PrEP Knowledge and Willingness Among Cisgender Black Women for Biomedical HIV Prevention: Assessing Substance Use and Sexual History Factors

doi:10.21203/rs.3.rs-5140501/v1

Download PDF

Short Report

PrEP Knowledge and Willingness Among Cisgender Black Women for Biomedical HIV Prevention: Assessing Substance Use and Sexual History Factors

https://doi.org/10.21203/rs.3.rs-5140501/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Cisgender Black women in the U.S. have an elevated risk of HIV acquisition, although their adoption of preexposure prophylaxis (PrEP) is low. Studies indicate that increased PrEP knowledge consistently increases the willingness to take PrEP; however, studies on cis Black women are limited. This study aimed to investigate the impact of alcohol and substance use and sexual history on the association between PrEP knowledge and willingness among cis Black women reporting substance use in two emergency departments (EDs). We conducted a secondary analysis of data from 40 HIV-negative cis Black women aged 18–55 years. Using the Anderson Behavioral Model, the variables included predisposing factors (sociodemographic data, PrEP knowledge), enabling factors (income and employment), and disabling factors (alcohol/substance use, condomless sex), with PrEP willingness. Moderation models were used to examine the potential effects of the disabling factors on PrEP knowledge and willingness. The majority (95%) of the participants were PrEP knowledgeable and 52% expressed PrEP willingness. Unemployed participants showed significantly higher willingness to use PrEP and, in multivariate models, were 13.6 times more likely to be PrEP-willing. No significant association was found between PrEP knowledge, frequency of alcohol problems, substance use problems, or condomless sex in the past 30 days. A history of recent alcohol problems, substance use, and condomless sex did not significantly moderate the relationship between PrEP knowledge and willingness among cis Black women. However, employment status was a significant predictor of PrEP willingness and may be important in PrEP uptake decisions. These findings may inform future PrEP interventions and contribute to our understanding of PrEP willingness in HIV-vulnerable populations.

Infectious Diseases

Women's studies

Drug Delivery

Sexual & Reproductive Medicine

Epidemiology

Preventive Medicine

Cisgender Black women

HIV prevention

Condomless sex

Substance Use

PrEP

Black individuals in the U.S., especially cisgender Black women, are disproportionately affected by HIV, accounting for 57% of new diagnoses (CDC, 2021; Patel, 2019; Pyra, 2021; Ruppe, 2021; Sheth, 2016). In 2022, Black women constituted 9% of HIV diagnoses, but represented 50% and 41% of diagnoses among cisgender and transgender women, respectively (CDC, 2024). With one in 48 Black women expected to be diagnosed in their lifetime (Hess, 2017), addressing this issue is crucial for the U.S. plan to End the HIV Epidemic (EHE) (CDC, 2022a). Despite the proven efficacy of pre-exposure prophylaxis (PrEP) in HIV prevention (Chandler, 2020), its uptake remains inequitable and perpetuates disparities (Bonacci, 2021; Calabrese, 2017; Glidden, 2019; Sullivan, 2018). Although PrEP could benefit many women (Huang, 2018; Sales, 2019), its use among cis Black women remains low. Understanding the factors influencing PrEP-eligible Black women's willingness to use PrEP and engaging them in the PrEP care continuum (Kelley, 2015; Hojilla, 2018) is essential to reduce HIV risk.

Alcohol and substance use can significantly increase HIV risk by encouraging risky sexual behaviors and reducing PrEP adherence (Sander, 2013; Hojilla, 2018; Hill, 2017; Oldenburg, 2016). Excessive drinking diminishes the motivation for and adherence to PrEP, highlighting the need for specific PrEP outreach and customized interventions (Pasipanodya, 2021; Shuper, 2020; Kalichman, 2017; Wray, 2021). Specifically, injection drug users (IDUs) exhibit an increased HIV risk due to compromised decision-making, leading to unprotected sex (Alpren, 2020; CDC, 2022b), yet display openness to PrEP adoption (Meyer, 2021; Qin, 2020). Inconsistent and unprotected sex are key predictors of HIV risk, making PrEP essential for individuals less inclined to use condoms, including women experiencing intimate partner violence (IPV) or those skeptical of monogamous commitments (Aaron, 2018; O’Malley, 2021; Taggart, 2020; Caldwell, 2015; Chandler, 2022).

PrEP knowledge significantly influences women's willingness to use it for HIV prevention, with increased awareness and accurate education correlating with greater willingness (Auerbach, 2015; Bradley, 2019; Calabrese, 2020; Kay & Pinto, 2020; Koren, 2018; Tims-Cook, 2019). Limited awareness and misinformation often hinder cis Black women's self-referrals to PrEP services (Chandler & Hull, 2020; Hirschhorn, 2020). Targeted education enhances PrEP knowledge and willingness to adopt PrEP (Flash, 2018; Garfinkel, 2017), with well-informed women being more open to initiating PrEP (Auerbach, 2015; Ojikutu, 2018). A better understanding of PrEP is linked to higher willingness to use it, emphasizing the importance of PrEP education in future interventions (Chandler, 2020, 2022; Ojikutu & Mayer, 2021).

Conceptual Model

The Andersen Behavioral Model, a widely accepted framework, was employed to theoretically investigate the relationship between PrEP knowledge and willingness among cis Black women (Andersen, 1995; Andersen, 1973; Lambert, 2018). Utilizing this model, which considers individual (predisposing), societal (enabling/disabling), and contextual (need) factors as determinants of healthcare utilization, enhanced our understanding and facilitated the identification of constructs potentially influencing PrEP knowledge and willingness in this population (Andersen, 1995; Lambert, 2018).

Objectives

The primary objectives of this study were to explore the effects of 1) alcohol use history (alcohol problems in the past 30 days), 2) substance use history (substance use problems in the past 30 days), and 3) sexual history (condomless sex in the past 30 days) on the relationship between PrEP knowledge and willingness to use PrEP in cis Black women.

To what extent do alcohol problems in the past 30 days influence the relationship between knowledge and willingness to use PrEP?

To what extent do substance use problems in the past 30 days influence the relationship between knowledge and willingness to use PrEP?

To what extent does condomless sex in the past 30 days influence the relationship between knowledge of and willingness to use PrEP?

Parent Study Overview

We conducted a secondary analysis of baseline data from the Increasing PrEP (iPrEP) study, a randomized controlled trial (RCT) investigating a survey-based behavioral intervention among cis Black women in two emergency departments (E.D.s) in Houston, Texas, led by Dr. Mandy Hill (Hill 2022; Hill 2023). The study protocol (HSC-MS-16-0892) was approved by the Institutional Review Board of the UTHealth Houston Center for Protection of Human Subjects.

Participants

Eligible participants were HIV-negative Black women, aged 18–55, with non-emergent health issues (emergency severity index, acuity level 3+) (AHRQ, 2020), a working mobile device, English literacy (Harris, 2019), and recent history of condomless sex and substance use in the last 30 days (Hill, Heads, Cardenas-Turanzas, & Grimes, 2020). Exclusion criteria included PrEP ineligibility based on the Public Health Service Clinical Practice Guidelines (CDC, 2017), male sex at birth, use of medications contraindicated for PrEP, and current PrEP use. Of the 2,490 participants screened via electronic medical records (EMR), 58 met the inclusion criteria, and intake screening confirmed 40 eligible participants (68%), all of whom consented to participate in the study, yielding a 100% response rate.

Setting

Study recruitment at two public hospitals spanned between August 27, 2019, and July 2, 2021. Recruitment was paused from March 2020 to March 2021 due to the COVID-19 pandemic but resumed from March 2021 through July 2022. Eligible participants completed an informed consent process and pre-test surveys on tablets using Qualtrics (Qualtrics, 2021), which covered sociodemographic factors, substance use, sexual behaviors, and PrEP-related factors.

Variables

Table 1 shows how the Andersen Behavioral Model factors were organized into one of three theoretical domains–predisposing factors, enabling/disabling factors, and need factors–to ensure adequate operationalization based on precedents from previous research using this model (Andersen, 1995; Andersen, 1973).

