Cisgender women (cis-women) account for nearly 20% of new HIV diagnoses in the United States each year1 and accounted for 27% of new HIV diagnoses in Rhode Island (RI) in 2016.12 The burden of HIV among US cis-women is characterized by racial and ethnic disparities, with black and Hispanic cis-women 17 and 3.5 times, respectively, more likely to acquire HIV in their lifetimes relative to white cis-women.2 In 2016, black cis-women accounted for 47% of new HIV diagnoses among RI women.12 Pre-exposure prophylaxis (PrEP) is a daily antiretroviral medication (emtricitabine/tenofovir disoproxil fumarate) that is effective in preventing HIV among cis-women.3,4 PrEP has the potential to prevent HIV among cis-women, including among black and Hispanic cis-women. However, only 7% of those currently using PrEP in the United States are cis-women.5
The US Food and Drug Administration approved PrEP in July 2012.6 Based on evidence that PrEP prevented HIV transmission among cis-women in heterosexual partnerships,3,4 the Centers for Disease Control and Prevention (CDC) published PrEP guidelines in 2014. The CDC recommends PrEP for heterosexual cis-women if women inject drugs or if women have male sexual partners, who are living with HIV, inject drugs, or have male sexual partners.7 The CDC also recommends that providers consider PrEP for cis-women who live in a high HIV prevalence area, are sex workers, or have had a sexually transmitted disease (STD) diagnosis in the previous 6 months.
Although PrEP has been approved in the United States for more than 5 years, PrEP uptake among cis-women has been slowed.8 In a 2014 study of 144 cis-women from 6 US cities, less than 10% were aware of PrEP.9 In a study of PrEP implementation at a major hospital in San Francisco, CA, less than 1% of individuals initiating PrEP were cis-women.10 Challenges to successful PrEP implementation include low awareness, access to health care, insurance and out-of-pocket costs, and low perceived risk.9 More recent estimates of PrEP awareness and use among cis-women are lacking, particularly among black and Hispanic cis-women. We sought to evaluate PrEP awareness and uptake among cis-women over time and by race and ethnicity.
We restricted the analysis to HIV-negative women who presented to the RI STD Clinic between January 1, 2013, and December 31, 2016, and who did not identify as transgender women (henceforth, cis-women). We used partially anonymous data collected on patient intake forms filled out by patients, and we used matching by phone number, birth date, sex, race, and ethnicity to assess repeat visits. We evaluated only the first visit for each participant. We defined cis-women as meeting CDC indications for PrEP if they reported injection drug use and sharing needles in the past 6 months or reported having one or more male sexual partners in the past 12 months who were HIV-positive, injected drugs, or had other male partners.
We first described the distribution of race, ethnicity, and age among all cis-women in the sample and among the subset of cis-women meeting CDC indications for PrEP.7 We also described the proportion of women with any STD. In the main analyses, the primary outcomes were PrEP awareness and use. PrEP awareness was based on a yes/no response to the following question: “Have you heard of taking HIV medications to prevent infection in people who are HIV negative? (PrEP).” PrEP use was based on the following question: “Have you ever taken pre-exposure prophylaxis?” We described PrEP awareness by race, ethnicity, and age and among women with any STD.
In a logistic regression analysis, we estimated PrEP awareness by year and by demographic characteristics among all cis-women and, in a separate analysis controlling for race and age, evaluated whether meeting CDC indications for PrEP was associated with PrEP awareness. As a reference for PrEP awareness among populations with indications for PrEP, we also performed logistic regression analyses comparing PrEP awareness among cis-women with CDC indications for PrEP to awareness among male persons who inject drugs (PWID) and non-PWID men who have sex with men (MSM) presenting to the clinic controlling for year, age, and ethnicity and with robust SEs to account for heteroskedasticity. We conducted all analyses in Stata Version 12 (StataCorp College Station, TX).
A total of 1431 HIV-negative cis-women presented for HIV/STD testing during the study period. Among those cis-women, 84 (5.9%) met CDC indications for PrEP, with 83 (5.8%) meeting sexual risk indicators and 8 (0.6%) reporting injection drug use and sharing needles; 7 (0.5%) met both criteria. One hundred sixty-four of 1046 (15.7%) of all women and 14 of 59 (23.7%) women meeting CDC indications for PrEP who were tested screened positive for hepatitis C, gonorrhea, chlamydia, or syphilis. Demographic characteristics of all cis-women, of cis-women meeting CDC indications for PrEP, and of the non-PWID MSM and PWID, comparison groups are presented in Table 1. Among all cis-women, 43% were non-Hispanic white, 17% non-Hispanic black, 27% Hispanic, and 14% of unknown or other race and ethnicity. Just under half were between 18 and 24 years old. Among cis-women with CDC indications for PrEP, 58% were non-Hispanic white, 5% non-Hispanic black, 23% Hispanic, and 14% of other or unknown race and ethnicity; 27% of cis-women indicated for PrEP were 18–24 years old, 31% were 25–34 years old, 38% were 35–54 years old, and 4% were 55+ years old. Significantly more cis-women with CDC indications for PrEP were non-Hispanic white, and significantly fewer were non-Hispanic black. Significantly fewer cis-women with CDC indications for PrEP were 18–24 years old and significantly more were 35–54 years old.
