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Based on an interview with Rachel Scott, MD, MPH.
Recent publications by MHRI investigator Dr. Rachel Scott aims to better understand the experiences of cisgender women with HIV prevention, specifically the uptake and persistence of HIV pre-exposure prophylaxis (PrEP), and to demonstrate that low-cost interventions can have a significant impact on screening, offering, and prescribing PrEPamong key populations.
In the U.S., almost 35,000 people were newly diagnosed with HIV in 2019, and 18% were women. Although HIV pre-exposure prophylaxis (PrEP) that can reduce transmission in women by up to 99%, the CDC estimates that only 10% of U.S. women who could benefit were prescribed the medication in 2019. PrEP is currently FDA approved in oral and injectable formulations and prevents HIV by preventing viral replication. As such, PrEP is one of the U.S. Centers for Disease Control’s six keys to ending the HIV epidemic. Many patients report feeling empowered while on PrEP, knowing their chances of contracting HIV are much lower.
HIV prevention efforts have primarily focused on men who have sex with men, to the detriment of women and especially women of color. Washington, D.C. remains an HIV hotspot, where about 1.8% of the population lives with HIV. Black residents are disproportionately affected—they make up about 1% of the population but 2.9% have been diagnosed with HIV.
Nine out of 10 women in D.C. diagnosed with HIV in 2020 were Black.
Recent publications by Dr. Rachel Scott and her team focus on identification of barriers to PrEP utilization by cisgender women (subsequently “women”) and a clinic-based intervention to improve provision of PrEP services for women.
Study 1: What are the barriers to PrEP uptake for women?
We surveyed 1,437 patients of a family planning and a sexual health clinic in Washington, DC to understand individual, interpersonal, community, health-system, and structural factors that influence HIV PrEP uptake among women in order to inform future clinic-based PrEP interventions.
By socio-ecological level, we found the following associations with intention to initiate PrEP:
- Individual-level: women’s positive attitudes towards PrEP and higher self-efficacy
- Community level: perceived future utilization of PrEP among peers and low fear of shame/stigma
- Institutional level: having discussed PrEP with a provider on the institutional-level
This research highlights the importance of multi-level interventions to promote sex-positive and preventative PrEP messaging, peer support to combat PrEP stigma, and training and support for women’s health medical providers to improve the provision of PrEP services for cisgender women.
Related Reading: Six Things to Know About HIV and Testing
Study 2: What are the barriers to PrEP perisistance among women?
A large meta-analysis showed that 72% of individuals who identified as heterosexual or straight who were prescribed PrEP had stopped taking PrEP by six months.
Dr. Scott’s researcher team interviewed 20 women prescribed PrEP at a government-sponsored sexual health center or a hospital-based family planning clinic in Washington, DC and identified several reasons for discontinuation among women:
- Low percieved potential HIV exposure
- Negative experience with side effects
- Negative emotional experience using PrEP (stigma associated with an implication of promiscuity)
- Negative experiences with the healthcare system
- A positive emotional experience using PrEP (feeling empowered)
- High perceived potential HIV exposure
- Good rapport with healthcare providers
This research highlights many factors in a patient’s decision to continue taking medication. It outlines opportunities to improve communication between patients and providers, to support patients in their sexual health, and to partner with women in shared decision-making.
Study 3: How can clinics improve provision of PrEP for women?
In this study, we worked with a D.C. Department of Health-sponsored sexual health clinic that serves patients with high potential exposure to HIV to implement provision of universal PrEP services for women. We studied the proportions of women screened for PrEP eligibility, offered and prescribed PrEP before and after the intervention.
The educational intervention to increase knowledge and comfort providing PrEP among clinicians and awareness among patients included:
- Clinic-wide training on PrEP for clinical staff and medical providers
- An electronic health record (EHR) prompt to encourage providers to educate and counsel patients about PrEP
- Educational videos about PrEP presented in the waiting room
- Screening rose from an average of 5.6% of women to 89.2% of women
- PrEP was offered to more women: 6.2% before the interventions, 69.8% after
- More women were prescribed PrEP, an average of 2.6% before and 8.1% after
Clinic staff and providers said the interventions were feasible and acceptable and noted their knowledge of PrEP increased following training activities. These results suggest that low-cost interventions to broaden education and improve communication between providers and patients can help more women with high potential HIV exposure access PrEP for protection against HIV.
More research and a toolkit for providers.
These studies have informed our current research, a socio-structural intervention to improve PrEP access among cisgender women of color in the southern U.S.
As part of this intervention we are developing a toolkit, which we hope to distribute throughout the MedStar Health system, to help providers have informed, shared decision-making conversations with patients.
Tools for providers will include:
- Clinic-level training modules, ranging from HIV and PrEP basics to integrating the principles of trauma informed care into PrEP care.
- Suggested language for framing patient conversations about PrEP
- Education about destigmatizing language, including while taking a complete sexual and social history
- EHR quick text
Talking about sexual health and HIV prevention with patients can be difficult, but it is critical to supporting women’s health. Making PrEP an accessible part of the preventative care conversation will significantly benefit women—especially women of color—their families, and our communities.
Our work to understand the experience of Black women with HIV prevention is an effort to bring their perspective to the scientific literature and reduce their inequitable burden of HIV transmission in Washington, DC, and beyond. These studies are examples of MedStar Health Research Institute’s strengths: patient-centered science that enables us to provide equitable, leading-edge care.
