An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP)
Abstract
:1. Introduction
2. Materials and Methods
Data Analysis
3. Results
3.1. Thematic Findings
3.1.1. External Locus of Control
Theme 1: Self-Advocacy with Providers about Health
- Code: Preference in having a Black provider
‘Yeah, I would want somebody Black because sometimes the other race don’t know what I’m talking about. Yeah, that matters. Yeah, I’m sorry, that matters.’
- 2.
- Code: Preference in having a female provider
‘I actually just had an appointment with them yesterday morning and I feel comfortable. They’re all women. So, ofcourse, I feel more comfortable talking to a woman than a man in my opinion. And they don’t tell me anything wrong. Any questions I have, any concerns, they always answer them. And then if they see something that’s not looking too good, they don’t hesitate to call me or text me and stuff like that. So, I’m very comfortable with my healthcare provider.’
Theme 2: Media Influences on Understanding of PrEP
- Code: TV Media messaging about PrEP
‘Actually, my first time actually seeing it was on How to Get Away with Murder. And I’m going to be honest, even as it may sound, I did not know PrEP medication was real. I thought that was just something that they put on TV.’
‘I guess for if we’re talking about video media, it would definitely need to be people who represent the community that I represent, what they display right now is just LGBTQ, so it doesn’t gravitate at least what the commercials that I’ve witnessed.’
- 2.
- Code: Perception that cis Black/African American women are not prioritized in TV media messaging about PrEP
‘But even with the commercial, it wasn’t representation for me. And so, it was like, “Oh, okay, so they’re trying to really get it for the LGBTQ community.” There was not any partners within the commercial that was heterosexual. So, I was like, “Oh, maybe this is not for me”.’
Theme 3: Comfort with Provider–Patient Interactions
- Code: Perceived comfort with discussing sexual health with provider
‘I’m very comfortable. I’ve been going to my provider for a while, but I think even if I hadn’t been going to my provider for a while, because I have awareness of HIPAA and privacy and all of that, that helps me to increase my comfort level in knowing that anything that I need to discuss, this is where I should be able to do it without any judgment or without anybody knowing what it is that I want to discuss.’
- 2.
- Code: Communicating openly with your provider is a part of your health
‘In college, I have thought, because I had unprotected sex, I really thought I had HIV and I started having symptoms that you would think I was dying because of how I was thinking. So, I choose to only have sex with one person. So, I think because I responded that way, she didn’t further ask questions. But I think if I would have been honest, if it was the case in telling her that I was having sex with several individuals or I was having unprotected sex, it could have become a greater conversation, she seemed open.’
Theme 4: Provider Engagement in Sexual Health of Cis Black Female Patients
- Code: Experience with provider offering HIV testing
‘‘I go to a male OB-GYN doctor, and I kind of regret that, but I’ve had him for so many years. It’s just like you get used to him, you just go just for the checkup. But he doesn’t ask any questions. And definitely he just says, okay, this month we’re going to check for STDs, whatever, and whatever. And that’s pretty much it. And sometimes I get offended because I’m like, why are you checking for that? I didn’t ask you to check for that.’
- 2.
- Code: Willingness to engage provider in HIV testing
‘I think I’ve done both. I think they’ve asked and then I think I’ve also asked them to run one.’
Theme 5: Awareness of Peers with HIV and/or Taking PrEP
- Code: Awareness of peers on PrEP
‘I only know one person that is on PrEP and he’s actually gone through a couple of PrEPs. And the only thing I know is that it, well, one of them, it lessened his alcohol tolerance. We were having a drink and he was like, “Yeah girl, I need to be real with my doctor. And so, she know I be out here.” So, she was like, “Hey, we’re going to try something else that better aligns with your lifestyle.” And in that moment, I was like, man, that’s what’s up. But I also felt like why can’t I have that same relationship with my doctor where I could feel comfortable to be like, “Girl, yes I drink and yes, I be throwing it back.”, if something that goes with both of those things. But yeah, I just know that one person.’
- 2.
- Code: Awareness of peers with HIV prompts willingness to learn more
‘I just think that realistically, because I always say, with diseases, if you don’t know anybody personally, it goes over your head. So, for us, had I not met two amazing people, one sitting here in this room, [de-identified name}, who had it, I would’ve never even gave HIV, or anything like that a second thought.’
Theme 6: PrEP-Related Concerns
- Code: Concern with cost and insurance coverage for PrEP
‘I’m very… I don’t like taking medication just period. So, for me it would be weighing the cost, risk, benefit if I’m really willing to take this pill every day. But I am now just learning, I believe this month about the injection, but I also have fears of injection.’
- 2.
- Code: Concerns for PrEP injectable
‘I believe this month about the injection, but I also have fears of injection and I think that kind of goes back to medical malpractice from back in the day when Black people were being given injections and it wasn’t what it said it was. And it’s the concern about side effects too.’
