A study published in AIDS and Behavior identified social and structural factors that impacted PrEP uptake, but also found that women facing barriers to PrEP still initiated it.

“Nearly 20% of all HIV infections in the United States are among cisgender women, and Black and Latina cisgender women make up nearly 90% of all HIV infections in this group,” Jelani B. Cheek, MPH, explains. “Compounding this issue, studies continuously find that low proportions of cisgender women are even aware of PrEP, let alone taking PrEP.”

Previous research by Cheek and colleagues for the New York City Department of Health and Mental Hygiene (NYC DOHMH)’s Status Neutral Care Coordination (SNC) program, a client-centered HIV prevention program, demonstrated the “exceptionally low proportion” of cisgender women who started PrEP compared with other priority populations in the program, according to Cheek.

For a study published in AIDS and Behavior, Cheek and colleagues used retrospective longitudinal data, including sociodemographic, behavioral, clinical, and psychosocial information, from cisgender women enrolled in SNC from January 2017 to December 2019 to examine the association between these factors and PrEP initiation.

PrEP Uptake Relatively High Despite Barriers, But Uneven

Researchers included 565 cisgender women in the analysis. Participants identified as Latina (47.1%), Black (31.9%), White (15.2%), and other (4.8%). Most participants (94%) reported having condomless sex in the preceding 6 months, and nearly 63% were unaware of PrEP.

Among individuals who met at least one HIV-related risk criterion for PrEP, only slightly more than a quarter (26%) started PrEP. Participants who were Latina (vs White; OR, 2.2; 95% CI, 1.2-4.1), experiencing unstable housing (OR, 1.7; 95% CI, 1.1-2.5), and aware of PrEP (OR, 5.2; 95% CI, 3.5-7.8) were considerably more likely to begin PrEP.

“These findings are encouraging because they illustrate that women experiencing known barriers to PrEP, such as low income and unstable housing, still initiated PrEP,” Cheek explains. “Positive associations between receiving benefits navigation services and PrEP initiation emphasize the importance a client-centered patient navigation model such as the one employed by SNC and how they can facilitate women to receive PrEP services effectively.”

He noted that the findings related to the uneven distribution of PrEP, especially among Latina women compared with White women, may be related to lower rates of HIV diagnoses and overall prevalence compared with Latina and Black women.

“Social and structural factors driven by, or rooted in, racism contribute to the inequities we see in both HIV diagnosis rates and PrEP uptake,” says Cheek.

Predominant behavioral characteristics of the study cohort included engaging in condomless sex in the last 6 months (94%) and having primarily only cisgender men as sexual partners in the last 6 months (84%), according to Cheek (Table).

Addressing Social & Structural Factors to Further PrEP Uptake

Overall, PrEP awareness was quite low in the study population, at slightly more than 36%. “These findings highlight the need to increase PrEP awareness among women,” Cheek noted. “Modifying current PrEP promotion strategies and messaging to reach and resonate with women is a necessity.”

Infectious disease clinicians and public health providers can use the findings from the current study in discussions of HIV risk and patients’ needs to determine PrEP eligibility, Cheek continues. “Providers should also take the opportunity to educate and offer educational materials on PrEP to women in a non-judgmental, stigma-free manner.”

Future research should examine the association between stigma and PrEP uptake among cisgender women, especially Black and Latina cisgender women, as “stigma is a known barrier to PrEP in these populations,” according to Cheek. Studies examining adherence to PrEP among Black and Latina cisgender women would be helpful “so that we can get ahead of addressing potential challenges with consistent PrEP use after initiation among these populations,” he says.

The need to acknowledge and address social and structural factors such as racism, sexism, and classism that result in disparities in HIV rates, PrEP uptake, and knowledge of PrEP among cisgender women, specifically Black and Latina cisgender women, is also important. “We must refine PrEP promotion strategies and services but do so in a way that is equitable and fair,” Cheek says. “PrEP access is very much a social justice issue as it is a clinical issue, and it must be approached as such if we truly want to reduce HIV incidence and disparities among women.”