Community Health Care Providers' Perspectives on Human Immunodeficiency Virus Pre-Exposure Prophylaxis Use Among Black Women in Eastern Virginia

Abstract

The most at-risk population among women for human immunodeficiency virus (HIV) diagnosis in the United States are Black women, accounting for 61% of all new HIV cases. Pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for people at risk of HIV acquisition. Although disproportionately affected by HIV, Black women's knowledge, perceived benefits, and uptake of PrEP remain low. The socioecological model (SEM) may be useful for understanding why there is a low uptake of PrEP among Black women. The current study used the SEM to explore provider perspectives on the barriers and facilitators of PrEP uptake among Black women in Eastern Virginia. Semistructured interviews were conducted with a total sample of 15 community health care providers. Barriers of PrEP uptake at the societal (e.g., PrEP advertisements focus on gay men), community/organizational (e.g., time constraints in the workplace), interpersonal (e.g., perceived monogamy), and individual (e.g., unmet basic needs) levels were identified. Providers also identified facilitators of PrEP uptake at the societal (e.g., PrEP advertisements that target women), community/organizational (e.g., PrEP education), interpersonal (e.g., HIV-positive partner), and individual (e.g., PrEP awareness and perceived susceptibility to HIV) levels. These findings highlight unique barriers to accessing and taking PrEP for Black women in the United States, and potential factors that could facilitate PrEP use. Both barriers and facilitators may be important targets for interventions to improve PrEP uptake. Future research focused on improving PrEP uptake among Black women in the United States should consider multi-level interventions that target barriers and facilitators to reduce rates of HIV infections.

Introduction

According to current population statistics, 1.2 million people are living with human immunodeficiency virus (HIV) in the United States.¹ These effects are magnified when considering HIV rates in the southern region of the United States, with 7 out of the 10 leading states for new HIV cases per year being located below the Mason–Dixon Line.^2
–4 Miami, Florida, New Orleans, Louisiana, Jackson, Mississippi, and Atlanta, Georgia, have been identified as “hot spot” cities with the highest rates of new HIV diagnoses for Black women.^5
–7

Black adults account for more than 40% of all new HIV diagnoses across the nation, despite comprising 13% of the population.⁸ Although annual HIV infections remained stable among Black women from 2015 to 2018, it has since skyrocketed and in 2019 the rate of new HIV infections among Black women was 11 times that of White women and four times that of Latina women.⁹ Safe and preventative measures to reduce the likelihood of contracting HIV were developed to offset the spread of the virus, but uptake of these treatments among Black women specifically is extremely low.^10
–12 Pre-exposure prophylaxis (PrEP) was developed to address the worldwide HIV epidemic as an antiviral medication people at risk for HIV can take to prevent contracting HIV through sex or injection drug use.^1,13 PrEP is highly effective at preventing HIV for people who are susceptible to HIV infection when used consistently.^14,15

When taken as prescribed, PrEP reduces the risk of getting HIV from sex by about 99% and reduces the risk by at least 74% among people who inject drugs.¹³ Daily oral pills and long-acting injectable cabotegravir are PrEP medications FDA-approved for use among women in the United States.¹⁶ Unfortunately, PrEP uptake remains low among Black women, as HIV surveillance regarding women's uptake of PrEP reports that only 15% of women with an indication for PrEP are actually on PrEP.^10
–12 Findings suggest race-based disparities in new HIV infections will continue to grow. The data confirm that there is a need to address the disproportionate rates of HIV diagnosis among Black women but suggest there are underlying factors at play that may be influencing and impeding Black women's decisions about engaging in beneficial health care practices.

