP implementation across Title X clinics in the Southern U.S. We discuss implementation strategies to promote pathways that led to implementation success, as well as strategies to overcome pathways to implementation failure. Notably, we identified regional differences in the pathways that led to PrEP implementation, with Southeastern clinics facing the most obstacles to implementation, specifically substantial resource constraints. Identifying implementation pathways is an important first step for packaging multiple implementation strategies that could be employed by state-level Title X grantees to help scale up PrEP.

Women's perspectives on barriers to potential PrEP uptake for HIV prevention: HIV risk assessment, relationship dynamics and stigma

HIV remains a significant health issue for women, and multiple overlapping factors shape women's HIV-related risk. Pre-exposure prophylaxis (PrEP) offers critical advantages over other existing options, yet it remains significantly underused among women in the USA where limited work has explored women's opinions on barriers to potential PrEP use. Using open-ended text responses from a sample of women seeking care at a US urban family planning health centre, this study aimed to understand perceptions of factors affecting potential PrEP use. Three themes concerning key factors impacting potential PrEP use emerged: HIV risk assessment, relationship dynamics, and anticipated stigma. Women's assessment of HIV risk suggests that identifying women in clinical settings as having low self-perceived risk may overlook the complexity of how women determine HIV-related risk and prevention needs. Women frequently referenced relationship dynamics when considering PrEP and discussed anticipated partner reactions about use contributing to non-use. Fear or worry of stigma were expressed as motivations to not use PrEP. Study results highlight the importance of public health and health care professionals normalising PrEP as a strategy in women's HIV prevention and sexual health decision-making. Woman-centred PrEP education, screening and communication strategies reflective of their unique HIV-related risk context are needed.

Understanding Retention in the HIV Pre-Exposure Prophylaxis Cascade Among Cisgender Women

HIV remains a significant public health concern in the United States, with 34,800 new cases diagnosed in 2019; of those, 18% were among women. Oral pre-exposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate/emtricitabine is effective and safe, reducing HIV transmission by up to 92% in women. Though studies demonstrate low rates of PrEP adherence among cisgender women prescribed oral PrEP, little is known about the factors that shape PrEP continuation among them. This study focuses on understanding the experiences of cisgender women who have initiated PrEP to gain insight into the factors that shape PrEP continuation. We conducted semi-structured interviews with (N = 20) women who had been prescribed oral PrEP. Interviews were guided by the social-ecological framework to identify multilevel factors affecting PrEP continuation; we specifically examined the experience of engagement and retention in the PrEP cascade. We recruited women who had been prescribed oral PrEP by a government-sponsored sexual health center or a hospital-based family planning clinic in Washington, DC. Factors facilitating PrEP continuation included a positive emotional experience associated with PrEP use, high perceived risk of HIV acquisition, and high-quality communication with health care providers. The most common reason for PrEP discontinuation was low perceived HIV risk (n = 11). Other factors influencing discontinuation were side effects, a negative emotional experience while using PrEP, and negative interactions with the health care system. This study underscores the importance of specific multi-level factors, including the provision of high-quality communication designed to resonate with women and shared decision making between women and their health care providers.

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.

Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States

OBJECTIVE

We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge.

METHODS

We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements.

RESULTS

Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP.

CONCLUSIONS

Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.

PrEP service delivery preferences of black Cis-gender women living in the Southern United States

To assess PrEP service delivery preferences among Black cis-gender women living in urban and rural settings in Alabama, we conducted a cross-sectional discrete choice experiment survey. Discrete choice experiments included five attributes. Hierarchical Bayes (HB) modeling and latent class analyses (LCA) were used to evaluate attribute preferences. Among 795 Black cis-gender HIV-negative women, almost two-thirds lived in urban settings and reported having at least some college; about a third reported a household income less than $25,000 annually; and reported willingness to use PrEP. Respondents placed the greatest importance on PrEP medication formulation and healthcare facility. LCA showed the group with the highest rural proportion preferred for on-line visits. Black women in the Deep South had distinct preferences regarding PrEP service delivery. These findings can inform tailored interventions to improve PrEP uptake among Black cis-gender women across diverse settings in the South.

Knowledgeable, aware / interested: Young black women's perceptions of pre-exposure prophylaxis

Purpose

HIV in the United States disproportionately affects young Black women. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option that has the potential to reduce HIV incidence among HIV-vulnerable populations. However, data regarding women's awareness, interest in starting, and feelings of acceptability or stigma about PrEP remains limited, particularly among adolescent and young Black women.

Materials and methods

A cross-sectional survey was conducted with 100 sexually active young Black women ages 13–24 years attending women's health clinics in Chicago, IL. Descriptive statistics were used to characterize the sample and determine more about what the PrEP needs and barriers are in this community. Associations were modeled using logistic regression and 95% confidence intervals for both bivariate and multivariable models.

Results

In our survey (N = 100), half of study participants (50%) expressed interest in starting PrEP in the next three months and a majority (80%) of young women were confident they could obtain PrEP. Pregnant young women were significantly more interested in starting PrEP than non-pregnant women [OR 2.3 95% CI (1.0, 5.4)], p = 0.05), however, this association did not remain significant in adjusted models.

Conclusions

This study provides a more complete understanding of awareness, interest in, and acceptability of PrEP among adolescent and young Black women attending women's health clinics. Findings indicate sustained interest in starting PrEP, reduced stigma, and increased awareness of PrEP among young Black women. These findings suggest that integrating PrEP into women's health clinics is a promising strategy to increase awareness and utilization of PrEP and decrease HIV transmission among youth at highest risk.

