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.

Health Justice: A Framework for Mitigating the Impacts of HIV and COVID-19 on Disproportionately Affected Communities.

Health crises have a disproportionate impact on communities that are marginalized by systems of oppression such as racism and capitalism. Benefits of advances such as in the prevention and treatment of HIV disease are unequally distributed. Intersecting factors including poverty, homophobia, homelessness, racism, and mass incarceration expose marginalized populations to greater risks while limiting access to resources that buffer these risks. Similar patterns have emerged with COVID-19. We identify comparable pitfalls in our responses to HIV and COVID-19. We introduce health justice as a framework for mitigating the long-term impact of the HIV epidemic and COVID-19 pandemic. The health justice framework considers the central role of power in the health and liberation of communities hit hardest by legacies of marginalization. We provide 5 recommendations grounded in health justice: (1) redistribute resources, (2) enforce mandates that redistribute power, (3) enact legislation that guarantees support for people with long-haul COVID-19, (4) center experiences of the most impacted communities in policy development, and (5) evaluate multidimensional effects of policies across systems. Successful implementation of these recommendations requires community organizing and collective action. (Am J Public Health. 2023;113(2): 194-201. https://doi.org/10.2105/AJPH.2022.307139).

Reimagining Preexposure Prophylaxis Provision for Women in the United States.

Structural determinants of health drive inequities in the acquisition of human immunodeficiency virus (HIV) and the use of preexposure prophylaxis (PrEP) for HIV prevention among cisgender women in the United States. However, current PrEP clinical guidance and implementation paradigms largely focus on individual behaviors and characteristics, resulting in missed opportunities to improve PrEP access, and the implicit transferring of prevention work from health systems to individuals. In this viewpoint article, we outline ways to apply a structural lens to clinical guidance and PrEP implementation for women and propose areas for future work.

Pre-exposure Prophylaxis (PrEP) Initiation Among Black and Latina Cisgender Women Receiving HIV Prevention Care Coordination Services in New York City.

Black and Latina cisgender women are disproportionately impacted by HIV in the US. Although PrEP is effective at preventing HIV infection, uptake in this population remains low. The aim of the study was to examine sociodemographic, behavioral, clinical, and psychosocial factors associated with PrEP initiation (defined as receiving a PrEP prescription) among 565 cisgender women enrolled in an HIV prevention services coordination program in NYC from January 2017 to December 2019 who met HIV risk criteria for PrEP. Of these, 26% initiated PrEP. Latina women were significantly more likely than white women to have initiated PrEP (Latina: 29.7%; Black: 26.1%; White: 16.3%; Other: 7.4%). PrEP initiation was significantly associated with PrEP awareness, an annual income < $20,000, being unstably housed, receiving benefits navigation services, and reporting non-injection drug use and/or a recent sexual relationship with an HIV-positive partner. The relatively low rate of PrEP initiation we observed suggests the need to increase PrEP access and uptake among women, particularly Black and Latina women who continue to be disproportionately at risk for HIV.

Coronavirus Disease 2019 (COVID-19) Infection Among People With Human Immunodeficiency Virus in New York City: A Population-Level Analysis of Linked Surveillance Data.