Barriers of PrEP uptake act as roadblocks that put Black women's health at risk. Many Black women are disadvantaged because of survival needs not being met and other attributes characteristic of lower socioeconomic status (SES) that limit practical accessibility to PrEP.^{3,4,17

–21} Risky sexual behavior, pressure from intimate partners, and perceived judgment are additional barriers for PrEP uptake.^20
–22 Engaging in unprotected sex, having multiple sex partners, not inquiring about partners' sexual history before engaging in sexual activity, exchanging sex for money, and sex under the influence of alcohol or drugs are examples of risky sexual behaviors.^21,22 Some providers report concern about prescribing PrEP because they think it will increase engagement in risky sexual behaviors.²¹

In addition, women in abusive perceptually monogamous relationships experience challenges such as their partner refusing to wear condoms, nondisclosure of sexual history, and concealment of cocurrent sexual partners, which discourages them from taking PrEP and influences their engagement in risky sexual behavior to avoid judgment of being uncooperative or upsetting their partner.²² Further, lack of quality, efficient, and informed health care within community health care settings from empathetic and culturally sensitive providers inhibits Black women's comfortability in seeking information regarding PrEP,^17,21 which lends itself to perceptions of stigma, medical mistrust, and other exacerbated societal barriers that fuel the disproportionate diagnosis rates of HIV among Black women.^1,3,4,18,19

Evaluating some of the known facilitators for getting Black women prescribed PrEP may shed light on other ways not yet discovered in research. Facilitators of PrEP uptake are Black women's open-mindedness, willingness to try, prior knowledge of known benefits, and favorable attitudes toward the medication.^{4,11,12,19,23} A sense of empowerment, control over sexual health, increased self-protection, and reduced anxiety of contracting HIV promote both women's uptake and long-term adherence to PrEP.^4,19 Being in a serodiscordant partnership (i.e., one partner is HIV positive and the other is not) and knowledge of a partner's HIV status and sexual behaviors also lead more Black women to take PrEP.^17,19,22,24 Additional facilitators of PrEP uptake among Black women cited throughout research include implementation of supportive factors from health care workers, peer navigators, outreach workers, patient navigators, and public communications.^17,25

Access to quality health care for minority individuals in underserved communities is an ongoing obstacle and extensive research findings of the perceived barriers of PrEP uptake among Black women do not extend to knowledge regarding facilitators.^1,21 Fewer studies add to the topic from the perspective of health care providers. Health care providers have a unique role in initiating PrEP uptake, and can act as the “front line” for disseminating information about PrEP to populations most at risk.²⁵ Thus, they have the highest likelihood of success in getting minority individuals to accept beneficial health care services. Community health care providers may offer insight for understanding the multi-faceted and interactive effects of personal and environmental factors that can guide well-informed prevention intervention and programs to reduce the rates of HIV infections among Black women in the United States.

The goal of the present study was to explore community health care providers' perspectives in engaging Black women in PrEP use via semistructured in-depth interviews. We used the socioecological model (SEM) to explain factors influencing the use of PrEP in Black women based on providers' perspectives. The SEM is a conceptual framework that examines the interplay between individuals and their broader social and environmental contexts.²⁶ It recognizes that human behavior and health outcomes are influenced by multiple interconnected levels, including individual, interpersonal, community, and societal factors. This model emphasizes the importance of considering other factors beyond the individual such as social relationships, physical environments, and policy influences in understanding and addressing health issues.²⁷ The overall goal of this work is to identify multi-level barriers and facilitators to PrEP uptake among Black women in the southern United States that could be targeted in future interventions.

Methods

Study setting

The study was conducted in Eastern Virginia, which consists of the following seven cities: Chesapeake, Hampton, Newport News, Norfolk, Portsmouth, Suffolk, and Virginia Beach. These cities are densely populated by people of diverse demographics and have the highest rate of persons living with HIV across all other regions in the state.²⁸ In 2020, 7315 people in the area were identified as living with HIV, an increase of 221 individuals from the previous year.²⁹ The Institutional Review Board of the Old Dominion University, in Norfolk, Virginia, determined all study procedures to be exempt. Ethical standards were upheld using informed consent, confidentiality, and the ability for participants to withdraw at any point.