3.1.2. Internal Locus of Control
Theme 1: Perceived PrEP Knowledge
- Code: Perception that PrEP is not for heterosexual people
‘I was going to say, the reason why I say that is because I typically--I mean I’m not trying to be funny. See it when I’m watching shows like “Pose” and stuff like that where those shows are catered to that community. That’s usually when I would see that.
Or if it’s an episode of a show I’m watching and you have a gay couple on that show, that’s when I’m seeing it. To me, it’s Blacks, or Black females, I’m thinking maybe they should have it on more networks where people are watching so why is it not on …or other places, that’s the target.
I mean, I don’t know if they are showing it on those channels, but I’m just saying. And then in the commercials, like I said, I never knew that it was for straight. Because it’s not any straight couples on the commercials. It’s two men, but the lady hosting the commercial is transgender. So, I mean, I never knew that was…’
- 2.
- Code: Perception that PrEP is for gay men
‘And then I could also see Black women just genuinely not taking it because they see it as the gay man’s drug. And so, if I take it, that means I am admitting to the world that either I am attracted to or have sexual relations with gay men, trans men, bisexual men, and what that would look like in the community if people knew that about me.’
- 3.
- Code: Perception that PrEP eligibility is based on sexual orientation
‘Of course, I’ve seen the commercials, but I thought it was mostly targeted towards homosexuality, just based on the people that are in the commercials. I’ve never seen a straight couple. It’s usually transgender or two males.’
Theme 2: PrEP Willingness
- Code: Stigma around PrEP uptake
‘But I think it comes with the stigmatism, like even when our parents used to struggle with the, “Well, if I give my child birth control, I’m giving them permission to just be free and have sex and no consequences because they’re on birth control.” So, someone can look at… PrEP like that, like, “Okay, if I’m taking this and I’m out here, I don’t have to use any other protection. Hey, I’m not going to get HIV.’
- 2.
- Code: Reasons women might be hesitant towards taking PrEP
‘Because they don’t think it’s for them in general. So, I don’t have it. So why would I take something that I don’t need? I feel like a lot of people too in general have issues with taking medicine or putting medicine in their body in any type of form. It doesn’t matter what it is. There are so many people that are against so many vaccines and this, that and the other, that will have a huge problem with having to take something else that is really not required.’
Theme 3: Knowledge of PrEP as a Prevention Tool
- Code: Perception that PrEP offers safety
‘I absolutely think it would. For me, it would be more so if I knew I was having sex with multiple people, but then also you have to rethink that too. But I do think that it would be empowering to know that I have control over not contracting this condition.’
- 2.
- Code: PrEP empowers ability to control personal sexual health
‘I think it will. I definitely believe you’re now able to take hold on exactly what is going to happen with your body. You don’t have to rely on a condom or a STD test to determine, you can actually do take the precautions to say, “Hey, you know what? I took this pill or I took this shot so I know I’m doing what I need to do to protect myself.” So I think that’s something that comes to mind, just like if I would, that’s what my IUD, I’m protecting myself to not get pregnant. I should also now include this into my regimen of my health. And so, I think that it does allow for me to control if I want to have a baby as well as if I want to be exposed to someone, to something out there that possibly I do not want to have in my life at this time.’
Theme 4: Awareness of Sexual Risk
- Code: Awareness of HIV risk within sexual relationships
‘Not ignorance, it’s maybe just not accepting the true reality of this can be contracted even from someone that you believe that you trust.’
- 2.
- Code: Perception of elevated HIV risk with new partner
‘Guess messing with someone new, a new situationship or whatever I’m doing. I’m definitely going to get tested.’
Theme 5: Perceived Facilitators of the Decision to Use PrEP
- Code: Perception that varied PrEP messaging can bring awareness
‘Just like that doggone, HPV vaccine and Gardasil. I want all of that. I want the same energy. I want women on all types of media, like the commercials. Thank you for showing Black men and trans women and I want to see some regular women in there. I want to see different types of relationships. I want to see young and old people because the senior citizens, they wilding out there too. I want it to be like, it’s kind of like diversity and inclusion, but I want the real one, not the watered down one that y’all keep giving us in corporate America. Give me the actual diversity and inclusion everywhere. Just like, yeah, just an apple a day keeps a doctor away. I want to know about PrEP if I’m sexually active.’
- 2.
- Code: Willingness to take PrEP
‘In my personal opinion, I don’t mind taking a pill every day because I have a reminder on my phone. So, me personally, because I have a very, very busy schedule, you would have to take time off of work to go and get the injectable. Don’t get me wrong, it may work for some women who can’t remember to take the pill every day, but for some of us that has a very busy schedule. If I have the pill right there in my area, I’ll just take it versus whether to take it off of work and going to go get the injectable. But maybe it’ll be easier for some women who don’t want to take the pill every day.’
