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

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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.