Participants and data collection

Participants were recruited from a convenience sample of community health care workers providing HIV testing and PrEP referral services (but do not actually prescribe PrEP) at HIV testing clinics in community health care settings in Eastern Virginia. Researchers contacted potential participants through direct email or email listservs that listed the study's purpose, the time commitment required of participants, compensation, and contact information for project team members. Interested participants contacted the project team member by email or text message to schedule an interview.

Semistructured phone and Zoom interviews were conducted, lasting ∼25–40 min with participants between May and June of 2022. All study interviews were conducted using a semistructured interview guide (Appendix A1) that queried participants about their experiences providing HIV testing services and PrEP referrals to patients who visit HIV clinics. The interview guides explored the factors that hindered or supported the use of PrEP in Black women. Before conducting the interviews, all participants were provided with information about the study's goals, the potential risks and benefits of participation, as well as their rights to voluntary involvement and the confidentiality of their data. Verbal consent was obtained from all participants at the beginning of each interview.

All interviews were audio-recorded with participants' consent, and a $50 gift card was provided after each interview, which was delivered to the participants at their place of work. Recruitment of provider participants was continued until no new information was generated in the interview, and saturation was confirmed after analysis.^30,31

Data analysis

Interviews were transcribed verbatim by a professional transcription service, and transcripts were checked for accuracy against the original recordings. Data were coded by two independent research team members to ensure that the interpretations of quotes were consistent, and that data analysis was rigorous and transparent. All coding was done using Nvivo.³² The data were coded and analyzed following Braun and Clarke's common thematic analysis approach,³³ which is an iterative process for finding meaning in data.

The six phases of thematic analysis as described by this approach are as follows: (1) becoming familiar with data; (2) generating initial codes across the data set and grouping each coded data; (3) searching for themes by collating analysis codes into possible themes and gathering data that are relevant to each possible theme; (4) reviewing themes and creating a ‘map’ of the analysis; (5) defining and naming themes; and (6) producing an analysis report and selecting appropriate, vivid quotes in support of described themes. Multiple investigators reviewed a sample of anonymized transcripts to gain multiple perspectives and ensure consistency in reading and understanding of the data. In the instances of coding discrepancies, at least two coders re-examined the transcripts together and discussed the possible thematic meanings associated with the text in question until all coders agreed on the assigned coding.

All codes were organized according to the SEM, namely (1) individual-level factors; (2) interpersonal-level factors; (3) community/organizational-level factors; and (4) societal/policy-level factors.

Results

Interviews were conducted with 14 community health care workers and 1 PrEP provider. There were a variety of barriers and facilitators at multiple levels of the SEM that community health care workers identified as influencing PrEP uptake among Black women based on their experience. Participants identified PrEP misconceptions and intersecting social determinants of health as overarching barriers that transcend multiple levels of influence within the SEM. At the societal/policy level, the focus on marketing PrEP primarily to gay men or men who have sex with men (MSM) perpetuates a perception among Black women that PrEP is not suitable, relevant, or beneficial to them.

Further, at the community/organizational level, limited resources in clinics and unaddressed misconceptions about PrEP had an impact on PrEP uptake among Black women. Also, unaddressed misinformation from partners at the interpersonal level along with the perception of low risk and lack of basic needs leads Black women not to prioritize HIV and PrEP education at the individual level. Consequently, this study highlights the intersectionality of issues that significantly hinders PrEP uptake among Black women, as is discussed in greater detail in the following sections.

Societal/policy level of influence: barriers and facilitators

At the highest level of the SEM, the most cited barrier to PrEP uptake among Black women was the notion that PrEP advertisements largely focus on gay men or MSM (Table 1). Community health care workers repeatedly commented on how the majority of Black female patients they see at the clinic believe PrEP medication is only for men due to the advertisements they see in media (e.g., television, online, social media). Consequences of this misbelief subsequently decreased the uptake of PrEP among Black women. One respondent reported:

Table 1.

