Stigma, Partners, Providers and Costs: Potential Barriers to PrEP Uptake among US Women

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.

A Systematic Review and Narrative Synthesis of Factors Affecting Pre-exposure Prophylaxis Willingness Among Black Women for HIV Prevention

Pre-exposure prophylaxis (PrEP) can significantly reduce human immunodeficiency virus (HIV) transmission among Black women in the United States (U.S.), a group disproportionately affected by HIV. However, PrEP uptake in this HIV-vulnerable population is low. This review analyzes the factors influencing Black women's PrEP willingness using the Behavioral Model for Vulnerable Populations (BMVP). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Population, Intervention, Comparison, Outcome, Study Design (PICOS) framework, we conducted a systematic literature search and selected 24 peer-reviewed studies on PrEP willingness. Narrative synthesis revealed a heterogeneous landscape of the determinants affecting PrEP willingness among Black women, categorized into three main domains. Predisposing demographic and social factors included younger age, unmarried status, higher education, sexual or gender minority identity, trust in healthcare providers, and perceived HIV risk. Predisposing behavioral factors included condomless sex, multiple partners, and engagement in sex work. Socioeconomic status, health insurance, healthcare access, support systems, and structural challenges were identified as enabling factors influencing Black women's PrEP willingness. Finally, the perceived need domain and health-related factors influencing the perceived need for PrEP included a history of sexually transmitted infections (STI), intimate partner violence (IPV), and birth control interference. This study emphasizes the complexity of the barriers and facilitators of PrEP uptake and, thus, the need for tailored interventions and health strategies to promote its use. Addressing the interconnected individual, interpersonal, and structural determinants of PrEP access is crucial for improving PrEP willingness and thereby advancing health equity in this population.

PrEP discontinuation, cycling, and risk: Understanding the dynamic nature of PrEP use among female sex workers in South Africa

PrEP cycling among women is thought to be safe when there are distinct "seasons of risk." However, cyclical PrEP use over short periods may be associated with increased risk of HIV acquisition. We aimed to characterize key social ecological factors contributing toward PrEP cycling among female sex workers (FSW) in the context of high HIV risk. Semi-structured, in-depth interviews were conducted with 36 FSW at risk for HIV acquisition and 12 key informant (KI) service providers in eThekwini (Durban), South Africa from January-October 2020. FSW identified key factors driving temporary discontinuation of PrEP including relocation, lack of information on or difficulty coping with side effects, and delays in accessing PrEP. In many cases, FSW were motivated to restart PrEP once barriers were overcome. In contrast, KIs emphasized the importance of individual adherence to PrEP and reliance on personal risk assessments when counselling FSW on cycling decisions. FSW and KI perspectives highlight a disconnect between providers' recommendations on the potential for cyclical use of PrEP during periods of minimal risk and actual drivers among FSW causing temporary PrEP discontinuation. Further interventions supporting safe PrEP cycling are needed to ensure decisions around cycling are deliberate and guided by changes in HIV risk rather than external factors.

Knowledge and Attitudes About HIV Pre-Exposure Prophylaxis Among Sexually Active Black and Latina Cisgender Women: Findings from the 2017 and 2018 New York City Sexual Health Survey

Pre-exposure prophylaxis (PrEP) is a highly effective tool to prevent HIV, yet it is underutilized among women. The current study aims to evaluate the awareness, attitudes, and perceptions of PrEP among a large survey sample of Black and Latina women in New York City (NYC). Interviewer-administered surveys were conducted in high HIV incidence neighborhoods in NYC among Black, Latina, and Afro-Latina women who reported recent sex with a man in 2017 (n = 398) and 2018 (n = 405). About 40% of participants were aware of PrEP, whereas 30.4% indicated interest in using it. The top reason for not utilizing it was low HIV risk perception. However, most participants supported the idea that using PrEP meant asserting control over their health (94.1%). Primary care providers and obstetricians/gynecologists were participants' preferred sources for PrEP (91.6%). Across survey cycles, compared to non-Black Latina participants, Black participants had significantly higher PrEP awareness (44.4% vs. 29.1%). PrEP awareness was also significantly higher among survey participants in 2018 (45.2%) than in 2017 (34.3%). Less than half of the participants were aware of PrEP, but those who were aware expressed largely positive attitudes toward the medication. Our findings may inform future PrEP implementation strategies to optimize awareness and access to PrEP among women disproportionately affected by HIV, like focusing on personal empowerment instead of risk-based messaging and training women's sexual health care providers in PrEP provision.

Betrayed, Beaten, Banished: The Stigma of Being a Rural Tongqi in China

In China, an emerging social issue involves a subset of rural women who, because of family and culture, become inadvertently matched up with and married to closeted men who have sex with men (MSM). These women-referred to as Tongqi-often discover they are in a loveless marriage, but any effort to change their situation results in intense backlash, discrimination, and stigma from families, village communities, and even government and healthcare institutions. This study explores the experiences of Tongqi, examining the influence of social interaction, community relationships, and macrostructural factors that coalesce to create an environment of chronic enacted stigma. In-depth interviews were conducted with 59 rural Tongqi, 11 of whom contracted human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) from their spouses. The findings reveal the significant role of extended kinship networks and macrostructural elements, such as hukou (household registration) and government officers, as well as village-level lineage structures. Informant data highlights how lineage relationships, interwoven with gender practices, contribute to the enacted stigma impacting the physical and psychological health of Tongqi. Tongqi report psychological effects such as an array of symptoms reflecting post-traumatic stress, chronic depression, and attempted suicide. Tongqi also report adverse physical health concerns involving reproductive health, unwanted pregnancies, sexually transmitted infections (STIs), and pregnancy complications. These findings helped produce possible policy recommendations to address the most pressing issues faced by Tongqi.

An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP)

Cisgender Black women (CBW) experience 67% of new HIV diagnoses among women in the South. Progress toward ending the HIV epidemic requires researchers to explore perceptions of factors related to the decision to initiate pre-exposure prophylaxis (PrEP) among CBW. Qualitative methods were used to explore how social and structural constructs influence individual decisions to use PrEP among 20 CBW through focus groups. The thematic data analysis identified how facilitators and barriers to PrEP uptake aligned with an external locus of control (LOC) [e.g., media influences on understanding of PrEP] or an internal LOC (e.g., awareness of personal vulnerability to HIV). Several participants highlighted that their PrEP knowledge was rooted in an external LOC, such as media campaigns. A participant stated, 'But even with the commercial, it wasn't representation for me.' Another participant described her personal HIV vulnerability in her sexual relationship as an internal LOC, stating, 'Not ignorance, it's maybe just not accepting the true reality of this can be contracted even from someone that you believe that you trust.' Due to gaps in media marketing, healthcare providers should be aware that some female patients may perceive that PrEP is not for them. Provider-led sexual health discussions are urgently needed to bridge the gap between PrEP eligibility and initiation.

