Adapting Provider Training and Pre-Exposure Prophylaxis Advertising to Increase Pre-Exposure Prophylaxis Awareness and Uptake Among Black Cisgender Women

Abstract

Black cisgender women (hereafter referred to as “women”) have disproportionately high rates of HIV infection yet low rates of pre-exposure prophylaxis (PrEP) utilization. Barriers to PrEP uptake exist at the system, provider, and individual/client level. To learn how existing training and advertising can be adapted to address race- and sex-based gaps within PrEP service delivery, we conducted focus groups with providers and Black women. Participants were recruited at three health care organizations in the Midwest and South, screened for eligibility, and consented verbally. Focus groups occurred from August 2022 to February 2023. Women were asked about their knowledge and thoughts on PrEP. Providers were asked about factors influencing their decision-making about PrEP. A codebook was developed based on the Consolidated Framework for Implementation Research. Transcripts were coded using the Stanford Lightning Report Method. We completed four focus groups with 10 providers and 9 focus groups with 25 women. Three major themes emerged: (1) low comfort level and limited cultural sensitivity/competency among providers discussing HIV risk and PrEP with Black women, (2) women's concerns about PrEP's side effects and safety during pregnancy, and (3) lack of Black women representation in PrEP advertisement/educational materials. In addition, women in the South reported general medical mistrust and specific misconceptions about PrEP. PrEP trainings for providers need detailed information about the safety of PrEP for women and should include role-playing to enhance cultural competency. Likewise, PrEP advertisements/materials should incorporate information regarding side effects and images/experiences of Black women to increase PrEP awareness and uptake among this population.

Clinical Trial Registration Number: NCT05626452.

Introduction

Cisgender women (hereafter referred to as “women”) comprised 18% of new HIV diagnoses in the United States in 2021.¹ Black/African American women are disproportionately affected by HIV, accounting for more than half (54%) of these new diagnoses.² Although pre-exposure prophylaxis (PrEP) utilization has increased each year since its approval in 2012, there still remain significant disparities in PrEP use among Black/African American people and women, especially in the southern United States. Black people constituted just 14% of PrEP users but 42% of new HIV diagnoses in 2021, and among all PrEP users in the United States, only 8% were female, indicating a high unmet need for PrEP in Black women.³ Moreover, people in the South accounted for 52% of new HIV diagnoses but only 38% of PrEP users, with Black people accounting for 48% of new diagnoses yet only 21% of PrEP users within the region.³

There are significant barriers to PrEP awareness and uptake for Black women at the individual, provider, and system level. Challenges include unawareness of PrEP or limited PrEP knowledge, inaccurate self-perception of HIV risk, low comfort level discussing sexual health, and ineffective PrEP marketing campaigns and advertisements for engaging women.^{4

–13} Provider-level barriers are critical to understand because bias in PrEP prescription has contributed to the minimal implementation of PrEP for certain populations, particularly women of color.^14
–16 A lack of education/training on PrEP has been reported by providers who are often asked about PrEP by their clients rather than initiating conversations themselves.^7,17

–20

By contrast, provider knowledge of PrEP is correlated with higher rates of PrEP prescription, as well as future intent/willingness to prescribe PrEP.^21,22 Key facilitators to PrEP access and uptake among Black women include delivering comprehensive PrEP education and centering women's experiences and needs in the context of structural and social interventions that have typically been designed for men who have sex with men (MSM) or the lesbian, gay, bisexual, transgender, queer, and or questioning (LGBTQ+) community.^{4,23

–28}

Understanding how to adapt existing materials and processes used for PrEP from both providers' and women's perspectives is crucial to improve PrEP use among Black women.²⁷ Our team has designed a set of five evidence-based, women-focused implementation strategies known as “POWER Up” (PrEP Optimization among Women to Enhance Retention and Uptake) that is being implemented at health care centers in the Midwest and South to increase PrEP use among Black women: (1) client education, (2) provider training, (3) electronic medical record optimization, (4) PrEP navigation, and (5) clinical champions.²⁹ As part of our preimplementation work, we aimed to ascertain providers' and Black women's awareness/thoughts on PrEP and potential local and contextual factors that could inform the adaptation and implementation of strategies for engaging Black women in the PrEP care continuum.

Through this study, we primarily sought to learn how existing training and education processes can be adapted to better address race- and sex-based gaps within PrEP service delivery for Black women.

Methods

Study design

We conducted a content analysis qualitative study via focus groups with providers and Black women at the following three health care organizations: one in the Midwest [Illinois (IL)] and two in the South [Florida (FL) and North Carolina (NC)]. The organizations range in number of individual health care centers, number of clients served, and familiarity with PrEP and available PrEP services. However, all three health care organizations are federally qualified health centers (FQHCs) and are used mostly for primary care by clients.

Providers were eligible to participate in the focus groups if they (1) had the ability to prescribe PrEP, (2) were at least 18 years of age, (3) were currently employed either full-time or part-time at one of the health care organizations, and (4) could speak and understand English. Women were eligible to participate if they (1) identified as Black/African American, (2) identified as cisgender women and female, (3) were at least 18 years of age, (4) currently received care at one of the organizations, and (5) could speak and understand English. Previous PrEP awareness/use was not included as a criterion; most women were PrEP-naive.

