Black women interested in HIV pre-exposure prophylaxis (PrEP) in rural Alabama are not interested in being rushed into a decision about starting the HIV prevention pill the same day, and they need to have positive, non-racist experiences with their health care providers, according to research presented at the 11th International AIDS Society Conference on HIV Science (IAS 2021).

This is important because Black cisgender women have the highest rate of new HIV diagnoses among women in the United States. Yet the PrEP gap persists. As of 2019, only 2,506 women in Alabama were using the prevention pill, said Christina Psaros, PhD, an associate director of behavioral medicine at Massachusetts General Hospital and associate professor of psychology at Harvard Medical School, who presented the findings.

Psaros and colleagues asked 41 people—21 cisgender Black women and 20 care providers—to discuss their knowledge of, experience with and barriers to using or prescribing PrEP in Alabama.

Most of the women (15) had never taken PrEP, but six had. All the health care providers worked at rural federally qualified health centers in Alabama.

The researchers asked women about their general beliefs and preferences around health care, their sense of their HIV risk, their beliefs and understanding of how PrEP works, any experience with PrEP and health care systems providing it and their experiences during the COVID-19 pandemic. For providers, the researchers asked about their background in serving Black women’s sexual health care needs, their beliefs and understanding of PrEP and their experience prescribing PrEP.

Perhaps unsurprisingly, three factors influenced Black women’s willingness to work with a health care provider on any health issue: trust, care and shared decision-making. Specifically, the women wanted a provider they could trust to offer comprehensive information, have a good attitude and keep their confidence; demonstrate they care by inquiringabout the women’s lives, following up on past concerns and checking in between appointments; and engage in shared decision-making, including providing a cost-benefit analysis of a given treatment or prevention strategy and not pushing them to begin care immediately.

“When they call me and check up on me, that’s another way of showin’ me that they really concerned about me,” said a 26-year-old woman currently using PrEP.

On the flip side, and also understandably, when a provider had a bad attitude, when they showed no empathy for patients or judged them or when women experienced racism or other discrimination at the clinic, they were less likely to want to engage in care there. Add to that the fact that health care providers are often unskilled in talking about sex and may know little to nothing about HIV and that the health care system is set up such that it’s impossible to deal with more than one issue at a time, and you have a recipe for poor communication between women and their providers.

“Some clients described anxiety around attending clinic and general health-related anxiety as well,” said Psaros. “Some clients described a history of negative provider interactions involving discrimination based on education level, race or socioeconomic status.”

Women said they’d prefer to receive PrEP care outside of an infectious disease clinic with support from PrEP navigators who could respond to questions or concerns as they come up, and they wanted to see PrEP integrated into a routine checklist to cover during an exam. And they wanted to see more Black women in advertisements for PrEP.

“Clients desire shared decision-making and respectful interactions with the medical system,” Psaros said. “Clients may not be ready to make decisions about PrEP on the spot, and providers can support women by integrating planned follow-up into protocols for introduction of PrEP.”

Click here to read the study abstract.

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