Multilevel determinants of HIV pre-exposure prophylaxis (PrEP) utilization and health disparities among Black and Hispanic women

在美国，女性在新诊断的艾滋病毒中占很大比例（20%），大多数感染 发生在有色人种女性中：黑人和拉丁裔女性共占新诊断女性的77% 但占女性人口的30%。基于性别的社会不平等加上男子的 对艾滋病毒预防方法的控制，如避孕套和病毒抑制，传统上限制了妇女的 关于自我保护的风险行为。HIV暴露前预防（PrEP），每日一次 避孕药（Truvada）代表了妇女预防艾滋病毒的历史性突破，因为它是第一个商业化的 不依赖于性行为，可由女性控制的有效方法。然而，只有大约 4%的艾滋病毒高危妇女正在服用这种药物。此外，尽管感染艾滋病毒的风险最大， 黑人和拉丁裔妇女最不可能服用PrEP。因此，有色人种妇女面临双重艾滋病毒相关健康问题 差异：他们的艾滋病毒感染率高得不成比例，但PrEP使用率低得不成比例 预防艾滋病。黑人和拉丁裔妇女中PrEP使用率低的原因尚不清楚。 为了解决这一差距，我们提出了一项混合方法纵向队列研究，具体目标如下： (1)描述PrEP护理连续体（PrEP-CC;意识，联系，吸收，保留和坚持） 艾滋病毒高危妇女的健康状况，包括健康差距;（2）确定多个层面的决定因素 （社会、医疗环境、社区、人际、个人），包括 健康差异;（3）确定哪些医疗保健提供战略和计划促进改善 PrEP-CC对女性的影响;（4）探讨提供者的态度，观点，实践和环境 这塑造了PrEP提供行为和患者互动。一个概念框架， 本文将性别与权力理论与盖尔伯格-安德森行为模式相结合，对性别与权力理论进行了深入的研究。 本研究将在纽约州的两个城市进行：纽约市和罗切斯特。纽约州 是美国艾滋病病毒感染率第二大种族差异。一组（N=360）女性（80%为少数民族）， 正在服用PrEP或有资格获得PrEP的人将被招募并进行为期12个月的季度评估，以获得调查， 生物特征和医疗记录数据。抽样和招聘战略将涉及答卷人驱动的抽样 结合时间-位置抽样的方法。社区级社会经济数据和医疗保健网站- 还将获得水平数据。定量数据分析将估计受试者内和受试者间效应 PrEP-CC结局的多水平预测因素。时间到事件的分析也将被用来模拟阶段 沿着PrEP-CC。将对50名女性进行定性访谈（按PrEP分层 使用和种族/民族），以及18个临床提供者提供三角测量的背景数据。时发现的问题 这项研究将提供一个证据基础，在此基础上制定和评估干预措施、方案和服务 为有色人种妇女解决艾滋病毒和PrEP结果和健康差距。

Women constitute a substantial proportion (20%) of new HIV diagnoses in the U.S., with the majority of infections occurring in women of color: Black and Latina women together account for 77% of newly diagnosed women nationally but represent 30% of the female population. Gender-based social inequalities combined with men’s control over HIV prevention methods, such as condoms and viral suppression, have traditionally limited women’s options with regard to self-protective risk behavior. HIV pre-exposure prophylaxis (PrEP) taken as a once-daily pill (Truvada) represents an historic breakthrough in HIV prevention for women, as it is the first commercially available effective method that is independent of the sexual act and can be controlled by women. Yet, only about 4% of women who are at high risk of HIV are taking the drug. Moreover, despite being at greatest risk for HIV Black and Latina women are the least likely to take PrEP. Women of color thus confront dual HIV-related health disparities: they have disproportionately high rates of HIV infection but disproportionately low rates of PrEP use for HIV prevention. The reasons for the low PrEP use among Black and Latina women are not well-understood. To address this gap, we propose a mixed methods longitudinal cohort study with the following specific aims: (1) characterize the PrEP care continuum (PrEP-CC; awareness, linkage, uptake, retention and adherence) among women at high risk for HIV, including health disparities; (2) identify determinants at multiple levels (societal, healthcare setting, community, interpersonal, individual) associated with PrEP-CC outcomes, including health disparities; (3) determine which healthcare provision strategies and programs promote improvement of PrEP-CC outcomes for women; and (4) explore providers’ attitudes, perspectives, practices, and environments that shape PrEP provision behavior and patient interactions. A conceptual framework integrating socioecological theory with the Gelberg-Andersen behavioral model and the Theory of Gender and Power will guide this work. The study will be conducted in two cities in New York State: New York City and Rochester. New York State has the second largest racial health disparity in HIV in the nation. A cohort (N=360) of women (80% minority) who are either taking PrEP or eligible for PrEP will be enrolled and assessed quarterly for 12 months to obtain survey, biometric, and medical record data. Sampling and recruitment strategies will involve respondent driven sampling methods in combination with time-location sampling. Community-level socioeconomic data and healthcare site- level data will also be obtained. Analyses of quantitative data will estimate within- and between-subject effects of multilevel predictors on PrEP-CC outcomes. Time-to-event analysis will also be employed to model stages along the PrEP-CC. Qualitative interviews will be conducted with a subsample of 50 women (stratified by PrEP use and race/ethnicity), and 18 clinical providers to provide contextual data for triangulation. Findings from this study will provide an evidence-base upon which to develop and evaluate interventions, programs and services for women of color to address HIV and PrEP outcomes and health disparities.