Potential participants were recruited using convenience sampling through text messages, emails, phone calls, and flyers posted throughout the health care centers. In addition, researchers conducted in-person recruitment and approached potential participants in the waiting area of health care centers to distribute recruitment flyers and inform women about the study. All participants were screened for eligibility by two members of the research team. Ultimately, 10 providers and 25 women verbally consented and were enrolled into the study. Participants were offered $50 for completion of the focus group. This study was approved by the Institutional Review Board at the University of Chicago (IRB21-0971).

Research team and reflexivity

Focus groups were facilitated by either a research coordinator (MS degree, cisgender woman, Black/African American) or an associate research professor (PhD and MSW degrees, cisgender woman, White). Field notes were taken during and after the focus groups by another research coordinator (MS degree, cisgender woman, Hispanic/Latina White). All three researchers were female and had extensive experience in qualitative research, including studies focused on sexual health and PrEP use in women. Before study commencement, researchers established a relationship with a select group of providers at each health care organization for the purpose of study recruitment and implementation. Researchers reported their interest in improving PrEP accessibility, awareness, and use among Black women to all study participants before screening for eligibility and enrolling them in the study. No one other than the research team and the participants were present during the focus groups. No repeat focus groups were conducted.

Focus groups occurred either in person within a private room at a health care center or remotely over a secure instance of Zoom from August 2022 to February 2023. Focus groups lasted 45–60 min and were audio-recorded and professionally transcribed. Transcripts were not returned to participants for comment and/or correction. However, participants' responses were summarized and repeated back to them for feedback and clarity during the focus groups.

Analysis and findings

Semistructured focus group discussion guides were developed for providers and women, respectively, using the Consolidated Framework for Implementation Research (CFIR).³⁰ Providers were asked about their knowledge about PrEP, factors that influence their decision-making regarding discussing PrEP with women and prescribing PrEP, their health care center's existing processes for identifying women who could benefit from PrEP and linking them to care, and how contextual factors may influence potential implementation strategies for increasing PrEP awareness and uptake among Black women. Women were asked about their knowledge and thoughts on PrEP, experiences of how providers approach topics of sexual health and PrEP at their health care center, and recommendations for how to better reach Black women so that they are informed about PrEP. In addition, participants were presented with existing PrEP educational materials and asked for their thoughts on how to improve PrEP awareness, access, and uptake among Black women.

Transcripts were analyzed using a combined functional and thematic approach. Functionally, transcripts were analyzed using a form of rapid qualitative analysis, the Stanford Lightning Report Method (SLRM),³¹ via Dedoose software, an online qualitative research software.³² The SLRM applies the analytic structure of Plus (“what works”), Delta (“what needs to be changed”), and Insights (participant or evaluator insights, ideas, and recommendations) to dynamic implementation evaluation. For thematic analysis, three coders used structured coding and developed a preliminary codebook based on implementation science barriers and facilitators outlined in the CFIR, with distinct definitions for each code.

There are five CFIR domains: “Intervention” (aspects of an intervention that may affect implementation success, such as relative advantage, adaptability, complexity, and cost); “Outer Setting” (the setting in which the Inner Setting exists, including external pressure, local attitudes, and policies and laws); “Inner Setting” (the setting in which the Intervention is implemented); “Individual” (the roles applicable to the project and their location in the Inner or Outer Setting); and “Process” (the stages of implementation and the activities and strategies used to implement the Intervention).³⁰ The preliminary codes were reviewed and revised by all coders (n = 3). The primary coder applied the codebook to five transcripts, and a secondary coder coded a subset of excerpts selected at random using the Dedoose test feature and achieved reliability at >0.80.

Most divergences occurred due to omission and upon review were quickly rectified to 100% agreement. The primary coder then applied codes to all 13 transcripts, which were reviewed by the two secondary coders for consensus.

Data saturation was determined when there was a high prevalence of codes applied to distinct themes and no emergence of new themes. Major and minor themes were derived based on clustering of code application on Dedoose. Quotations were selected to illustrate the themes/findings, which were presented to the research team for consensus. Each quotation was identified by participant (provider vs. woman), location of focus group (Illinois = IL, North Carolina = NC, or Florida = FL), and number of provider or women focus groups conducted within the specific location (from #1 up to #4).

Results

Sample characteristics

We completed four focus groups with providers (n = 10) and nine focus groups with Black women (n = 25) (Table 1). Among providers, half (50%) were non-Hispanic White and half (50%) were non-Hispanic Black. The majority of providers (90%) were cisgender female. There was equal representation from the Midwest and South among providers. Almost half (48%) of the women participants received care in NC, and the majority identified as non-Hispanic/Latina (76%).

Table 1.

Participant Demographics (n = 35)

	Providers (n = 10) n (%)	Women (n = 25) n (%)	Total (N = 35) n (%)
Geographic location
Florida (FL)	3 (30)	12 (48)	15 (43)
North Carolina (NC)	2 (20)	9 (36)	11 (31)
Illinois (IL)	5 (50)	4 (16)	9 (26)
Race^a
Black/African American	5 (50)	25 (100)	30 (86)
White	5 (50)	0 (0)	5 (14)
Gender^b
Cisgender female	9 (90)	25 (100)	34 (97)
Nonbinary/queer	1 (10)	0 (0)	1 (3)
Ethnicity
Hispanic/Latino	0 (0)	1 (4)	1 (3)
Not Hispanic/Latino	10 (100)	19 (76)	29 (83)
Unknown/undetermined	0 (0)	5 (20)	5 (14)

Black/African American, White, Asian/Asian American/Pacific Islander, Middle Eastern/Arab American, Native American/American Indian/Alaska Native/Indigenous, and other.