BACKGROUND: New York City (NYC) was hard-hit by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and is also home to a large population of people with human immunodeficiency virus (PWH). METHODS: We matched laboratory-confirmed coronavirus disease 2019 (COVID-19) case and death data reported to the NYC Health Department as of 2 June 2020 against the NYC HIV surveillance registry. We describe and compare the characteristics and COVID-19-related outcomes of PWH diagnosed with COVID-19 with all NYC PWH and with all New Yorkers diagnosed with COVID-19. RESULTS: Through 2 June, 204 583 NYC COVID-19 cases were reported. The registry match identified 2410 PWH with diagnosed COVID-19 eligible for analysis (1.06% of all COVID-19 cases). Compared with all NYC PWH and all New Yorkers diagnosed with COVID-19, a higher proportion of PWH with COVID-19 were older, male, Black, or Latino, and living in high-poverty neighborhoods. At least 1 underlying condition was reported for 58.9% of PWH with COVID-19. Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced hospitalization, intensive care unit admission, and/or death; most PWH who experienced poor COVID-19-related outcomes had CD4 <500 cells/µL. CONCLUSIONS: Given NYC HIV prevalence is 1.5%, PWH were not overrepresented among COVID-19 cases. However, compared with NYC COVID-19 cases overall, a greater proportion of PWH had adverse COVID-19-related outcomes, perhaps because of a higher prevalence of factors associated with poor COVID-19 outcomes. Given the pandemic's exacerbating effects on health inequities, HIV public health and clinical communities must strengthen services and support for people living with and affected by HIV.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention.

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention's women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women's focus; and consider providing same-day PrEP.

A Pilot Study to Evaluate a Novel Pre-exposure Prophylaxis Peer Outreach and Navigation Intervention for Women at High Risk for HIV Infection.

Pre-exposure prophylaxis (PrEP) uptake remains woefully low among U.S. women at high risk for HIV acquisition. We evaluated a pilot intervention which involved Peers providing brief PrEP education and counseling at mobile syringe exchange sites and at sex worker and syringe exchange drop-in centers followed by navigation to PrEP care. Peers recruited English-proficient, self-identified women (i.e., cisgender and transgender women and persons with other transfeminine identities) over a 3-month period and delivered the intervention to 52 HIV-negative/status unknown participants. Thirty-eight participants (73.1%) reported PrEP interest, 27 (51.9%) accepted the offer of a PrEP appointment, 13 (25.0%) scheduled a PrEP appointment, 3 (5.8%) attended an initial PrEP appointment, and none were prescribed PrEP. We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.

Electronic Dissemination of a Web-Based Video Promotes PrEP Contemplation and Conversation Among US Women Engaged in Care at Planned Parenthood.

We evaluated the acceptability and impact of a web-based PrEP educational video among women (n = 126) by comparing two Planned Parenthood centers: one assigned to a Web Video Condition and one to a Standard Condition. Most women reported the video helped them better understand what PrEP is (92%), how PrEP works (93%), and how to take PrEP (92%). One month post-intervention, more women in the Web Video Condition reported a high level of comfort discussing PrEP with a provider (82% vs. 48%) and commonly thinking about PrEP (36% vs. 4%). No women with linked medical records initiated PrEP during 1-year follow-up.

Racial and ethnic differences in women's HIV risk and attitudes towards pre-exposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemic.

Women with syndemic conditions, i.e., two or more co-occurring epidemics, are at elevated risk for HIV acquisition and are therefore prime candidates for pre-exposure prophylaxis (PrEP). However, PrEP uptake remains low among women, especially among Black and Hispanic women. This study examined associations of syndemic conditions with PrEP attitudes and HIV risk among women, and the moderating effect of race and ethnicity. In 2017, 271 non-Hispanic Black, non-Hispanic White, and Hispanic, PrEP-eligible women engaged in care at Planned Parenthood in the northeastern region of the U.S. completed an online survey. Participants reported syndemic conditions (i.e., intimate partner violence, depression, substance use), PrEP attitudes (e.g., PrEP interest), HIV sexual risk (e.g., multiple male sexual partners), and sociodemographics. Structural equation modeling was used to examine the effects of syndemic conditions on PrEP attitudes and HIV risk, and the moderating effect of race and ethnicity. Women with more syndemic conditions had a higher odds of reporting multiple male sexual partners. Syndemic conditions were positively associated with PrEP attitudes for Hispanic women than non-Hispanic Black and White women. Women with syndemic conditions, particularly Hispanic women, may be receptive to interventions promoting PrEP.

The Relationship Between Discrimination and Missed HIV Care Appointments Among Women Living with HIV.

Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women's Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.

