Barriers to Pre-Exposure Prophylaxis (PrEP) Use Among Black Women in Eastern Virginia: Perspectives of Community Healthcare Providers

Background and Purpose: Black women in the United States continue to experience disparities in HIV incidence, accounting for most new HIV diagnoses among all women. In 2019, Black women accounted for 60% of new HIV diagnoses among women in the United States, and the majority of these cases occurred in the Southern States. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. However, it is underutilized among Black women in the U.S. We explored the barriers to PrEP use among Black women, including systemic factors such as medical mistrust, stigma, and individual-level factors such as lack of PrEP knowledge or misconception and perceived HIV risks.

Methods: In 2022, we used purposive sampling to conduct semi-structured in-depth interviews with 15 community healthcare workers who provide HIV testing and PrEP referral services at HIV testing clinics in Eastern Virginia. We used the socioecological framework to develop the interview guide, and questions included barriers and facilitators of PrEP use at individual, interpersonal, clinical/organizational, and society/policy levels. Interviews were transcribed, and two coders analyzed the data inductively in NVivo using thematic analysis.

Results: Participants identified PrEP stigma, lack of PrEP knowledge, medical mistrust, and lack of basic needs such as food, housing, transportation, and medical insurance as barriers that transcended multiple levels of influence in PrEP use. At the individual level, participants identified a lack of PrEP knowledge, low perceived HIV risk, and medical mistrust as key barriers. At the interpersonal level, PrEP stigma resulted from negative attitudes and beliefs about PrEP and HIV perpetuated by friends, partners, and family members. At the community level, PrEP use was perceived to promote risky sexual behaviors (PrEP stigma), insufficient PrEP marketing information that targets Black women, food insecurity, housing instability, and lack of medical insurance were reported as barriers. These factors at the individual and community levels relate to system policies that have resulted in Black women not trusting the medical care system. Additionally, Black women face structural barriers to accessing healthcare, including unequal access to insurance coverage and institutional racism within the healthcare system.

Conclusions and Implications: Our study findings indicate that barriers to PrEP uptake among Black women exist at multiple levels of influence. Addressing these barriers requires a comprehensive approach that addresses social determinants of health, combats stigma, and misinformation, and promotes equitable access to healthcare and preventive services. Strategies to promote PrEP uptake among Black women should address these barriers through culturally tailored education and awareness interventions, providing accessible and affordable HIV prevention options, and ensuring healthcare providers are trained to provide non-judgmental and comprehensive care. In addition, addressing basic life needs like housing, food, transportation, and employment can help individuals prioritize their sexual health and access HIV prevention services. By addressing these barriers, we can work towards reducing HIV disparities and promoting equitable access to effective HIV prevention tools.