Barriers of Influence Across All Socioecological Levels

SEM level	Theme	Quote
Societal	PrEP marketing	“Yeah, and you have seen the commercials, even the pamphlets that we have at our clinic, it only targets men, and is men who have sex with men. And sometimes I am like you know where is the pamphlet for women?” (Participant 5)
	PrEP marketing	“We put in little advertisement. It's all men. It's all men, right? We don't have advertisement for Black women.” (Participant 1)
	HIV education	“Well, this is very tricky, but in terms of the higher up, they really do not embrace the importance of HIV education. I mean, you know, I say it's like that (i.e., education) is what should be in the forefront.” (Participant 10)
Community/organizational	PrEP health care facility	“Also, PrEP windows processing…the process is too long…sometimes when you refer or link a client to PrEP, the process is so cumbersome some do not follow through.” (Participant 2)
		“Well, it takes long…like 45 minutes to educate and counsel patients about PrEP…and once we link them to the doctor, there is a lengthy process of taking all those tests.” (Participant 4)
		“So, there's a very personal element to this, but we are all in the office five days a week split between care, navigation, and testing. So, until we get the internal staffing, we just can't. We can't keep up with some of the needs.” (Participant 1)
Interpersonal	Perception of monogamy	“Most women feel that they do not need to take PrEP for the simple fact that they know their partners. They know who they are sleeping with, and they feel safe. But I tell them the fact they are here to test says you are not feeling safe about something.” (Participant 4)
Individual	Perceived low susceptibility of HIV infection	“I've heard, you know, people just tell me flat out that they just don't believe that they are at high risk.” (Participant 14)
	Perceived low susceptibility of HIV infection	“I think that they are aware [of HIV], having heard of PrEP…but they still don't see themselves being at risk [for HIV] …even though they may be seeing multiple partners…yeah, still they don't perceive themselves to be at higher risk [of contracting HIV].” (Participant 6)
	Unmet basic needs/social determinants of health	“Transportation…unfortunately, we tend to link [clients] with one clinic, [and] we cannot refer them to other places…so for some of the clients, the issue is transportation.” (Participant 1)
		“I'm saying perhaps [being] housing insecure.” (Participant 15) “Yeah, [PrEP] is like the last thing I gotta worry about..I gotta worry about food, childcare.” (Participant 3)
		“Not all clients have health insurance.” (Participant 4)
		“Because yeah [insurance] covers the medicine…but then you have deductibles and copays for your office visits and your labs…that's a lot because deductibles have gotten so high so [clients] are paying out of pocket.” (Participant 13)

HIV, human immunodeficiency virus; PrEP, pre-exposure prophylaxis; SEM, socioecological model.

“In most advertisements for example PrEP focuses on men, especially gay White men. So, they [i.e., Black women] don't see a lot of advertisement getting to them. Like, they will say—I don't see in any of the commercials that it's saying anything about me.” (Participant 2)

In this capacity, limited inclusivity of advertisements and materials disseminated to the outer public from government proceedings directly fuels the faulty narrative that Black women are not at risk for HIV diagnosis and that PrEP is not applicable to them. In addition, HIV education and prevention not prioritized among Black women were also commonly reported as a barrier of PrEP uptake. Sex education is provided in public settings such as schools. However, state curriculum standards for such programs vary widely across the nation as HIV education and prevention are specifically mandated in approximately half the number of states.³⁴

Solutions for societal/policy-level issues were offered that predominantly focus on improving sex education and prevention practices, as well as improving PrEP media marketing and advertisement to increase awareness (Table 2). Suggestions included a greater emphasis on HIV education and prevention in schools and the creation of an objective PrEP propaganda to be more inclusive of Black women. Implementation of these methods from community health care providers was thought to not only reduce the rates of HIV diagnosis but increase PrEP uptake as well.

Table 2.