Examining adherence barriers among women with HIV to tailor outreach for long-acting injectable antiretroviral therapy.

BACKGROUND: Long-acting (LA) injectable antiretroviral therapy (ART) has been found non-inferior to daily oral ART in Phase 3 trials. LA ART may address key barriers to oral ART adherence and be preferable to daily pills for some people living with HIV. To date, women have been less represented than men in LA ART research. Using longitudinal data from the Women's Interagency HIV Study (WIHS) cohort of women living with HIV in the United States, we examined barriers and facilitators of daily oral ART adherence that may be related to or addressed by LA ART. METHODS: We conducted a secondary analysis of WIHS cohort data from 1998 to 2017 among participants seen for at least 4 visits since 1998 who reported using ART at least once (n = 2601). Two dichotomous outcomes, patient-reported daily oral ART adherence and viral suppression were fit using generalized linear models, examining the role of socio-demographic and structural factors. RESULTS: At study enrollment, the median age was 40.5 years, 63% of participants were African American and 22% were Latina. The majority (82%) reported taking ART more than 75% of the time and 53% were virally suppressed. In multivariate analysis, several sub-groups of women had lower odds of reported adherence and viral suppression: 1) younger women (adherence aOR: 0.71; viral suppression aOR: 0.63); 2) women who inject drugs (adherence aOR: 0.38; viral suppression aOR: 0.50) and those with moderate (adherence aOR: 0.59; viral suppression aOR: 0.74) and heavy alcohol consumption (adherence aOR: 0.51; viral suppression aOR: 0.69); 3) those with depressive symptoms (adherence aOR: 0.61; viral suppression aOR: 0.76); and 4) those with a history of going on and off ART (adherence aOR: 0.62, viral suppression aOR: 0.38) or changing regimens (adherence aOR: 0.83, viral suppression aOR: 0.56). CONCLUSIONS: Current injectable contraceptive users (vs. non-users) had greater odds of oral ART adherence (aOR: 1.87) and viral suppression (aOR: 1.28). Findings identify profiles of women who may benefit from and be interested in LA ART. Further research is warranted focused on the uptake and utility of LA ART for such key subpopulations of women at high need for innovative approaches to achieve sustained viral suppression.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices. OBJECTIVE: We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP. DESIGN AND PARTICIPANTS: We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA. KEY RESULTS: We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation. CONCLUSIONS: We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

PrEP in the Real World: Predictors of 6-Month Retention in a Diverse Urban Cohort.

The effectiveness of HIV pre-exposure prophylaxis (PrEP) depends on adherence, which requires retention in PrEP care. We sought to examine factors associated with six-month retention in PrEP care among individuals prescribed PrEP between 2011 and 2015 in a large, academic health system in the Bronx, New York. We used multivariable logistic regression to identify factors independently associated with six-month retention. Among 107 patients, retention at 6 months was 42%. In the multivariable analysis, heterosexual individuals were less likely to be retained in PrEP care at 6 months, but individuals who received prescriptions from attending physicians were more likely to be retained in care. Larger prospective studies are needed to better evaluate the individual and health system factors associated with long-term engagement in PrEP care.

Differences in Medical Mistrust Between Black and White Women: Implications for Patient-Provider Communication About PrEP.

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention method. PrEP uptake has been persistently low among US women, particularly Black women, who account for 61% of new HIV diagnoses among women. Further understanding of barriers to Black women accessing PrEP is needed. This 2017 cross-sectional survey study explored race-based differences in PrEP interest and intention among women and the indirect association between race and comfort discussing PrEP with a healthcare provider through medical mistrust. The sample consisted of 501 adult women (241 Black; 260 White) who were HIV-negative, PrEP-inexperienced, and heterosexually active. Black women reported greater PrEP interest and intention than White women. However, Black women expressed higher levels of medical mistrust, which, in turn, was associated with lower comfort discussing PrEP with a provider. Medical mistrust may operate as a unique barrier to PrEP access among Black women who are interested in and could benefit from PrEP.