CDC Prioritizes HIV Prevention and Treatment to Reduce HIV Disparities Among Cis-Gender Black Women

To succeed in ending the HIV epidemic in the United States, the Centers for Disease Control and Prevention (CDC) focuses on delivering combinations of scientifically proven, cost-effective, and scalable interventions to priority populations. Systemic factors continue to contribute to persistent health disparities and disproportionately higher rates of HIV diagnosis in some communities. The National HIV/AIDS Strategy has designated cis-gender Black women (CgBW) as a priority population to address the racial and ethnic inequities in HIV. This report presents the portfolio of projects, programs, and initiatives funded by the CDC's Division of HIV Prevention (DHP) to address disparities in HIV and improve health and QOL among CgBW. These funded activities include the development, planning, and implementation of HIV prevention programs, mass media campaigns, and behavioral interventions focused on CgBW. This report also summarizes DHP's community engagement, capacity building, and partnership efforts, and highlights research and surveillance activities focusing on CgBW. Finally, this report outlines future directions for CDC's efforts to improve access to HIV testing, treatment, and prevention for CgBW in the United States.

Effectiveness of a culturally tailored HIV intervention in promoting PrEP among black women who use drugs in community supervision programs in New York City: a randomized clinical trial

BACKGROUND

In the U.S. there are significant racial and gender disparities in the uptake of pre-exposure prophylaxis (PrEP). Black Americans represented 14% of PrEP users in 2022, but accounted for 42% of new HIV diagnoses in 2021 and in the South, Black people represented 48% of new HIV diagnoses in 2021 but only 21% of PrEP users in 2022. Women who use drugs may be even less likely than women who do not use drugs have initiated PrEP. Moreover, women involved in community supervision programs (CSP) are less likely to initiate or use PrEP, More PrEP interventions that focus on Black women with recent history of drug use in CSPs are needed to reduce inequities in PrEP uptake.

METHODS

We conducted a secondary analysis from a randomized clinical trial with a sub-sample (n = 336) of the total (N = 352) participants from the parent study (E-WORTH), who tested HIV negative at baseline were considered PrEP-eligible. Black women were recruited from CSPs in New York City (NYC), with recent substance use. Participants were randomized to either E-WORTH (n = 172) an HIV testing plus, receive a 5-session, culturally-tailored, group-based HIV prevention intervention, versus an HIV testing control group (n = 180). The 5 sessions included an introduction to PrEP and access. This paper reports outcomes on improved awareness of PrEP, willingness to use PrEP, and PrEP uptake over the 12-month follow-up period. HIV outcomes are reported in a previous paper.

RESULTS

Compared to control participants, participants in this study assigned to E-WORTH had significantly greater odds of being aware of PrEP as a biomedical HIV prevention strategy (OR = 3.25, 95% CI = 1.64-6.46, p = 0.001), and indicated a greater willingness to use PrEP as an HIV prevention method (b = 0.19, 95% CI = 0.06-0.32, p = 0.004) over the entire 12-month follow-up period.

CONCLUSIONS

These findings underscore the effectiveness of a culturally-tailored intervention for Black women in CSP settings in increasing awareness, and intention to initiate PrEP. Low uptake of PrEP in both arms highlight the need for providing more robust PrEP-on-demand strategies that are integrated into other services such as substance abuse treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02391233 .

Avoiding Shots in the Dark: Learning from the Past To Inform the Implementation of Long-Acting Injectable Pre-Exposure Prophylaxis for Black American Cisgender Women

The FDA's approval of long-acting injectable cabotegravir pre-exposure prophylaxis (LAI PrEP) as an alternative to daily oral PrEP represents a crucial development in HIV prevention, particularly for American Black cisgender women who face high HIV-1 risks. Yet, uptake may be hindered by racial and gender inequities. Addressing these requires learning from the roll-out of oral PrEP, creating culturally tailored PrEP campaigns, and enhancing provider training to meet Black women's needs. Tools for discussing PrEP within personal relationships and product preference research tailored to Black women's needs are essential for effective LAI PrEP delivery. Deliberative implementation of LAI PrEP must employ strategies that are community-sensitive, -responsive, and -inclusive. It should prioritize the incorporation of Black women's voices in decision-making and should promote community-led strategies. By addressing historical injustices and fostering trust, healthcare systems can enhance LAI PrEP uptake by Black women. Emphasizing a community-centered approach that ensures health equity and acknowledges the crucial role that social media and Black-led organizations play in promoting PrEP awareness and adoption within Black communities is necessary for successful implementation.

Knowledge and attitude to HIV pre exposure prophylaxis among women in five sub-Saharan African countries: a multilevel model analysis of population-based survey 2021-2022

BACKGROUND

HIV Pre-Exposure Prophylaxis (HIV PrEP) may help reduce the rate of HIV infection among women in sub-Saharan Africa (SSA). This study aimed to assess women's knowledge and attitudes toward PrEP, a crucial component of HIV prevention, using nationwide data. It is the first study of its kind conducted in five SSA countries: Burkina Faso, Ghana, Côte d'Ivoire, Kenya, and Tanzania. The primary objective was to examine women's knowledge and attitudes toward PrEP for the prevention of HIV infection, as well as to explore individual- and community-level factors associated with it.

METHODS

The current study utilized the 2021/22 demographic and health survey datasets from five African nations, namely Burkina Faso, Côte d'Ivoire, Ghana, Kenya, and Tanzania. The analysis was performed using Stata 17. A weighted sample of 77,052 women of reproductive age participated in the survey. Univariate and multivariable multilevel logistic regressions were conducted to assess parameters related to knowledge and attitudes toward PrEP in these countries. In both the univariate regression and the final model, the significance of variables was determined using P values of ≤ 0.2 and < 0.05.

RESULTS

Overall, only about 13.88 (95% CI: 13.64,14.12) of women had knowledge and attitudes toward HIV PrEP. The highest (34.29%) and lowest (5.61%) values were observed for Kenya and Tanzania respectively. Higher rates of knowledge, and attitude toward HIV PrEP among women were independently associated with age 25-34 years old (AOR = 1.52, 95% CI:1.41,1.64), and 35-49 years old (AOR = 1.56, 95% CI:1.43,1.69), primary education level (AOR = 1.79,95% CI:1.65,1.95), and secondary/higher education level (AOR = 2.92, 95% CI: 2.67,3.20), richer (AOR = 1.14, 95% CI:1.02,1.27), and richest (AOR = 1.21, 95% CI:1.06,1.37), employed women (AOR = 1.82, 95% CI:1.65,1.99), had media exposure (AOR = 1.49,95% CI:1.40,1.59),knowledge of modern contraception (AOR = 2.62, 95% CI: 1.94,3.43), had at least one ANC visit (AOR = 1.99, 95% CI:1.47,2.69), gave birth at health institutions (AOR = 1.17, 95% CI: 1.02,1.37), ever had given birth (AOR = 1.53, 95% CI: 1.41,1.66), female household heads (AOR = 1.24, 95% CI:1.17,1.31), rural women (AOR = 0.83, 95% CI: 0.76,0.89). Similarly, women from communities with high ANC coverage (AOR = 1.84, 95% CI: 1.61,2.11), high community mass media exposure (AOR = 1.62, 95% CI: 1.39,1.88), and high community wealth level (AOR = 1.48, 95% CI: 1.30,1.68), and women from the high illiteracy rate community (AOR = 0.71, 95% CI: 0.61,0.82) showed statistically significant associations with the outcome variable in the final model.

CONCLUSIONS

Less than one-seventh of women exhibited knowledge of and positive attitudes toward HIV PrEP. All stakeholders involved in HIV/AIDS prevention and control have recognized the significance of the factors mentioned above. Enhancing maternal health services, such as promoting institutional delivery, contraception, antenatal care (ANC), and women's empowerment, alongside harnessing the power of media and embracing these transformative changes, will contribute to a greater understanding of and more favorable attitudes toward HIV PrEP within the population.