Table 1

Conceptual Framework of the Andersen Behavioral Model Factors Influencing PrEP Knowledge and Willingness
Andersen Behavioral Model Factors
Predisposing	Enabling/Disabling	Need
Demographic Variables: - Age	Enabling Factors: (Individual/family resources) - Monthly household income - Employment status	Not applicable (NA) (Presented in the ED for non-emergent healthcare)
Social Structure Variables: - Education - Marital status - Sexual Orientation	Disabling Factors: (Key predictors) - Alcohol problems - Substance use problems - Condomless sex
Health Belief Variables: - PrEP knowledge
^aTable 1 illustrates the organization of the Andersen Behavioral Model factors into three theoretical domains: predisposing factors (demographic, social structure, and health belief variables), enabling factors (individual and family resources), and disabling factors (key predictors of risk behaviors). The 'Need' category refers to participants presenting in the emergency department for non-emergent healthcare. This framework is based on previous research by Andersen (1995, 1973).

Measures

Predisposing Factors

Sociodemographic data included age, education, marital status, and sexual orientation (D’Avanzo 2019; Chandran 2019; Seidu 2020). Age was assessed with the question, "My age (in years) is," and left continuous. Education was measured by the question "I have completed" and recoded into three groups: 0 (some high school education), 1 (high school graduate or some college), and 2 (college graduate). Marital status was determined using the question, "What is your marital status (select one)?” and recoded into two groups: 0 (unmarried) and 1 (married). Sexual orientation was determined by the question "My sexual preferences are (select one)?" with three answers: 0 (women who have sex with women (WSW]), 1 (women who have sex with men [WSM]), and 2 (women who have sex with women and men [WSWM]). PrEP knowledge was measured using a survey question explaining PrEP as a daily HIV prevention medication, coded as 0 (not PrEP-knowledgeable) or 1 (PrEP-knowledgeable) (Hill, 2022; Hill, 2023).

Enabling Factors

The enabling factors included monthly household income and employment status. Monthly household income was assessed by the question “My monthly household income is,” and was recoded into three categories: 0) less than $1,000, 1) between $1,001 and $2,000, and 2) $2,000 or more. Employment status, measured by the question “My employment status is,” had two response categories: 0) unemployed and 1) employed.

Disabling Factors

Hill et al. (2023) evaluated substance-using behaviors in three domains:1) alcohol use history, 2) substance use history, and 3) sexual history, which were determined by participants’ answers to questions regarding the frequency with which they experienced these behaviors in the past 30 days (Hill, 2020). The survey questions were specifically worded as follows; "How many days in the past 30 days have you experienced:1) alcohol problems? 2) substance use problems? 3) condomless sex?" (Hill, 2020). The response options for each measure are as follows: (0) none or zero, 1) 1–15 days, 2) 16–30 days (Hill, 2022), which are common approaches in similar studies (Floyd, 2007; Robinson, 2014; Metzger, 1992, 1993; Davies, 2016). This aligns with assessment tools such as Davie's willingness scale and the timeline follow-back method, which considers substance use and sexual risk behaviors within a specific timeframe (Davies, 1996; Bernstein, 2016; RAB, 2023). This approach is statistically valid, avoids arbitrary cutoffs, preserves ordinal data, and allows for meaningful comparisons between individuals with different engagement levels (Sobell 1996; Seidu 2020; Hill 2022).F

The 'need' category refers to participants presenting in the emergency department for non-emergent healthcare (Table 1).

Outcome Variable

The survey evaluated the willingness of individuals to uptake PrEP by posing the question, "Would you be willing to take PrEP to reduce your own risk of contracting HIV?" (Chandran, 2019; D'Avanzo, 2019; Hill, 2020). Originally designed to assess willingness to use alcohol in young adults (Davies, 2017), this scale was modified to evaluate willingness to use PrEP among Black women who reported substance use in the iPrEP study and was dichotomized as 0 (not willing [between 0–5]) and 1 (willing [between 6–10]) (Hill, 2022).

Statistical Analysis

We used descriptive statistics and Chi-square (χ^2) tests for categorical predictors and Mann-Whitney-Wilcoxon tests for continuous predictors in STATA (StataCorp. 2021) to analyze PrEP knowledge, willingness, and various variables. Alcohol problems, substance use issues, and condomless sex were converted into continuous scales to improve analytical accuracy and to manage data gaps. This included multiple imputations using chained equations to address missing data for several critical variables, thus maintaining the robustness of our model (Azur, 2011).

Linear regression models were imputed for continuous variables, with 40 observations per variable. Ten imputed datasets were utilized for reliable estimation with chained equations based on variable relationships to ensure theoretical coherence (Azur, 2011). Logistic regressions for PrEP willingness were conducted by calculating odds ratios (ORs) and 95% confidence intervals (C.I.s) using STATA (StataCorp, 2021), with statistical significance set at p < 0.05, for the predisposing, enabling, and disabling factors.

Moderation Analyses

Moderation analyses were conducted to examine the influence of the enabling/disabling factors on the relationship between PrEP knowledge and willingness. The predictor and moderator variables were mean-centered to address multicollinearity and simplify interpretation. Three logistic regression models were used to test the three research hypotheses, with PrEP willingness as the outcome variable.

Hypothesis 1

Alcohol problems will moderate the relationship between PrEP knowledge and willingness to use PrEP such that the relationship will be weaker among cis Black women with more days of alcohol problems.

Hypothesis 2

Substance use problems will moderate the relationship between PrEP knowledge and willingness to use PrEP such that the relationship will be weaker among cis Black women with more days of substance use problems.

Hypothesis 3

Engaging in condomless sex moderates the relationship between PrEP knowledge and willingness to use PrEP such that the relationship will be weaker among cis Black women who engage in more days of condomless sex.

Socio-demographic Characteristics

Predisposing Factors. The average age of the participants was 33 (SD = 8.5) years, ranging from 18 to 53 years. Regarding level of education, 57% (n = 23) had completed high school, 20% (n = 8) had some high school education, and 23% (n = 9) were college graduates. Most participants identified as WSM (77%, n = 31) and were unmarried (77%, n = 31). A high level of PrEP knowledge was observed, with 95% (n = 38) of participants being knowledgeable about PrEP.

Enabling Factors. The financial status of the participants varied: 48% (n = 19) reported a monthly household income below $1,000, 20% (n = 8) fell within the $1,001–$2,000 bracket, and 30% (n = 12) earned $2,000 or more monthly. Regarding employment, 58% (n = 23) of participants were employed.

Disabling Factors. Alcohol consumption patterns in the last 30 days varied, with 23% reporting no alcohol problems, 46% experiencing problems for 1–15 days, and 31% experiencing problems for 16–30 days. Substance use problems in the past 30 days were reported by 29% of the participants, while 47% had problems for 1–15 days and 24% for 16–30 days. Regarding sexual behavior, 21% did not have condomless sex in the past 30 days, 54% engaged in it for 1–15 days, and 25% engaged in condomless sex for 16–30 days. Overall, 53% (n = 21) of the participants expressed willingness to take PrEP to reduce their HIV risk (Table 2).

