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

在美国新确诊的艾滋病毒患者中，女性占了相当大的比例(20%)，感染人数居多 发生在有色人种女性中：黑人和拉丁裔女性加起来占新诊断女性的77% 在全国范围内，但占女性人口的30%。基于性别的社会不平等与男性的 对避孕套和病毒抑制等艾滋病毒预防方法的控制，传统上限制了妇女的 关于自我保护风险行为的选择。HIV暴露前预防(PrEP)，每天一次 避孕药(特鲁瓦达)代表着妇女艾滋病毒预防方面的历史性突破，因为它是第一个商业化的 可用的有效方法，独立于性行为，可由女性控制。然而，只有大约 4%的艾滋病毒高危女性正在服用这种药物。此外，尽管感染艾滋病毒的风险最大 黑人和拉丁裔女性最不可能服用PrEP。有色人种女性因此面临着与艾滋病毒相关的双重健康问题 差异：他们的艾滋病毒感染率高得不成比例，但PrEP使用率却低得不成比例 用于预防艾滋病毒。黑人和拉丁裔女性中PrEP使用率较低的原因尚不清楚。 为了解决这一差距，我们提出了一项混合方法的纵向队列研究，具体目标如下： (1)描述PrEP护理连续体的特征(PrEP-CC；意识、联系、吸收、保留和坚持) 在感染艾滋病毒的高危妇女中，包括健康差距；(2)在多个层面确定决定因素 (社会、医疗保健环境、社区、人际、个人)与PrEP-CC结果相关，包括 健康差距；(3)确定哪些医疗保健提供战略和计划促进改善 (4)探索提供者的态度、观点、做法和环境 这塑造了PrEP预置行为和患者互动。整合社会生态学的概念框架 盖尔伯格-安徒生行为模式的理论和性别与权力理论将指导这项工作。 这项研究将在纽约州的两个城市进行：纽约市和罗切斯特。纽约州已经 艾滋病毒方面的种族健康差距在全国排名第二。一组(N=360)女性(80%为少数民族) 参加PrEP或有资格参加PrEP的学生将参加为期12个月的季度评估，以获得调查， 生物识别和医疗记录数据。抽样和招募战略将涉及受访者驱动的抽样 方法采用时点抽样相结合的方法。社区层面的社会经济数据和医疗保健网站- 还将获得级别数据。对量化数据的分析将估计受试者内部和之间的影响 多水平预测因子对PrEP-CC结局的影响。还将使用事件间隔时间分析来对阶段进行建模 沿着PrEP-CC。定性访谈将在50名女性中进行(按PrEP分层 使用和种族/民族)，以及18个临床提供者，为三角测量提供背景数据。由此得出的结论 研究将为制定和评估干预措施、方案和服务提供证据基础 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.