Facilitators, Barriers, and Opportunities to Implementing Sexual History Screening and Human Immunodeficiency Virus Pre-Exposure Prophylaxis at a Federally Qualified Health Center

Sexual history screening (SHS) is recommended to determine risk for acquisition of human immunodeficiency virus (HIV) and eligibility for pre-exposure prophylaxis (PrEP). SHS and PrEP are underutilized, sequential screening, and prevention practices. This study aimed to understand factors impacting the implementation of SHS and PrEP at a multi-site federally qualified health center (FQHC) in Connecticut. Guided by the Consolidated Framework for Implementation Research, semistructured interviews were conducted on Zoom with primary care providers (PCPs), medical assistants, clinical leadership, and PrEP navigators. Convenience and purposive sampling took place via email until thematic saturation was achieved. Thematic analysis was conducted. Twenty-two participants were interviewed for this study. PCPs lacked knowledge and reported limited or no use of SHS to determine patients' level of HIV risk, which may explain why most PCPs relied on patients to request PrEP. While PCPs perceived organizational support to prescribe PrEP, clinical staff were unaware of structural resources. Lastly, participants described a vertical trajectory of influence from external sources (policies and insurance) to time allocated to appointments that limits their ability to implement SHS and PrEP, further complicated by the electronic health record and disparities in structural resources across clinical sites. This study provides foundational evidence for future research on implementation strategies to improve HIV prevention through universal, comprehensive SHS to identify patients for PrEP. Overcoming barriers to SHS and PrEP, particularly in clinical settings such as FQHCs that care for vulnerable populations, may improve identification, prevention, and treatment of HIV and aid in ending the HIV epidemic.

Increasing Urban African American Women's Readiness for Pre-exposure Prophylaxis: A Pilot Study of the Women Prepping for PrEp Plus Program (WP3+)

BACKGROUND

African American women are disproportionately at risk for HIV infection. To increase women's readiness to consider taking pre-exposure prophylaxis (PrEP), we conducted a pilot study of Women Prepping for PrEP Plus (WP3+). Adapted from an evidence-based HIV risk reduction intervention for African American couples who are HIV-serodiscordant, WP3+ is a group-based culturally congruent program designed for African American women without HIV.

METHODS

Women were screened for eligibility; if eligible, they were invited to participate in the four-session WP3+ group. Participants completed surveys at baseline (n = 47) and post-implementation (n = 28); surveys assessed demographics, HIV and PrEP knowledge, depression and posttraumatic stress (PTS) symptoms, substance use, sexual risk behaviors, health care-related discrimination, and social support. In a process evaluation, a subset of women completed qualitative interviews at baseline (n = 35) and post-implementation (n = 18); the interviews were designed to converge with (e.g., on HIV and PrEP knowledge) and expand upon (e.g., unmeasured perceived impacts of WP3+) quantitative measures. To triangulate with the quantitative data, deductive qualitative analysis concentrated on women's knowledge and awareness of PrEP and HIV, their relationship dynamics and challenges, and their considerations (e.g., barriers, facilitators) related to taking PrEP; inductive analysis focused on women's experiences in the intervention.

RESULTS

Participants in the WP3+ intervention reported: improved proportion of condom use in the past 90 days (p < .01) and in a typical week (p < .05); reduced PTS symptoms (p < .05); increased HIV knowledge (p < .0001) and awareness of PrEP (p < .001); and greater consideration of using PrEP (p < .001). In interviews, participants expressed not only increased knowledge but also appreciation for learning how to protect themselves against HIV, communicate with their partners, and take charge of their health, and they expressed greater receptiveness to using PrEP as a result of the knowledge and skills they gained.

CONCLUSIONS

The WP3+ pilot study demonstrated preliminary efficacy and acceptability as an HIV-prevention program for African American women. A controlled trial is needed to confirm its efficacy for increasing PrEP use among African American women.

A secondary gendered analysis of interviews with Latina cisgender women indicated for HIV pre-exposure prophylaxis

HIV infections disproportionately impact Latinx populations in the United States, yet oral pre-exposure prophylaxis (PrEP) uptake is low. This study was a secondary gendered analysis of interviews with Latina cisgender women (n = 20) recruited from an urban safety net hospital inNew York City between August 2019 and October 2022. All women were indicated for PrEP by the provider. In-depth interviews were conducted with participants in English and Spanish and asked about social determinants of health, sexual partnerships and behaviors, and PrEP-specific enablers and barriers. Secondary thematic content analysis was conducted to identify gender-related factors influencing PrEP uptake. The following themes emerged from the data:structural factors (e.g., employment), partner-related factors, low sexual health knowledge, and resilience and empowerment. Partner-related factors were the most salient; partner infidelity served as reasons for initiating PrEP. Despite being constrained by low power in relationships, women made empowered choices to initiate PrEP and protect themselves. Findings indicated that the impact of gender inequity was an important factor in Latina women's PrEP decision making, pointing to a need to address partner-driven HIV risk, imbalance of power in relationships, and gender norms.

Social and structural factors associated with interest in HIV preexposure prophylaxis among Black women in the United States

In a nationwide sample of cisgender Black women in the US, we assessed the associations between social and structural factors and interest in using HIV preexposure prophylaxis (PrEP). Among 315 respondents, 62.2% were interested in PrEP if it were provided for free. Positive social norms surrounding PrEP, including injunctive norms (perceived social acceptability of PrEP use) and descriptive norms (perceived commonality of PrEP use), were positively associated with interest in using PrEP. Concerns about HIV infection, recently visiting a health care provider, and comfort discussing PrEP with a provider were also positively associated with interest in using PrEP. Anticipating PrEP disapproval from others was negatively associated with interest in PrEP. Although PrEP can promote autonomy and personal discretion, Black women's PrEP-related decisions occur in a complex social environment. Black women may benefit from interventions to promote positive norms and attitudes surrounding PrEP at the community level and empower them in discussions with their providers about PrEP.

Barriers to HIV Pre-Exposure Prophylaxis Use Among Women in the US: A Systematic Literature Review

Introduction

The high acquisition rate of HIV infection among women in the United States is concerning. Despite the FDA approving the first pre-exposure prophylaxis (PrEP) drug in 2012, PrEP utilization remains significantly lower among women. This literature review aims to analyze the current body of research concerning HIV PrEP usage among women in the US.

Methods

A search of three medical databases was conducted. After the screening, 19 studies were selected for analysis. A risk of bias assessment was performed.

Results

A final set of records meeting the inclusion criteria (n=19) was included in the review for data collection and analysis. The study methodology for these research articles included interview-based designs (semi-structured and brief formats) in 1-on-1 meetings, focus groups, surveys, and retrospective data analysis. Participants' HIV risk characteristics were reported by way of sexual behavior, drug use, combined sexual behavior and drug use, and living in a high HIV rate neighborhood. Nineteen themes were identified and organized into three categories: (1) Common medication administration barriers, (2) PrEP-specific barriers, and (3) Situational barriers. The three most common themes reported by participants included a concern about side effects, low perceived risks of HIV, and lack of PrEP information. The CASP Qualitative Checklist and risk assessment summary showed acceptable validity among studies.

Discussion

This review identifies significant barriers hindering women's PrEP utilization, which would benefit from more prevalent stakeholder communication and education directed to at-risk populations. Inconsistently reported descriptive data on participants and the low patient populations make it difficult to generalize outcomes.