Table 2

Socio-Demographic and Behavioral Characteristics of the Sample (N = 40)
Variable	Category	Frequency	Percent
Predisposing Factors
Age (in years)	(continuous)	M = 33 yrs.	SD 8.5
Education level	0. Some high school education 1. High school graduate 2. College graduate	8 23 9	20% 57% 23%
Marital status	0. Unmarried 1. Married	31 9	77% 23%
Sexual orientation	0. WSW 1. WSM 2. WSWM	1 31 8	3% 77% 20%
PrEP knowledge	0. Not PrEP knowledgeable 1. PrEP knowledgeable	2 38	5% 95%
Enabling/Disabling Factors
Monthly household income	0. Less than $1000 1. Between $1,001 and $2,000 2. $2,000 or more	19 8 12	48% 20% 30%
Employment status	0. Unemployed 1. Employed	17 23	42% 58%
Disabling Factors
Alcohol problems in the past 30 days	0. None or zero 1. 1–15 days 2. 16–30 days	3 6 4	23% 46% 31%
Substance use problems in the past 30 days	0. None or zero 1. 1–15 days 2. 16–30 days	5 8 4	29% 47% 24%
Condomless sex in the past 30 days	0. None or zero 1. 1–15 days 2. 16–30 days	6 15 7	21% 54% 25%
PrEP outcome
PrEP willingness	0. Not willing (between 0–5) 1. Willing (between 6–10)	19 21	47% 53%
^aTable 2 describes the sociodemographic and behavioral characteristics of the study sample, including predisposing factors (age, education level, marital status, sexual orientation, and PrEP knowledge), enabling/disabling factors (monthly household income and employment status), and disabling factors (alcohol and substance use problems and condomless sex).
^bMean (SD); N (%) = frequency and percentages.

Bivariate Analysis of PrEP Willingness and PrEP Knowledge

Our bivariate analysis investigated the association of PrEP willingness and knowledge with various predisposing, enabling, and disabling factors.

Predisposing Factors

There were no significant associations between participants' age and their willingness to take PrEP (p = .34) or their knowledge of PrEP (p = .45). Regarding education, there was no significant correlation with PrEP willingness (p = .40) or PrEP knowledge (p = .49) across education levels.

Marital status was also not significantly associated with PrEP willingness, with currently married individuals showing 44% willingness and those who were not married showing 55% willingness (p = .58). Knowledge of PrEP was high among married (100%) and unmarried (94%) participants, with no significant difference (p = .43). Regarding sexual orientation, the analysis did not reveal a significant association with willingness to take PrEP, with 0% WSW, 48% WSM, and 75% WSWM showing willingness (p = .23). PrEP knowledge was consistently high, although it was not significantly different across all sexual orientations (p = .74).

Enabling Factors

We observed a significant association between employment status and PrEP willingness (p = .00), indicating that unemployed participants showed a higher willingness to use PrEP (77%) than employed participants (35%). However, employment status was not significantly correlated with PrEP knowledge (p = .21). For monthly household income, the analysis did not reveal a significant association with PrEP willingness (p = .68). Similarly, knowledge of PrEP was high but not significantly different across all income brackets (p = .71).

Disabling Factors. Our study did not find a significant correlation between alcohol problems in the past 30 days and PrEP willingness (p = .31) or PrEP knowledge (p = .89). While substance use problems did not show a significant association with PrEP knowledge (p = .91), there was a trend towards PrEP willingness (p = .07), potentially warranting further research. Over the past 30 days, the frequency of condomless sex was not significantly associated with either PrEP willingness (p = .42) or knowledge (p = .95) (Table 3).

Table 3

Bivariate Analyses of PrEP Willingness and Knowledge by Socio-Demographic and Behavioral Factors
Variable	Category	PrEP willingness		PrEP knowledge
		N, %	p-value	N, %	p-value
Predisposing Factors
Age (in years)	Continuous		.34		.45
Education	0) Some HS 1) HS grad or some college 2) College grad	5 (63%) 13 (56%) 3 (33%)	.40	7 (87%) 22 (95%) 9 (100%)	.49
Marital status	0) Currently married 1) Not married	4 (44%) 17 (55%)	.58	9 (100%) 29 (94%)	.43
Sexual orientation	0) WSW 1) WSM 2) WSWM	0 15 (48%) 6 (75%)	.23	1 (100%) 29 (94%) 8 (100%)	.74
Enabling Factors
Monthly household income	0) Less than $1,000 1) Between $1,001- $2,000 2) $2,000 or more	11 (58%) 4 (50%) 5 (41%)	.68	18 (95%) 8 (100%) 11 (92%)	.71
*Employment status	0) Unemployed 1) Employed	13 (77%) 8 (35%)	*.00	17 (100%) 21 (91%)	.21
Disabling Factors
Alcohol problems in the past 30 days	0) None or zero 1) 1–15 days 2) 16–30 days		.31		.89
Substance use problems in the past 30 days	0) None or zero 1) 1–15 days 2) 16–30 days		.07		.91
Condomless sex in the past 30 days	0) None or zero 1) 1–15 days 2) 16–30 days		.42		.95
^aTable 3 presents the findings from bivariate analyses exploring the associations between PrEP willingness and knowledge with various predisposing factors (age, education level, marital status, and sexual orientation), enabling (monthly household income, employment status), and disabling factors (alcohol and substance use problems, and condomless sex).
^bN (%) = frequency and percentages; p < 0.05 indicates a statistically significant association.

Logistic Regression Analysis of Predictors for PrEP Willingness

Most predisposing sociodemographic factors, including age, education level, sexual orientation, and marital status, were not significantly associated with PrEP willingness in the multivariate models. Employment status was a significant predictor of willingness for PrEP uptake. Unemployed individuals were 13.6 times more likely to be PrEP-willing (AOR = 13.6, p = .03, 95% CI [0.13, 5.08]) than their employed counterparts did. However, income was not significantly associated with the willingness to take PrEP for HIV prevention. Regarding disabling factors, alcohol problems (p = .99), substance use problems (p = .59), and condomless sex (p = .97) in the past 30 days were not significantly associated with willingness (StataCorp, 2021) (Table 4).

Table 4

Logistic Regression Analysis of Predictors for PrEP Willingness
Predictors	B	SE	AOR	P	95% CI
Predisposing Factors
Age	− .1	.97	.89	.28	− .30, .08
Level of education	-1.03	1.00	.35	.31	-3.02, .95
Sexual orientation	.59	.64	1.80	.36	− .67, 1.85
Marital status	− .06	1.09	.93	.95	-2.20, 2.07
Enabling Factors
Monthly household income	1.11	1.01	3.04	.27	− .88, 3.10
*Employment Status	2.61	1.0	13.6	*.03	.13, 5.08
Disabling Factors
Alcohol problems in the past 30 days	− .00	.071	.99	.99	− .15, .14
Substance use problems in the past 30 days	− .04	.07	.95	.59	− .12, .20
Condomless sex in the past 30 days	− .00	.06	.99	.97	− .13, .13
^aTable 4 displays the results of the logistic regression analysis examining the predictors of PrEP willingness.
^bAOR = Adjusted Odds Ratio.
^cStatistical significance is indicated at p < .05.
^d95% CI = 95% Confidence Interval.

Moderation Analyses

The main effects model for Hypothesis 1 examined the impact of alcohol problems on the willingness to use PrEP. The moderation analysis did not find a significant moderating effect of alcohol problems in the last 30 days on the relationship between PrEP knowledge and willingness to use PrEP (B = .10, SE = .08, t = 1.30, p = .19, 95% CI [-0.05, 0.26]) (Table 5).

Table 5

Moderation Findings for Main Effects Models (Hypothesis 1, 2, and 3)
Variable	B	S.E.		t	p		[95% CI]
HYPOTHESIS 1 (Alcohol problems in the past 30 days):
PrEP knowledge (centered)	Omitted
Alcohol problems (centered)	.10	.08		1.30	.19		[-.05, .26]
Interaction knowledge X alcohol problems	Omitted
Age (centered)	0.00	0.10		0.01	0.99		[-.20, .20]
Monthly household income (centered)	-1.07	1.54		-0.69	0.48		[-4.09, 1.95]
Constant	-0.12	1.02		-0.12	0.90		[-2.13, 1.89]
HYPOTHESIS 2 (Substance use problems in the past 30 days):
Substance use problems in the past 30 days	.25	.13		1.89	.059		[-.00, .51]
Age	− .11	.11		-1.03	.30		[-.34, .10]
Interaction (knowledge X substance use problems)	Omitted
Monthly household income	-2.33	2.00		-1.17	.24		[-6.26, 1.59]
Intercept	-1.06	1.35		− .78	.43		[-3.73, 1.59]
HYPOTHESIS 3 (Condomless sex problems in the past 30 days):
PrEP knowledge	Omitted
Condomless sex problems in the past 30 days	.02	.04		.66	.50		[-.05, .11]
Interaction (knowledge X condomless sex)	Omitted
Age	.02	.05	.37		.71	[-.09, .13]
Monthly household income	− .13	.50	− .27		.78	[-1.11, .84]
^aTable 5 describes the moderation findings for the main effects model testing Hypothesis 1, examining the impact of alcohol problems on PrEP willingness; the moderation findings of the main effects model testing Hypothesis 2, examining the impact of substance use problems on PrEP willingness; and the findings from the main effects model testing Hypothesis 3, examining the impact of condomless sex on PrEP willingness in the past 30 days.
^bSE = Standard Error.
^cStatistical significance is indicated at p < .05.
^d95% CI = 95% Confidence Interval [lower, upper].