Barriers to accessing pre-exposure prophylaxis among women experiencing intimate partner violence in the United States: a systematic literature review

Women experiencing intimate partner violence (IPV) are at increased risk of human immunodeficiency virus (HIV) infection but have limited uptake of pre-exposure prophylaxis (PrEP). We systematically reviewed the existing evidence for the association between IPV and PrEP use, and barriers to accessing PrEP among women with a history of IPV in the United States. A keyword search of PubMed, CINAHL, ScienceDirect, and Web of Science for relevant articles within the United States from 2012 to 2022 yielded 133 articles, of which 15 were ultimately included in the analysis. A qualitative synthesis of evidence suggests that the association between IPV and PrEP awareness, PrEP acceptability, PrEP use, and HIV risk perception was contingent on the mediating or moderating effects of women's relationship status, social network characteristics, and the timing and types of IPV. Controlling partners' reactions and a lack of independent decision-making in the abusive relationship were salient barriers. The methodological quality of qualitative studies was high; however, there were important risks of bias among quantitative and mixed-method studies. Additional studies are needed to understand barriers to PrEP use among women with IPV in more diverse settings and to provide rigorous evidence for developing targeted HIV prevention strategies for them.

Cultivating PEARL (Promoting Empowerment and Risk Reduction): Formative Research for a PrEP Intervention Among Female Sex Workers in Baltimore, Maryland

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, including a community forum, key informant interviews with providers, and focus group discussions with FSW. FSW and providers acknowledged challenges to building rapport and establishing continuity in care settings. FSW reported low PrEP awareness, with high interest once aware. FSW and providers reported uptake barriers including perceived financial issues, lack of PrEP awareness, and mistrust of the pharmaceutical industry. Concerns were raised about substance use and daily PrEP adherence. Developing a tailored PrEP intervention for FSW necessitates multiple perspectives (e.g. FSW, service providers). Resumen La profilaxis preexposición (PrEP) es un componente vital de la prevención integral del VIH para las trabajadoras sexuales (TSF). En los Estados Unidos, hay pocas intervenciones de PrEP dirigidas a las TSF, quienes experiencian un riesgo elevado de contraer el VIH. Se realizó una investigación formativa para informar a PEARL (Promoción del empoderamiento y la reducción de riesgos), una intervención de PrEP para TSF en Baltimore, MD-la cual incluyó un foro comunitario, entrevistas con proveedores de servicios a las TSF y discusiones entre grupos focales de TSF. TSF y proveedores de servicio reconocieron los retos de mantener buenas relaciones y establecer continuidad en los servicios de salud. TSF exhibieron conocimiento limitado sobre la PrEP, pero expresaron gran interés en la PrEP después de estar informadas. TSF y los proveedores de servicios hablaron de barreras aceptando a la PrEP, incluyendo problemas financieros percibidos, falta de conocimiento sobre la PrEP y desconfianza en la industria farmacéutica. Se expresaron preocupaciones sobre el uso de sustancias y la adherencia diaria a la PrEP. El desarrollo de una intervención de PrEP personalizada para TSF requiere varias perspectivas (por ejemplo, TSF, proveedores de servicios).

Understanding the Impact of Intimate Partner Violence Type and Timing on Pre-exposure Prophylaxis Knowledge, Acceptability, Sexual Behavior, and Gender Roles Among Women of Color

Knowledge and acceptability are key factors for pre-exposure prophylaxis (PrEP) use among women with a history of intimate partner violence (IPV) and research suggests that different types of IPV affect PrEP uptake differently. Few studies have examined whether the type (i.e., physical, sexual, and psychological) and timing (i.e., lifetime, past year) of IPV experiences are related to PrEP knowledge and acceptability, or whether gender roles and sexual risk behaviors affect PrEP use. We aimed to examine the associations between lifetime and past-year physical, sexual, and psychological IPV experiences on PrEP-related outcomes (i.e., knowledge, acceptability, sexual behavior if on PrEP) and the association between gender roles and PrEP-related outcomes. A total of 186 women of color at risk for HIV participated in this study, of whom 54% had ever experienced partner violence. Results showed that lifetime psychological (OR 3.0, 95% CI 1.1-9.4) and lifetime physical IPV (OR 5.5, 95% CI 1.2-18.9) were significantly associated with increased PrEP knowledge. lifetime psychological (OR 6.3, 95% CI 1.0-13.6) and lifetime physical IPV (OR 4.3, 95% CI 4.3-11.5) were significantly associated with increased sexual behavior if on PrEP. Past year physical IPV was significantly associated with interest in using PrEP (OR 1.9, 95% CI 1.7-4.3) and with sexual behavior if on PrEP (OR 4.0, 95% CI 1.1-13.1). Being subordinate to others was also significantly associated with interest in using PrEP (OR 1.5, 95% CI 1.2-2.4) Self-silencing was significantly associated with increased sexual behavior if on PrEP (OR 1.2, 95% CI 1.0-1.5). Gender norms and IPV type and timing can influence whether a person is interested in PrEP use. Both lifetime and past-year IPV experiences need to be examined in the context of gender norms when prescribing PrEP to encourage uptake and continuation among vulnerable women at risk for HIV.

Factors Associated with Intention to Initiate Pre-exposure Prophylaxis in Cisgender Women at High Behavioral Risk for HIV in Washington, D.C

Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use.

