Women of color in the South have disproportionately high rates of new HIV infections, but low use of HIV pre-exposure prophylaxis (PrEP). Mechanisms to best identify US women eligible for PrEP are lacking, which contributes to limited PrEP uptake. Identifying factors associated with PrEP eligibility could facilitate improved screening, offering, and uptake of PrEP among US women at risk for HIV.
We applied CDC criteria for PrEP use to at-risk HIV negative women enrolled in the Southern sites (Atlanta, Chapel Hill, Birmingham/Jackson, Miami) of the Women’s Interagency HIV Study (WIHS) from 2014-15 to estimate PrEP eligibility. PrEP eligibility was determined using number of male sex partners, partner HIV status, condom use, and injection drug use in the past 6 months. Factors associated with PrEP eligibility were assessed using unadjusted odds ratios (OR) and 95% confidence intervals (CI). PrEP willingness and use was determined at baseline visit.
Of 225 women, 187 (83%) identified as African-American, median age was 45 years, and 120 (53%) had health insurance. In the past 6 months, 43% reported ≥ 2 partners, 7.1% had a partner with HIV, and 11.1% reported a sexually transmitted infection. Overall, 72 (32%) women met CDC criteria for PrEP; the most common PrEP indicator was condomless sex (25.5%). Education of ≤ high school (OR 2.66, CI 1.45, 4.85); experienced physical violence (OR 2.56, CI 1.07, 6.13), sexual violence (OR 4.74, CI 1.56, 14.44) or engaged in transactional sex (OR 3.99, CI 1.76, 9.06) in the last 6 months; non-injection drug use in the last 6 months (OR 2.07, CI 1.15, 3.72); and any previous incarceration (OR 1.87, CI 1.05, 3.36) were associated with PrEP eligibility (Table 1). Further, self-perception of HIV risk (medium vs low/none OR 3.46, CI 1.52, 7.88; high vs low/none OR 16.44, CI 5.28, 51.18) was highly predictive of PrEP eligibility. At baseline, 24 (11%) women previously heard of PrEP, and only 1 reported prior use. Overall, 189 (84%) were willing to take PrEP, including the majority of PrEP-eligible women (86%).
Nearly one-third of Southern HIV negative WIHS women were eligible for PrEP. Extremely low PrEP awareness and use despite high acceptability signify a critical need to enhance PrEP delivery for women in this region. Supplementing CDC eligibility criteria with questions about violence, transactional sex, incarceration, non-injection drug use and HIV risk self-assessment may enhance PrEP screening and uptake among US women.