The main effects model for Hypothesis 2 examines the impact of substance use problems on PrEP willingness. Despite the initial model estimation challenges (perfect prediction) (StataCorp. 2021) in the moderation analysis, we applied Firth's logistic regression to each imputed dataset, adhering to Rubin’s rules (1987). The analysis revealed a relationship between substance use problems in the past 30 days and willingness to use PrEP (B = .25, SE = .13, z = 1.89, p = .059, 95% CI [-.00, .051]) (Table 5). Although not statistically significant at the set level, with a p-value of .059, this suggests a potential association that merits further examination in future studies.

The main effects model for Hypothesis 3 examined the impact of condomless sex on PrEP willingness over the past 30 days. Conducted using ten imputations, the moderation analysis for Hypothesis 3 indicated that the frequency of condomless sex in the past 30 days did not significantly moderate the relationship between PrEP knowledge and willingness to use PrEP (B = .02, SE = .04, z = .66, p = .50, 95% CI [-.05, .11]), and thus was not a significant predictor of PrEP willingness (Table 5).

This study examined the associations between PrEP knowledge, willingness, sociodemographic factors, problematic alcohol and substance use, and recent condomless sex among cis Black women. Unemployment was linked to higher PrEP willingness, while education, sexual orientation, marital status, and income were not significantly related to PrEP knowledge or willingness. Studies have shown a significant interest in PrEP use among cis Black women at risk for HIV (Haider, 2022; Kerr, 2022; Towe, 2020; Ransome, 2020). Despite high PrEP awareness, only 52% of cis Black women in our study were willing to use it, primarily due to concerns about side effects outweighing perceived benefits (Hill, 2023). PrEP knowledge encourages information seeking and greater willingness to use the medication (Auerbach, 2015; Ojikutu, 2018). However, this discrepancy in willingness highlights the need to address barriers beyond knowledge dissemination for effective PrEP uptake. High PrEP knowledge alone does not guarantee willingness or uptake, indicating that additional support is crucial for enhancing overall willingness among cis Black women (Villalba, 2022; Johnson, 2022).

Age and PrEP Knowledge and Willingness

Our research revealed no significant differences in PrEP knowledge among various age groups, yet a strong positive correlation exists between age and PrEP knowledge, suggesting that understanding PrEP increases with age. This correlation aligns with the predisposing factors of the model, emphasizing that age may be crucial for PrEP knowledge acquisition. Higher PrEP knowledge correlates with hesitancy in younger participants, who may be reluctant due to unfamiliarity with the medication (Ayangeakaa, 2023). Ayangeakaa (2023) also noted that young individuals are uncertain about the appropriateness and affordability of PrEP. These findings suggest that while knowledge increases with age, younger Black women's willingness to use PrEP may be hindered by their limited understanding and related apprehensions.

Age did not significantly influence PrEP willingness in our study, consistent with the findings of Towe (2020) and Shrestha (2018) among substance-using women. Conversely, Elopre (2022) and Baldwin (2021) observed higher willingness among younger sex workers, whereas Restar (2018) and Scott (2019) reported increased willingness among older individuals. The inconsistent role of age in PrEP willingness highlights its complexity, warranting additional research to understand its nuanced impact on PrEP uptake.

Education and PrEP Knowledge and Willingness

No significant association was found between education level and PrEP knowledge or willingness among cis-Black women, which is consistent with prior research (Stein, 2014; Tekeste, 2019). This implies that PrEP access disparities may originate from factors such as medical mistrust, lower income, and limited PrEP knowledge, rather than education level per se. The complex interactions between education level and PrEP disparities warrant further investigation. These paradoxical findings emphasize the necessity for comprehensive research to elucidate the intricate relationships between education, knowledge acquisition, and willingness to use PrEP for HIV prevention.

Sexual Orientation and PrEP Willingness

Our study found that women engaging sexually with both genders exhibited a higher willingness to use PrEP, although this was not statistically significant when compared to WSW and WSM. This might be due to the perceived or actual increased risk from diverse sexual partners, but the small sample size limits definitive conclusions. The observed willingness among cis-women with both-gender sexual encounters underscores the importance of partner-related risk perceptions in PrEP adoption. The non-significant decrease in willingness among certain groups highlights the need for culturally sensitive interventions to address the diverse factors influencing PrEP adoption among cis-Black women.

Marital Status and PrEP Willingness

Investigating marital status within the Andersen Behavioral Model revealed no significant link to willingness to initiate PrEP. Previous studies have indicated that cis-women in monogamous relationships are less likely to consider PrEP due to a perceived lower risk (Willie, 2021; Chandler, 2022), suggesting that HIV risk perception impacts PrEP deliberation. Young, single cis-women are more receptive to PrEP adoption (Willie, 2021), and unmarried or non-cohabiting individuals show higher willingness to use PrEP (Uzoeghelu, 2021; Ojikutu, 2021).

Employment and PrEP Willingness

Unemployment was significantly correlated with higher PrEP willingness even after adjusting for confounders, emphasizing the influence of social, cultural, and economic factors on women's HIV vulnerability and PrEP willingness (Aholou, 2017; Wingood & DiClemente, 2000; Willie, 2021). Addressing structural barriers such as poverty and under-employment is crucial in PrEP engagement interventions (Nydegger, 2021).

Income and PrEP Willingness

The study found no significant association between monthly household income and PrEP adoption willingness. PrEP affordability and cost issues are influenced by socio-structural factors such as racialized gender pay inequities, limiting Black women's ability to afford PrEP, and exacerbating economic inequality (Willie, 2021). Lower-income individuals may be more inclined to initiate PrEP because of cost concerns and the need for financial support (Cheek, 2022; Arnold, 2022). Paradoxically, high-income individuals ($50,000+) were less likely to use PrEP compared to those earning $15,000 or less (Wingood, 2014), highlighting the complex relationship between income and PrEP willingness, with affordability and insurance being crucial factors (Stein, 2014; Towe, 2020).

Condomless Sex and PrEP Willingness

The association between engaging in condomless sex and willingness to adopt PrEP offers insights into the interaction between risk behaviors and preventive strategies. Individuals engaging in condomless sex exhibited higher PrEP knowledge, albeit not statistically significant, potentially indicating information-seeking tendencies among those involved in high-risk behaviors. While condomless sex is generally associated with increased PrEP willingness owing to related risks (Bond, 2017), our results diverge from this pattern. Nevertheless, this study offers valuable insights into the intricate relationship between condomless sex, PrEP knowledge, and willingness, emphasizing the need for additional research on Black women's sexual practices.

Alcohol and Substance Use Problems and PrEP Willingness

Self-reported problematic alcohol use did not significantly influence the relationship between PrEP knowledge and willingness, aligning with Walter’s (2017) findings in women who inject drugs. While Kalichman (2017) noted that high alcohol consumption may decrease PrEP willingness, individuals with higher alcohol intake might perceive a greater need for PrEP because of intoxication-related behaviors that increase HIV risk (Oldfield, 2021). Moreover, Shah (2019) discovered that unhealthy alcohol use during sexual encounters did not correlate with PrEP willingness among young adult women.

