Development and Evaluation of a PrEP Decision Aid for Women Seeking Domestic Violence Services in Baltimore

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HIV and intimate partner violence (IPV) are intersecting, mutually-reinforcing epidemics that significantly affect Black women, particularly in the U.S. South. IPV escalates heterosexual transmission of HIV. IPV-exposed women are four-times more likely to be infected with HIV than their counterparts. IPV-exposed women are at greater risk for HIV infection due to forced and coerced sex with partners with HIV, condomless sex, enduring fear of safe sex (condom) negotiations and substance use. Male IPV perpetrators are more likely to have untreated HIV, directly increasing women’s HIV risk. In response to the intersection of HIV and IPV among U.S. women, the 2020 National HIV/AIDS Strategy calls for initiatives that “expand public outreach, education, and prevention efforts on HIV and other intersecting issues such as IPV.” The Ending the HIV Epidemic (EHE) Plan further emphasizes the need to increase HIV prevention in areas with high HIV burden, and there is an opportunity to increase uptake of partner-independent HIV prevention among IPV-exposed Black women in these areas. Pre-exposure prophylaxis (PrEP) is a user-controlled, effective HIV prevention strategy for IPV- exposed Black women, but national data indicates that PrEP is severely underutilized by women compared to men. The CDC has outlined two challenges to PrEP implementation for women: (1) women’s accurate assessment of their personal and partners’ HIV risk; and (2) few settings offer PrEP introductions. Informed decision aids can overcome these obstacles because they are patient-centered interventions that can increase PrEP awareness, reorient personal risk estimation, and empower women to make informed, values-based decisions. A PrEP decision aid in domestic violence (DV) agencies could address these PrEP implementation challenges. Our Type II hybrid effectiveness-implementation study seeks to adapt an existing PrEP decision aid to IPV-exposed Black women seeking DV services in Baltimore, Maryland, an EHE priority area. Self- and advocate-administered versions of the PrEP decision aid will be implemented and the aid will be evaluated using a two-arm randomized trial, guided by the Consolidated Framework for Implementation Research (CFIR). A formative evaluation using qualitative interviews with IPV-exposed Black women (N=20) and DV advocates (N=10) will be conducted to adapt the existing PrEP decision aid. Next, the decision aid will be implemented in a DV agency and 60 IPV-exposed Black women will be randomized to either the self- or advocate-administered versions of the aid to compare feasibility, acceptability and preliminary effectiveness at PrEP uptake with baseline, 1-, 3-, and 6-month surveys. Focus groups with DV advocates will assess for implementation process outcomes. This study will: provide support for a PrEP decision aid that addresses HIV prevention for the key population of IPV-exposed Black women; use implementation science to increase PrEP uptake in the geographic priority area of Baltimore, Maryland; include DV agencies in intervention development and implementation; and inform PrEP scale-up by addressing implementation factors in settings that serve IPV-exposed Black women.