In 2009, an estimated 11,200 women were diagnosed with HIV, representing 23% of persons diagnosed with HIV infection in the United States.1 Of all new HIV infections in women, 57% occurred in African American women compared with 21% in White women; the rate of new HIV infections among African American women was 15 times the rate of new infections in White women.1 Evidence-based behavioral interventions designed to promote HIV-preventive practices, particularly consistent and correct condom use, have demonstrated efficacy.2 Yet, these interventions, although necessary, may not be sufficient in and of themselves to control the spread of HIV. Most behavioral interventions focus on condom use, which requires male cooperation. A female-controlled method that could be used covertly3 and provide long-lasting protection4 would be a tremendous benefit in reducing women's vulnerability to HIV.5 One HIV prevention approach that could be used in combination with behavioral interventions that emphasize condom use is preexposure prophylaxis (PrEP).
PrEP involves using antiretroviral drugs traditionally used to treat HIV infection, such as tenofovir and emtricitabine, as a biomedical HIV prevention strategy. Several trials have examined the efficacy of topical and oral PrEP to prevent HIV infection, with promising results. Noteworthy is the CAPRISA-004 study, which demonstrated the efficacy of topical tenofovir gel in reducing the risk of HIV acquisition among at-risk heterosexual women in South Africa.6 Use of tenofovir gel successfully reduced HIV acquisition by 39% overall and by 54% in women with high levels of adherence.6 Proof of concept has also been demonstrated for oral PrEP regimens in 3 trials. The Pre-Exposure Prophylaxis Initiative study demonstrated the efficacy of a combination of 2 oral antiretroviral drugs, tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC), in reducing the risk of HIV acquisition by 44% among men who have sex with men and transgender women across 6 countries.7 PartnersPrep demonstrated the efficacy of TDF (68%) and TDF–FTC (62%) in preventing HIV acquisition among women in serodiscordant couples in Kenya and Uganda.8 Additionally, TDF2 demonstrated the efficacy of PrEP with TDF–FTC in preventing heterosexual men and women from acquiring HIV in Botswana (62.6% efficacy overall, 75.5% efficacy among women).9 Unfortunately, other studies (ie, Preexposure Prophylaxis Trial for HIV Prevention among African Women) have been unable to demonstrate the efficacy of PrEP for HIV prevention.10–12
On July 16, 2012, the US Food and Drug Administration (FDA) approved the use of PrEP, specifically Truvada, as the first drug approved to reduce the risk of HIV infection among men and women who are at high risk for HIV infection.13 Although this is an important step toward preventing HIV among high-risk populations, adoption of PrEP as an HIV prevention strategy will undoubtedly be influenced by sociodemographic factors (eg, race, education, and income), behavioral factors (eg, condom use and number of sexual partners), and social factors (eg, peer norms, stigma, and cost of medication). Little research has explored potential determinants of PrEP uptake among women in the general population. The present study examines the association between sociodemographic factors, sexual behaviors, and social factors on potential uptake of PrEP among African American and White adult women in the United States.
PATIENTS AND METHODS
We conducted a nationally representative, random-digit dial telephone household survey of 1453 women between October 2006 and May 2007. Potential participants who self-reported being women, African American or White, aged 20–45 years, and unmarried or not currently in any relationship equivalent to marriage were eligible for inclusion.
Sampling employed a dual-frame design, incorporating 2 selection stages without stratification in each frame. The larger frame was designed to provide coverage of the eligible population (both White and African American) on a national basis, defined as all counties with an eligible household incidence of 10% or greater; this frame included 1096 of 3140 counties. The second frame targeted areas containing a high density of African American women and was restricted to counties with a household incidence of African American women of 7% or greater. Within each residential household contacted, a female adult in the target age range was selected via simple random sampling and screened for remaining eligibility criteria. Those agreeing to participate were compensated $50 for completing the assessment. A total of 1453 interviews were completed: 1042 African American and 411 White women.
All interviews were conducted using computer-assisted telephone interviewing technology for, on average, 50 minutes. The response rate was 49%.14 An analysis weight was computed to reflect the dual-frame design, unequal selection probabilities, and calibration to Census-based estimates of the population of eligible women. The institutional review boards at Emory University and Macro International approved all study procedures.
Potential PrEP uptake was assessed by asking women, “If there was a pill that you could take once a day, everyday, to PREVENT getting HIV and if this pill caused mild side effects, such as nausea, headaches, and rashes in a small number of people, would you take the pill?”15
Sociodemographic factors assessed included race, age, education, employment, and income.
Sexual behaviors assessed included number of unprotected sex acts and percent condom use in the past 90 days, number of male sex partners in past year and lifetime, history of exchanging sex for money/drugs, history of concurrency,16 and having sex with a risky male partner (ie, partners who ever injected illegal drugs, were incarcerated for more than 24 hours, ever had sex with a man, ever had an sexually transmitted disease).