Self-reported problematic substance use in the past 30 days was not significantly associated with PrEP willingness and knowledge (p = .059); however, the results indicate a potential connection that merits further examination with a larger sample. Understanding the influence of problematic alcohol and substance use frequency on PrEP knowledge and willingness is essential for HIV prevention research in key demographic groups.

Implications

This cross-sectional study yielded preliminary insights into the factors influencing PrEP uptake among cis Black women, indicating the need for future research on tailored interventions. Targeted outreach should encompass community workshops, counseling, and customized materials to address specific concerns, lifestyles, and structural barriers. The study also identified a non-significant link between PrEP knowledge and willingness concerning problematic substance use, suggesting further investigation. This potential link underscores the importance of incorporating substance use considerations into PrEP education and support. Initiatives such as Just4Us, which offer theory-based behavioral counseling and adherence strategies (Teitelman, 2021), and UT-HEARTS, which integrate substance use and HIV/AIDS prevention services (TEMRC, 2020), could inform future programs to enhance PrEP uptake tailored to cis Black women's needs, particularly those at high risk of HIV transmission.

Limitations

The data analysis framework employed in this study had both strengths and limitations. The finite sample size reduced the statistical power but was designed for the parent study's research questions. Confidence intervals reliably replace post-hoc power calculations. Comprehensive evaluations risk Type I errors, where false significance emerges. Logistic regression analysis was used to identify relationships without causality. Multiple imputation using chained equations addresses missing data gaps (Azur, 2011) but is problematic with invalid assumptions. Firth's logistic regression on individual imputed datasets and Rubin's rules (Rubin, 1987) strategically respond, although Ahmed and Cheng (2020) noted potential reliability issues compared with logistic regression. Despite these challenges, this study demonstrated the methodological accuracy of managing complex statistical issues.

This study explored cis-Black women's willingness to adopt PrEP. While PrEP knowledge was high, employment status and problematic substance use history affected their decision to use it. Traditional sociodemographic factors such as education and income did not significantly impact PrEP knowledge or willingness. These findings indicate that interventions should consider factors beyond sociodemographics to enhance the willingness to take PrEP.

Funding

The study data were obtained from a parent study supported by Gilead Sciences, Inc. (IN-US-276-5464, PI: Hill) through an Investigator Sponsored Research award awarded to MH. The funding source was not involved in the development, execution, analysis, interpretation, or writing of this research or its results.

Conflict of Interests

MH conducted the research with grant support from Gilead Sciences Inc. (IN-US-276-5464). However, the conflict was mitigated as the sponsor of this research was UTHealth Houston.

Financial Interests

The authors MH and RS declare that they have competing financial interests. Each author received salary support for the parent study, from which this data is derived through an investigator-sponsored research award by Gilead Sciences, Inc. (IN-US-276-5464).

Data Availability

Not applicable. The participants of this study did not provide written consent for their data to be shared publicly; therefore, due to the sensitive nature of the research, supporting data is not available.

Code Availability

Not applicable. No new software applications or custom codes were used during manuscript preparation.

Authors Contributions

To facilitate masked (i.e., double-blind) peer review, please see the authors’ contributions on the accompanying title page.

Compliance with Ethical Standards

Research Involving Human and Animal Rights

The study protocol for the trial (HSC-MS-16-0892) was approved by the Institutional Review Board of the UTHealth Center for Protection of Human Subjects. The trial was registered at ClinicalTrials.gov (NCT03930654, 29/04/2019).

Informed Consent

Informed consent was obtained from all participants for participation in the parent study. All methods were performed in accordance with the relevant guidelines and regulations.

Consent to Participate

All participants in the parent study were informed of the study's purpose and signed informed consent forms before engaging in the study activities. Participants were assured of the confidentiality of their information and all responses were coded anonymously.

Consent for Publication

The authors agree to the publication of the data, images, and results of this study submitted in this manuscript. All human subjects freely and willingly provided informed consent during the parent study to participate in the research activities.