Knowledge, attitudes, and associated factors towards HIV pre-exposure prophylaxis among health care providers

The knowledge and attitudes of health care providers were limited as reviewed in many studies. Attitudes and knowledge about pre-exposure prophylaxis among healthcare providers have not been investigated in Ethiopia even though pre-exposure prophylaxis is a novel healthcare topic. The aim was to assess knowledge, attitudes, and associated factors towards pre-exposure prophylaxis among healthcare providers in Gojjam health facilities, North West Ethiopia, 2022. An institutional-based cross-sectional study was conducted from June 1-30 among 410 healthcare providers in public health facilities in the East Gojjam zone. A simple random sampling technique was used to recruit the required study participants. The statistical program EPI Data version 4.6 was used to enter the data, and statistical packages for Social science version 25 was used for analysis. Variables with a p-value less than 0.25 in the bivariable analysis were included in the multivariable logistic regression analysis. Statistical significance was determined with a p-value less than 0.05. The good knowledge and the favorable attitude of healthcare providers toward HIV pre-exposure prophylaxis were 55.7% (50.6-60.2%) and 60.2% (55.0-65.0%) respectively. male participant (AOR 1.67; 95% CI (1.01-2.55), service year ≥ 10 years (AOR 2.52; 95% CI (1.23-5.17), favorable attitudes (AOR 1.92; 95%CI (1.25-2.95), and providers good sexual behavior (AOR 1.85; 95%CI (1.21-2.82) were significantly associated with the good knowledge, and training (AOR 2.15; 95% CI (1.23-3.76), reading the guideline (AOR 1.66; 95% CI (1.02-2.70), and good knowledge (AOR 1.78; 95% CI (1.16-2.75) was significantly associated with the favorable attitudes. In general, the finding of this study shows that the knowledge and attitudes of healthcare providers were low. Since this is a new initiative their knowledge is lower than their attitudes. Male, service year 10 years, and good provider sexual behavior were factors significantly associated with good knowledge. Training, reading the guidelines, and good knowledge were factors significantly associated with a favorable attitudes. As a result, healthcare facilities intervention programs and strategies better target these factors to improve the knowledge and attitudes of healthcare providers. Preparing training programs to enhance knowledge and attitudes towards PrEP is recommended.

"Just the Stigma Associated with PrEP Makes You Feel Like It's HIV Itself": Exploring PrEP Stigma, Skepticism, and Medical Mistrust Among Black Cisgender Women in Urban and Rural Counties in the U.S. Deep South

Despite its effectiveness in HIV prevention, PrEP use among Black women is suboptimal. Notably in the Deep South, Black women have the lowest PrEP uptake rates among all US regions. To increase PrEP engagement, research suggests the implementation of structural and social interventions particular to the needs of Black women. The state of Alabama is of priority to federal HIV prevention initiatives; therefore, this study conducted focus groups among 47 cis-gender Black women in rural and urban Alabama counties, with the highest statewide HIV incidence rates, to understand perceptions of PrEP and decision-making processes. Deductive coding analysis was conducted and themes were finalized based on consensus among the two coders. Four themes were identified. Findings show stigma undergirds Alabaman Black women's decisions to engage in PrEP care. Moreover, women reported stigma stifled community-level education about PrEP. Despite these experiences, education was regarded as a strategy to decrease stigma and PrEP skepticism, the latter of which emerged as a prominent theme. Medical mistrust and healthcare engagement were the other emergent themes influencing participation in PrEP care. To ensure PrEP efforts meet the needs of Black cisgender women in Alabama counties, interventions must address longstanding stigma, increase educational initiatives, and ensure interventions consider women's experiences with medical mistrust and health care engagement.

Addressing Unmet PrEP Needs in Women: Impact of a Laboratory-Driven Protocol at an Urban, Essential Hospital

Background

HIV pre-exposure prophylaxis (PrEP) uptake in women remains low. We developed a laboratory result-driven protocol to link women with a positive bacterial sexually transmitted infection (STI) to HIV PrEP at an urban safety-net hospital.

Methods

Electronic health records of women with positive chlamydia, gonorrhea, and/or syphilis tests were reviewed, and those eligible for PrEP were referred for direct or primary care provider-driven outreach. We assessed the proportion of women with STIs who received PrEP offers, acceptance, and prescriptions before (July 1, 2018-December 31, 2018) and after (January 1, 2019-June 30, 2020) implementation to evaluate changes in the delivery of key elements of the PrEP care cascade (ie, PrEP offers, acceptance, and prescribing) for women with STIs after protocol implementation.

Results

The proportion of women who received PrEP offers increased from 7.6% to 17.6% (P < .001). After multivariable adjustment, only the postintervention period was associated with PrEP offers (odds ratio [OR], 2.49; 95% CI, 1.68-3.68). In subgroup analyses, PrEP offers increased significantly among non-Hispanic Black (OR, 2.75; 95% CI, 1.65-4.58) and Hispanic (OR, 5.34; 95% CI, 1.77-16.11) women but not among non-Hispanic White women (OR, 1.49; 95% CI, 0.54-4.05). Significant changes in PrEP acceptance and prescriptions were not observed in the sample overall.

Conclusions

A laboratory result-driven protocol was associated with a significant increase in PrEP offers to Black and Hispanic women with STI. These results provide concrete suggestions for health systems seeking to increase PrEP access and equity among women.

The development of a conceptual framework on PrEP stigma among adolescent girls and young women in sub-Saharan Africa

INTRODUCTION

Stigma is a well-known barrier to HIV testing and treatment and is an emerging barrier to pre-exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for PrEP.

METHODS

A literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio-ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023.

RESULTS

The conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high-risk populations), health systems (e.g. youth-friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency.

CONCLUSIONS

Our PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.

Dimensional Reduction in Barriers and Facilitators to Pre-exposure Prophylaxis (PrEP) Uptake Willingness for Full-Service Sex Workers

Full-Service Sex Workers (FSSWs) face heightened risk of acquiring HIV, yet exhibit relatively low adoption of pre-exposure prophylaxis (PrEP)-an antiviral that substantially reduces HIV acquisition risk. Little work examines barriers and facilitators to PrEP uptake willingness among FSSWs. This study aimed to identify the distinct components of barriers and facilitators to PrEP uptake willingness for FSSWs. Here, we subjected 19 PrEP barriers and facilitators identified in the literature to a principal component analysis (PCA) among a sample of 83 FSSWs. Preliminary statistics supported factorability of data. PCA revealed three distinct components of barriers and facilitators that explained 62.80% of the total variance in survey responses. We labeled these components Behavioral and Social Concerns (α = 0.93), Access and Affordability (α = 0.67), and Biologically Based Health Concerns (α = 0.79). This study shows promise for future clinical and research utility of these factors and provides a basis for future psychometric studies of barriers and facilitators to PrEP uptake willingness among FSSWs.

Increasing providers' PrEP prescription for Black cisgender women: A qualitative study to improve provider knowledge and competency via PrEP training

BACKGROUND

Awareness and uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) remains low among Black/African American cisgender women, partly due to low self-reported PrEP knowledge and comfort among primary care providers. Ensuring providers are trained on PrEP is crucial, as increased PrEP knowledge is associated with higher rates of PrEP prescription.