Preferences for HIV Preexposure Prophylaxis Products Among Black Women in the U.S

In a nationwide sample of Black women in the U.S., we assessed preferences for HIV preexposure prophylaxis (PrEP) products, including long-acting injectable (LAI) PrEP and once-daily oral PrEP. Among 315 respondents, 32.1% were aware of PrEP and 40.6% were interested in using it; interest increased to 62.2% if PrEP were provided for free. Oral PrEP was the preferred option (51.1%), followed by LAI PrEP (25.7%), vaginal gel (16.5%), and vaginal ring (6.7%). When examining oral and LAI PrEP alone, most (62.7%) preferred oral PrEP. LAI PrEP was more likely to be preferred among respondents with concerns about healthcare costs or PrEP-related stigma, and among those who reported inconsistent condom use and multiple sexual partners. Although most Black women preferred oral PrEP, LAI PrEP may be appealing to a subset with social and structural barriers to PrEP use, such as cost and stigma, and those at increased risk of HIV infection.

'If the Partner Finds Out, then there's Trouble': Provider Perspectives on Safety Planning and Partner Interference When Offering HIV Pre-exposure Prophylaxis (PrEP) to Women Experiencing Intimate Partner Violence (IPV)

Pre-exposure prophylaxis is an effective women-controlled HIV prevention strategy but women experiencing intimate partner violencefear partners' interference and subsequent violence could limit its utility. This study explores provider perceptions of safety planning strategies to prevent escalating violence, mitigate partner interference, and promote daily oral PrEP adherence. We conducted interviews (N = 36) with healthcare providers (n = 18) and IPV service providers (n = 18) in Baltimore and New Haven. Using the Contextualized Assessment for Strategic Safety Planning model we organized data into two categories: the appraisal process and strategic safety planning. Themes revealed during the appraisal process, providers conduct routine IPV screening, facilitate HIV risk perception, and offer PrEP. Strategic safety planning utilizes concealment tactics, informal sources of support, role playing and cover stories. Future interventions to enhance PrEP services among women exposed to IPV should implement safety planning strategies, integrate PrEP care with IPV services, and employ novel PrEP modalities to maximize effectiveness.

Implementing pre-exposure prophylaxis for HIV prevention in women: the role of the obstetrician-gynecologist

Pre-exposure prophylaxis is a powerful HIV prevention tool that can reduce the risk of acquiring HIV by >90% from unprotected sex and >70% from injection drug use. The peripartum period is a time of heightened HIV risk, which underscores the need for HIV prevention counseling and the provision of biomedical interventions in all stages of a woman's reproductive life. It is important that women receive nonjudgmental care, have access to discussions of HIV risk, and are provided with pre-exposure prophylaxis counseling from their women's health practitioners. Obstetrician-gynecologists and other women's health providers are uniquely positioned to identify women who would benefit from pre-exposure prophylaxis and provide it in trusted clinical settings.

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.

Using an Intersectional Framework to Understand the Challenges of Adopting Pre-exposure Prophylaxis (PrEP) Among Young Adult Black Women

INTRODUCTION

There is limited functional knowledge and utilization of pre-exposure prophylaxis (PrEP) among young adult Black cisgender women (YBW).

METHODS

We conducted four focus groups with YBW using an intersectional framework to explore multiple levels of factors that impede YBW awareness, interest, and utilization of PrEP in conjunction with their sexual and reproductive healthcare needs.

RESULTS

Influences at the cultural-environmental level included a lack of information and resources to access to PrEP and medical mistrust in the healthcare system. At the social normative level, influences included attitudes towards the long-term effects on sexual and reproductive health and self-efficacy to follow the PrEP regimen. At the proximal intrapersonal level, influences included anticipated HIV stigma from family and peers along with the fear of rejection from their main partners.

CONCLUSIONS

Translation of these results indicated that interventions to increase PrEP utilization and adherence among YBW will require multi-level strategies to address barriers to integrating HIV prevention into sexual and reproductive healthcare.

Perceived HIV Invulnerability and PrEP Knowledge and Attitudes among Black Sexual Minority Women

Black women have disproportionate rates of HIV compared to women of all other racial groups. The purpose of this analysis was to investigate perceived HIV risk, HIV and STI testing behaviors, and PrEP knowledge and attitudes among Black sexual minority women (SMW) and examine differences based on their history of male sex partners. Secondary data analysis was conducted using data from the Generations Study. This analysis used a sample of N=149 participants who identified as Black cisgender women. Results showed Black SMW with a history of male sex partners reported a higher perceived risk of contracting HIV and significantly more frequent HIV and STI testing than those without a history of male sex partners. Overall, most of the sample was not familiar with PrEP, but one-third had favorable attitudes towards it, and half felt like they did not know enough about PrEP to form an opinion. Implications for culturally relevant public health campaigns and comprehensive sexuality education that integrate PrEP are included.

Awareness, acceptability, and intention to initiate HIV pre-exposure prophylaxis among pregnant women

HIV prevention is critically important during pregnancy, however, pre-exposure prophylaxis (PrEP) is underutilized. We conducted a survey of pregnant and non-pregnant women in a high HIV prevalence community in Washington D.C. to evaluate determinants of PrEP initiation during pregnancy. 201 pregnant women and a reference population of 1103 non-pregnant women completed the survey. Among pregnant women, mean age was 26.9 years; the majority were Black with household-incomes below the federal poverty level. Despite low perceived risk of HIV acquisition and low prior awareness of PrEP, 10.5% of respondents planned to initiate PrEP during pregnancy. Pregnant women identified safety, efficacy, and social network and medical provider support as key factors in PrEP uptake intention. The belief that PrEP will "protect (their) baby from HIV" was associated with PrEP uptake intention during pregnancy. Concerns regarding maternal/fetal side effects, and safety in pregnancy or while breastfeeding were not identified as deterrents to uptake intention. When compared to a nonpregnant sample, there were no significant differences in uptake intention between the two samples. These findings support the need for prenatal educational interventions to promote HIV prevention during pregnancy, as well as interventions that center on the role of providers in the provision of PrEP.