Ethical Approval

The institutional review board at UTHealth, The Center for Protection of Human Subjects, approved the study protocol for the parent study (HSC-MS-16-0892) from which these data were derived. All procedures performed in the parent study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Aaron E, Blum C, Seidman D, Hoyt MJ, Simone J, Sullivan M, Smith DK (2018) Optimizing delivery of HIV preexposure prophylaxis for women in the United States. AIDS Patient Care STDs 32(1):16–23. 10.1089/apc.2017.0201
Ahmed I, Cheng W (2020) The Performance of Robust Methods in Logistic Regression Model. Open J Stat 10:127–138. 10.4236/ojs.2020.101010
Aholou TM, McCree DH, Oraka E, Jeffries WL, Rose CE, DiNenno E (2017) Sexual risk and protective behaviors among reproductive-aged women in the United States. Journal of Women's Health (2002), 26(11), 1150–1160. 10.1089/jwh.2016.6224
AHRQ (2020) Emergency Severity Index (ESI): Triage tool for emergency dept. care V.4 implementation handbook, 2012 Ed. Agency for Healthcare Research and Quality
Alpren C, Dawson EL, John B, Cranston K, Panneer N, Fukuda HD, Buchacz K (2020) Opioid use fueling HIV transmission in an urban setting: An outbreak of HIV infection among people who inject drugs-Massachusetts, 2015–2018. Am J Public Health (1971) 110(1):37–44. 10.2105/AJPH.2019.305366
Andersen RM (1995) Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav 36(1):1–10
Anderson JG (1973) Health Service Utilization. Health Services Research, 8(3), 184–199. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071757/
Arnold T, Whiteley L, Elwy RA, Ward LM, Konkle-Parker, Brock J (2022) B., Mapping implementation science with expert recommendations for implementing change (MIS-ERIC): Strategies to improve PrEP use among black cisgender women in Mississippi. Cham]: Springer International Publishing. 10.1007/s40615-022-01452-x
Auerbach JD, Kinsky S, Brown G, Charles V (2015) Knowledge, attitudes, and likelihood of pre-exposure prophylaxis (PrEP) use among U.S. women at risk of acquiring HIV. AIDS Patient Care STDs 29(2):102–110. 10.1089/apc.2014.0142
Ayangeakaa SD, Kerr J, Combs R, Harris L, Sears J, Parker K (2023) Understanding influences on intention to use preexposure prophylaxis (PrEP) among African American young adults. J Racial Ethnic Health Disparities 10(2):899–910. 10.1007/s40615-022-01278-7
Baldwin A, Light B, Allison WE (2021) Preexposure prophylaxis (PrEP) for HIV infection in cisgender and transgender women in the U.S.: A narrative review of the literature. Arch Sex Behav 50(4):1713–1728. 10.1007/s10508-020-01903-8
Bond KT, Gunn AJ (2017) Perceived advantages and disadvantages of using preexposure prophylaxis (PrEP) among sexually active black women. J Black Sexuality Relationships 3(1):1–24. 10.1353/bsr.2016.0019
Bradley E, Forsberg K, Betts JE, DeLuca JB, Kamitani E, Porter SE, Hoover KW (2019) Factors affecting preexposure prophylaxis implementation for women in the United States: A systematic review. J Women’s Health (2002) 28(9):1272–1285. 10.1089/jwh.2018.7353
Calabrese SK, Galvao RW, Dovidio JF, Willie TC, Safon CB, Kaplan C, Kershaw TS (2020) Contraception as a potential gateway to preexposure prophylaxis: U.S. women’s preexposure prophylaxis modality preferences align with their birth control practices. AIDS Patient Care STDs 34(3):132–146. 10.1089/apc.2019.0242
Centers for Disease Control and Prevention (2019) PrEP | HIV basics | HIV/AIDS | CDC. Retrieved from https://www.cdc.gov/hiv/basics/prep.html
Centers for Disease Control and Prevention (2021) HIV Surveillance Reports. Retrieved from https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
Centers for Disease Control and Prevention (2022a) Ending the HIV epidemic in the U.S. (EHE) | CDC. Retrieved from https://www.cdc.gov/endhiv/index.html
Centers for Disease Control and Prevention (2022b) HIV among people who inject drugs | HIV by group | HIV/AIDS | CDC. Retrieved from https://www.cdc.gov/hiv/group/hiv-idu.html
Centers for Disease Control and Prevention Estimated HIV incidence and prevalence in the United States, 2018–2022. HIV Surveillance Supplemental Report 2024;29(1). https://www.cdc.gov/hiv-data/nhss/estimated-hiv-incidence-and-prevalence.html. Published May 2024
Chandler R, Guillaume D, Wells J, Hernandez N (2022) Let me prep you to PREP me: Amplifying the voices of black women and their providers to consider PrEP as an HIV prevention option. Int J Environ Res Public Health 19(3). 10.3390/ijerph19031414
Chandler R, Hernandez N, Guillaume D, Grandoit S, Branch-Ellis D, Lightfoot M (2020) A community-engaged approach to creating a mobile HIV prevention app for black women: Focus group study to determine preferences via prototype demos. JMIR mHealth health 8(7). 10.2196/18437
Chandler R, Hull S, Ross H, Guillaume D, Paul S, Dera N, Hernandez N (2020) The preexposure prophylaxis (PrEP) consciousness of black college women and the perceived hesitancy of public health institutions to curtail HIV in black women. BMC Public Health 20. 10.1186/s12889-020-09248-6
Chandran A, Marcell AV, Sanders RA, Perin J, Page KR, Loosier PS, Jennings JM (2019) Characteristics of the provider-patient encounter associated with awareness of and willingness to take PrEP among young minority urban males in Baltimore city. AIDS Educ Prev 31(3):237–245. 10.1521/aeap.2019.31.3.237
Cheek JB, Feldman MB, Montero N, Gambone GF, Hoffman S, Blackstock OJ (2022) Preexposure prophylaxis (PrEP) initiation among black and Latina cisgender women receiving HIV prevention care coordination services in New York City AIDS and Behavior. 26(10):3174–3184. 10.1007/s10461-022-03661-1
Collier KL, Colarossi LG, Sanders K (2018) A PrEP information and self-screening tool for women. AIDS Educ Prevention: Official Publication Int Soc AIDS Educ 30(1):13–25. 10.1521/aeap.2018.30.1.13
D'Avanzo P, Bass A, Brajuha SB, Gutierrez-Mock J, Ventriglia L, Wellington N, C., Sevelius J (2019) Medical mistrust and PrEP perceptions among transgender women: A cluster analysis. Behav Med (Washington D C) 45(2):143–152. 10.1080/08964289.2019.1585325
Elopre L, Boutwell A, Gordon B (2022) PrEP service delivery preferences of black Cis-gender women living in the Southern United States. AIDS Behav 26:3469–3479. https://doi.org/10.1007/s10461-022-03691-9
El-Bassel N, Caldeira NA, Ruglass LM, Gilbert L (2009) Addressing the unique needs of African American women in HIV prevention. Am J Public Health 99(6):996–1001. 10.2105/AJPH.2008.140541
Flash CA, Adegboyega OO, Yu X, Avalos C, Johnson S, Mayer KH, Giordano TP (2018) Correlates of linkage to HIV preexposure prophylaxis (PrEP) among HIV testing clients. J Acquir Immune Defic Syndr 77(4):365–372. 10.1097/QAI.0000000000001605
Garfinkel DB, Alexander KA, McDonald-Mosley R, Willie TC, Decker MR (2017) Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients. AIDS Care 29(6):751–758. 10.1080/09540121.2016.1234679
Gelberg L, Andersen RM, Leake BD (2000) The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health Serv Res 34(6):1273–1302. ncbi.nlm.nih.gov/pmc/articles/PMC1089079/
Glidden DV, Mehrotra ML, Dunn DT, Geng EH (2019) Mosaic effectiveness: Measuring the impact of novel PrEP methods. Lancet HIV 6(11):e800–e806. 10.1016/S2352-3018(19)30227-9
Haider S, Friedman EE, Ott E, Moore A, Pandiani A, Desmarais C (2022) Knowledgeable, aware, and interested: Young Black women's perceptions of preexposure prophylaxis. Front Reproductive Health 4:671009. 10.3389/frph.2022.671009
Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, Duda SN (2019) The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 95:103208. https://doi.org/10.1016/j.jbi.2019.103208
Hess KL, Hu X, Lansky A, Mermin J, Hall HI (2017) Lifetime risk of a diagnosis of HIV infection in the United States. Ann Epidemiol 27(4):238–243. 10.1016/j.annepidem.2017.02.003
Hill MJ, Granado M, Villarreal Y, Fuega J, Robinson DJ, Stotts AL (2017) Predictors of sexual scripts among young, sexually active, substance-using African American women. Journal of AIDS and Clinical Research, 8(1) Retrieved from https://www.cabdirect.org/cabdirect/abstract/20173321003
Hill MJ, Andrews S (2017) Evolution of the sexual script: Insight into sexual decision making among young African American women. J Gen Emerg Med, 2(4)
Hill MJ, Heads AM, Green C, Suchting R, Stotts AL (2022) Pilot testing the effectiveness of whether a survey-driven tablet-based intervention increased willingness of black women to attend to an initial PrEP clinic visit: The protocol for the pilot randomized controlled trial design and methods. Contemp Clin Trials Commun 29:100985. 10.1016/j.conctc.2022.100985
Hill MJ, Heads AM, Suchting R, Stotts AL (2023) A survey with interventional components delivered on tablet devices versus usual care to increase preexposure prophylaxis uptake among cisgender Black women: a pilot randomized controlled trial. BMC Infect Dis 23(1):57. https://doi.org/10.1186/s12879-023-08019-z
Hill MJ, Heads AM, Cardenas-Turanzas M, Grimes RM (2020) PrEP education and awareness building through an intervention for African Americans reporting both condomless sex and substance use during an emergency department visit. AIDS Care. https://doi.org/10.24966/ACRS-7370/100028
Hillis A, Germain J, Hope V, McVeigh J, Van Hout MC (2020) Preexposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM): A scoping review on PrEP service delivery and programming. AIDS Behav 24(11):3056–3070. 10.1007/s10461-020-02855-9
Hirschhorn LR, Brown RN, Friedman EE, Greene GJ, Bender A, Christeller C, Ridgway JP (2020) Black cisgender women’s PrEP knowledge, attitudes, preferences, and experience in Chicago. J Acquir Immune Defic Syndr 84(5):497–507. 10.1097/QAI.0000000000002377
Hodder SL, Justman J, Haley DF, Adimora AA, Fogel CI, Golin CE, El-Sadr WM (2010) Challenges of a hidden epidemic: HIV prevention among women in the United States. J Acquir Immune Defic Syndr 55(Suppl 2):S69–S73. 10.1097/QAI.0b013e3181fbbdf9
Hojilla JC, Vlahov D, Glidden DV, Amico KR, Mehrotra M, Hance R, Carrico AW (2018) Skating on thin ice: Stimulant use and sub-optimal adherence to HIV preexposure prophylaxis. Journal of the International AIDS Society, 21(3), e25103-n/a. 10.1002/jia2.25103
Hojilla JC, Hurley LB, Marcus JL, Silverberg MJ, Skarbinski J, Satre DD, Volk JE (2021) Characterization of HIV preexposure prophylaxis use behaviors and HIV incidence among U.S. adults in an integrated health care system. JAMA Netw Open 4(8):e2122692. 10.1001/jamanetworkopen.2021.22692
Huang YA, Zhu W, Smith DK, Harris N, Hoover KW (2018) HIV preexposure prophylaxis by race and ethnicity — United States, 2014–2016. Morbidity and Mortality Weekly Report, 67(41), 1147–1150. 10.15585/mmwr.mm6741a3
Johnson R, Myers D, McKellar M, Saint-Hillaire L, Randolph SD (2021) Perspectives of Black women in the United States on salon-based intervention to promote the uptake of preexposure prophylaxis (PrEP) for HIV. J Clin Nurs 30(21–22):3281–3289. https://doi.org/10.1111/jocn.15838
Kalichman SC, Eaton L (2017) Alcohol-antiretroviral interactive toxicity beliefs as a potential barrier to HIV preexposure prophylaxis among men who have sex with men. J Int AIDS Soc 20(1). 10.7448/IAS.20.1.21534
Kay ES, Pinto RM (2020) Is insurance a barrier to HIV preexposure prophylaxis? clarifying the issue. Am J Public Health 110(1):61–64. 10.2105/AJPH.2019.305389
Kelley CF, Kahle E, Siegler A, Sanchez T, Del Rio C, Sullivan PS, Rosenberg ES (2015) Applying a PrEP continuum of care for men who have sex with men in Atlanta, GA. Clin Infect Dis 61(10):1590–1597. doi.org/10.1093/cid/civ664