OBJECTIVE

We aimed to develop a PrEP training for providers to improve their self-efficacy in discussing and prescribing PrEP for Black women, with the ultimate goal of increasing PrEP awareness and utilization among Black women.

DESIGN

In this qualitative study, we conducted focus groups with medical providers at three federally qualified health centers in the Southern and Midwestern United States to identify themes informing the development of a provider PrEP training.

METHODS

Providers were asked for input on content/design of PrEP training. Transcripts underwent rapid qualitative analysis using the Stanford Lightning Report Method. Themes were identified and presented under the domains of the Consolidated Framework for Implementation Research.

RESULTS

Ten providers completed four focus groups. Themes included the individual characteristics of providers (low comfort initiating PrEP discussions, particularly among White providers) and the outer setting of client attitudes (perceptions of potential provider bias/racism, varying levels of concern about HIV acquisition). Opportunities were identified to maximize the benefit of training design (e.g., developing case scenarios to enhance providers' cultural competency with Black women and PrEP knowledge).

CONCLUSION

This comprehensive PrEP training features both didactic material and interactive role-plays to equip providers with the clinical knowledge for prescribing PrEP while building their competency discussing PrEP with Black women. This training is particularly important for providers who have racial or gender discordance with Black women and express lower comfort discussing PrEP with these clients. Provider training could lead to minimizing racial- and gender-based inequities in PrEP use.

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.

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.

The Impact of Providers as Health Discussants on Black Women's Interest in PrEP for HIV Prevention

This study sought to examine the role of providers as health discussants (HD) on interest in preexposure prophylaxis for HIV prevention in a national sample of adult Black cisgender women (N = 315). Health discussant networks, a type of social network, may be influential in HIV prevention efforts. These networks, often composed of individuals' families, have improved health utilization outcomes in other disciplines. However, health discussants in HIV prevention are understudied, especially when considering providers as network members. We conducted a cross-sectional online survey and collected socio-demographic information, sexual history, HIV concerns, PrEP attitudes, healthcare utilization, mistrust, social support, and HD information. We used descriptive statistics and logistic regression to analyze data. Associations between PrEP interest and variables were examined. We found that older, partnered, who had recent healthcare visits or health insurance were more likely to involve healthcare providers as discussants. Anticipated PrEP stigma decreased provider involvement. Among participants listing providers as discussants, there was a greater likelihood of interest in using PrEP. Our findings indicate that healthcare provider support and social factors are crucial in promoting PrEP engagement among Black women. Integrating social dynamics and positive provider-patient interactions is essential for successful PrEP implementation.

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.

Adapting Provider Training and Pre-Exposure Prophylaxis Advertising to Increase Pre-Exposure Prophylaxis Awareness and Uptake Among Black Cisgender Women

Black cisgender women (hereafter referred to as "women") have disproportionately high rates of HIV infection yet low rates of pre-exposure prophylaxis (PrEP) utilization. Barriers to PrEP uptake exist at the system, provider, and individual/client level. To learn how existing training and advertising can be adapted to address race- and sex-based gaps within PrEP service delivery, we conducted focus groups with providers and Black women. Participants were recruited at three health care organizations in the Midwest and South, screened for eligibility, and consented verbally. Focus groups occurred from August 2022 to February 2023. Women were asked about their knowledge and thoughts on PrEP. Providers were asked about factors influencing their decision-making about PrEP. A codebook was developed based on the Consolidated Framework for Implementation Research. Transcripts were coded using the Stanford Lightning Report Method. We completed four focus groups with 10 providers and 9 focus groups with 25 women. Three major themes emerged: (1) low comfort level and limited cultural sensitivity/competency among providers discussing HIV risk and PrEP with Black women, (2) women's concerns about PrEP's side effects and safety during pregnancy, and (3) lack of Black women representation in PrEP advertisement/educational materials. In addition, women in the South reported general medical mistrust and specific misconceptions about PrEP. PrEP trainings for providers need detailed information about the safety of PrEP for women and should include role-playing to enhance cultural competency. Likewise, PrEP advertisements/materials should incorporate information regarding side effects and images/experiences of Black women to increase PrEP awareness and uptake among this population. Clinical Trial Registration Number: NCT05626452.

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective.

METHODS

Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants.

CONCLUSIONS

Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

Assessing the Preliminary Efficacy of a Nonrandomized, Clinic-Based HIV Risk Reduction Pilot Intervention for PrEP-Initiated, Alcohol- and Other Drug-Using Women of Color in Miami, FL

In this paper, we assessed the preliminary efficacy and acceptability of a quasi-experimental, clinic-based sexual risk reduction pilot intervention for pre-exposure prophylaxis (PrEP)-initiated, alcohol- and other drug-using women of color and explored their self-reported barriers to, and facilitators of, PrEP use. Using a mixed methods design, analyses incorporated pre- and post-intervention study assessment data from 38 women and semi-structured process evaluations using a subsample of 25. The intervention administered over an 8-week period consisted of 4 one-on-one in person educational sessions, a process evaluation, and study assessments conducted at baseline and 3 and 6 months. Post intervention, statistically significant changes in sexual risk scores were not observed; however, we found significant decreases in alcohol use (Z =  - 3.02, p = .003, η2 = .41). Process evaluation data revealed interpersonal relationships as a key motivator for PrEP initiation as well as a prominent barrier to PrEP use; these relationships rarely facilitated adherence. Overall, women found the intervention to be acceptable and reported a wide range of benefits of participation-most notably its therapeutic benefits. Findings from this study provide preliminary evidence of the potential for the Talking PrEP with Women of Color intervention to improve risky behaviors, knowledge, and attitudes related to sexual risk taking. Furthermore, findings suggest that interventions to increase PrEP uptake and adherence in at-risk women may benefit from supporting them in accurately estimating their risk for HIV and increasing their sense of social support.

"It's already in your body and it's preventing": a qualitative study of African female adolescent's acceptability and preferences for proxy HIV prevention methods in Cape Town, South Africa

BACKGROUND

Advances in biomedical HIV prevention will soon offer young women a choice of HIV prevention methods, including various pre-exposure prophylaxis (PrEP) modalities such as daily oral pills, dapivirine vaginal ring, and long-acting injectable agents. By understanding preferences for contraceptive methods, we may draw analogies for the HIV prevention needs of young women. The UChoose Study was an open-label randomised cross-over study designed to evaluate the acceptability and preference for several contraceptive options as a proxy for HIV prevention methods that use similar types of administration. The study enrolled healthy HIV uninfected young women aged 15 to 19 years. At enrolment, participants were randomly assigned to a contraceptive method for a period of 16 weeks in the form of monthly Nuvaring® (vaginal ring), daily combined oral contraceptive (daily pills), or bi-monthly injectable contraceptive (injectable). After 16 weeks, participants crossed over to another contraceptive method, and those who had received the injectable and the daily pills received the vaginal ring for another 16 weeks, whereas those who had received the vaginal ring were able to choose between the injectable and daily pills, to ensure that all participants tried the vaginal ring-the least familiar option to the study population.

RESULTS

Thirty-three participants were purposively recruited to participate in seven focus group discussions (FGD) and completed a pre-survey for their assigned group. Our sample comprised 14 participants randomised to use of the vaginal ring and daily pills and 19 participants randomised to use of the vaginal ring and injectable. For most participants, their preferences for a prevention method were based primarily on their desire to avoid negative aspects of one method rather than their positive user experience with another method. Most participants expressed initial hesitancy for trying new contraception method products; however, a lack of familiarity was moderated by a strong interest in diverse user-controlled prevention methods. Participants valued methods that had infrequent dosing and simplified use requirements. The injection and vaginal ring were preferred over daily pills as a potential HIV prevention method.