Cisgender female, cisgender male, transgender female, transgender male, nonbinary/queer, and other.

Themes and insights

Theme #1: Within this theme, we found that providers expressed low comfort level and limited cultural sensitivity/competency discussing HIV risk and PrEP with Black women. However, among women, we found a willingness to engage with providers around PrEP.

Providers at all sites, particularly those who were not themselves Black/African American, described feeling uncomfortable discussing HIV prevention with Black women.

“I am a White provider, and so that could be challenging at times, because I have had patients who – when I've even just mentioned screening them for HIV that they felt like, because of their race and presentation that I chose to target them.” (Provider, NC, #1)

When deciding whether to discuss PrEP with a Black woman in particular, providers reported concerns of potentially offending them.

“What's been challenging for me, for…approaching Black cisgendered women is…how to bring it [PrEP] up…to help patients assess their risk on their own, and also let them know that their risk actually may be higher than they are assessing themselves to be without offending them.” (Provider, IL, #2)

Although the majority of providers reported low comfort level discussing PrEP, nearly every Black woman participant expressed willingness to talk about PrEP and believed “if physicians were introducing it all the time, they'd [physicians] be more comfortable too” (Woman, NC, #1).

“I actually would want my doctor to bring this [PrEP] up…I feel like this is a conversation that needs to be had…because even if it doesn't affect you personally…you can always spread that information. But if you don't know, you [are unaware that] any of these resources [PrEP] are available for you.” (Woman, NC, #2)

Women offered suggestions (insights) for how providers can improve PrEP engagement with Black women at their health care centers. Participants emphasized, “it's all about how you explain it” (Woman, NC, #4). They also stressed the importance of “bedside manner” (Woman, NC, #1), which includes using a “personable approach” (Woman, NC, #4), “building the level of trust being upfront…by giving it straight” (Woman, NC, #1), and avoiding risk-based language in the context of PrEP because “when you say ‘high risk,’ they're [women] going to get on the defense” (Woman, NC, #1).

Further, the majority of Black women participants advised framing PrEP as “a preventive measure along with birth control” (Woman, NC, #4) and “when they're [providers] going through all those STD infections…when you talk about preventative care or things of that nature…[PrEP] should definitely be part of that conversation because knowledge is power” (Woman, NC, #2).

“I think it [PrEP] should be brought up with reproductive conversations, like birth control…it'll stick with some people and they will tell others and that's how that thing works. So, I think it's a place for it. You can't be talking about a colonoscopy and then PrEP, it doesn't make sense. But if we're talking about keeping yourself safe, condoms, birth control, STIs, and stuff like that, I think it [PrEP] should be slid in there every time.” (Woman, NC, #4)

Providers also recognized the need to normalize PrEP among Black women and to “start a conversation even when a patient doesn't appear to be especially high risk that lets them know this [PrEP] is something available for them” (Provider, IL, #1).

“It is important to bring up PrEP when people come in asking for it or when they come in with an STI. But it's also important to normalize PrEP for…cishetero Black women as a preventive tool in their toolbox just like we talk to people about birth control and condoms all the time.” (Provider, IL, #1)

Among providers, several ideas (insights) emerged regarding provider communication for improving PrEP engagement among Black women. Participants highlighted the need for “better ways to phrase it [PrEP as an option for HIV prevention]…because that's what's going to build that bridge to help get people the access and continuity of care” (Provider, NC, #1). One provider suggested having a “script that is culturally sensitive and appropriate” (Provider, IL, #2). Women echoed the importance of establishing trust with their providers.

“In order to build that relationship with your doctor, you have to let that doctor know what is going on. Even if you don't want them in your business, it's kind of their business to be in your business.” (Woman, FL, #3)

In addition, providers advocated for including role-playing within PrEP trainings to practice discussing HIV risk and PrEP with Black women, which “would probably be uncomfortable but helpful” (Provider, IL, #1) because “culture plays a big role in patient compliance.” (Provider, FL, #1).

“They [Black women] don't recognize themselves as being at risk for HIV…And I think having a case like that [situation for discussing HIV risk and PrEP with a woman] is a good way to role play those different scenarios.” (Provider, FL, #1).

Insights for Theme 1: PrEP training for providers could benefit from role-playing to build trust with Black women and case scenarios to help develop the skills/language needed to initiate these conversations. Resources such as a culturally informed script could help to improve providers' comfort level discussing HIV risk and PrEP with Black women, who want to hear about PrEP from their providers (CFIR domains: Intervention Characteristics; Process; Individual; Inner Setting).

Theme #2: Within this theme, we identified multiple concerns about women regarding PrEP, including its side-effects and safety during pregnancy. A minor theme of general medical mistrust and specific misconceptions about PrEP underlined and, in some cases, amplified these concerns, especially among women in the South. Among providers, we found a recognition of the need to be equipped to address these concerns adequately.

As part of shared decision-making regarding PrEP, women expressed they would be concerned about taking PrEP, with one woman asking, “Can I die from this medication? Will it make me have blood clots? Will it shut my lungs down?” (Woman, NC, #1). Another woman specifically worried about renal function “because everything [medication] tears up your kidneys” (Woman, NC, #2). In general, most women reported that they would “need to know the side effects and how it [PrEP] affects you” (Woman, NC, #4).