Missed Opportunities for HIV Prevention: Individuals Who HIV Seroconverted Despite Accessing Healthcare.

Individuals with a negative HIV test before a positive one (seroconverters) may represent missed opportunities for prevention. To inform HIV prevention strategies, we aimed to characterize patients who seroconverted despite accessing care. We identified patients at a large, urban healthcare system who seroconverted between 2009 and 2014. Demographics, visits, and HIV-related variables were extracted from the medical records. We performed descriptive statistics, assessed for trends, and tested for associations according to sex. 220 seroconverters were identified: 45% were female, 87% were non-Hispanic Black or Hispanic, and median number of negative tests prior to diagnosis was 2 (IQR 1-3). Overall, 49% reported heterosexual contact as their risk factor and the proportion with heterosexual risk increased over time (24% in 2009 vs. 56% in 2014, p = 0.03). Compared to men, women were older at the time of diagnosis (35 vs. 26 years old, p < 0.01), had more visits between their latest negative and positive HIV test (4 vs. 2, p < 0.01), and were more likely to be diagnosed in the context of screening (64% vs. 56%, p = 0.05). We identified a population that became HIV-infected despite multiple healthcare encounters and undergoing HIV testing multiple times. Patients were mostly heterosexual and almost half were female. To avoid missed opportunities for those already accessing care, HIV prevention efforts should include strategies tailored to individuals with less frequently recognized risk profiles.

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians.

BACKGROUND: Among health care providers, prescription of HIV pre-exposure prophylaxis (PrEP) has been low. Little is known specifically about primary care physicians (PCPs) with regard to PrEP awareness and adoption (i.e., prescription or referral), and factors associated with adoption. OBJECTIVE: To assess PrEP awareness, PrEP adoption, and factors associated with adoption among PCPs. DESIGN: Cross-sectional online survey conducted in April and May 2015. RESPONDENTS: Members of a national professional organization for academic primary care physicians (n = 266). MAIN MEASURES: PrEP awareness, PrEP adoption (ever prescribed or referred a patient for PrEP [yes/no]), provider and practice characteristics, and self-rated knowledge, attitudes, and beliefs associated with adoption. KEY RESULTS: The survey response rate was 8.6 % (266/2093). Ninety-three percent of respondents reported prior awareness of PrEP. Of these, 34.9 % reported PrEP adoption. In multivariable analysis of provider and practice characteristics, compared with non-adopters, adopters were more likely to provide care to more than 50 HIV-positive patients (vs. 0, aOR = 6.82, 95 % CI 2.06-22.52). Compared with non-adopters, adopters were also more likely to report excellent, very good, or good self-rated PrEP knowledge (15.1 %, 33.7 %, 30.2 % vs. 2.5 %, 18.1 %, 23.8 %, respectively; p < 0.001) and to perceive PrEP as extremely safe (35.1 % vs. 10.7 %; p = 0.002). Compared with non-adopters, adopters were less likely to perceive PrEP as being moderately likely to increase risk behaviors ("risk compensation") (12.8 % vs. 28.8 %, p = 0.02). CONCLUSIONS: While most respondents were aware of PrEP, only one-third of PrEP-aware PCPs reported adoption. Adopters were more likely to have experience providing HIV care and to perceive PrEP as extremely safe, and were less likely to perceive PrEP use as leading to risk compensation. To enhance PCP adoption of PrEP, educational efforts targeting PCPs without HIV care experience should be considered, as well as training those with HIV care experience to be PrEP "clinical champions". Concerns about safety and risk compensation must also be addressed.

Reaching Key Populations: PrEP Uptake in an Urban Health Care System in the Bronx, New York.