In Table 2, we describe PrEP awareness by demographic characteristics for all cis-women and for those meeting CDC indications for PrEP. Among all cis-women, 17.3% were aware of PrEP in 2016, relative to 13.9% in 2013, an increase that was not statistically significant [adjusted odds ratio (AOR): 1.34, 95% confidence interval (CI): 0.84 to 2.15]. Among all cis-women, PrEP awareness was significantly lower among Hispanic cis-women (11.0%; 0.46, 95% CI: 0.31 to 0.66) and non-Hispanic black cis-women (13.8%; AOR: 0.59, 95% CI: 0.39 to 0.89) relative to non-Hispanic white cis-women (20.7%). PrEP awareness was similar for Hispanic cis-women (10.5%) and non-Hispanic white cis-women (22.5%) with CDC indications for PrEP. There were not enough non-Hispanic black cis-women with CDC indications for PrEP to estimate PrEP awareness in this subgroup. PrEP awareness among cis-women 25–34 years (20%; AOR: 1.38, 95% CI: 1.01 to 1.88) was significantly greater than PrEP awareness among cis-women 18–24 years (15%). Cis-women with CDC indications for PrEP were not more likely to be aware of PrEP relative to other cis-women (AOR: 1.48, 95% CI: 0.85 to 2.57). Among the 164 cis-women who tested positive for an STD, 19 (11.6%) were aware of PrEP before their appointment.
In logistic regression analysis of PrEP awareness among cis-women with CDC indications for PrEP relative to non-PWID MSM and to male PWID, non-PWID MSM had significantly greater PrEP awareness (60.3%; AOR: 5.85, 95% CI: 3.35 to 10.23) relative to cis-women with CDC indication for PrEP (22.9%). PrEP awareness among male PWID was 34.6%, a difference that was not significantly greater than among cis-women with CDC indications for PrEP (AOR: 2.10, 95% CI: 0.99 to 4.48). PrEP awareness increased over time among cis-women with CDC indications for PrEP and among non-PWID MSM, whereas it remained consistent over time among male PWID.
Six cis-women reported ever using PrEP, a sample size that precluded a logistic regression analysis. One non-Hispanic white, 54-year-old woman with CDC indications for PrEP (a male sexual partner with HIV) reported current PrEP use. Of the 6 cis-women who reported ever taking PrEP, 3 (50%) were non-Hispanic black, 2 (33%) were non-Hispanic white, and one (17%) was of unknown race and ethnicity. The majority (67%) were between 25 and 34 years old, whereas 1 (17%) was between 18 and 24 years old and 1 (17%) was between 35 and 54 years old.
Focused PrEP scale-up efforts in the United States have increased PrEP awareness and use among MSM, but not cis-women. We found that PrEP awareness among all cis-women and among those with CDC indications for PrEP remain low, with less than one-third aware of PrEP as of 2016. Just one woman with CDC indications reported PrEP use. Our findings are consistent with earlier studies indicating that cis-women in the United States have low PrEP awareness and uptake.5,9 Improved efforts by health care providers, sex educators, and policymakers are needed to increase PrEP awareness and use among cis-women at risk of HIV while maintaining important efforts to promote PrEP awareness and uptake among MSM and male PWID.
Non-Hispanic black and Hispanic cis-women are more likely to acquire HIV relative to non-Hispanic white cis-women2 but had lower PrEP awareness in this study. Among all cis-women in this study, 11% of Hispanic cis-women and 14% of non-Hispanic black cis-women were aware of PrEP, relative to 21% of non-Hispanic white cis-women. Racial and ethnic disparities in PrEP awareness among cis-women are similar to those among MSM at the RI STD Clinic11 and across the country.8 Efforts to increase PrEP awareness among cis-women at risk of HIV should focus on non-Hispanic black cis-women and Hispanic cis-women. Providers should assess whether cis-women meet CDC indications for PrEP and have culturally appropriate and Spanish language materials on PrEP available for patients. Given that awareness was also lower among younger cis-women, PrEP implementation efforts should also focus on this group through strategies such as incorporating HIV prevention education into school-based sex education curriculum and programs.
Importantly, the demographic characteristics of cis-women who meet CDC indications for PrEP do not align with the demographic characteristics of cis-women who are most likely to acquire HIV in the United States or in RI.2,12 Although HIV transmission is most concentrated in cis-women who are young and non-Hispanic black, there were significantly fewer young and non-Hispanic black cis-women who reported meeting CDC indications for PrEP. The CDC criteria defining cis-women's sexual risk indications for PrEP are based on cis-women's reported male sexual partners' characteristics and behaviors, which male partners may not disclose to cis-women.13 It is possible that this is especially true for cis-women who are young or non-Hispanic black given that these behaviors may be more stigmatized in these populations. Further research is needed on how to best identify cis-women who may benefit most from PrEP.
Our study was subject to several limitations, including that we did not collect or account for data on income or educational attainment, which may affect PrEP awareness. Individuals were asked whether they identified as transgender women, but not whether their sex at birth differed from their gender identity, and it is possible that some transgender women who identified as women were included in the sample. The low number of cis-women with CDC indications for PrEP and the low number of cis-women who had used PrEP also limited the power of the study. We conducted this study among cis-women presenting to the RI STD Clinic, a population that may have increased HIV risk relative to cis-women in the general population. On the other hand, it is possible that those presenting to the STD Clinic had more previous sexual and reproductive health counseling from health care providers relative to other cis-women in RI, and thus that, this population had greater PrEP awareness than the general population. The results of the analysis may not be generalizable to other settings. However, a significant strength of the study was a robust and large data set on PrEP awareness and uptake over time among cis-women presenting to an STD clinic.
PrEP awareness among cis-women remains low, with less than one-third of 84 women with CDC indications for PrEP aware of the medication and its HIV prevention benefits, and just one reporting taking PrEP. There is a critical need for public health professionals and health care providers to increase PrEP awareness and use among cis-women at risk for HIV through clinics and community organizations that reach those most at risk of HIV, particularly non-Hispanic black and Hispanic cis-women.
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