CONCLUSION

Expanding the availability of diverse products could provide adolescents with multiple choices in HIV prevention for the uninitiated.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02404038 ). Registered March 31, 2015-Registered.

"I care about sex, I care about my health": A mixed-methods pre-test of a HIV prevention mobile health app for Black women in the southern United States

BACKGROUND

Black women experience higher rates of adverse sexual and reproductive health and HIV outcomes, however the use of mHealth to address these health disparities in this population has been inadequate. This study involved a one-month pre-test with Black women living in metro-Atlanta to evaluate the usability, acceptability, and engagement of an HIV prevention app SavvyHER.

METHODS

An explanatory mixed-methods design was employed in which quantitative data was collected through weekly cross-sectional surveys, and qualitative data was collected through semi-structured in-depth interviews. Descriptive and ANOVA analysis was conducted for the quantitative data using STATA software. Qualitative data was analyzed through qualitative descriptive methods on Atlas.ti.

RESULTS

Participants had high levels of acceptability towards the app and used SavvyHER moderately. The most frequently used features were live groups (2.96 ±0.22, 95% CI 2.51,3.41), viewing resources and educational information (2.77 ± 0.21, 95% CI 2.33,3.20), and mental health monitoring (2.73 ±0.21, 95% CI 2.29,3.12). The least used features were pregnancy symptom monitoring (1.92 ±0.27, 95% CI 1.38,2.47) and STI symptom monitoring (2.0 ±0.25, 95% CI 1.48,2.52). In qualitative interviews, several women discussed how the ability to engage in active discussions and join live sessions with other end-users was a favorable aspect of SavvyHER. Although the app's primary focus was on sexual and reproductive health and HIV prevention, women were more likely to access mental health monitoring and physical activity monitoring features. Women expressed their fondness of the app design and interface as it was reflective of the diversity of Black women.

CONCLUSION

Further research is needed to explore the efficacy in using SavvyHER and additional mHealth interventions to enhance Black women's sexual and reproductive health and overall wellness.

Assessing the association of stigma and HIV service and prevention uptake among men who have sex with men and transgender women in South Africa

HIV prevention for gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) is critical to reducing health disparities and population HIV prevalence. To understand if different types of stigma impact engagement with HIV prevention services, we assessed associations between stigmas and use of HIV prevention services offered through an HIV prevention intervention. This analysis included 201 GBMSM and TGW enrolled in a prospective cohort offering a package of HIV prevention interventions. Participants completed a baseline survey that included four domains of sexual identity/behavior stigma, HIV-related stigma, and healthcare stigma. Impact of stigma on PrEP uptake and the number of drop-in visits was assessed. No domain of stigma was associated with PrEP uptake. In bivariate analysis, increased enacted sexual identity stigma increased number of drop-in visits. In a logistic regression analysis constrained to sexual identity stigma, enacted stigma was associated with increased drop-in visits (aIRR = 1.30, [95% CI: 1.02, 1.65]). Participants reporting higher enacted stigma were modestly more likely to attend additional services and have contact with the study clinics and staff. GBMSM and TGW with higher levels of enacted stigma may seek out sensitized care after negative experiences in their communities or other healthcare settings.

Confidence in Ability to Communicate With Sexual Partners About PrEP Among Black Cisgender Women

This study explored the factors associated with Black women's confidence in their ability to engage male sexual partners in discussions about PrEP. Communication about PrEP with male partners is an important, yet minimally explored, outcome in PrEP research among Black women in heterosexual partnerships. Among 315 respondents, results show significant differences in anticipated stigma and interest in PrEP between a binary outcome variable being confident and not-confident discussing PrEP with sexual partners. Further, factors such as employment, worrying about HIV infection, interest in taking oral PrEP, subjective norms, injunctive norms, and descriptive norms were associated with Black women's higher odds of confidence in their ability to engage sexual partners about PrEP. Conversely, PrEP disapproval and stigma resulted in lower odds of Black women's confidence in their ability to engage sexual partners about PrEP. Results indicate the need for continued investigation of confidence and, relatedly, communication about PrEP among heterosexual couples and communitylevel interventions normalizing PrEP discussions and uptake.

Predictors of PrEP retention in at risk patients seen at a HIV primary care clinic in San Diego

BACKGROUND

Adherence to medication and retention in care are key contributors to the efficacy of pre-exposure prophylaxis (PrEP) for prevention of HIV. Therefore, it is important to understand factors that may impact retention in various settings that prescribe PrEP.

METHODS

We evaluated factors associated with retention in care 3 and 12 months after PrEP initiation at a primary care HIV clinic in San Diego. Retention was defined as having an office/virtual visit within 1 month from the 3- or 12-months time point or interacting with the clinic leading to medication being refilled.

RESULTS

A total of 199 patients were included. Retention rates were 74.4% and 52.8% at 3 and 12 months respectively. In the multivariate analysis, reporting depression or anxiety was associated with being retained in care (p = 0.004) and identifying as cisgender female was associated with lack of retention (p = 0.04) at 3 months. Testing positive for a sexually transmitted infection was associated with 12-months retention (p = 0.004); however, this was likely influenced by difference in the frequency of testing in those retained versus not retained.

CONCLUSION

Ongoing efforts to determine the optimal method for provision of PrEP care that supports retention for different populations at risk for HIV, are needed.

"Protected Means Armed": Perspectives on Pre-Exposure Prophylaxis (PrEP) Among Women Who Engage in Sex Work and Use Drugs in Kazakhstan

Pre-exposure prophylaxis (PrEP) for HIV prevention has recently become available in Kazakhstan, but women engaged in sex work who use drugs (WESW-UD) could benefit from tailored approaches to support uptake and adherence. To better understand how best to support WESW-UD at each stage of the PrEP continuum (awareness, acceptability, uptake, and adherence), we analyzed data from 30 in-depth interviews and four focus groups with 48 WESW-UD from two cities in Kazakhstan. We conducted thematic analysis to characterize perceptions, barriers, and motivators within each step of the PrEP continuum. Participants reported low awareness, but high interest in PrEP. Motivating factors included optimizing health and increased confidence. Participants expressed many preferences and concerns regarding PrEP modality and delivery. Participants also described how organizational mistrust and social support can prevent or facilitate PrEP uptake or adherence. Kazakhstan's scale-up of PrEP should consider the needs and preferences of WESW-UD to ensure equitable access.

HIV Pre-exposure Prophylaxis at Two Urban Obstetrics/Gynecology Clinics in Buffalo: Awareness and Attitudes Among Non-Hispanic Black vs. Latinx Patients

PURPOSE

Non-Hispanic Black and Latinx women are disproportionately affected by HIV when compared to the general population. This study evaluated awareness of and attitude towards PrEP, self-perceived HIV infection risk, and factors constituting high-risk behavior for HIV infection at two general OB/GYN clinics in Erie County, which exhibited a 31.6% increase in HIV cases from 2019 to 2020.

METHODS

One thousand twenty-five self-administered surveys were analyzed.