Facilitators of Influence Across All Socioecological Levels

SEM level	Theme	Quote
Societal/policy	PrEP marketing	“I think they need to make it more inclusive. You know the single mom out there both see this out there and say, OK, you know, if I'm going back into the dating scene, let me protect myself, you know what I'm saying? So, I think they need to make it inclusive. And I see that usually when it comes to the prep ads.” (Participant 11)
	PrEP marketing	“I think just having our marketing materials about PrEP that feature women around the clinic would be helpful. You know, just in general having more commercials and things like that where women are featured would be really beneficial.” (Participant 14)
	HIV education	“So, I think we need more education to address the issue to let people know that HIV is still around and people are still contracting HIV…you know, if you can prevent diagnosis of HIV from happening, what not do it? That's what society and the community, that's what we need.” (Participant 11)
Community/organizational	PrEP health care facility	“Sometimes it is just a lack of awareness and so with proper education we can definitely increase PrEP uptake for women. We explain how PrEP works and how you can access it.” (Participant 2)
Interpersonal	Serodiscordant relationship	“For women who have partners that are living with HIV, they are more accepting to getting on PrEP. If they break up with their partner, then you know, sometimes they come off.” (Participant 9)
Individual	Prior PrEP knowledge	“There have been times when people have been like, I've heard about PrEP…[but] I would like some more information about it…they'll have the basics, but they want to know more in-depth stuff that usually isn't discussed, like on the news.” (Participant 9)
	Perceived susceptibility to HIV infections	“When people leave [the clinic]…then the nurse calls and says you're negative for all STDs we tested…they feel relief…now they're interested in PrEP…especially when they think they may have gotten an STD… they're like…I need to protect myself, I want PrEP.” (Participant 15)
	Perceived susceptibility to HIV infections	“Sometimes when you call [clients] with the results of their [STD/STIs] tests and it is positive results…they [ask] what about medications…could you tell me more about how it works.” (Participant 7)

HIV, human immunodeficiency virus; PrEP, pre-exposure prophylaxis; SEM, socioecological model; STD/STI, sexually transmitted diseases/sexually transmitted infections.

Community/organizational level of influence: barriers and facilitators

Community health care workers identified numerous structural limitations within the health care facility that act as barriers for providing adequate HIV and PrEP help to Black women seeking care at the community or organizational level (Table 1). Provider time constraints, understaffed facilities, competing services, providers' referrals to predominately individuals who identify as a sexual minority, and no tracking process for continuity of care were among the most frequently reported barriers that exist at the community/organizational level. Whereby the clinic could be used as an intimate setting for community health care workers to provide informative and corrective feedback regarding HIV prevention and PrEP to Black women, structurally imposed obstacles outside of the providers' and patients' control inhibited workers from comprehensively assisting Black women seeking services. Participants believed these community/organizational challenges contribute to why Black women have an erroneous perception of PrEP.

Many respondents spoke to how demanding it is to be a community health care provider. It was expressed that while they understand how the ramification of lack of services is supported by their behaviors, solving the issue is complex due to procedural constraints and there simply not being human resources available to accommodate the amount of need. A respondent explained:

“We have so much that we have to do in 45 minutes. Whether it is paperwork or something else. It's just a lot of cramming for 45 minutes to really pick up on a lot of things. It's just too much! It's too much, really. It's too much to give someone a thorough, you know, work up, right? Like you wanna give the information, but I mean, PrEP is one of the many services that we provide.” (Participant 6)

Community health care workers' assessment of the problem from a community/organizational level echoed solutions endorsed from the societal/policy level. The importance of education regarding PrEP appeared to prevail through multiple socioecological levels, emphasizing its role in promoting uptake among Black women who are unaware of their risk for contracting HIV (Table 2). Within health care facilities, workers suggested spending more time educating patients about services available would allow them to make more health conscious and informed decisions relating to their sexual well-being.

