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Barriers to expanding PrEP uptake among cisgender African American women in the South

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BACKGROUND: Pre-exposure prophylaxis (PrEP) is a potent biomedical tool for HIV prevention; however, PrEP is underutilized among African American (AA) women in the Deep South of the United States, despite an inequitable HIV burden. This study explored patient and provider perceptions, attitudes, and preferences for PrEP service delivery, aiming to identify social, behavioral, and cultural factors influencing uptake among AA women.
METHODS: In-depth, semi-structured qualitative interviews were conducted among cisgender AA women at risk for HIV (based on sexual activity in the last 6 months), both with PrEP experience (N=6) and without PrEP experience (N=15), as well as providers (N=20) from two federally qualified health centers (FQHCs) and HIV service agencies serving rural communities in Alabama. Data were coded in NVivo software (v.12), and analyzed using content analysis.
RESULTS: Overall attitudes and perceptions of PrEP among AA women and providers were positive; however, numerous barriers to widespread PrEP uptake were discussed. Barriers to effective patient-provider relationships reported by AA women included perceived discrimination (e.g., based on patients' income, education, and/or race), a lack of provider empathy (e.g., feeling judged due to one's health status or circumstances), a lack of shared medical decision-making, general healthcare-related anxiety, difficulty assessing one's true HIV risk, and a desire for providers to view patients' health more holistically. Both patients and providers desired an 'under one roof' approach, whereby all PrEP-related services are consolidated (e.g., prescribers, pharmacy, labs, educational materials), along with mechanisms for reducing PrEP-related costs and improving access. Participants also discussed a need for normalization of PrEP use specifically among AA women, via increased and frequent visibility in public-facing contexts (e.g., marketing campaigns, incorporation of PrEP information into standard medical appointment checklists), as well as increased PrEP training for providers.
CONCLUSIONS: These data identify key determinants that will influence PrEP uptake among cisgender AA women in the South receiving care at FQHCs and HIV service organizations. Individual, structural, and system level barriers were identified that will inform adaptations of effective patient-provider communication interventions to be formally tested using implementation science frameworks (i.e., Exploration, Preparation, Implementation, Sustainment [EPIS] and Dynamic Adaptation Process [DAP] frameworks).