Cisgender women in the United States have a high level of awareness about pre-exposure prophylaxis (PrEP), but only one in ten are using daily pills for HIV prevention, according to research presented at the recent IDWeek 2022 conference. However, the survey revealed that new prevention methods for women could encourage greater uptake.

Women accounted for nearly one in ten new HIV diagnoses in 2019, according to the Centers for Disease Control and Prevention (CDC). While many men who have sex with men—especially white gay and bisexual men—have eagerly adopted PrEP, the CDC estimates that just 10% of women with an indication for PrEP had a prescription for it. The Ending the HIV Epidemic initiative hopes to raise this figure to 50% by 2025.

“The large gap between women who can benefit from PrEP and women who use PrEP highlights the unmet need for HIV prevention among women,” according to Tonia Poteat, PhD, MPH, of the University of North Carolina School of Medicine, and colleagues. “Understanding women’s PrEP awareness and preferences may help address this need, especially as new PrEP options become available.”

Poteat’s team conducted a study to better understand PrEP awareness, preferences, willingness and usage among sexually active women in the United States. They administered a national survey with around 90 questions covering health care access and experiences, substance use, and sexual behavior and health, including PrEP awareness and use. Respondents were recruited via social media and a dating app. The ongoing study aims to survey about 2,000 women annually for three years.

The initial analysis included 961 cisgender women (assigned female at birth and currently identify as such) who were sexually active (anal or vaginal sex during the past six months) who completed the survey between November and December 2021. All were either HIV negative or did not know their status—about half had never been tested. More than 60% were in the 18 to 29 age range. About a third were non-Hispanic Black, 20% were Black Hispanic, 21% were non-Hispanic white, 12% were white Hispanic and 12% identified as another race or ethnicity. About half were single and half were married or in a stable partnership.

A large majority of respondents (85%) said they were very or somewhat unlikely to acquire HIV or STIs. However, one in five respondents reported exchanging sex for money, and 9% reported having a sexually transmitted infection (STI) during the past year.

Results from this first group of respondents revealed that a substantial majority (71%) had heard of PrEP. This differed by age, with 74% of women ages 18 to 29, 67% of those ages 30 to 39 and 93% of those 40 to 49 saying they knew about PrEP. White Hispanic women were mostly likely to be aware of PrEP (79%), followed by non-Hispanic Black women (72%) and non-Hispanic white women (67%). Half had heard about long-acting injectable PrEP (Apretude), which is administered by a health care provider every other month. Here, younger respondents were more likely to know about it.

However, just 38% of the women had ever spoken to a health care provider about PrEP, and 34% said they knew someone taking PrEP (including 19% whose partner did so). Women discussed PrEP with providers in hospitals (47%), primary care clinics (43%) and sexual health clinics (40%). Two thirds of those who had spoken about PrEP said a provider brought it up.

Even fewer women said they had ever taken PrEP (19%) or were currently using it (9%). Most (84%) used daily tenofovir disoproxil fumarate/emtricitabine (Truvada and generic equivalents), the only PrEP pill approved for cisgender women. However, 12% reported using tenofovir alafenamide/emtricitabine (Descovy), even though it is not indicated for people at risk for HIV exposure via vaginal sex due to inadequate research. None reported using long-acting PrEP injections.

Black Hispanic women were much more likely to have used PrEP than Black non-Hispanic women (49% versus 15%), categories that are not broken out in many studies. Adherence was generally low, with just 40% saying they took all their doses during the past month. Among women who had taken and discontinued PrEP, 40% said they did so because they started a monogamous relationship.

Most respondents (78%) said they intended to regularly use some HIV prevention method. Condoms were the preferred method for 47%, although just 16% reported using them all the time. This was followed by long-acting injectable PrEP administered by a health care provider (24%), self-administered PrEP injections (9%), vaginal rings (9%) and PrEP pills (7%).

Two thirds of respondents said they would be somewhat (35%) or very (31%) likely to use long-acting injectable PrEP if available. Asked if they’d prefer injectable or oral PrEP, 62% chose injections, 9% chose pills and 29% said neither. Concerningly, some women cited STI prevention as a motivation for using injectable PrEP, although it does not do so.

Unfortunately, some of the HIV prevention options that might appeal to women are not currently available in the United States.

As noted, daily tenofovir disoproxil fumarate/emtricitabine is the only PrEP pill approved for cisgender women, although tenofovir alafenamide/emtricitabine for this population is now in clinical trials. There is not enough data about the effectiveness for women of on-demand PrEP taken before and after sex. Self-administration of long-acting injectable PrEP is not yet possible, though it is being studied. And a vaginal ring containing dapivirine, which is recommended by the World Health Organization and available in several countries, was withdrawn from Food and Drug Administration consideration earlier this year.

“Although most women demonstrated high PrEP awareness and interest, many had never discussed PrEP with a health care provider,” the researchers concluded. “The availability of long-acting PrEP may be an important opportunity for health care providers to discuss a preferred PrEP option with women.” They noted, however, that high awareness of or interest in using PrEP may not translate into uptake.

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