Kerr J, Ayangeakaa S, Bullock NAA, Burton K, Combs R, Harris L A qualitative exploration of various stigmas impacting HIV preexposure prophylaxis (PrEP) uptake among African American young adults. Fam Community Health, 45(4), 218–227. 10.1097/FCH.0000000000000346
Koren DE, Nichols JS, Simoncini GM (2018) HIV preexposure prophylaxis and women: Survey of the knowledge, attitudes, and beliefs in an urban obstetrics/gynecology clinic. AIDS Patient Care STDs 32(12):490–494. 10.1089/apc.2018.0030
Kulie P, Castel AD, Zheng Z, Powell NN, Srivastava A, Chandar S, McCarthy ML (2020) Targeted screening for HIV preexposure prophylaxis eligibility in two emergency departments in Washington, D.C. AIDS Patient Care and STDs. 34(12):516–522. 10.1089/apc.2020.0228
Lambert CC, Marrazzo J, Amico KR, Mugavero MJ, Elopre L (2018) PrEParing women to prevent HIV: An integrated theoretical framework to PrEP black women in the United States. J Association Nurses AIDS Care: JANAC 29(6):835–848. 10.1016/j.jana.2018.03.005
Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE (2014) Intimate partner violence and HIV infection among women: a systematic review and meta-analysis. Journal of the International AIDS Society, 17(1).10.7448/IAS.17.1.18845
Hill M, Andrews S, Granado M, Nielsen E, Grimes R (2018) Just: An Indicator of Minimized Value of the Sexual Act. HIV AIDS Res J 1:2
Meyer J, Price C, Tracey D, Sharpless L, Song Y, Madden L, Altice F (2021) Preference for and efficacy of a PrEP decision aid for women with substance use disorders. Patient Prefer Adherence 15:1913–1927. 10.2147/PPA.S315543
Nydegger LA, Dickson-Gomez J, Ko TK (2021) A longitudinal, qualitative exploration of perceived HIV risk, healthcare experiences, and social support as facilitators and barriers to PrEP adoption among Black women. AIDS Behav 25(2):582–591. 10.1007/s10461-020-03015-9
Ojikutu BO, Bogart LM, Higgins-Biddle M, Dale S, Allen W, Dominique T, Mayer KH (2018) Facilitators and barriers to preexposure prophylaxis (PrEP) use among black individuals in the United States: Results from the National Survey on HIV in the Black community (NSHBC). AIDS Behav 22(11):3576–3587. 10.1007/s10461-018-2067-8
Ojikutu BO, Bogart LM, Ransome Y, Ojikutu BO, Bogart LM, Mayer KH (2019) Spatial access and willingness to use preexposure prophylaxis among black/African American individuals in the United States: A cross-sectional survey. JMIR, Toronto. 10.2196/12405
Ojikutu BO, Mayer K (2021) HIV prevention among black women in the US-time for multimodal integrated strategies. JAMA Netw Open 4(4):e215356. 10.1001/jamanetworkopen.2021.5356
Oldenburg CE, Mitty JA, Biello KB, Closson EF, Safren SA, Mayer KH, Mimiaga MJ (2016) Differences in attitudes about HIV preexposure prophylaxis use among stimulants versus alcohol use among men who have sex with men. AIDS Behav 20(7):1451–1460. 10.1007/s10461-015-1226-4
Oldfield BJ, Edelman EJ (2021) Addressing Unhealthy Alcohol Use and the HIV Preexposure Prophylaxis Care Continuum in Primary Care: A Scoping Review. AIDS Behav 25(6):1777–1789. https://doi.org/10.1007/s10461-020-03107-6
O’Malley TL, Egan JE, Hawk ME, Krier SE, Burke JG (2021) Intimate partner violence, HIV preexposure prophylaxis (PrEP) acceptability, and attitudes about use: Perspectives of women seeking care at a family planning clinic. AIDS Behav 25(2):427–437. 10.1007/s10461-020-03003-z
Pasipanodya EC, Stockman J, Phuntsog T, Morris S, Psaros C, Landovitz R, Blumenthal J (2021) PrEPing for a PrEP demonstration project: Understanding PrEP knowledge and attitudes among cisgender women. BMC Women’s Health 21. 10.1186/s12905-021-01348-8
Patel AS, Goparaju L, Sales JM, Mehta CC, Blackstock OJ, Seidman, Sheth AN (2019) Brief report: PrEP eligibility among at-risk women in the southern United States: Associated factors, awareness, and acceptability. J Acquir Immune Defic Syndr 80(5):527–532. 10.1097/QAI.0000000000001950
Pyra M, Johnson AK, Devlin S, Uvin AZ, Irby S, Stewart E, Ridgway JP (2021) HIV preexposure prophylaxis use and persistence among black ciswomen: Women need to protect themselves, period. J Racial Ethnic Health Disparities 1–10. 10.1007/s40615-021-01020-9
Qin Y, Price C, Rutledge R, Puglisi L, Madden LM, Meyer JP (2020) Women’s decision-making about PrEP for HIV prevention in drug treatment contexts. J Int Association Providers AIDS Care 19. 10.1177/2325958219900091
Qualtrics (2021) Qualtrics (Version Feb.–June 2021) [Software]. Provo, Utah, USA: Qualtrics. https://www.qualtrics.com
Ransome Y, Bogart LM, Kawachi I, Kaplan A, Mayer KH, Ojikutu B (2020) Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among black people in the United States. Annals of Epidemiology, 42, 33–41
Restar AJ, Ogunbajo A, Mimiaga MJ, Kuhns L, Garofalo R, Reisner SL (2018) Acceptability of antiretroviral preexposure prophylaxis from a cohort of sexually experienced young transgender women in two U.S. cities. AIDS Behav 22(11):3649–3657. 10.1007/s10461-018-2127-0
Ruppe LB, Spencer LA, Kriebs JM (2021) Preexposure prophylaxis for HIV infection and the role of the women’s health care provider in HIV prevention. J Midwifery Women’s Health 66(3):322–333. 10.1111/jmwh.13231
Sales JM, Sheth AN (2019) Associations among perceived HIV risk, behavioral risk, and interest in PrEP among black women in the southern U.S. States AIDS and Behavior. 23(7):1871–1876. 10.1007/s10461-018-2333-9
Sanders PM, Cole SR, Stall RD, Jacobson LP, Eron JJ, Napravnik S, Ostrow DG (2013) Joint effects of alcohol consumption and high-risk sexual behavior on HIV seroconversion among men who have sex with men. AIDS 27(5):815–823. 10.1097/QAD.0b013e32835cff4b
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G (2018) Drug and opioid-involved overdose deaths — United States, 2013–2017. Morbidity and Mortality Weekly Report, 67(5152), 1419–1427. 10.15585/mmwr.mm675152e1
Scott HM, Spinelli M, Vittinghoff E, Morehead-Gee A, Hirozawa A, James C, Hammer H, Liu A, Gandhi M, Buchbinder S (2019) Racial/ethnic and HIV risk category disparities in preexposure prophylaxis discontinuation among patients in publicly funded primary care clinics. AIDS 33(14):2189–2195
Seidu A (2020) Using Anderson’s model of health service utilization to assess the use of HIV testing services by sexually active men in Ghana. Front Public Health. 10.3389/fpubh.2020.00512
Shah M, Gillespie S, Holt S, Morris CR, Camacho-Gonzalez AF (2019) Acceptability and Barriers to HIV Preexposure Prophylaxis in Atlanta’s Adolescents and Their Parents. AIDS Patient Care STDS Oct 33(10):425–433
Sheth AN, Rolle CP, Gandhi M (2016) HIV preexposure prophylaxis for women. J Virus Eradication 2(3):149–155. https://www.ncbi.nlm.nih.gov/pubmed/27482454
Shrestha R, Copenhaver M (2018) Exploring the use of preexposure prophylaxis (PrEP) for HIV prevention among high-risk people who use drugs in treatment. Front Public Health 6:195. 10.3389/fpubh.2018.00195
Shuper PA, Joharchi N, Bogoch II, Loutfy M, Crouzat F, El-Helou P, Rehm J (2020) Alcohol consumption, substance use, and depression in relation to HIV preexposure prophylaxis (PrEP) nonadherence among gay, bisexual, and other men-who-have-sex-with-men. BMC Public Health 20. 10.1186/s12889-020-09883-z
Shuper PA, Joharchi N, Monti, Loutfy PM, Rehm M J (2017) Acute alcohol consumption directly increases HIV transmission risk: A randomized controlled experiment. J Acquir Immune Defic Syndr 76(5):493–500. 10.1097/QAI.0000000000001549
StataCorp (2021) Stata Statistical Software: Release 17. College Station. TX, StataCorp LLC
Stein M, Thurmond P, Bailey G (2014) Willingness to use HIV preexposure prophylaxis among opiate users. AIDS and Behavior, 18.10.1007/s10461-014-0778-z
Sullivan PS, Giler RM, Mouhanna F, Pembleton E, Guest J, Jones J, Siegler A (2018) Trends in use of oral emtricitabine/tenofovir disoproxil fumarate for preexposure prophylaxis against HIV infections, united states, 2012–2017. Ann Epidemiol 28(12):833–840. 10.1016/j.annepidem.2018.06.009
Taggart T, Liang Y, Pina P, Albritton T (2020) Awareness of and willingness to use PrEP among Black and Latinx adolescents residing in higher prevalence areas in the United States. PLoS ONE 15(7):e0234821. 10.1371/journal.pone.0234821
Teitelman AM, Koblin BA, Brawner BM, Davis A, Darlington C, Lipsky RK, Iwu E, Bond KT, Westover J, Fiore D, Tieu HV (2021) Just4Us: Development of a Counselor-Navigator and Text Message Intervention to Promote PrEP Uptake Among Cisgender Women at Elevated Risk for HIV. J Association Nurses AIDS Care: JANAC 32(2):188–204. https://doi.org/10.1097/JNC.0000000000000233
Texas Emergency Medicine Research Center (TEMRC) (2020) UTHEARTS. from https://med.uth.edu/temrc/sections/population-health/ut-hearts/
Tims-Cook Z (2019) A retrospective assessment of antecedent preexposure prophylaxis eligibility of HIV-positive women in the south. AIDS Patient Care STDs 33(9):384–387. 10.1089/apc.2019.0046
Towe SL, Sullivan CA, McKellar MS, Meade CS (2020) Examining the potential of preexposure prophylaxis (PrEP) for HIV prevention in a community sample of people who use stimulants living in the southern United States. AIDS Behav. 10.1007/s10461-y
U.S. Public Health Services Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2017 Update, A Clinical Practice Guideline., Atlanta, GA: Center for Disease Control and Prevention
Uzoeghelu U, Bogart LM, Mahoney TF, Ojikutu BO (2021) Results from the national survey on HIV in the black community (NSHBC). J Immigr Minor Health 23(6):1152–1158. 10.1007/s10903-021-01244-1. Association between HIV testing and HIV-related risk behaviors among U.S. and non-US born black individuals living in the U.S.
Villalba K, Jean-Gilles M, Rosenberg R, Cook RL, Ichite A, Martin P (2022) Understanding the impact of intimate partner violence type and timing on preexposure prophylaxis knowledge, acceptability, sexual behavior, and gender roles among women of color. J interpers Violence 37(15–16):NP12998–NP13017. 10.1177/08862605211001468
Walters SM, Reilly KH, Neaigus A, Braunstein S (2017) Awareness of preexposure prophylaxis (PrEP) among women who inject drugs in NYC: The importance of networks and syringe exchange programs for HIV prevention. Harm Reduct J June 29(1):40
Willie TC, Kershaw TS, Blackstock O, Galvao RW, Safon CB, Tekeste M (2021) Racial and ethnic differences in women’s HIV risk and attitudes towards preexposure prophylaxis (PrEP) in the context of the substance use, violence, and depression syndemic. AIDS Care 33(2):219–228. 10.1080/09540121.2020.1762067
Wingood GM, Dunkle K, Camp C, Patel S, Painter JE, Rubtsova A, DiClemente RJ (2013) Racial differences and correlates of potential adoption of preexposure prophylaxis (PrEP): Results of a national survey. Journal of Acquired Immune Deficiency Syndromes (1999), 63(0 1), S95-S101. 10.1097/QAI.0b013e3182920126
Wray TB, Celio MA, Pérez AE, DiGuiseppi GT, Carr DJ, Woods LA, Monti PM (2019) Causal effects of alcohol intoxication on sexual risk intentions and condom negotiation skills among high-risk men who have sex with men (MSM). AIDS Behav 23(1):161–174. 10.1007/s10461-018-2243-x
Wray TB, Chan PA, Kahler CW (2021) Game plan, a web-based intervention to improve adherence and persistence to HIV preexposure prophylaxis and reduce heavy drinking in gay, bisexual, and other men who have sex with men: Usability and user experience testing. JMIR Formative Res 5(11):e31843. 10.2196/31843
Wray TB, Chan PA, Guigayoma JP, Kahler CW (2022) Game plan—a brief web-based intervention to improve uptake and use of HIV preexposure prophylaxis (PrEP) and reduce alcohol use among gay and bisexual men: Content analysis. JMIR Formative Res 6(1). 10.2196/30408