Incorporating HIV Pre-Exposure Prophylaxis Care for Patients Seeking Induced Abortion and Pregnancy Loss Management

BACKGROUND

Family planning clinical encounters are important opportunities for HIV prevention. Our objectives were to 1) estimate the proportion of patients seeking induced abortion and early pregnancy loss management eligible for HIV pre-exposure prophylaxis (PrEP) and 2) compare PrEP eligibility and uptake between patients with unintended and intended pregnancy.

METHODS

We conducted a cross-sectional survey and a nested prospective cohort study of patients seeking an induced abortion or early pregnancy loss management. We assessed pregnancy intendedness, PrEP awareness, HIV risk and risk perception, desire for same-day PrEP start, and PrEP continuation at 30 days. We used the χ² and Fisher's exact tests to assess differences between the participants with intended and unintended pregnancy. We had 80% power to detect a 14% difference in PrEP eligibility between the groups.

RESULTS

We enrolled 250 women. Fifty-six percent (139) had an unintended pregnancy and 44% (110) had an intended pregnancy. PrEP eligibility did not differ significantly between the patients with intended and unintended pregnancy (16% vs. 10%; p = .18). More than one-half (54%, 135/250) were unaware of PrEP before their study visit, and 93% (232/250) considered themselves unlikely to acquire HIV. Of 33 women who were PrEP eligible, 11 accepted same-day start and 1 continued PrEP at 30 days.

CONCLUSIONS

Intendedness of pregnancy was unrelated to PrEP eligibility in women seeking induced abortion and early pregnancy loss management. Most patients seeking these services are unaware of PrEP. Integrating PrEP into family planning care is likely to increase awareness and uptake of PrEP in women.

US Black cisgender women and pre-exposure prophylaxis for human immunodeficiency virus prevention: A scoping review

BACKGROUND

Black cisgender women in the United States experience a disproportionate burden of human immunodeficiency virus acquisition. Pre-exposure prophylaxis is an effective oral daily medication that reduces the risk of human immunodeficiency virus through sex by 99% when taken as prescribed. However, less than 2% of eligible Black cisgender women take pre-exposure prophylaxis. The purpose of this scoping review was to describe the types of research studies done in this area, gaps in knowledge, and potential areas of research needed to increase pre-exposure prophylaxis use among Black cisgender women in the United States.

METHODS

We conducted our search in MEDLINE (PubMed), Embase (Elsevier), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), and Scopus (Elsevier) using a combination of keywords and database-specific subject headings for the following concepts: pre-exposure prophylaxis, African American/Black or minority, and women. We used the Joanna Briggs Institute's Reviewers' Manual process for Scoping Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews to ensure comprehensive and standardized reporting of each part of the review.

RESULTS

Fifty-nine studies were included in the final review. Results of the study were classified according to the three phases of the Human Immunodeficiency Virus Prevention Cascade-demand side, supply side, and adherence and retention. The majority of studies (n = 24, 41%) were cross-sectional quantitative surveys and 43 (34%) focused on the demand-side phase of the Human Immunodeficiency Virus Prevention Cascade. Fifty-eight percent of studies either assessed women's pre-exposure prophylaxis knowledge, attitudes, and intentions to use, or assessed perceived barriers and facilitators. Seven studies (12%) tested pre-exposure prophylaxis uptake and adherence among Black cisgender women.

CONCLUSION

This review found multiple missed opportunities to increase women's demand for pre-exposure prophylaxis and health care provider screening and referral for pre-exposure prophylaxis. Additional studies are needed to effectively assess pre-exposure prophylaxis uptake and adherence among Black cisgender women.

Pre-Exposure Prophylaxis Perspectives, Sociodemographic Characteristics, and HIV Risk Profiles of Cisgender Women Seeking and Initiating PrEP in a US Demonstration Project

Little information is known about the cisgender women who seek and initiate pre-exposure prophylaxis (PrEP) for HIV prevention in the United States. Adherence Enhancement Guided by Individualized Texting and Drug Levels was a 48-week single-arm open-label demonstration study of daily oral tenofovir disoproxil fumaratel emtricitabine (TDF/FTC) in cisgender women ≥ 18 years old at risk for HIV. Participants were surveyed at screening and enrollment about sociodemographics, HIV risk perception and behaviors, and PrEP perspectives and aggregated into three risk groups according to HIV sexual risk behavior: being in a serodiscordant partnership (SD), engaging in sex work (SW), and having partners with unknown HIV status at risk for HIV (UP). One hundred sixty-seven women presented for screening with n = 31 screen failures. Of the 162 women completing enrollment, mean age was 40 (standard deviation 11), with 41% non-Hispanic Black, 22% non-Hispanic White, and 19% Latina. Compared with those who screened ineligible, enrolled participants were more likely to have heard of PrEP, had higher HIV risk perception, and reported higher perceived PrEP efficacy. Sixty-four women (47%) were categorized as SD, 21 (15%) as SW, and 51 (38%) as UP. The SW were more likely to report higher levels of drinking and drug use (p = 0.002) and history of intimate partner violence in the past year (p < 0.001) compared with SD and UP. Among cisgender women enrolled, there were significant differences between the three risk groups by demographics, HIV risk behavior, and PrEP perspectives, suggesting that interventions to successfully implement PrEP in US women may need to be tailored by HIV risk group. Clinical Trial Registration number: NCT02584140.

Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings

There is limited information on contraceptive values and preferences of sex workers. We conducted a mixed-method study to explore contraceptive values and preferences among sex workers. We conducted an online survey with individuals from 38 countries (n = 239), 6 focus group discussions (FGD, n = 68) in Zimbabwe, and 12 in-depth phone interviews (IDI) across 4 world regions, in June and July of 2019. Participants were asked about awareness of contraceptives, methods they had used in the past, and the determinants of their choices. Differences between respondents from high-, low- and middle- income countries were examined. Qualitative data were analysed thematically. Survey participants reported an awareness of modern contraceptive methods. FGDs found that younger women had lower awareness. Reports of condomless sex were common and modern contraceptive use was inconsistent. Determinants of contraceptive choices differed by setting according to results of the survey, FGD, and IDI. Regardless of country income level, determinants of contraceptive choices included ease of use, ease of access to a contraceptive method, and fewer side effects. Healthcare provider attitudes, availability of methods, and clinic schedules were important considerations. Most sex workers are aware of contraceptives, but barriers include male partners/clients, side effects, and health system factors such as access and clinic attitudes towards sex workers.

Assessing Provider-, Clinic-, and Structural-Level Barriers and Recommendations to Pre-Exposure Prophylaxis (PrEP) Uptake: A Qualitative Investigation Among Women Experiencing Intimate Partner Violence, Intimate Partner Violence Service Providers, and Healthcare Providers

Intimate partner violence (IPV) relates to HIV susceptibility and acquisition. Existing research examined barriers to pre-exposure prophylaxis (PrEP) uptake among women but few studies assess uptake and delivery among IPV service providers, along with provider-, clinic-, and structural-level barriers. We conducted 34 semi-structured interviews with PrEP-eligible cisgender heterosexual women experiencing IPV, Reproductive Health providers, PrEP providers, and IPV service providers in Northeast US. Systems theory was used to examine barriers from individuals who either work closely with or are part of the population. The framework method was used to draw descriptive and explanatory conclusions. Findings suggest limited knowledge for Reproductive Health and IPV Service Providers. Providers often did not feel equipped to discussed PrEP in visits or focused efforts solely on safety. Expanding PrEP awareness is necessary and marketing should include women. Future research should investigate how providers can work collaboratively across sectors to ensure women receive comprehensive trauma-informed care.

Contraceptive Method Mix and HIV Risk Behaviors Among Kenyan Adolescent Girls and Young Women Seeking Family Planning Services: Implications for Integrating HIV Prevention

Background: Understanding HIV risk behaviors among adolescent girls and young women (AGYW) seeking contraception could help inform integrating HIV prevention services within family planning (FP) clinics. Methods: From 10/2018 to 04/2019, we conducted a survey at 4 FP clinics in Kisumu, Kenya to evaluate risk behaviors among AGYW without HIV infection seeking contraception. All AGYW aged 15-24 were invited to participate following receipt of FP services. Adolescent girls and young women initiating or refilling contraception were included in this analysis. Long-acting reversible contraceptives (LARC) included intrauterine devices, implants, or injectables. Non-LARC methods included oral contraceptive pills (OCP) or condoms. We used an empiric risk score to assess HIV risk behaviors; HIV risk scores of ≥5 (corresponding to 5-15% HIV incidence) defined "high" HIV risk. Results: Overall, 555 AGYW seeking FP were included. Median age was 22 years [interquartile range (IQR) 20-23], median completed education was 12 years (IQR 10-12); 23% of AGYW had HIV risk scores of ≥5. The most frequent form of contraception was injectables (43%), followed by implants (39%). After adjustment for education, prior pregnancy, and marital status, LARC users more frequently engaged in transactional sex than non-LARC users [6 vs. 0%, adjusted prevalence ratio (PR) = 1.17, 95% CI 1.09-1.29, p < 0.001]; LARC use was not associated with HIV risk scores ≥5. Among LARC users, AGYW using injectables more frequently had condomless sex compared to AGYW using other LARC methods (85 vs. 75%, adjusted PR = 1.52, 95% CI 1.09-2.10, p = 0.012); injectable use was not associated with HIV risk scores ≥5. Conclusions: Adolescent girls and young women seeking contraception frequently had high HIV risk, emphasizing the importance of integrating HIV prevention within FP. Multipurpose technologies for contraception and HIV prevention could particularly benefit AGYW.

Get PrEPPT (pre-exposure prophylaxis and pregnancy termination): an exploration of the values, attitudes and preferences regarding HIV and PrEP among women seeking abortion

INTRODUCTION

Pre-exposure prophylaxis (PrEP) for the prevention of HIV transmission is under utilised by women in the US. Women seeking abortion have a higher HIV prevalence than women who continue prenatal care and could benefit from HIV risk assessment and PrEP counselling. We assessed the knowledge, attitudes, and preferences of women seeking abortion care regarding their HIV risk and knowledge of PrEP, and identified individual and system barriers to PrEP access.

METHODS

We performed a cross sectional descriptive study of English speaking women at a freestanding abortion clinic through an anonymous survey. Participants with indications for PrEP care included those who performed sex work, experienced a recent sexually transmitted infection, or had multiple sexual partners and inconsistent condom use. We performed descriptive statistics on response data; Wilcoxon tests were used to compare continuous variables across groups.

RESULTS

64 (32.3%) participants had indications for PrEP, but only 31 (16.1%) had previous knowledge of PrEP. After the concept was explained, attitudes towards PrEP were generally positive, and 54 participants (27.8%) would consider starting PrEP in the next 6 months. Participants were most interested in receiving PrEP care from their primary care provider rather than from an abortion clinic.

CONCLUSIONS

Among women seeking abortion, women vulnerable to HIV infection outnumbered those with PrEP knowledge by 2 to 1. Prior knowledge of PrEP as an HIV prevention method was low, but women found PrEP acceptable. While women reported preferring to receive PrEP from a primary care provider, the abortion clinic visit may also represent an important time for HIV education and risk screening.