Interpersonal level of influence: barriers and facilitators

Interpersonally, involvement in a romantic relationship appeared to act as both a facilitator and barrier of PrEP uptake among Black women. Specifically, unyielding trust toward a partner puts women at risk for contracting HIV, while unyielding openness about one's sexual health may be the biggest safeguard. Community health care providers stated factors such as length of the relationship, informed sexual activity (e.g., identity of all sexual partners, frequency of sexual contact with other partners, type of sex engaged in with other partners, known sexual history of other partners), sex partner history, and loyalty often keep Black women from getting tested for sexually transmitted infections (STI), as well as being open to taking PrEP (Table 1). A respondent explained:

“Some say they have been with their partners for more than 15 years and believe they will never get HIV.” (Participant 11)

However, openness about one's sexual history and HIV status is a prominent decision-making factor of PrEP uptake among Black women. Participants reported that an HIV-negative Black woman in a serodiscordant relationship was more accepting and compliant with prescription of PrEP than women not in a serodiscordant relationship (Table 2).

Individual level of influence: barriers and facilitators

Low perceived risk and intersecting social determinants of health were identified as the two main barriers to Black women's uptake of PrEP on the individual level of influence, which appeared to be heavily endorsed by HIV and PrEP education not prioritized in the daily lives of Black women (Table 1).

Black women's low perceived risk of contracting HIV is associated with lower instances of HIV testing and prescription of PrEP when seeking health care services. As per those interviewed, regardless of having unprotected sex, sex with multiple partners, or being unaware of one's sexual health status, many Black women believe they have no risk of contracting HIV. Engagement in risky sexual behaviors does not illicit a sense of increased susceptibility for Black women who have sex with men. A community health care provider stated:

“I think the greatest barrier is this low perception of risk, that they don't see themselves at risk to acquire HIV.” (Participant #9)

Moreover, for Black women who live in lower SES environments that are riddled with less access to financial, educational, social, and health resources, competing life stressors often impede the prioritization of HIV and PrEP education, increasing the likelihood of the development of a low perceived risk perspective. When one's basic survival needs are unmet, preventative health care and other protective health factors that many individuals from higher SES backgrounds often take for granted are not viewed as high on the totem pole of importance. Rather than prioritizing health literacy, there is a stronger emphasis on securing housing, food, childcare, employment, and other necessitates of life. When a respondent was questioned about challenges that may prevent Black women specifically from taking PrEP, they replied:

“There are barriers like maybe housing [and] transportation or so that affect some clients and we sometimes offer them help.” (Participant #4)

Community health care workers' insight of the challenges of the populations they serve fosters understanding for why Black women, particularly those of low SES, do not prioritize HIV and PrEP education. The combination of Black women's misconceived risk and unmet needs lends itself to a domino effect of decreased information attainment of HIV and PrEP, decreased inquiry of HIV testing and prescription of PrEP among Black female patients in the community health care setting, decreased promotion of PrEP medication from community health care workers to Black female patients, and inevitably lower rates of PrEP uptake with exacerbated rates of HIV diagnosis in the Black female population.

Prior knowledge of PrEP and of one's personal sexual health status was identified by participants as facilitators of increased PrEP uptake among Black women on the individual level (Table 2). After individuals face the reality of their sexual health status through testing, they are more inclined to protect themselves to retain negative results or take action to treat whatever STI they contracted. Regardless, both reactions evoke a more vested and considerate interest in one's sexual health. The facilitators discussed help to combat the barriers of having a low perceived risk of contracting HIV and being of lower SES.

Discussion

We examined the barriers and facilitators to PrEP uptake for Black women from the perspectives of community health care providers in Eastern Virginia. Our findings show that barriers to PrEP uptake exist across all levels of the SEM. The majority of these barriers extend beyond the individual and stem from factors rooted in society, community, interpersonal interactions, and individual levels. Facilitators to PrEP uptake were also present at the levels of SEM. The primary barriers to PrEP uptake in Black women highlighted in this study are PrEP misconceptions and intersecting social determinants of health across all levels of SEM. PrEP marketing mainly targets MSM and not women, leading to low perceived HIV risk among Black women at individual and interpersonal levels. Black women with unmet basic needs were less likely to prioritize HIV prevention strategies such as PrEP.