RESULTS

Of participants, 69.3% were non-Hispanic Black, 13.4% were Latinx, and 22.4% were White. There was no significant difference in awareness of or attitude toward PrEP between non-Hispanic Black and Latinx participants (p = 0.197, p = 0.467). Latinx participants exhibited the lowest awareness of PrEP compared with non-Hispanic Black and White participants (p = 0.002).

CONCLUSIONS

In our high-risk group, most participants had low self-perceived risk of HIV infection and low awareness of PrEP, and most were unwilling or unsure as to whether they would take PrEP. This calls attention to a need for improved counseling regarding PrEP and what constitutes risk of HIV infection at our general OB/GYN clinics, with a potential focus on Latinx individuals.

Effectiveness, Acceptability, and Feasibility of a Telehealth HIV Pre-Exposure Prophylaxis Care Intervention Among Young Cisgender Men and Transgender Women Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite its promise for HIV prevention, the uptake of pre-exposure prophylaxis (PrEP) has been slow, and there have been substantial inequities in PrEP access. Young men who have sex with men and transgender women of color are most in need of PrEP and least likely to have that need fulfilled. PrEP telehealth care, which provides remote PrEP care via electronic communication, seems well suited to address several of the challenges of PrEP provision, including discomfort with stigmatizing and difficult-to-access health care systems, transportation challenges, and privacy concerns, and address disparities in PrEP access. Research suggests that PrEP telehealth care has promise and is a favored option for many prospective recipients of PrEP. However, despite growing attention to telehealth approaches as an avenue for increasing access to PrEP amidst the COVID-19 pandemic, there have been no published randomized controlled trials (RCTs) on PrEP telehealth care to date, making it difficult to draw strong conclusions about the advantages or disadvantages of telehealth compared with usual PrEP care. We developed PrEPTECH, a telehealth intervention that focuses specifically on alleviating issues of stigma, access, cost, and confidentiality for young people with risk factors for HIV infection who are seeking PrEP care. Leveraging data from the 2017 observational pilot study, we redesigned and enhanced PrEPTECH.

OBJECTIVE

This study aims to assess the effectiveness, acceptability, and feasibility of a telehealth HIV PrEP care intervention, PrEPTECH, in increasing PrEP uptake.

METHODS

This is the protocol for an RCT of young cisgender men and transgender women who have sex with men in 4 regions within the United States: the San Francisco Bay Area, California; Los Angeles County, California; Miami-Dade County, Florida; and Broward County, Florida. Participants in the intervention arm received access to a web-based telehealth program, PrEPTECH, which offers a fully web-based pathway to PrEP, whereas those in the control arm received access to a dynamic web page containing publicly available informational resources about PrEP. Follow-up data collection occurred at 3 and 6 months. An analysis will be conducted on outcomes, including PrEP initiation, persistence, adherence, coverage, and medication prescription, as well as PrEPTECH acceptability and feasibility.

RESULTS

The study was funded in 2019 and received institutional review board approval in 2020. The PrEPTECH intervention was developed over the next 1.5 years. Study recruitment was launched in February 2022 and completed in September 2022, with 229 participants recruited in total. Data collection was completed in April 2023.

CONCLUSIONS

The results of this RCT will offer valuable evidence regarding the effectiveness, acceptability, and feasibility of telehealth HIV PrEP care interventions among young cisgender men and transgender women who have sex with men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04902820; https://clinicaltrials.gov/ct2/show/NCT04902820.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47932.

Factors Associated with Comfort Discussing PrEP with Healthcare Providers among Black Cisgender Women

Preexposure prophylaxis (PrEP) for HIV prevention uptake remains low among Black cisgender women in the United States, despite their disproportionate HIV burden. This study aimed to examine factors associated with Black women's comfort discussing PrEP with healthcare providers and its link to their interest in PrEP use. A cross-sectional survey was conducted with a national sample of 315 Black cisgender women. Descriptive statistics and logistic regression models were utilized for data analysis. The results showed that 79% of Black women felt comfortable discussing PrEP with their healthcare provider. Age, recent healthcare provider visit, interest in PrEP, and positive social norms were associated with increased odds of comfort in discussing PrEP, while anticipated PrEP disapproval and stigma were associated with decreased odds. Older age was related to greater comfort, potentially due to increased familiarity and self-efficacy in discussing sexual health. Recent healthcare utilization indicated positive provider relationships, facilitating discussions about sexual health. Anticipating support from social networks positively influenced comfort levels. Conversely, PrEP-related stigma and anticipated disapproval were barriers to comfort. These findings highlight the importance of provider-patient communication and social support in facilitating PrEP engagement among Black cisgender women. Interventions should consider age-appropriate strategies and address structural and provider biases to improve PrEP discussions and promote HIV prevention.

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.

Implementation of an Educational Intervention to Improve HIV Pre-Exposure Prophylaxis Services for Women in an Urban Sexual Health Clinic

To test the hypothesis that implementation of a multicomponent, educational HIV pre-exposure prophylaxis (PrEP) intervention to promote universal PrEP services for cisgender women (subsequently "women") in sexual and reproductive health centers would improve the proportion of women screened, offered, and prescribed PrEP, we implemented a multicomponent, educational intervention in a Washington D.C. Department of Health-sponsored sexual health clinic. The clinic serves a patient population with high-potential exposure to HIV. The intervention included clinic-wide PrEP trainings, an electronic health record prompt for PrEP counseling by providers, and educational videos in the waiting room. We collected preimplementation data from March 22, 2018 to July 4, 2018, including 331 clinical encounters for 329 women. Between July 5, 2018 and July 1, 2019, there were 1733 clinical encounters for 1720 HIV-negative women. We used mixed methods to systematically assess intervention implementation using the Reach Effectiveness Adoption Implementation Maintenance framework. Additionally, we assessed the interventions' acceptability and feasibility among providers through semistructured interviews. The proportion of women screened by providers for PrEP (5.6% preimplementation to a mean of 89.2% of women during the implementation period, p < 0.01), offered (6.2 to 69.8%, p < 0.01), and prescribed PrEP (2.6 to 8.1%, p < 0.01) by providers increased significantly in the implementation period. Providers and clinic staff found the intervention both highly feasible and acceptable and demonstrated increased knowledge of PrEP and HIV prevention associated with the clinic-wide trainings. Our results demonstrate the effectiveness of a low-cost educational intervention to increase provision of integrated PrEP services in an urban sexual health clinic serving women with high-potential exposure to HIV. ClinicalTrials.gov ID NCT03705663.

PrEP and HIV prevention decision-making among social network members of women who have experienced incarceration: a qualitative study

ABSTRACTIncarceration and HIV are a syndemic for US women, yet very few women who have experienced incarceration use pre-exposure prophylaxis (PrEP) for HIV. We conducted semi-structured interviews with 32 participants recruited by women who have experienced incarceration from their social networks, informed by the modified social ecological model for PrEP. Emergent themes from the interviews included individual-level (low personal HIV risk assessment, personal responsibility for HIV prevention, and decisions in addiction versus recovery), network-level (influential sex partners and the importance of trust, supportive treatment peers, and high-risk but indifferent drug use networks), community-level (stigma, and mitigation of stigma in supportive substance use disorder treatment environments), and public policy-level (incarceration and PrEP cost and access) determinants. PrEP interventions for women who have experienced incarceration and their networks will need to incorporate contingency planning into HIV risk assessment, navigate complex network dynamics, and be situated in trusted contexts to address structural barriers.

