How a Bias-Breaking Approach Increased PrEP Offers to Women of Color

Testing and treatment for human immunodeficiency virus (HIV) has advanced tremendously in the last three decades. Still, nearly 40,000 people in the U.S. are diagnosed with HIV every year. There are highly effective HIV prevention medications, called pre-exposure prophylaxis, or PrEP. One medication, a pill taken daily, has been approved and available for HIV prevention in the U.S. since 2012 — yet it is still under-prescribed. 

Though PrEP has historically been marketed to cisgender men in the U.S., it is also approved and effective for cisgender and transgender women, and in recent years, guidelines for offering PrEP have become more inclusive for all people at risk, regardless of gender. Despite these widened guidelines, only 10% of U.S. women who could benefit from PrEP were prescribed it in 2019, according to the Centers for Disease Control and Prevention. Women of color face specific inequities in PrEP prescribing. And a recent survey indicates that 1 in 3 student health centers at New England colleges and universities do not offer PrEP — a troubling deficiency given that high HIV risk often coincides with the college age range. 

At Boston Medical Center (BMC), researchers have piloted an intervention that successfully increased PrEP offers to women, particularly Black and Hispanic women. In the study, described in a recent paper in Open Forum Infectious Diseases, the health system’s PrEP team implemented a daily, institution-wide report of women diagnosed with bacterial sexually transmitted infections (STI) and initiated a prompt to providers or patients in each case to offer PrEP to that patient. The study looked to see if that systems-level approach improved PrEP offers and/or acceptances. 

HealthCity spoke with two of the paper’s authors, Jessica Taylor, MD, an HIV and addiction medicine physician and medical director of HIV prevention programs at BMC, and Jessica Stewart, quality manager for HIV prevention programs at BMC and the PrEP program coordinator, about the study and its implications for increasing PrEP access, the study, and its implications for increasing PrEP access. 

HC: Why are women less likely to be prescribed PrEP?

Jessica Stewart: Historically, PrEP delivery in the U.S. has focused on men who have sex with men. Even though the need for and benefits of PrEP in other populations are now well known, and guidelines have been expanded, it is still primarily used for that initial population; some provider attitudes haven’t caught up. The mindset is still that it’s only for men who have sex with men, or that HIV risk is low in other populations, when really,  PrEP is for anyone who has condomless sex or engages in needle-sharing.

“The populations that are the most likely to acquire HIV because of factors like sexism, structural racism, medical stigma, misogyny, and transphobia are also the populations least likely to be able to access PrEP because of those same barriers.”

Jessica Taylor, md, hiv medical director of hiv prevention programs at bmc

Jessica Taylor, MD: Women still face outsized burdens of new HIV infections, and we see these inequities track with PrEP delivery. The populations that are the most likely to acquire HIV because of factors like sexism, structural racism, medical stigma, misogyny, and transphobia are also the populations least likely to be able to access PrEP because of those same barriers. In the U.S., women of color are extremely underserved by PrEP. The beauty of a systems-level intervention, like the approach we took in this study, is that you bypass a lot of individual factors around bias and assumptions. 

HC: How effective were your interventions? 

JS: We were able to increase PrEP offers to a significant number of women. From reviewing the medical records, we can see that a lot of those women had never been offered PrEP and had never heard of PrEP before. This is very different than what we hear about in some communities of men who have sex with men, where PrEP is often more familiar and even advertised on dating apps. I think, down the line, as we eliminate some of the medical system’s blind spots and stigma around PrEP for other groups, access will improve.

JT: Our intervention was delivered to all women, cisgender and transgender, and we were interested and surprised to see that PrEP offers increased significantly among non-Hispanic Black women and among Hispanic women. Additionally, non-Hispanic Black women had an increase in PrEP acceptance as well.

HC: Why do you think there was a difference in outcome for women of color?

JT: Black and Hispanic women have very disparate rates of bacterial STIs that are rooted in structural inequities. This program by its design is delivering an intervention to women with bacterial STIs, which, because of these inequities, was more likely to include Black and Hispanic women.  

HC: What sorts of questions do doctors need to ask patients to assess their need for PrEP that maybe they’re not regularly asking now?

JT: Providers across care settings should be asking patients about their sexual histories and about substance use. We know those are two topics that are still, unfortunately, quite stigmatized, and a lot of providers don’t feel that they had adequate training, nor do they feel comfortable and confident asking these questions. We also know time pressure is a reality. This combination of lack of training and confidence means these important questions get pushed to the wayside. Even if it feels uncomfortable at first, our patients deserve these conversations, which make us more effective in offering the HIV prevention options that best fit their goals and needs.

HC: What’s next? What are you hoping might come out of this study?

JT: Offering PrEP to every woman with a bacterial STI in a systematic way is important — and this study clearly showed it’s effective. Our study showed that it increases PrEP offers, and it is very effective among Black and Hispanic women. Other health systems can easily replicate it because this intervention is relatively easy to set up without AI or expensive IT builds. However, we also recognize that women with bacterial STI are just a small fraction of the overall number of women who would benefit from PrEP. More work is needed to identify PrEP-eligible women who do not have a bacterial STI.  

Our intervention also doesn’t solve for downstream barriers in the PrEP cascade. Once someone is offered PrEP, we need to ensure that they’re able to start it, pick it up at the pharmacy, and actually continue it over the course of many months. Since the time of this study, we also have a new injectable form of PrEP that is expanding options, including for women. We can and must do more to support people in staying on PrEP, but this is an exciting start.

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This interview has been edited and condensed for clarity and length.