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Clinical Director of Pharmacy
Nevada Health Centers
Las Vegas, Nevada
Samantha Strong, PharmD, BCACP, AAHIVP, CDCES: consultant/advisor/speaker: Gilead Sciences.
The PrEP Gap
Pre-exposure prophylaxis (PrEP) is an effective method to reduce HIV transmission. In the United States, however, only 10% of women who could benefit from PrEP were prescribed it in 2019. Moreover, PrEP uptake in Black women, who remain disproportionately affected by HIV in the United States, is considerably lower than that in White women. Black women represent 13% of the US female population but account for 55% of women diagnosed with HIV. Furthermore, the lifetime risk of acquiring HIV is 1 in 54 for Black women compared with 1 in 256 for Hispanic/Latina women and 1 in 941 for White women.
Addressing racial- and gender-related disparities in HIV prevention requires a deep understanding of the social, economic, and historical context from which these disparities arise. Below are some key barriers and facilitators to PrEP initiation.
Addressing Barriers to PrEP
One significant barrier to PrEP uptake is lack of patient and healthcare professional (HCP) knowledge about PrEP. Many Black cisgender women are unaware of PrEP, and some who are aware feel that PrEP is not “for them” because of the way it has been marketed historically. Moreover, although HIV rates are high among Black women, many HCPs do not perceive women as “high risk” for HIV acquisition. PrEP awareness and acceptance in the Black community can be increased by organizing more awareness/public health campaigns centered on women and increasing positive messaging to Black women via social networks and social media.
Another challenge was the previous guidelines, which made it difficult to identify women who might benefit from PrEP and assess a woman’s risk of acquiring HIV. However, this has been dealt with in the recent updates in PrEP guidelines, which state that PrEP should be discussed with all sexually active adults and adolescents and prescribed if requested by the patient.
HCP bias also hinders PrEP uptake. Biases based on a woman’s race, social class, or sexual behavior may hinder effective communication about HIV risk and result in missed PrEP prescribing opportunities. However, these biases can be addressed through awareness and cultural competency training within healthcare organizations and medical training institutions.
Medical mistrust, another barrier to PrEP uptake, prevails in the Black community due to the history of unethical medical practices and discrimination in the United States. However, Black women who do start PrEP report that they trust their individual HCPs or other clinical staff who recommend PrEP to them, showing the importance of building trusting relationships between HCPs and patients. Moreover, PrEP information shared through trusted community ambassadors helps overcome medical or pharmaceutical distrust, reinforcing the need for recruiting more Black HCPs.
Closing the Gap
Black cisgender women choose to start and continue PrEP for a sense of empowerment, control over their sexual health, reduced anxiety, and added protection in serodiscordant or nonmonogamous relationships, all of which are key facilitators to focus on during PrEP education.
Other strategies to engage Black women in PrEP care include normalizing conversations about women’s sexual health, thereby decreasing stigma; sharing current and relevant information about trends in new HIV diagnoses; emphasizing that PrEP is a user-controlled prevention method that can empower women; educating patients that PrEP is safe in women who are trying to conceive or who are pregnant, postpartum, or breastfeeding; and having multiple conversations about PrEP with patients, as increased exposure facilitates attitude change and offers them the opportunity to think about how PrEP fits into their lives.
Conversely, for women ready to start PrEP, using telemedicine, walk-in clinics, or same-day PrEP options can decrease health system–related barriers to PrEP care (eg, multiple office visits, copays, childcare, transportation). Overall, better education and communication between patients and HCPs are vital in addressing inequities in PrEP uptake and closing the PrEP gap.
What are you doing in your practice to close the PrEP gap for Black cisgender women? Join the discussion by posting in the comments section.