Policy considerations for scaling up access to HIV pre-exposure prophylaxis for adolescent girls and young women: Examples from Kenya, South Africa, and Uganda

Adolescent girls and young women (aged 15-24 years; AGYW) continue to carry a disproportionate burden of HIV in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) helps reduce the risk of acquiring HIV for persons at substantial risk, including AGYW. As countries plan for the rollout of PrEP across sub-Saharan Africa, PrEP policies and programs could address the unique needs of AGYW. The purpose of this analysis was to identify policy considerations to improve AGYW access to PrEP. After reviewing the literature, we identified 13 policy considerations that policymakers and stakeholders could evaluate when developing or reviewing PrEP-related policies. We sorted these considerations into five categories, which together comprise an AGYW Access to PrEP Framework: AGYW-friendly delivery systems, clinical eligibility and adherence support, legal barriers and facilitators, affordability, and community and AGYW outreach. We also reviewed policies in three countries (Kenya, South Africa, and Uganda) to explore how PrEP-related policies addressed these considerations. Some of these policies addressed some of the 13 policy considerations, but none of the policies directly addressed the unique needs of AGYW for accessing PrEP. To improve access to PrEP for AGYW, country policies could include specific components that address these 13 considerations. To reach AGYW effectively, each country could use the 13 considerations we have identified to analyze current policies to identify existing programmatic barriers to AGYW accessing HIV services and address these barriers in PrEP-related policies.

Awareness and acceptability of HIV pre-exposure prophylaxis (PrEP) among students at two historically Black universities (HBCU): a cross-sectional survey

Background

Despite young African American adults (ages 18–24) being among the highest risk groups for HIV infection, little is known about their awareness of HIV pre-exposure prophylaxis (PrEP) – a once daily pill shown to be > 90% effective in preventing HIV. To explore awareness and acceptability of PrEP among college students in this demographic, we conducted a survey of attendees at two large historically Black universities (HBCU) in North Carolina.

Methods

We administered a 14-item questionnaire to students at two HBCUs in North Carolina between February and April 2018. Questions were formatted in a yes/no or multiple choice format. Questionnaire items specifically addressed PrEP awareness and acceptability. Surveys were administered to students at a campus health fair and while transiting the campus student union via iPad. Response to all questions was optional. We fit a logistic regression model to determine association of key demographic determinants with PrEP acceptability and awareness. Statistical analyses were conducted using SAS 9.4 (SAS, Cary, NC).

Results

Overall, 210 students participated in the survey, of which 60 completed all survey items as presented. The survey cohort was 75% female, 89% heterosexual and 39% freshmen. The mean age of respondents was 19.8 years (SD: 1.8). Fifty-two percent of survey respondents reported that they were aware of PrEP prior to the time of survey administration. Only 3% of respondents reported that they were on PrEP. The most common sources of information on PrEP were campus health services (24%) and non-social media advertising (15%). Of respondents who were aware of PrEP, 61% reported that they had heard about in the 6 months prior to survey administration, while only 19% say they were aware of it for more than a year. Regarding acceptability of PrEP, 58% of respondents reported that they would take a once a day pill for HIV if they were at risk. Our logistic regression analysis found no statistically significant associations between key demographic factors and PrEP awareness. However, persons who perceived themselves to be at risk for HIV acquisition were more likely to find once daily oral PrEP (relative risk 2.66 (95% CI 1.31–5.42)) as an acceptable prevention strategy than the rest of the survey cohort.

Conclusions

African American HBCU students are becoming aware of PrEP, and generally perceive the intervention as acceptable and worth consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10996-2.

Perspectives of Black women in the United States on salon-based intervention to promote the uptake of pre-exposure prophylaxis (PrEP) for HIV

AIMS AND OBJECTIVES

To understand Black women's perspectives on a pre-exposure prophylaxis (PrEP) education intervention in a salon setting.

BACKGROUND

Black women have a significant lifetime risk of acquiring HIV. Pre-exposure prophylaxis (PrEP) is an effective prevention approach in reducing that risk. Despite this, Black women are least likely to use PrEP.

DESIGN

This was a qualitative study to identify Black women's perspectives on acceptability of a PrEP education intervention in a salon setting using hair stylists. The paper adhered to the COREQ checklist in reporting.

METHODS

Seven focus groups among Black women (n = 44) living in north-central North Carolina were conducted. Ethical approval was obtained. The interview guide included questions on knowledge of PrEP and barriers and facilitators to a PrEP promotion programme in a salon setting.

RESULTS

Conventional content analysis considered content in relation to themes of facilitators, barriers and women's preferences for intervention delivery. Facilitators included the salon characteristics, social culture and relationship with the stylist. Women noted concerns of accuracy of content from stylists and privacy as barriers.

CONCLUSIONS

Participants' trust with their stylists make a PrEP education salon-based intervention feasible. Salon-based interventions are not one-size-fits-all and researchers interested in this setting should tailor interventions to the individual salon. Interventions for PrEP in a salon setting should be culturally appropriate, confidential and consider the potential reach to the social networks of Black women in the salon.

RELEVANCE TO CLINICAL PRACTICE

The insights shared by Black women can contribute to developing a PrEP uptake intervention as a way of reducing new cases of HIV.

Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: a qualitative exploration

In the USA, Black women are at disproportionately higher risk for HIV compared to women of other races/ethnicities, which can be explained by the Substance Abuse, Violence and AIDS (SAVA) syndemic. Disparities in HIV, substance use and violence are driven by multiple influences, including structural factors (e.g. housing and poverty), which exacerbate social- and individual-level factors leading to more sex partners, engaging in unprotected sex, having sex for money, experiencing forced sex from an intimate partner or increased substance use, all of which increase HIV risk. Pre-exposure prophylaxis (PrEP), a pill that can prevent HIV, is a discreet and underutilised method that Black women experiencing syndemics can use to decrease their risk. This study explored Black women's interest in, and barriers to adopting PrEP over 6 months. Thirty Black women (age M = 32.2) who experienced multiple substance use, violence and HIV-related syndemic factors were interviewed four times over a 6-month period. Results demonstrated that experiencing intimate partner violence, substance use, community violence and other structural factors (poor access to social services, transport and childcare) all acted as barriers to PrEP adoption. Future research should consider multi-level interventions that include methods such as media campaigns, providing PrEP or referrals where women who experience syndemic and structural factors seek help, and implement a PrEP adherence programmes and interventions in support group settings.

Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature

Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.

Persistence With Human Immunodeficiency Virus Pre-exposure Prophylaxis in the United States, 2012-2017

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) infection if used adherently throughout periods of HIV risk. We estimated PrEP persistence among cohorts of persons with commercial or Medicaid insurance.

METHODS

We analyzed data from the IBM MarketScan Research Database to identify persons aged 18-64 years who initiated PrEP between 2012 and 2017. We assessed PrEP persistence by calculating the time period that each person continued filling PrEP prescriptions until there was a gap in prescription fills > 30 days. We used Kaplan-Meier time-to-event methods to estimate the proportion of PrEP users who persisted with PrEP at 3, 6, and 12 months after initiation, and constructed Cox proportional hazards models to determine patient characteristics associated with nonpersistence.

RESULTS

We studied 11 807 commercially insured and 647 Medicaid insured persons with PrEP prescriptions. Commercially insured patients persisted for a median time of 13.7 months (95% confidence interval [CI], 13.3-14.1), compared to 6.8 months (95% CI, 6.1-7.6) among Medicaid patients. Additionally, female sex, younger age, residence in rural location, and black race were associated with shorter persistence. After adjusting for covariates, we found that female sex (hazard ratio [HR], 1.81 [95% CI, 1.56-2.11]) and younger age (18-24 years: HR, 2.38 [95% CI, 2.11-2.69]) predicted nonpersistence.

CONCLUSIONS

More than half of commercially insured persons who initiated PrEP persisted with it for 12 months, compared to a third of those with Medicaid. A better understanding of reasons for nonpersistence is important to support persistent PrEP use and to develop interventions designed for the diverse needs of at-risk populations.

Role of Social Networks and Social Norms in Future PrEP Use in a Racially Diverse Sample of At-Risk Women and Members of Their Social Networks

OBJECTIVE

Despite the efficacy of pre-exposure prophylaxis (PrEP) in reducing the risk of HIV infection, uptake remains low among many who are most vulnerable to HIV, such as Black and Latinx women. Interventions that target social networks to encourage at-risk women to initiate PrEP are underused.

DESIGN

This study used an egocentric network design and sampled Black/African American and Latinx women at risk of HIV as well as people from their social networks (N = 211) in a small, western city.

METHODS

Multivariable generalized linear mixed effects regression models investigated individual-level and network-level characteristics associated with likely future PrEP use.

RESULTS

PrEP awareness was low, but once informed, 36% considered themselves likely to take it in the future. Perceived risk of HIV, perceived barriers to HIV testing, and participation in a 12-step program increased odds of anticipated PrEP use. A higher proportion of friends in one's network decreased odds of future PrEP use, whereas a higher proportion of network members who tested regularly for HIV increased odds of future PrEP use. A marginally significant interaction was detected between proportion of friends in one's network and proportion of the network perceived to test for HIV regularly (ie, testing norms). When HIV testing norms were low, a higher proportion of friends in the network decreased odds of likely PrEP use. However, this effect was reversed in contexts with strong testing norms.

CONCLUSION

Women who are interested in PrEP may be embedded within social and normative contexts that can foster or inhibit PrEP uptake.

Awareness of and Attitudes Toward Pre-exposure Prophylaxis Among Predominantly Heterosexual Black Adolescents and Young Adults and Their Guardians in an Urban Area With HIV Epidemic in the United States

Among 185 Black, cis-gender, predominantly heterosexual adolescents and young adults (AYA) and 35 guardians surveyed in Washington, DC, the majority of AYA (96.8%) and guardians (94.3%) were unaware of pre-exposure prophylaxis (PrEP); 62.2% of AYA were uncertain if PrEP was safe or effective against HIV. Of 41.6% of AYA willing to use PrEP, 24.9% reported concern about PrEP-related social stigma.

Interest in Long-Acting Injectable Pre-exposure Prophylaxis (LAI PrEP) Among Women in the Women's Interagency HIV Study (WIHS): A Qualitative Study Across Six Cities in the United States

Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has the potential to facilitate adherence and transform HIV prevention. However, little LAI PrEP research has occurred among women, who face unique barriers. We conducted 30 in-depth interviews with HIV-negative women from 2017-2018 across six sites (New York; Chicago; San Francisco; Atlanta; Washington, DC; Chapel Hill) of the Women's Interagency HIV Study. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Few women expressed interest in PrEP and when prompted to choose a regimen, 55% would prefer LAI, 10% daily pills, and 33% said they would not take PrEP regardless of formulation. Perceived barriers included: (1) the fear of new-and perceived untested-injectable products and (2) potential side effects (e.g., injection-site pain, nausea). Facilitators included: (1) believing shots were more effective than pills; (2) ease and convenience; and (3) confidentiality. Future studies should incorporate women's LAI PrEP-related experiences to facilitate uptake.