Theme 6: Factors That Inform the Choice for or against PrEP Use among Cis Black Women
- Code: Reasons why cis Black women might be willing to take PrEP
‘I believe that women would choose, especially Black women to use PrEP because I feel like we’re definitely becoming more, what’s the word, sensitive or aware of the things that we need in order to stay healthy, in order to be around.’
- 2.
- Code: Scientific data are not always reflective of cis Black women
‘I think if they did more researches like this for Black women, I think it would definitely build some more trust because we don’t have enough information. And a lot of times when they do focus groups, it’s not really with Black women, it’s a lot on the Caucasian and male or female, because I used to work in the medical center and most of the time they would be geared towards other races. Not saying that they’re against Blacks, but they just don’t promote it towards Blacks. So, I don’t know how they can build that to where Blacks and Black women would want to join. But that would be great if we had more resources as far as information that was put into focus groups or research.’
Theme 7: Willingness for Self-Advocacy with Healthcare Provider
- Code: Willingness to take PrEP
‘So, anything that I can help to help me prevent, yes. And like I said, like I explained to y’all earlier, my mother is a HIV patient, so if I can help myself prevent, yes.’
- 2.
- Code: Willingness to advocate for self with healthcare provider
‘Now I am 29, the answer is yes. Now, when I was younger, especially in college when I didn’t have insurance and I was going to the free clinic and things like that, I wasn’t very, and I was in Alabama, so I didn’t really feel like I could ask those questions. But now that I sought out a Black OB-GYN, which unfortunately all skin folk aren’t your kin folk, I’ve had to be a little bit more vocal of just because I am a single Black woman, that doesn’t mean that my reproductive health or my sexual health are still not priority. So, do I feel comfortable enough to say something? Yes. Whether or not she listens to me or not, that’s another story. But yeah, I feel comfortable enough pressing for my own, being my own advocate now. But that’s like recent.’
Theme 8: Acceptance of PrEP as Approved
- Code: Acceptance of side effects with PrEP
‘So, in terms of side effects, I’ve pretty much gotten past the thought of just being hyper-focused on that, because I think COVID definitely did it for me where it was just like, okay, you got to take this vaccination if you want to avoid transmitting or receiving COVID. So from that standpoint, I’m more comfortable.’
- 2.
- Code: Acceptance of longevity of PrEP regimen
‘But what I will say is it’s taking something long term that it was like, okay, it’s like a vitamin that I’ll have to add to my regimen and just know that it’s something that I have to continue. So, if that ever changed, I’d be like, this is great. But I do know that that’s one of the things.’
Theme 9: Awareness of HIV Risk with Drug Use
- Code: Awareness of HIV risk due to personal drug use
‘I was vulnerable at a time. I’m an ex-drug user, so I was out there doing bad things. But now that I’m wiser, I think it’s good to get tested regularly.’
Theme 10: Perceived HIV Knowledge
- Code: Awareness of HIV transmission routes
‘My mother diagnosed with HIV. My mother’s still living, thank God. I can’t remember the damn year, though, because it was so long ago. And the first thing I thought about is, “I’m fixin’ to lose my mother.” My mother got it through a blood transfusion. But she’s been good. Mother’s been good. She takes medicine or whatever and then she go sees a doctor and she let us know. She lets us know how her T-cell count and stuff is like that. I mean, so it is in my family, But I would’ve never thought… All I thought about was gay men when I did see it. Yeah.’