The authors declare potential competing interests as follows: Conflict of Interests Mandy J. Hill conducted sponsored research with grant support from Gilead Sciences Inc. (IN-US-276-5464).

Financial Interests The authors, Mandy J. Hill and Robert Suchting declare that they have competing financial interests. Each author received salary support for the parent study, from which these data were derived through an investigator-sponsored research award by Gilead Sciences, Inc. (IN-US-276-5464).

Download PDF

Version 1

posted

You are reading this latest preprint version

PrEP Knowledge and Willingness Among Cisgender Black Women for Biomedical HIV Prevention: Assessing Substance Use and Sexual History Factors

Status:

Version 1

Abstract

Introduction

Conceptual Model

Objectives

Methods

Parent Study Overview

Participants

Setting

Variables

Measures

Predisposing Factors

Enabling Factors

Disabling Factors

Outcome Variable

Statistical Analysis

Moderation Analyses

Results

Socio-demographic Characteristics

Bivariate Analysis of PrEP Willingness and PrEP Knowledge

Logistic Regression Analysis of Predictors for PrEP Willingness

Moderation Analyses

Discussion

Age and PrEP Knowledge and Willingness

Education and PrEP Knowledge and Willingness

Sexual Orientation and PrEP Willingness

Marital Status and PrEP Willingness

Employment and PrEP Willingness

Income and PrEP Willingness

Condomless Sex and PrEP Willingness

Alcohol and Substance Use Problems and PrEP Willingness

Implications

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1