Improving HIV Prevention Services among Socioeconomically Disadvantaged Cis-gender Women

ABSTRACT Nearly one out of five new HIV infections in the United States occurs among cisgender women, with 85% of cases attributed to heterosexual contact. Black women are disproportionately affected, comprising 60% of new HIV infections among women, although they comprise only 14% of the female population. Consistent condom use, daily oral tenofovir disoproxil fumarate 300mg-emtricitabine 200mg (TDF-FTC) as pre-exposure prophylaxis (PrEP), and male partner HIV testing are evidence-based interventions for women to reduce their risk of HIV acquisition. Yet, only 1-6% of women who could benefit from PrEP are prescribed it. Barriers to PrEP uptake are multifactorial. Patient-level barriers to PrEP uptake include women who may not think PrEP is for them, given that the majority of PrEP clinical trials and marketing strategies have targeted men who have sex with men. Also, cisgender women may not perceive themselves as being at risk for HIV. Further exacerbating the discordance between risk perception and actual risk is that women tend to be unaware of their male partners' HIV serostatus and HIV risk factors. Provider-level barriers include difficulty identifying patients at high risk for HIV, discomfort with sexual history taking, and lack of PrEP knowledge. Unfortunately, an accurate HIV risk assessment tool does not exist for U.S. cisgender women and may not ever exist because the HIV incidence in U.S. women is too low to develop it. An alternative evidence-based intervention is desperately needed. We plan to fill this gap by identifying an effective intervention and implementation strategy to increase PrEP uptake in an ObGyn clinical setting (where women receive prenatal care and sexual and reproductive health services). Since TDF-FTC was approved, women have consistently expressed a preference for receiving HIV prevention services in clinics where they receive ObGyn care. Our multi-level (patient and provider-level), multi-component intervention includes EHR data collection and education using multi-media tools. Our central hypothesis is that communicating tailored HIV risk messaging in real-time in a relatable and comprehensive manner to patients and ObGyn providers can increase conversations about HIV prevention. Aim 1A: To determine the most effective intervention and evaluate its implementation in an ObGyn clinical setting. 1B: To identify modifiable contextual factors associated with effective implementation using the RE-AIM framework. Aim 2: To evaluate the cost-effectiveness, return on investment, budget impact, and equity impact of the multi-level intervention components and the implementation strategy. In collaboration with our local government- and a HRSA-funded implementing partner sites, we hope to demonstrate a sustainable and scalable solution to increasing PrEP counseling by ObGyn providers and PrEP uptake by patients.