“If you're going to recommend that [PrEP], then I need a little bit more data at that point because now I need to know what are the side effects, what studies have been done…I just need a little bit more information before I ingest something like that…How is it going to affect me? How is it going to affect my body, my menstrual, all of those things? Is it going to affect me?” (Woman, NC, #2)

Many women had particular concerns related to PrEP and pregnancy, wondering if it could “affect your hormone imbalance or…inside of your body as a woman” (Woman, NC, #2). A few women specifically expressed doubt in the safety and efficacy of PrEP during pregnancy.

“I'm pregnant, like what do I do when I take that medication, and what if it has a side effect and it does something to my baby?…Now you make it scary for us because we don't know what the side effects will be, that it could possibly give us some type of gene or something [that causes HIV]. And then we end up with HIV, or it might protect us from getting it, but then how do we know [PrEP is preventing HIV], because we're not messing with anyone that has it [HIV]?…And how do I know if I take it [PrEP], it protects me but it won't harm my baby?” (Woman, FL, #3)

The concerns related to PrEP in pregnant women led to a bigger discussion among Black women regarding medical mistrust. One woman noted “what makes us resistant as a people [Black/African American people] to meds is distrust of the system as a whole because of the times when we've been used as lab rats” (Woman, NC, #1). Another participant echoed this sentiment and expressed needing “more information on what they [physicians] try to sell me or put inside me” (Woman, FL, #1). In addition, women had specific misconceptions about PrEP and wondered, “If I take this pill, is it going to put something [HIV] in me?” (Woman, FL, #3).

“Because people really don't know what it is, and I want to know how they know if that's [PrEP] 100% accurate to get involved with somebody with HIV while you taking it, like what's really your chance [of getting HIV]?” (Woman, FL, #3)

Providers acknowledged the importance of knowing accurate information regarding not only “the side effects to expect but also how to deal with it” (Provider, IL, #2) so that they can help support women.

“I definitely think that we are often faced with questions about the side effects. So, I think it is helpful for not just the training of like, what do you do when a patient reports something, but also make you realize, like maybe going over the side effects in office during that visit will be beneficial, because that way the patient can kind of already anticipate what the plan might be in the event that X were to happen, especially since nausea and loss of appetite are very common amongst the PrEP medications.” (Provider, NC, #1)

Providers also recognized the need for having reliable and trustworthy information regarding PrEP and educating Black women about PrEP.

“I think, at least in my experience, there is a thought that PrEP is…only for LGBTQ individuals. So, I think just educating that it [PrEP] is not [only for the LGBTQ+ community], and anyone engaging in high risk kind of sexual behavior can benefit from that medication…is a really big piece [of increasing awareness and use of PrEP among Black women].” (Provider, NC, #1)

Providers and Black women alike offered recommendations (insights) for how to address these misconceptions about PrEP so that women are properly informed. Women emphasized the need for “some accountable website, some source of true information” (Woman, NC, #1) because they “want to know ‘down to the T’ what is this going to do to me? What is this going to do to my body? What is this going to do to my children? How is this harmful? How is this helpful?” (Woman, FL, #3).

Women also recognized the importance of PrEP commercials and printed materials at local health care centers to address their concerns, dispel any potential misconceptions, and aid in their decision-making regarding PrEP.

“That's where you push out the pamphlets, and you push out commercials, you give out paperwork, of course. And, just make [Black women] more aware.” (Woman, FL, #3)

Insights for Theme 2: Topics for PrEP training for providers should include accurate and detailed information regarding potential side-effects of PrEP and management of side effects. In addition, safety of PrEP for pregnant women and common misconceptions about PrEP should be reviewed, with recommendations for how to address medical mistrust reported by Black women. These topics should also be included in PrEP educational materials and online resources so that they are more pertinent to Black women (CFIR domains: Intervention Characteristics; Individual; Outer Setting; Process).

Theme 3: Within this theme, we found that providers and women alike recognized the lack of Black women representation in both mainstream PrEP advertisements and in resources within their health care centers.

Participants highlighted the fact that Black women are often absent from PrEP commercials and large campaign efforts, noting that these programs/advertisements have “always been [targeted] towards men or towards the LGBTQ community.” (Woman, NC, #2).

“[PrEP] commercials [have been] geared towards homosexual Black men or Hispanics…but not a Black woman per se…I think we are overlooked as Black women for a lot of things…we're slighted all the time.” (Woman, NC, #1)

When offering suggestions (insights) for how to increase awareness and interest in PrEP among Black women, participants emphasized that they need to see themselves in commercials and on pamphlets to feel like PrEP is an option for them because “when our face isn't there, we don't know it's for us or about us.” (Woman, NC, #1) and that “advertising will get a woman's attention quicker than anything” (Woman, NC, #4).

“You got to have some female in it [a commercial about PrEP] for other females [to] relate to what you want us to do because they're going to think that's [PrEP]…for just men or…[transgender] women. So, ain't no women going to know that this is also for them if they don't invite us to let us know that it's for us as well.” (Woman, FL, #1)

In addition to women, providers also commented on the lack of Black women representation in PrEP advertisements and educational materials at their own health care centers. Providers ranged from being unaware of any materials regarding PrEP at their health care center to having “printed information…that [is] geared more towards men who have sex with men” (Provider, IL, #2). In response to recognizing the target population of typical PrEP educational materials, providers recommended having access to “some less gendered, less targeted information that's easily available…so that it could be more generalizable” (Provider, IL, #2).