Social factors that may influence PrEP uptake were assessed by a 4-item index. This index included items on peer norms supportive of PrEP, physician recommendation for PrEP, embarrassment of requesting PrEP from a doctor, and cost of PrEP at a hypothetical amount of $200/yr. One insurance company has been quoted as saying that they would provide preventive coverage for PrEP for $250–$300 a year.17
Data analysis was conducted in STATA 10 using survey estimation commands to account for the complex sample design. Initial bivariate analyses examined the relationship between a range of sociodemographics, sexual behaviors, and social influences with potential uptake of PrEP. Variables associated with potential PrEP uptake (P < 0.20) in bivariate analyses were considered in multivariable logistic regression models. Variables were entered in blocks beginning with sociodemographic characteristics, then lifetime sexual behavior, and then social influences; those that remained significant were retained. Additional bivariate analyses calculated the prevalence and crude odds ratios (OR) of potential PrEP uptake and social influences on potential PrEP uptake by race. ORs for each measure were then adjusted for socioeconomic status by including age, education, employment, and income.
Approximately 96% of participants (sample weighted) answered questions on PrEP and are included in the analyses. Most of those excluded responded Don't Know when asked about potential PrEP uptake, whereas the remainder did not provide a response.
Bivariate Analyses of Potential PrEP Uptake
Bivariate analyses showed that women at higher risk of HIV, as indicated by sexual behavior and socioeconomic status, were more likely to report potential use of PrEP (Table 1). In general, women of lower socioeconomic status were more likely to report potential PrEP uptake—for example, women completing high school or having less education had 2.04 times higher odds than women having at least a college education (P ≤ 0.001); unemployed women had 1.8 times higher odds than women holding full-time jobs (P ≤ 0.01). In contrast, women with personal incomes of $50,000 or more had 56% lower odds of potential PrEP use than those with income of $15,000 or less (P ≤ 0.001). The likelihood of potential PrEP uptake was also increased by riskier sexual behaviors. For example, women reporting engaging in sex for money or drugs had 5.78 times greater odds of potential PrEP uptake (P ≤ 0.001). Finally, these analyses identified the potential impact of social factors on PrEP use. Supportive social environment greatly increased the likelihood of potential PrEP uptake—the odds were 16.2 times higher for women who believed that many of their girlfriends would take the pill (P ≤ 0.001), whereas health-care provider recommendation of the pill would increase the odds by 22 times (P ≤ 0.001).
On the contrary, women were less likely to use PrEP if they were embarrassed to ask health-care providers for such a pill [OR = 0.58, 95% CI (confidence interval) = 0.35 to 0.97, P ≤ 0.05] or if the potential cost of the pill was prohibitive at $200/yr (OR = 0.66, 95% CI: 0.47 to 0.93, P ≤ 0.05).
Logistic Regression Models of Potential PrEP Uptake
Multivariate logistic regression models are reported in Table 2. In model 1, which focused on sociodemographic characteristics and sexual behavior, women who engaged in riskier sexual behaviors (ie, those with more lifetime sexual partners, women who ever had an HIV test, and women who ever exchanged sex for money/drugs) were more likely to report potential PrEP use, whereas women of higher socioeconomic status (ie, White women, those over 30, and women with any college education) were less likely to report that they would use PrEP.
Similarly, when potential social influences on PrEP acceptability were added to the model (model 2 in Table 2), African American women maintained a higher likelihood of using PrEP [adjusted OR (aOR) = 1.4, 95% CI: 0.94 to 2.11, P ≤ 0.10]. Women reporting more lifetime sexual partners (aOR = 1.8, 95% CI: 1.12 to 2.73, P ≤ 0.01), women who perceived that many of their peers would use PrEP (aOR = 8.25, 95% CI: 4.80 to 14.2, P ≤ 0.001), less educated women (aOR = 1.79, 95% CI: 1.15 to 2.85, P ≤ 0.01), and those who reported they would be more likely to use PrEP if recommended by a health-care provider (aOR = 13.2, 95% CI: 7.54 to 23.1, P ≤ 0.001) were all significantly more likely to report willingness to use PrEP. Women were less likely to use PrEP if the cost was $200/yr (aOR = 0.60, 95% CI: 0.38 to 0.95, P ≤ 0.05).
Racial Differences in Potential PrEP Uptake and PrEP-Related Social Influences
Significant differences were identified in potential uptake of PrEP and perceived social influences by race (Table 3). Unadjusted bivariate analyses showed that compared with White women, African American women were significantly more likely to report potential PrEP use (69.1% vs. 54.2%, P ≤ 0.001). Moreover, compared with White women, African American women would be more likely to report potential PrEP use if they perceived that their significant others would also use PrEP, especially their female peers (82.4% vs. 68.6%, P ≤ 0.001) and their male peers (68.6% vs. 61.5%, P ≤ 0.05). Furthermore, African American women would be more likely to use PrEP if it was recommended by a health-care provider (81.0% vs. 69.8%, P ≤ 0.001).