Pre-exposure prophylaxis (PrEP) has been established as an effective HIV prevention tool, but real world studies are limited. To inform dissemination efforts, we sought to describe individuals prescribed PrEP in the largest health care system in the Bronx, New York, an urban region with a high burden of HIV. We used a clinical database and chart review to identify individuals prescribed PrEP between 2011 and 2015 (n = 108). A majority were Black and Hispanic, half were men who have sex with men, and nearly a third were cisgender women who have sex with men. Primary care settings were the most common site of PrEP prescription and PrEP prescription rates increased over time. Despite reaching a diverse patient population, PrEP prescribing rates were low, underscoring the urgent need for PrEP scale-up.

Pain is Associated with Missed Clinic Visits Among HIV-Positive Women.

Pain is highly prevalent among HIV-positive individuals, with women representing a large subset of those with pain. However, little is known about the relationship between pain and retention in HIV medical care. Among a cohort of HIV-positive women of color, we evaluated the association between pain and retention in care, as measured by missed clinic visits. The Health Resources and Services Administration's Women of Color Initiative was a multi-site observational cohort study evaluating demonstration projects to engage HIV-positive women in medical care. From November 2010 to July 2013, 921 women were enrolled in the study across nine U.S. sites; baseline interviews collected data on socio-demographic, clinical, and risk behavior characteristics. Pain was assessed at baseline based on number of days in pain over the last 30 days and was categorized as no pain (0 days), infrequent pain (1-13 days), and frequent pain (14-30 days), with 14 days being the median. Missed visits over the one-year follow-up period, evaluated by chart abstraction, were dichotomized as ≤1 missed visit versus >1 missed visit. We conducted multivariate logistic regression to assess the association between pain at baseline and missed visits, adjusting for pertinent covariates. Among our sample (N = 862), 52.2 % of women reported no pain, 23.7 % reported infrequent pain and 24.1 % reported frequent pain. Forty-five percent had >1 missed visit during the one-year follow-up period. Overall, we did not find a significant association between pain and missed visits (aOR 2.30; 95 % CI 1.00-5.25). However, in planned stratified analyses, among women reporting current substance use at baseline, reporting frequent pain was associated with a higher odds of missed visits as compared with reporting no pain (aOR 15.14; 95 % CI 1.78-128.88). In our overall sample, pain was not significantly associated with missed visits. However, frequent pain was associated with missed visits among HIV-positive women of color who reported substance use at baseline. A better understanding of the relationship between pain and missed visits could guide efforts to improve retention in care in this population.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs.

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

Pre-exposure prophylaxis prescribing and retention in care among heterosexual women at a community-based comprehensive sexual health clinic.

In the United States, heterosexual women account for 20% of new HIV infections. As a user-controlled HIV prevention method, pre-exposure prophylaxis (PrEP) has substantial potential to reduce new infections among women. However, among women, PrEP is vastly underutilized. To guide efforts to increase women-at-risk's PrEP use, we sought to describe the characteristics of women prescribed PrEP as well as their retention in PrEP care. We conducted a chart review of women who received care at a comprehensive sexual health clinic within a large urban health care system. Referral sources included the health care system's clinics and HIV testing program, as well as local community-based organizations. From 1 December 2014 to 5 August 2016, 554 women received care at the clinic. During this period, 21 heterosexual women (3.8%) received at least one prescription for daily oral PrEP. For women prescribed PrEP, median age was 35 years old (range: 20-52). The majority (66.7%) were either Latina or non-Latina Black and most (81.2%) had public health insurance. The most common PrEP indication was being in a known sero-discordant partnership (85.7%). Of women in such partnerships, 83.3% reported their male partner was currently taking antiretroviral medications (ARVs) and 16.7% reported trying to conceive with their partner (not mutually exclusive). Of women with ARV-using partners, 66.7% reported that their partners were virally suppressed. Retention in PrEP care at three months was 61.1% and, at six months, 37.5%. Further study is necessary to expand PrEP to women whose risk factors extend beyond being in a known sero-discordant partnership, and to understand the reasons for the observed drop-off in PrEP care visits in real-world settings.