“Sometimes I'll go on Google and just like print out PrEP patient information, like just a general packet. And I will give that to a patient that doesn't fit in that specific MSM population but who could still benefit from PrEP, just because I don't want them to see that pamphlet [that is geared toward MSM] and feel like, ‘This isn't for me.’” (Provider, IL, #2)

Insights for Theme 3: To increase awareness, perceived relevance/appropriateness, and interest in PrEP, there needs to be adequate representation of Black women in commercials and advertisements. In addition, health care centers should have PrEP pamphlets and other available resources that are designed specifically to include images and stories/experiences of Black women (CFIR domains: Intervention Characteristics; Inner Setting; Outer Setting; Process).

Discussion

In our study of providers and Black women at three health care organizations in the midwestern and southern United States, there were several common themes regarding perceived barriers to PrEP awareness and uptake among Black women. Providers expressed difficulty initiating conversations about PrEP with Black women and prescribing PrEP, which has been seen in other studies.^33

–36 In contrast, the majority of Black women in our study were unaware of PrEP but reported they would prefer to learn about PrEP from their health care providers. Women in other studies have also emphasized the importance of support and tailored guidance from their health care providers, viewing them as their preferred source of PrEP information and the best person to deliver PrEP to women,²⁶ as well as being more likely to take PrEP if their provider recommended it.³⁷

In addition to providers' limited cultural competency and willingness to discuss PrEP with women, Black women also reported concerns and misconceptions about PrEP that may limit its uptake among this population. The women in our study expressed concerns about the safety of PrEP during pregnancy, which has been reported elsewhere.^4,7,38,39 Despite research demonstrating the safety and efficacy of PrEP for both pregnant women and their fetuses,^40

–44 there still remains a gap in PrEP education in which providers can help women make informed decisions about PrEP by establishing trust and integrating PrEP counseling into standard sexual/reproductive health practices.⁷ In addition, the majority of our participants, particularly the women in NC and FL, reported misconceptions about PrEP (e.g., PrEP can give a person HIV; PrEP is only for men or the LGBTQ+ community) and expressed high levels of medical mistrust.

These barriers to PrEP uptake and HIV care adherence among Black women—including distrust of the medical system,^39,45,46 low PrEP awareness,^{4,12,47
–49} low PrEP knowledge, and high levels of misconceptions/stigma toward PrEP^{8,23,24,27,50

–54}—have been widely reported. Other studies have found a high level of PrEP unawareness in the southern United States,^55,56 which may result from deep-rooted and pervasive HIV-related stigma within the region and limited HIV testing and prevention services.⁵⁷ These misconceptions may also stem from traditional marketing campaigns and advertisements for PrEP, which primarily target the MSM and the LGBTQ+ community rather than Black women or heterosexual individuals.⁴ Our findings highlight the need for women-centered information on PrEP within broader educational campaigns that address common concerns and misconceptions.^55,58

Providers and women alike highlighted the lack of Black women representation in both mainstream PrEP advertisements and PrEP educational pamphlets at their local health care centers. The women expressed feeling a disconnect from current PrEP campaigns, and providers reported how it negatively affected their ability to inform Black women about PrEP. The absence of Black women representation in PrEP communication and the inconsistent messaging in PrEP marking campaigns have been noted in other studies as well and can hamper Black women's acceptability and uptake of PrEP.^4,7,23,50,59 Increasing PrEP advertisement among women using various modes of delivery (e.g., leveraging existing social organizations or utilizing social media platforms) and in places where women seek health and reproductive care (e.g., gynecologists' offices), while simultaneously framing it as an empowering and safe HIV prevention option, may help to optimize PrEP implementation and uptake among women.^4,39,50

To better address the concerns and needs of Black women regarding PrEP, trainings for providers and educational/advertising processes must be adapted. We propose that a provider training for PrEP should include the following two sessions: (1) a didactic session, with topics including potential side effects and management of side effects, safety during pregnancy, and common misconceptions regarding PrEP; and (2) an interactive session, with role-playing to address medical mistrust and to engender rapport with Black women and case scenarios to help providers develop the competency/skills to initiate conversations about PrEP with Black women. In addition to a two-part training series, ongoing support and resources for providers (e.g., a culturally informed script with empowering language rather than risk-based language for discussing PrEP and HIV prevention) should be available at local health care centers for engaging Black women in the PrEP care continuum.

In addition, PrEP campaign efforts, commercials, and other advertisements should include accurate information regarding PrEP and images/stories of Black women. Similarly, we propose that local health care centers design their PrEP brochures and educational resources with Black women in mind. As part of the POWER Up study, we have utilized these findings to inform the implementation of provider training sessions and the use of relevant, woman-focused pamphlets to support PrEP education at each participating site. We expect that this type of comprehensive approach to PrEP marketing, provider training, and PrEP education/counseling will contribute to increased awareness and uptake of PrEP among Black women at the participating health care organizations.

