Although there have been exciting advances in the field of HIV pre-exposure prophylaxis (PrEP) over the past several years, the implications of PrEP for women have been more murky. Some major PrEP trials have shown efficacy of this strategy in heterosexual African women, but there have been no clinical trials investigating the utility of PrEP in U.S. women.
A report by Monica Gandhi, MD, MPH, associate professor of clinical medicine, UCSF Division of HIV/AIDS, at San Francisco General Hospital and Medical Center:
Findings from a focus group study of at-risk, HIV-negative women in Oakland, Memphis, San Diego and Washington, D.C.
The FDA recently approved Truvada® for PrEP for all high-risk adults in this country, including women. This investigative team, represented by Judith Auerbach PhD, consultant to the San Francisco AIDS Foundation, presented late-breaking results on a qualitative study conducted in four U.S.-based cities among HIV-negative women at risk regarding attitudes towards PrEP.
Focus groups were conducted with 92 women, all identified as being at “high-risk” for HIV infection, as defined by social networks, sex and drug-related practices or socioeconomic studies, in four U.S .cities, specifically Memphis, San Diego, Oakland and Washington DC. The women in the focus groups were representative of the racial/ethnic diversity of the U.S. female population at risk for HIV infection (69% African Americans, 19% Latina, 7% white); approximately half were unemployed and most were low-income. Most notable among the results of the baseline demographic and behavioral survey, as well as the qualitative discussions, was that only 5 of the 92 women had ever heard of PrEP as a prevention modality. The women were then asked about which populations should be offered PrEP, perceived barriers to uptake, and modalities to facilitate PrEP uptake among U.S. women.
In general, the women of the focus groups felt that young women or sex workers would be populations for which PrEP should be offered. One mother, pointing out that young women are at high risk for pregnancy due to unwillingness to use condoms, stated “I put her on the pill, might as well put her on PrEP too at age 12, 13 and 14, whatever”. Other women stated that all women should be offered PrEP since “you don’t know what your partner is up to”, reflecting a general distrust of men and their honesty regarding their risk factors in the focus groups. Women defined a number of barriers to the widespread implementation of PrEP in U.S. women, including cost, resistance among churches and faith-based organizations, mistrust of the medical system and government, and the “newness” of the drug. The women stressed that this modality must be provided free of charge to underserved communities for uptake to occur. Most women also expressed fear of adverse events and drug-drug interactions; one woman commented, when read the list of potential side effects of Truvada-based PrEP, “that sounds like HIV”.
Many women expressed concern about the complexity of taking a daily pill for prophylaxis with one woman pithily summarizing the problem: “After we get through putting on the condom and takin’ all the pills we have to before sex, you are going to be dry, asleep and tired.” Finally, when asked about facilitators for PrEP uptake, women mentioned peers, friends, medical providers, family planning clinics, and schools. However, one woman cautioned that this message should not just be spread in African American communities or “we are going to start thinkin’ it’s a government thing.” There a few site differences in the focus group responses, with women from Washington DC and Oakland being more likely to express mistrust of government, the health care system and men. The women from Memphis were more likely to be older, consider HIV infection risk as a “class issue”, and express the importance of church in their lives. Overall, this is an important study focused on asking women around the country their perceptions of risk and the benefit of PrEP following the FDA announcement approving Truvada for PrEP in all adult populations at risk in the U.S. Study findings should help inform policy decisions on how to offer and promote the benefits of PrEP, when appropriate, among U.S. women.