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Source: Centers for Disease Control and Prevention. (2023). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2021. HIV Surveillance Supplemental Report, 28(4). http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.
Table 9a: https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-28-no-4/content/tables.html
Note: Coverage is calculated by dividing the number of individuals on PrEP by the number of individuals for whom PrEP is indicated. A treatment is considered “indicated” if it is medically reasonable to administer in a given situation.
Barriers to PrEP Uptake
To examine what is known about providing and improving uptake of PrEP among Black cisgender women, Child Trends and the University of Missouri, Kansas City conducted a literature review of studies published from 2014 to 2023. Using PubMed, EbscoHost, and CINHAL databases, the team identified 157 abstracts and assessed the full articles across a number of criteria for inclusion. Of the 157 articles, 29 were ultimately chosen for full review and included in our analysis. A peer-reviewed scoping review article is forthcoming; in the meantime, highlights of our analysis are below.
Research suggests there are multiple barriers for both providers and patients that limit PrEP uptake among Black cisgender women. In our review of the literature, several themes emerged for why there is inadequate prescription and use of this preventive HIV medicine.
Provider barriers
For health care providers, the research highlights the following top barriers to prescribing PrEP:
- Lack of provider knowledge in terms of PrEP guidelines and side effects[4]
- Discomfort discussing sexual health, HIV, and/or drug use with patients[5]
- Competing needs during patient appointments[6]
- Concerns that the patient will be uncomfortable discussing sexual behaviors, sexuality, HIV, and/or drug use[7]
- Age, gender, and racial biases, including providers’ assumptions about patients’ behaviors (or lack thereof)[8]
- Lack of continuity of care and time needed for follow-up with patients[9]
- Concerns about the cost of PrEP to patients[10]
Patient barriers
The literature we reviewed focused most heavily on patient barriers, a framing that incorrectly presumes that a patient’s lack of PrEP use is more an individual than a structural or systematic issue and places more responsibility on the patient than on trained, professional providers. Barriers from the patient-centered perspective include the following:
- Low awareness of their individual risk of acquiring HIV[11]
- Lack of PrEP knowledge[12]
- Concerns about cost[13]
- Concerns about interactions and side effects[14]
- Concerns about their ability to adhere to daily regimens[15]
- Low confidence in PrEP’s efficacy[16]
- Medical mistrust[17]
- Concerns about stigma and/or judgement from partners, family, and/or friends[18]
Recommendations for Health Care, Public Health, and Research Professionals
Health care and public health professionals and researchers can help increase knowledge of, access to, and uptake of PrEP among Black women, and especially among young cisgender Black women. Below are several recommendations to increase use of and adherence to this preventive medicine:
Health care professionals
Clinicians need more formal education in nursing and medical school and continued professional development in sexual health, including how to take a sexual history using practical, comprehensive tools. A 2020 narrative review published in Sexually Transmitted Diseases found that sexual histories were obtained in less than one third of clinic well-visits and in anywhere from 8 percent to 82 percent of visits for which clients presented with a STI-related or genitourinary/abdominal complaint.
Once trained, health care providers need to integrate age-appropriate comprehensive sexual health assessments into routine care to better understand their patient’s sexual health, risks, and needs; determine frequency of STI/HIV screenings; and guide counseling. These conversations must be normalized with every patient to help end the stigma and shame associated with STIs and HIV. Additionally, providers must talk with patients about PrEP and its effectiveness, the various ways in which it can be administered (i.e., daily, injectable, oral), the side effects of PrEP, and the cost. Providers also cannot make assumptions about a person’s partners, HIV status, substance use, and behaviors based on their age, sex, gender, or race/ethnicity. Providers must start assessments early in their relationship with a patient and routinize them over time as they build rapport.
Thorough sexual health assessments are also critical for accurate data on the percentages of female PrEP users. The CDC calculates percentages by dividing the number of people prescribed PrEP by the number of people with indications for receiving PrEP. Findings from our literature review suggest that the reported number of people with indications for PrEP is likely to be dramatically lower than the actual number, due to a lack of screening and gender and racial biases among providers.
Public health professionals
Public health professionals need to improve and expand their messaging about PrEP to cisgender young women to increase their awareness and knowledge. Sales et al. (2019) point out that men who have sex with men have been the main audience for highly visible PrEP awareness campaigns and, although some recent campaigns include messaging directed to women, these campaigns are small and have not penetrated the cultural zeitgeist. Such campaigns must address misinformation and misconceptions about HIV and PrEP; introduce the various forms of the medicine, including oral and injectable PrEP; and be inclusive of adolescent and young adult audiences.
Researchers
Researchers need to report and disseminate data on PrEP uptake accurately and responsibly. By combining data from cisgender and transgender people by sex assigned at birth, researchers misgender transgender people and inaccurately report findings, which have critical consequences for understanding patterns of HIV acquisition.
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