This study has a few limitations to acknowledge. First, we recruited participants at FQHCs, and so, our findings are likely biased toward those who seek regular care at these organizations and may not reflect the perspectives of women who are less engaged in the health care system (e.g., young women with no health problems, women who are unstably housed, or do not have insurance/access to health care). Second, we compared the results based on geographic region (i.e., Midwest vs. South); however, there were only three health care organizations involved in the study and may not accurately represent their given state/region or account for state-by-state differences. For that reason, we limited the geographic comparisons to those themes that had clear distinctions based on participants from IL vs. those from FL and NC.

Similarly, as stated previously, each health care organization differs in its availability of PrEP services and staff who specifically help clients with PrEP initiation and persistence, as well as the number of clients who are taking PrEP at a given time, which could explain some of the variances between sites. As such, these findings may not be transferable to rural or smaller health care organizations. Lastly, various sources of inevitable bias associated with qualitative research (e.g., by facilitators during focus groups or by coders during the analysis process) may have affected study findings. However, we established inter-rater reliability and ensured consensus on code application and theme elicitation to mitigate the potential effects of bias.

To increase awareness, accessibility, understanding, and utilization of PrEP among Black women, current approaches for PrEP implementation must be adapted for this specific population. Providers should receive PrEP training in which they receive accurate and comprehensive information regarding PrEP, with considerations for women, and in which they can practice role-playing to enhance their comfort level discussing PrEP and sexual health with Black women. Future PrEP commercials and campaign efforts, as well as educational resources and brochures used at local health care centers, should ensure that Black women are adequately represented.

Footnotes

Acknowledgments

We would like to thank the women for their time and willingness to share their experiences and insights with us. We would also like to acknowledge our coinvestigators and community partners involved in the POWER Up study, particularly the three participating health care organizations. Lastly, we would like to thank the six members serving on the expert advisory board for the POWER Up study.

Authors' Contributions

S.A.D.: methodology, validation, formal analysis, investigation, writing—original draft, and project administration. J.P.R.: conceptualization, methodology, resources, writing—reviewing and editing, supervision, project administration, and funding acquisition. A.D.: validation, formal analysis, investigation, and writing—reviewing and editing. O.E.E.: methodology and investigation. G.L.: writing—reviewing and editing. N.K.: writing—reviewing and editing. M.P.: methodology and writing—reviewing and editing. L.R.H.: methodology and writing—reviewing and editing. J.S.: methodology, writing—reviewing and editing, and project administration. S.H.: methodology. K.D.: writing—reviewing and editing. A.K.J.: conceptualization, methodology, validation, formal analysis, investigation, resources, writing—reviewing and editing, project administration, and funding acquisition. All the authors have approved and read the final version of the article.

Author Disclosure Statement

J.P.R. has received consulting fees from Gilead Sciences.

Funding Information

This study was supported by the National Institutes of Health (1R01MH128051-01). G.L. was supported by a grant from the ANRS | Emerging Infectious Diseases for this work.

References

Diagnoses of HIV Infection in the United States and Dependent Areas, 2021. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention: Atlanta, GA; 2023.

HIV and Women: HIV Diagnoses. Centers for Disease Control and Prevention. 2022. Available from: https://www.cdc.gov/hiv/group/gender/women/diagnoses.html [Last accessed: June 26, 2023 ].

AIDSVu Releases New Data Highlighting Ongoing Inequities in PrEP Use among Black and Hispanic People and across Regions of the Country. AIDSVu. Available from: https://aidsvu.org/aidsvu-releases-new-data-highlighting-ongoing-inequities-in-prep-use-among-black-and-hispanic-people-and-across-regions-of-the-county/#:∼:text=Data%20on%20AIDSVu%20show%20significant,18%25%20of%20new%20HIV%20diagnoses [Last accessed: June 26, 2023 ].

Hirschhorn

, Brown

, Friedman

, et al. Black cisgender women's PrEP knowledge, attitudes, preferences, and experience in Chicago. J Acquir Immune Defic Syndr, 2020; 84(5):497–507.

Agovi

, Anikpo

, Cvitanovich

, et al. Knowledge needs for implementing HIV pre-exposure prophylaxis among primary care providers in a safety-net health system. Prev Med Rep, 2020; 20:101266.

Bond

, Gunn

, Williams

, et al. Using an intersectional framework to understand the challenges of adopting pre-exposure prophylaxis (PrEP) among young adult black women. Sexual Res Soc Policy, 2022; 19(1):180–193.

Pyra

, Johnson

, Devlin

, et al. HIV pre-exposure prophylaxis use and persistence among black ciswomen: “Women need to protect themselves, period”. J Racial Ethn Health Disparities, 2022; 9(3):820–829.

Bond

, Gunn

. Perceived advantages and disadvantages of using pre-exposure prophylaxis (PrEP) among sexually active black women: An exploratory study. J Black Sex Relatsh, 2016; 3(1):1–24.

Nydegger

, Dickson-Gomez

, Ko

. Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: A qualitative exploration. Cult Health Sexual, 2021; 23(5):659–673.

10.

Sales

, Sheth

. Associations among perceived HIV risk, behavioral risk and interest in PrEP among black women in the southern US. AIDS Behav, 2019; 23(7):1871–1876.

11.

Johnson

, Pyra

, Devlin

, et al. Provider perspectives on factors affecting the PrEP care continuum among black cisgender women in the Midwest United States: Applying the consolidated framework for implementation research. J Acquir Immune Defic Syndr, 2022; 90(S1):S141–s148.

12.

