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Black Cisgender Women's PrEP Knowledge, Attitudes, Preferences, and Experience in Chicago
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Providers PrEP: Identifying Primary Health care Providers' Biases as Barriers to Provision of Equitable PrEP Services - (10/07/21)
JAIDS 2020

Although black cisgender women in Chicago continue to disproportionally account for new HIV diagnoses, few are on pre-exposure prophylaxis (PrEP). We used concurrent mixed-methods to understand women's PrEP knowledge, attitudes, experience, and preferences in Chicago.
Setting and Methods:
We surveyed 370 HIV(-) cisgender women visiting a sexually transmitted infection clinic (n = 120) or emergency department (n = 250). Two focus groups were conducted with PrEP-naive women, and interviews were conducted with 7 PrEP-experienced women. Quantitative data were analyzed using descriptive statistics and multivariable logistic regression, and qualitative data using thematic analysis.
Majority of women identified as black (83.0%) and had a regular source of health care (70.0%). In the past 6 months, 84.1% had vaginal or anal sex, most with inconsistent condom use (94.2%). Only 30.3% had heard of PrEP, but once explained, one-quarter considered starting PrEP, with protecting health (76.4%) and reducing HIV worry (58.1%) the most common reasons. Factors associated with considering PrEP included being Latina [adjusted odds ratio (aOR): 3.30, 95% confidence interval (CI): (1.21 to 8.99)], recent sexually transmitted infection [aOR: 2.39, 95% CI: (1.25 to 4.59)], and higher belief in PrEP effectiveness [aOR: 1.85, 95% CI: (1.22 to 2.82)]. Most (81.1%) had concerns about taking PrEP with side effects a common concern. Qualitative themes aligned with survey results, revealing a disconnection from current PrEP marketing, need for community-level PrEP education/outreach, and importance of provider trust.
Lessons Learned:
Despite significant PrEP implementation work in Chicago, less than one-third of women in our study had heard of PrEP. Once informed, PrEP attitudes and interest were positive. Translating these results into interventions reflecting women's preferences and barriers is critical to increase PrEP uptake by cisgender women in Chicago and elsewhere.
In our study in Chicago, we found low PrEP awareness and knowledge among cisgender women despite one-third of the survey sample meeting PrEP criteria and significant public health work to increase availability of and community education around PrEP.16 However, once PrEP was explained, most of the women reported positive attitudes toward PrEP, with almost one-third of survey respondents interested in starting PrEP in the near future. In addition, these women had clear preferences of where they would like to receive PrEP information and PrEP care, and what type of support they would need to overcome barriers at the individual, partner, and health system levels. Seventy percent of women had a regular source of care, largely physician offices or health centers, which were also the most common place where they wanted to receive information and start PrEP.
Potential barriers and needed support identified in both quantitative and qualitative findings included concerns about side effects, drug interactions, disclosure, financial challenges, and incomplete HIV protection as well as remembering to take a daily pill. These findings are consistent with previous PrEP research as well as earlier findings for HIV-positive women and antiretroviral therapy.4,9
Women noted that if they were to decide to take PrEP, most preferred to start PrEP in their usual source of medical care (64.3%), followed by a STI clinic (12.2%) or a family planning clinic (8.4%) (Table 4). Preferred places for regular PrEP care follow-up were slightly different, although the usual source of care remained most common (56.8%), followed by a pharmacy (18.6%), STI clinic (12.2%), and family planning clinic (5.1%). The top reasons influencing where women would want to receive PrEP included cost (23.5%), familiarity with the clinic (22.2%), confidentiality (22.7%), and ease of access (13.8%).
Most women (80.7%) reported concerns about taking PrEP that included side effects (68.4%), incomplete HIV protection (25.4%), cost (24.3%), and drug interactions (23.2%). Almost three-quarters (72.2%) said they would need some form of support around using PrEP, including financial support (34.6%), disclosure to partners and/or family (25.4%), and adherence (29.5%) (Table 4).

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