Just4Us: Development of a Counselor-Navigator and Text Message Intervention to Promote PrEP Uptake Among Cisgender Women at Elevated Risk for HIV

ABSTRACT

In the United States, pre-exposure prophylaxis (PrEP) uptake among eligible cisgender women has been slow, despite the availability of oral PrEP since 2012. Although women make up nearly 20% of those living with HIV, there are currently few PrEP uptake interventions for cisgender women at elevated risk for acquiring HIV. Here we describe the process used to design and pre-pilot test Just4Us, a theory-based behavioral intervention to promote PrEP initiation and adherence among PrEP-eligible cisgender women. This work was part of a multiphase study conducted in New York City and Philadelphia, two locations with HIV rates higher than the national average. The counselor-navigator component of the intervention was designed to be delivered in a 60- to 90-min in-person session in the community, followed by several phone calls to support linkage to care. An automated text messaging program was also designed for adherence support. Just4Us addressed personal and structural barriers to PrEP uptake using an empowerment framework by building on women's insights and resources to overcome barriers along the PrEP cascade. Usability pre-pilot testing results were favorable and provided valuable feedback used to refine the intervention.

Implementation of HIV pre-exposure prophylaxis for women of color: Perspectives from healthcare providers and staff from three clinical settings

Women of color (WOC) account for 83% of new HIV infections among women in the United States. While pre-exposure prophylaxis (PrEP) is a safe, effective HIV prevention method for women, WOC are less likely to be prescribed PrEP than other populations. Guided by an implementation science research framework, we investigated the implementation of a PrEP initiative for WOC in a US city with high HIV incidence. Across three clinical sites, only three WOC were prescribed PrEP after one year. Analysis of qualitative interviews with clinic staff and providers identified time constraints, reluctance to prescribe PrEP, and discomfort with counseling as implementation barriers. Implementation facilitators included staff and leadership support for PrEP, alignment of PrEP services with organizational missions, and having a centralized PrEP Coordinator. By addressing these identified implementation barriers and facilitators, clinic staff and providers can ensure that WOC are provided with the full range of HIV prevention options.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. “High objective risk” (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18–29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), “rather high”/ “high” self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

Intimate Partner Violence, HIV Pre-Exposure Prophylaxis (PrEP) Acceptability, and Attitudes About Use: Perspectives of Women Seeking Care at a Family Planning Clinic

Pre-exposure prophylaxis (PrEP) presents an opportunity to expand prevention options for women at risk for HIV infection. Yet, women's PrEP use remains low and relatively little is known about PrEP acceptability and attitudes among a sub-population of women at risk for HIV-those experiencing intimate partner violence (IPV). A cross-sectional survey included closed and open-ended questions to assess IPV, PrEP acceptability, and attitudes about PrEP use among women seeking care at an urban family planning clinic in Pittsburgh, Pennsylvania (N = 145). Approximately 70% of women reported being willing to use PrEP with the key reasons for potential use including previous STI diagnosis, inconsistent condom use, and lack of or dishonest conversations with partners. Among women reporting recent IPV (41%), potential barriers to PrEP included concerns around drug effects, access/affordability, and adherence. Over half of women reporting recent IPV reported concerns around partner reaction impacting potential PrEP use. Results from this mixed-methods study highlight the need for a woman-centered PrEP intervention that uniquely includes awareness raising and understanding of PrEP for women, as well as reflects the context of IPV in decision-making and care.

A Longitudinal, Qualitative Exploration of Perceived HIV Risk, Healthcare Experiences, and Social Support as Facilitators and Barriers to PrEP Adoption Among Black Women

Black women contract HIV at much higher rates than White or Hispanic women. Pre-exposure prophylaxis (PrEP) is an underutilized prevention tool among this population. We sought to determine participants' interest in PrEP and facilitators and barriers to PrEP adoption. This longitudinal, qualitative study included 30 Black women (Mage = 32.2) interviewed 4 times over 6 months. Most participants had never heard of PrEP and a majority expressed initial interest. Barriers to PrEP initiation included low perceived HIV risk, medical mistrust, provider experiences and knowledge, negative reactions from family and friends, low perceived efficacy to adherence, and transportation. This study demonstrated actual, rather than hypothetical, PrEP interest and attitudes among Black women, and the barriers that arose over time during the study. PrEP awareness needs to be promoted among Black women and medical providers. Future research should address individual risk perception, medical mistrust, increasing social support, and decreasing transportation barriers.

PrEP Knowledge and Attitudes Among Adults Attending Public Health Clinics in Southern Arizona

HIV pre-exposure prophylaxis (PrEP) is underutilized among Hispanics, women, and low-income individuals. To better understand PrEP barriers in this population, questionnaires were administered to 500 patients attending public health clinics in southern Arizona which provide family planning and sexually transmitted infections care. Sixty-three percent believed that they had no risk of HIV infection. When asked "Before today, did you know that there was a pill that can prevent HIV infection?" 80% of persons answered no. Among women, 88% answered no to this question. As expected, individuals with a higher perceived HIV risk (OR 1.76) or one HIV risk factor (OR 5.85) had a higher probability of knowledge. Among survey participants 87% would take a daily pill, 91% would visit a health-care provider every 3 months, and 92% would have laboratory testing every 3 months. Fifty-four percent would not be afraid or embarrassed if friends or family knew they were taking PrEP. Seventy-two percent would take PrEP despite temporary nausea. Sixty-two percent would pay ≥ $40 every 3 months for PrEP. Lack of knowledge, rather than patient attitudes, is the more important barrier to wider utilization of PrEP among individuals, especially women, attending public health clinics in Southern Arizona. Future efforts need to focus on education and access to PrEP in underserved populations including women and Hispanics.