Johnson

, Fletcher

, Ott

, et al. Awareness and intent to use pre-exposure prophylaxis (PrEP) among African American women in a family planning clinic. J Racial Ethn Health Disparities, 2020; 7(3):550–554.

13.

Craddock

, Mangum

, Aidoo-Frimpong

, et al. The associations of HIV pre-exposure prophylaxis interest and sexual risk behaviors among young black women. AIDS Patient Care STDS, 2021; 35(7):263–270.

14.

Adams

, Balderson

. HIV providers' likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: A short report. AIDS Care, 2016; 28(9):1154–1158.

15.

Kimmel

, Messersmith

, Bazzi

, et al. Implementation of HIV pre-exposure prophylaxis for women of color: Perspectives from healthcare providers and staff from three clinical settings. J HIV AIDS Soc Serv, 2021; 19(4):299–319.

16.

Pearson

, Chandler

, McCreary

, et al. Perceptions of African American women and health care professionals related to pre-exposure prophylaxis to prevent HIV. J Obstet Gynecol Neonatal Nurs, 2020; 49(6):571–580.

17.

Goparaju

, Praschan

, Warren-Jeanpiere

, et al. Stigma, partners, providers and costs: Potential barriers to PrEP uptake among US Women. J AIDS Clin Res, 2017; 8(9):730.

18.

Calabrese

, Krakower

, Mayer

. Integrating HIV preexposure prophylaxis (PrEP) into routine preventive health care to avoid exacerbating disparities. Am J Public Health, 2017; 107(12):1883–1889.

19.

Ojikutu

, Mayer

. Hidden in plain sight: identifying women living in the United States who could benefit from HIV preexposure prophylaxis. J Infect Dis, 2020; 222(9):1428–1431.

20.

Sell

, Chen

, Huber

, et al. Primary care provider HIV PrEP knowledge, attitudes, and prescribing habits: A cross-sectional survey of late adopters in rural and suburban practice. J Prim Care Community Health, 2023; 14:21501319221147254.

21.

Krakower

, Ware

, Mitty

, et al. HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: A qualitative study. AIDS Behav, 2014; 18(9):1712–1721.

22.

Blumenthal

, Jain

, Krakower

, et al. Knowledge is power! increased provider knowledge scores regarding pre-exposure prophylaxis (PrEP) are associated with higher rates of PrEP prescription and future intent to prescribe PrEP. AIDS Behav, 2015; 19(5):802–810.

23.

Chandler

, Hull

, Ross

, et al. The pre-exposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women. BMC Public Health, 2020; 20(1):1172.

24.

Ojikutu

, Mayer

. HIV prevention among black women in the US-time for multimodal integrated strategies. JAMA Netw Open, 2021; 4(4):e215356.

25.

Cernasev

, Walker

, Armstrong

, et al. Changing the PrEP narrative: A call to action to increase PrEP uptake among women. Women, 2021; 1(2):120–127.

26.

Auerbach

, Kinsky

, Brown

, et al. Knowledge, attitudes, and likelihood of pre-exposure prophylaxis (PrEP) use among US women at risk of acquiring HIV. AIDS Patient Care STDS, 2015; 29(2):102–110.

27.

Chandler

, Guillaume

, Wells

, et al. Let me prep you to PREP me: amplifying the voices of black women and their providers to consider PrEP as an HIV prevention option. Int J Environ Res Public Health, 2022; 19(3):1414.

28.

Blumenthal

, Landovitz

, Jain

, et al. Pre-exposure prophylaxis perspectives, sociodemographic characteristics, and HIV risk profiles of cisgender women seeking and initiating PrEP in a US demonstration project. AIDS Patient Care STDS, 2021; 35(12):481–487.

29.

Ridgway

, Devlin

, Friedman

, et al. POWER Up—Improving pre-exposure prophylaxis (PrEP) uptake among Black cisgender women in the Southern United States: Protocol for a stepped-wedge cluster randomized trial (SW-CRT). PLoS One, 2023; 18(5):e0285858.

30.

Safaeinili

, Brown-Johnson

, Shaw

, et al. CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learn Health Syst, 2020; 4(1):e10201.

31.

Brown-Johnson

, Safaeinili

, Zionts

, et al. The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations. Learn Health Syst, 2020; 4(2):e10210.

32.

Dedoose Version 8.0.35, web application for managing, analyzing, and presenting qualitative and mixed method research data [computer program]. Los Angeles, CA 2021.

33.

Pina

, Taggart

, Sanchez Acosta

, et al. Provider comfort with prescribing HIV pre-exposure prophylaxis to adolescents. AIDS Patient Care STDS, 2021; 35(10):411–417.

34.

Petroll

, Walsh

, Owczarzak

, et al. PrEP awareness, familiarity, comfort, and prescribing experience among US primary care providers and HIV specialists. AIDS Behav, 2017; 21(5):1256–1267.

35.

Jones

, deCastro

, August

, et al. Pre-exposure prophylaxis (PrEP) awareness and prescribing behaviors among primary care providers: DocStyles survey, 2016–2020, United States. AIDS Behav, 2021; 25(4):1267–1275.

36.

Storholm

, Ober

, Mizel

, et al. Primary care providers' knowledge, attitudes, and beliefs about HIV pre-exposure prophylaxis (PrEP): Informing network-based interventions. AIDS Educ Prev, 2021; 33(4):325–344.