Participants identified food insecurity, lack of transportation, housing, and health insurance as the social determinants influencing PrEP uptake in Black women. These factors are beyond an individual and require policy changes, community resources, and support systems at the interpersonal level to promote equitable access to PrEP for Black women. Conversely, the key drivers behind the adoption of PrEP were the individuals' perception of their susceptibility to HIV and their awareness of PrEP.

Historically, PrEP messaging has predominantly targeted MSM and transgender populations due to the high prevalence of HIV within these groups.^35
–37 As a result, Black women may not have received the same level of exposure to PrEP advertisements or messaging. This discrepancy in messaging and outreach may contribute to the misunderstanding and limited awareness of PrEP among Black women. These findings align with previous studies that have demonstrated that women are not aware of PrEP as a method to prevent HIV, which could potentially benefit them.^23,38

–41 Our study adds to the existing literature on factors that prevent PrEP use in Black women by incorporating the insights of health care providers working in nontraditional clinical settings.

The lack of targeted advertising for women may lead to a perception that PrEP is primarily for men, reinforcing misconceptions or limited awareness about its potential benefits for women's HIV prevention. Recently, notable efforts have been made to promote PrEP specifically for women in the United States.^42,43 However, a recent review noted that Black women were underrepresented in PrEP marketing,⁴² which is concerning given the high HIV incidence among Black women in the United States. This highlights an opportunity for future research studies and interventions to propose strategies that promote PrEP use in Black women.

In addition, within the clinical setting, health care providers are often busy and may not have sufficient time to engage patients on HIV prevention tools.⁴⁴ Patient demand is steadily on the rise, while provider resources are steady on the decline due to the current nationwide labor shortage in the United States.⁴⁵ Further, the demand on health care is growing at an unprecedented pace, as 2030 projections report almost half the states across the country will have shortages above the national average with a widespread shortage of 139,160 physicians.⁴⁵ According to predictions, the labor shortage will continue to climb, making the role of providing health care services increasingly more difficult to maintain with even fewer means. This will likely exacerbate the already disproportionately affected sexual health status of Black women.

Therefore, finding alternative ways besides interpersonal interaction to educate women about PrEP may increase its uptake. Such efforts should stress the importance of PrEP for women's HIV prevention, debunk misconceptions, provide accessible and culturally appropriate information, and train health care providers to communicate effectively the benefits of PrEP as a preventive measure. Indeed, studies have shown that individuals with prior PrEP knowledge are more likely to use PrEP.^40,46,47 By addressing these gaps in PrEP marketing, education, and provider awareness, we can strive to reduce misinformation and access disparities related to PrEP among Black women. It is crucial to challenge and correct women's misconceptions that they are not at risk of HIV infection. This can be achieved through comprehensive and culturally sensitive educational campaigns that highlight the potential risks and provide accurate information about HIV and effective prevention strategies.

The sex education curriculum in most southern states' schools discusses birth control options, abstinence, and safe sex practices to prevent STI.⁴⁸ However, the instruction emphasizes abstinence as its primary method of prevention. Further, while the education is state mandated, at any point a parent and/or guardian may opt a child out of the curriculum. The scarce, vague, and conservative nature of HIV education and prevention fosters a widespread lack of awareness for large demographics of individuals, particularly negatively affecting Black women.

The current study also highlights how intersecting social determinants of health impact the level of interest in PrEP among Black women. Challenges such as food insecurity, unstable housing, limited transportation, and lack of health insurance can result in a decreased priority given to HIV prevention measures, including PrEP. Individuals with unmet basic needs (social determinants of health) have been shown not to engage in HIV prevention and care services.^49

–52 These individuals may have other priorities that divert their focus from engaging in HIV prevention services. By addressing these underlying determinants at the SEM's structural and organization/community levels, individuals will be better positioned to prioritize their health and engage in HIV prevention measures such as PrEP.