These relationships remained significant after adjusting for age, education, employment, and income. Thus, compared with White women, African American women were 1.76 times as likely to report potential use of PrEP (P ≤ 0.001). Furthermore, compared with White women, African American women were 2.2 times as likely to report potential PrEP use if they perceived that their female friends would also use PrEP (P ≤ 0.001) and 1.65 times as likely to report potential PrEP use if it was recommended by a health-care provider (P ≤ 0.001). Analyses also showed that African American women had 41% lower adjusted odds of being embarrassed to ask a doctor for PrEP (aOR = 0.59, 95% CI = 0.36 to 0.98, P ≤ 0.05). Importantly, there were no racial differences in potential impact of PrEP on sexual behavior, meaning African American women were no more likely than White women to report risk compensation, that is, no intent to decrease condom use or increased number of sexual partners as a consequence of potential PrEP uptake.
This is among the first studies examining potential PrEP uptake as an HIV prevention strategy among a national sample of African American and White women not enrolled in a PrEP efficacy trial. Results from this population-based study indicate that racial differences exist in the potential uptake of PrEP. Noteworthy, in multivariable analyses, compared with White women, African American women are more likely to report potential adoption of PrEP. Social factors play a key role in African American women's potential adoption of PrEP. Specifically, African American women's potential adoption of PrEP is more influenced by the opinions of important referents, particularly other women's decision to adopt this same preventive practice. Moreover, African American women are more likely to express an interest in potential PrEP uptake if it was recommended by a physician. Furthermore, African American women's potential interest in adopting PrEP is associated with the perception of requesting PrEP from a physician as less stigmatizing. These findings have important implications for public health efforts designed to enhance PrEP adoption among African American women and are encouraging with respect to African American women's trust in their health-care providers to recommend PrEP if necessary.
Moreover, the study provides evidence that does not corroborate racial differences in sexual risk compensation as a function of PrEP use. These findings are encouraging with respect to incorporating PrEP as a biomedical strategy to reduce HIV infection among African American women.
Additional multivariable analyses revealed that women with more lifetime sexual partners and less educational attainment are more likely to report potential PrEP uptake. Women with greater numbers of lifetime sexual partners may be aware of their heightened HIV risk and believe that PrEP provides a more realistic and effective option for preventing HIV acquisition relative to other strategies such as condoms. Additionally, previous research has indicated that African American women with higher educational attainment may be at lower risk for sexually transmitted diseases and HIV.18 Thus, women with higher educational attainment may perceive themselves to be at lower risk for HIV and, consequently, less interested in adopting PrEP as an HIV prevention strategy. These findings are congruent with the recent FDA licensure of PrEP for individuals, including men and women, at high risk for HIV infection.13 After the FDA's approval of Truvada for use as HIV prevention in high-risk populations, the Centers for Disease Control and Prevention issued guidelines for the use of PrEP for the prevention of HIV infection in heterosexual adults.19 This will serve as a useful tool, given the key role that health-care providers will have as gatekeepers in access to PrEP, particularly among women.
Finally, it is important to note that the potential cost for PrEP was identified as a barrier for all respondents. If efficacious and affordable, PrEP could reduce socioeconomic disparities in HIV among women. However, if at-risk women cannot afford PrEP or if the cost of PrEP becomes a barrier to medication adherence, then the potential exists for worsening racial disparities in HIV rates. At the estimated cost of over $10,000/yr,20 it is unclear whether low-income women would be able to afford PrEP. It is also unclear whether PrEP would be cost effective for women, compared with alternative prevention strategies.21
This study has several limitations. First, this study was conducted before the FDA licensure of PrEP. Therefore, participant acceptability is hypothetical. Now that PrEP has been approved for use, similar studies should be conducted to assess acceptance among adult women at risk for HIV infection. Second, this is a cross-sectional study. Thus, the temporal relationships between predictors and potential use of PrEP cannot be established. Third, the Centers for Disease Control and Prevention advises that the efficacy of Truvada for HIV prevention is highly dependent on daily medication adherence.19 Although potential adoption of PrEP may be important for HIV prevention, future research should examine adherence that may be equally important.
Findings from this nationally representative sample are informative and encouraging with respect to potential PrEP uptake among African American women, women with lower educational attainment, and women with increased lifetime sexual partners. Now that Truvada has been licensed for HIV prevention use by the FDA, future studies should be conducted to assess factors influencing actual PrEP uptake and adherence among women at increased risk for HIV. Future studies should also investigate financial mechanisms for increasing women's access to PrEP for HIV prevention.
The authors thank Bill Sribney for providing statistical support and performing data weighting and Elizabeth Nesoff for support with preparing the article.
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