37.

Jackson

, Darlington

, Van Tieu

, et al. Women's views on communication with health care providers about pre-exposure prophylaxis (PrEP) for HIV prevention. Cult Health Sexual, 2022; 24(5):642–656.

38.

Joseph Davey

, Daniels

, Beard

, et al. Healthcare provider knowledge and attitudes about pre-exposure prophylaxis (PrEP) in pregnancy in Cape Town, South Africa. AIDS Care, 2020; 32(10):1290–1294.

39.

Pasipanodya

, Stockman

, Phuntsog

, et al. “PrEP”ing for a PrEP demonstration project: Understanding PrEP knowledge and attitudes among cisgender women. BMC Womens Health, 2021; 21(1):220.

40.

Mugo

, Hong

, Celum

, et al. Pregnancy incidence and outcomes among women receiving preexposure prophylaxis for HIV prevention: A randomized clinical trial. JAMA, 2014; 312(4):362–371.

41.

Joseph Davey

, Pintye

, Baeten

, et al. Emerging evidence from a systematic review of safety of pre-exposure prophylaxis for pregnant and postpartum women: Where are we now and where are we heading?. J Int AIDS Soc, 2020; 23(1):e25426.

42.

Nachega

, Uthman

, Mofenson

, et al. Safety of tenofovir disoproxil fumarate-based antiretroviral therapy regimens in pregnancy for HIV-infected women and their infants: A systematic review and meta-analysis. J Acquir Immune Defic Syndr, 2017; 76(1):1–12.

43.

Mofenson

, Baggaley

, Mameletzis

. Tenofovir disoproxil fumarate safety for women and their infants during pregnancy and breastfeeding. AIDS, 2017; 31(2):213–232.

44.

Moodley

, Lombard

, Govender

, et al. Pregnancy and neonatal safety outcomes of timing of initiation of daily oral tenofovir disoproxil fumarate and emtricitabine pre-exposure prophylaxis for HIV prevention (CAP016): An open-label, randomised, non-inferiority trial. Lancet HIV, 2023; 10(3):e154–e163.

45.

Tekeste

, Hull

, Dovidio

, et al. Differences in medical mistrust between black and white women: Implications for patient-provider communication about PrEP. AIDS Behav, 2019; 23(7):1737–1748.

46.

Saha

, Jacobs

, Moore

, et al. Trust in physicians and racial disparities in HIV care. AIDS Patient Care STDS, 2010; 24(7):415–420.

47.

Hill

, Lightfoot

, Riggins

, et al. Awareness of and attitudes toward pre-exposure prophylaxis among African American women living in low-income neighborhoods in a Southeastern city. AIDS Care, 2021; 33(2):239–243.

48.

Nydegger

, Dickson-Gomez

, Ko Ko

. A longitudinal, qualitative exploration of perceived HIV risk, healthcare experiences, and social support as facilitators and barriers to PrEP adoption among black women. AIDS Behav, 2021; 25(2):582–591.

49.

Raifman

, Schwartz

, Sosnowy

, et al. Brief report: Pre-exposure prophylaxis awareness and use among cisgender women at a sexually transmitted disease clinic. J Acquir Immune Defic Syndr, 2019; 80(1):36–39.

50.

Hill

, Patel

, Haughton

, et al. Leveraging social media to explore black women's perspectives on HIV pre-exposure prophylaxis. J Assoc Nurses AIDS Care, 2018; 29(1):107–114.

51.

Pleuhs

, Quinn

, Walsh

, et al. Health care provider barriers to HIV pre-exposure prophylaxis in the United States: A systematic review. AIDS Patient Care STDS, 2020; 34(3):111–123.

52.

Dale

. Using motivational interviewing to increase PrEP uptake among black women at risk for HIV: An open pilot trial of MI-PrEP. J Racial Ethn Health Disparities, 2020; 7(5):913–927.

53.

Flash

, Stone

, Mitty

, et al. Perspectives on HIV prevention among urban black women: A potential role for HIV pre-exposure prophylaxis. AIDS Patient Care STDS, 2014; 28(12):635–642.

54.

Chapman Lambert

, Marrazzo

, Amico

, et al. PrEParing women to prevent HIV: An integrated theoretical framework to PrEP black women in the United States. J Assoc Nurses AIDS Care, 2018; 29(6):835–848.

55.

Mayer

, Agwu

, Malebranche

. Barriers to the wider use of pre-exposure prophylaxis in the United States: A narrative review. Adv Ther, 2020; 37(5):1778–1811.

56.

Patel

, Goparaju

, Sales

, et al. Brief report: PrEP eligibility among at-risk women in the Southern United States: Associated factors, awareness, and acceptability. J Acquir Immune Defic Syndr, 2019; 80(5):527–532.

57.

Reif

, Wilson

, McAllastter

. Percptions and impact of HIV stigma among high risk populations in the US deep south. J HIV AIDS, 2018; 4(2); doi: 10.16966/2380-5536.154.

58.

#ShesWell: PrEP for Women. 2022. Available from: https://www.cdc.gov/stophivtogether/sheiswell/index.html [Last accessed: June 30, 2023 ].

59.

Ridgway

, Almirol

, Schmitt

, et al. Exploring gender differences in PrEP interest among individuals testing HIV negative in an urban emergency department. AIDS Educ Prev, 2018; 30(5):382–392.