Perceived HIV risk or susceptibility to HIV infection was a key facilitator of PrEP uptake identified in this study. Recognizing one's personal reasons for HIV prevention and understanding the potential consequences of HIV infection motivated Black women to consider and use PrEP. Prior studies have also supported this finding.^{23,39,40,42,53} Frequent HIV testing for all sexually active adults and adolescents as recommended by the Centers for Disease Control and Prevention^2,5,6,8 creates opportunities for health care providers to discuss sexual health, assess risk factors, and initiate timely prevention strategies such as PrEP. By integrating PrEP education in routine HIV testing, providers can proactively address women's risk profiles and educate them about the benefits of PrEP. Also, support from partners can play a significant role in facilitating PrEP uptake and adherence.⁵⁴

Participants in this study reported that HIV-negative Black women with an HIV-positive partner were willing to start PrEP. When partners are supportive and understand the importance of PrEP as a prevention tool, it creates a nonstigmatizing environment for open discussions and joint decision-making regarding HIV prevention. HIV-negative individuals in relationships with HIV-positive individuals are much more likely to use PrEP.⁵⁵ Also, prior knowledge about PrEP in Black women facilitated willingness to use PrEP. This finding is consistent with previous studies.^54,56 Black women who are aware of PrEP are comfortable making informed decisions about their sexual health, including considering PrEP to protect themselves from potential exposure to HIV infections.^4,57

These findings should be understood within the context of certain limitations. First, this study's findings are limited to Eastern Virginia and might not be generalizable to other regions of the United States. However, these are common issues that affect Black women across all regions in the United States. Also, we used a small convenience sample of 15 community health care providers, but during the analyses, we followed recommendations of reaching 80–90% saturation of key concepts.^30,58 Interviews were primarily conducted with health care providers who provide HIV testing and PrEP referral and one PrEP prescriber. In the community health care facility in this setting, there are only three medical doctors who prescribe PrEP. We contacted all three PrEP prescribers, but only one was available to be interviewed. Finally, although several providers shared personal experiences engaging with Black women, we acknowledge that the study lacked the direct voices of patients.

This gap highlights the importance of future research in exploring patients' experiences and perceptions regarding PrEP uptake. Conducting interviews with Black women can provide valuable insights on the unique barriers such as stigma, cultural factors, and health care access issues, which may not be fully captured through provider perspectives.

We note some strengths of this study. We provide the perspectives of community health care providers who provide HIV testing and STI services to patients seeking these services, meaning they provide a key phase to intervene and provide timely preventive services to patients vulnerable to HIV infections. Also, previous studies have primarily focused on traditional health care providers, such as clinicians in traditional health care settings. Exploring the perspectives of community health care providers expands the understanding of PrEP uptake among Black women, who are less likely to trust the health care system and face unique challenges related to intersecting social determinants of health. Understanding the perspectives of providers who are embedded in the community and have a deeper understanding of the challenges faced by their patients can inform the development of tailored interventions to promote PrEP uptake among these individuals.

In conclusion, our findings highlight the importance of addressing factors beyond the individual, including marketing strategies specifically tailored to Black women and addressing social determinants of health to promote PrEP initiation among Black women. To achieve the US National HIV/AIDS Strategy goal of reducing HIV incidence,⁵⁹ it is important to include all populations vulnerable to HIV infections, including Black women in HIV prevention campaigns. Multi-level interventions that consider individual and structural factors are necessary to ensure equitable access to PrEP.

Footnotes

Acknowledgments

We thank the community health care providers who participated in the study. We acknowledge the important logistical support of the LGBT life center, especially the administrative leadership. Portions of this article have been previously presented as a poster at the Society of Behavioral Medicine 44th Annual meeting found here: https://academic.oup.com/abm/issue/57/Supplement_1 and at Old Dominion University graduate student posters found here: https://digitalcommons.odu.edu/gradposters2023_sciences/19/

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The Old Dominion University College of Health Sciences Joint Intramural School of Public Health Initiative Funding supported this work (Award number IRP2021-22).

Appendix

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