Associations Between Sexual History Documentation in Electronic Health Records and Referral to Pre-Exposure Prophylaxis Navigator on Prescription of Pre-Exposure Prophylaxis at a Multi-Site Federally Qualified Health Center

This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.

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.

Protocol for WeExPAnd: a prospective, mixed-methods pilot demonstration study to increase access to pre-exposure prophylaxis among women vulnerable to HIV infection in the Southern USA

INTRODUCTION

African American women (AA), particularly those living in the Southeastern USA, experience disproportionately high rates of HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool that may circumvent barriers to traditional HIV prevention tools, such as condom use; however, very little is known about how to improve PrEP access and uptake among AA women who may benefit from PrEP use. This project aims to understand how to increase PrEP access among AA women in the rural Southern USA, which may ultimately affect HIV incidence in this population.

METHODS AND ANALYSIS

The goal of the current study is to systematically adapt a patient-provider communication tool to increase PrEP uptake among AA women receiving care at a federally qualified health centre in Alabama. We will use an iterative implementation process, by assessing the feasibility, acceptability and preliminary impact of the tool on PrEP uptake, using a pilot preintervention/postintervention design (N=125). We will evaluate women's reasons for declining a referral to a PrEP provider, reasons for incomplete referrals, reasons for not initiating PrEP after a successful referral and ongoing PrEP use at 3 and 12 months after PrEP initiation among our sample. The proposed work will significantly contribute to our understanding of factors impacting PrEP uptake and use among AA women, particularly in underserved areas in the Deep South that are heavily impacted by the HIV epidemic and experience worse HIV-related health outcomes relative to other areas in the USA.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board (IRB) at University of Alabama at Birmingham (Birmingham, AL; protocol 300004276). All participants will review a detailed informed consent form approved by the IRB and will provide written or verbal informed consent prior to enrolment. Results will be disseminated through peer-reviewed manuscripts, reports, and local, national and international presentations.

TRIAL REGISTRATION NUMBER

NCT04373551.

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.

Changes in Cost and Insurance Challenges to Cover PrEP Between 2019 and 2021

INTRODUCTION

Pre-Exposure Prophylaxis (PrEP) use continues lag estimated need among gay and bisexual men in the United States. Studies report that challenges paying for PrEP may undermine continued use. Our study aimed to measure these challenges over time.

METHODS

Data were taken from a US national cohort study of cisgender gay and bisexual men and transgender individuals aged 16-49 years. We analyzed data from PrEP-using participants between 2019 and 2021 and observed cost-related and insurance-related challenges participants experienced while on PrEP across time points. We report McNemar and Cochrane Q test statistics to compare differences between groups by year(s).

RESULTS

In 2019, 16.5% (n = 828/5013) of participants were on PrEP; by 2020, 21% (n = 995/4727) were on PrEP, and by 2021, 24.5% (n = 1133/4617) were on PrEP. The proportion of those experiencing challenges paying for PrEP care decreased significantly across time points for clinical appointments, laboratory work, and prescriptions. Those experiencing insurance and copay approval issues did not change significantly. Although not statistically significant, the only proportion that increased over time was those reporting PrEP-related insurance approval issues. In a post hoc analysis, we found that those reporting PrEP use in the past year who were not currently on PrEP were significantly more likely to report experiencing most PrEP challenges, when compared with current PrEP users.

DISCUSSION

We found significant reductions in insurance and cost-related challenges between 2019 and 2021. However, those who discontinued PrEP within the past year reported greater challenges paying for PrEP, suggesting that cost and insurance issues may undermine PrEP persistence.

Self-awareness as the key to successful adherence to antiretroviral therapy among people living with HIV in Indonesia: A grounded theory study

Background

Adherence to antiretroviral therapy (ART) continues to pose a significant challenge for people living with HIV (PLWH). Non-adherence to ART can have far-reaching implications for patient well-being, particularly in increasing the risk of opportunistic infections when medication is not taken as prescribed.

Objective

This study aimed to develop a theoretical model that explains how PLWH in Indonesia adhere to their ART regimen and the strategies they follow to maintain adherence.

Methods

The study used a grounded theory approach. Data were collected through face-to-face in-depth interviews with 21 PLWH who had been taking ART for six months or more at a non-governmental organization (NGO) in Jakarta, Indonesia, between July 2019 and November 2019. Theoretical sampling was used, and the data analysis method of Corbin and Strauss was utilized, including open coding, axis coding, and selective coding.

Results

Three stages were identified as a process of adherence to the ART regimen: 1) initiating ART, 2) missing the connection, and 3) taking control. Self-awareness was identified as the central core theme describing the ART adherence process.

Conclusion

Having adequate self-awareness to take ART regularly is crucial to improving adherence to ART. Moreover, social support from one's spouse and family members can help patients maintain adherence. Therefore, self-awareness and support systems should be included as components in nursing interventions when starting ART therapy. In addition, nurses can help identify potential support persons and provide information related to ART therapy.

Extending the Influence of Presumed Influence Hypothesis: Information Seeking and Prosocial Behaviors for HIV Prevention

The influence of presumed influence hypothesis (IPI hypothesis) explains that people have biased perceptions of media influence and they change their behavior based on such perceptions. This study explicated the mechanisms of influence of presumed influence in health communication by integrating the theoretical explanations of the IPI hypothesis with theories of normative influence. The causal chains of the IPI hypothesis were examined using an experimental methodology with a HIV prevention, PrEP (pre-exposure prophylaxis). The results supported the expectations. Presumed exposure to health messages about PrEP shaped presumed influence of the messages on others, which in turn affected one's own intentions for information seeking and prosocial behaviors about PrEP. The findings also show that descriptive norms and injunctive norms interact with presumed influence differently. This study discusses the potential benefits of the IPI hypothesis in health communication.

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.

A Qualitative Systematic Literature Review of the Role of U.S. Pharmacists in Prescribing Pre-Exposure Prophylaxis (PrEP)

Pre-Exposure Prophylaxis (PrEP) is an effective treatment to combat the human immunodeficiency virus (HIV) endemic, but the uptake of PrEP has been low in the United States (U.S.). While individuals may access PrEP via obtaining a prescription from their prescriber and having it dispensed by their pharmacist, less cumbersome access points may exist. This systematic literature review evaluates qualitative literature to explore the role of pharmacists, pharmacy services, and interprofessional collaborations for persons seeking PrEP in the United States. Four electronic databases (PubMed, Scopus, CINAHL, and Embase) were searched in February 2022 and yielded 3841 results. After excluding duplicates, two researchers reviewed 2461 studies. These results were screened for inclusion and exclusion criteria and yielded 71 studies for full review. Out of these 71 studies, five studies met the pre-selected inclusion criteria. Of the five studies, four were qualitative studies, and one was a mixed-methods study. The studies examined different aspects of initiating PrEP and diverse outcomes, such as screening for PrEP, barriers to access PrEP, feasibility to access PrEP, accessibility via community pharmacy to PrEP, and interdisciplinary collaboration between members of the healthcare team to expand patient access to PrEP. A gap in the qualitative literature focusing on U.S. pharmacists' roles in initiation and provision of PrEP for diverse populations may exist. While PrEP promotion and uptake are largely affected by convenience and accessibility, future interventions and strategies should include training pertaining to PrEP screening, stigma reduction, privacy considerations, and PrEP dispensing.