4. Discussion
4.1. External Locus of Control
4.2. Potential Pathway from External Locus of Control to Internal Locus of Control
4.3. Internal Locus of Control
4.4. Interplay of Locus of Control and Determinants of Health
4.5. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variables | Subcategories | Respondents (241) | Study Participants | Respondents | Study Participants |
---|---|---|---|---|---|
Biological Sex | N = 230 | N = 20 | % | % | |
Female | 226 | 20 | 98.26% | 100.00% | |
Male | 4 | 0 | 1.74% | 0.00% | |
Unsure | 0 | 0 | 0.00% | 0.00% | |
Missing | 0 | 0 | 0.00% | 0.00% | |
Age | N = 225 | ||||
<18 years | 1 | 4 | 0.44% | 20.00% | |
18–29 years | 148 | 4 | 65.78% | 20.00% | |
30–39 years | 49 | 4 | 21.78% | 20.00% | |
40–49 years | 17 | 7 | 7.56% | 35.00% | |
>49 years | 10 | 5 | 4.44% | 25.00% | |
Race | N = 164 | ||||
African American | 82 | 13 | 50.00% | 65.00% | |
Black | 81 | 7 | 49.39% | 35.00% | |
Other | 1 | 0 | 0.61% | 0.00% | |
City of Residence | N = 142 | ||||
Houston, TX | 140 | 19 | 98.59% | 95.00% | |
Other | 2 | 1 | 1.41% | 5.00% | |
English Speaking | N = 213 | ||||
Yes | 193 | 20 | 90.61% | 100.00% | |
No | 20 | 0 | 9.39% | 0.00% | |
Sexual activity with a male partner within the last 12 months | N = 224 | ||||
Yes | 214 | 20 | 95.54% | 100.00% | |
No | 10 | 0 | 4.46% | 0.00% | |
Access to a phone and/or internet | N = 191 | ||||
Yes | 189 | 20 | 98.95% | 100.00% | |
No | 2 | 0 | 1.05% | 0.00% | |
Ability to provide informed consent | N = 191 | ||||
Yes | 180 | 20 | 94.24% | 100.00% | |
No | 11 | 0 | 5.76% | 0.00% | |
Current HIV Status | N = 180 | ||||
HIV-positive | 16 | 0 | 8.89% | 0.00% | |
HIV-negative | 164 | 20 | 91.11% | 100.00% | |
Willing to participate | N = 160 | ||||
Yes | 158 | 20 | 98.75% | 100.00% | |
No | 2 | 0 | 1.25% | 0.00% |
Category of Themes | Themes | Codes (n = 1217) | Frequency of Codes |
---|---|---|---|
External Locus of Control | |||
Self-advocacy with providers about health | 7 codes | ||
Preference in having a Black provider | 14 | ||
Preference in having a female provider | 10 | ||
Provider not discussing PrEP | 5 | ||
Provider not discussing sexual health | 5 | ||
Relationship with provider supports comfort to discuss PrEP | 3 | ||
Provider comfort talking about sexual health | 2 | ||
Perception that provider’s knowledge is outdated | 1 | ||
Media Influences on understanding of PrEP | 6 codes | ||
TV media messaging about PrEP | 60 ** | ||
Perception that cis Black/African American women are not prioritized in TV media messaging about PrEP | 26 * | ||
Media messaging suggests that PrEP is for LGBTQ+ community | 19 | ||
Females may feel excluded due to lack of representation in media marketing | 7 | ||
Perception that PrEP commercials were not relatable due to lack of representation | 2 | ||
Lack of PrEP awareness due to disconnect from media | 1 | ||
Comfort with provider–patient interactions | 12 codes | ||
Perceived comfort with discussing sexual health with provider | 8 | ||
Communicating openly with your provider is part of your health | 8 | ||
Perceived comfort in having a female provider | 5 | ||
Comfort talking about PrEP with provider | 5 | ||
Perceived trust in provider | 4 | ||
Discomfort communicating with provider about sexual health | 4 | ||
Long-term relationship with provider promotes comfort to discuss sexual health | 2 | ||
Perceived comfort in having a Black provider | 2 | ||
Honest communication as a remedy for medical mistrust | 2 | ||
Comfort with talking about PrEP with provider regardless of provider’s gender | 2 | ||
Perceived higher level of trust in having a Black provider | 1 | ||
Acknowledged the need for transparency in health communication with providers | 1 | ||
Provider engagement in sexual health of cis Black female patients | 10 codes | ||
Experience with provider offering HIV testing | 13 | ||
Willingness to engage provider in HIV testing | 10 | ||
Experience with provider discussing sexual health | 5 | ||
Level of trust influencing decision to get HIV test | 4 | ||
Experience with provider offering STD testing | 3 | ||
Patient desires to have preventative conversations with provider | 2 | ||
Hesitancy for conversations about PrEP due to perceived stigma or judgment | 2 | ||
Assumption of sexual risk for provider | 2 | ||
Level of trust within relationship influencing decision to take PrEP | 1 | ||
Experience with provider discussing PrEP | 1 | ||
Awareness of peers with HIV and/or taking PrEP | 4 codes | ||
Awareness of peers on PrEP | 2 | ||
Awareness of peers with HIV prompts willingness to learn more | 2 | ||
Awareness of peers taking PrEP opens communication about PrEP | 1 | ||
Awareness of peers with HIV and PrEP experience | 1 | ||
PrEP-related concerns | 5 codes | ||
Concern with cost and insurance coverage for PrEP | 4 | ||
Concerns for PrEP injectable | 4 | ||
Cost as a barrier to PrEP readiness | 3 | ||
Concerns for PrEP as an injection | 2 | ||
Concerns for PrEP oral pill | 2 |
Category of Themes | Themes | Codes (n = 1217) | Frequency of Codes |
---|---|---|---|
Internal Locus of Control | |||
Perceived PrEP knowledge | 13 codes | ||
Perception that PrEP is not for heterosexual people | 28 * | ||
Perception that PrEP is for gay men | 24 * | ||
Perception that PrEP eligibility is based on sexual orientation | 23 * | ||
Concern about PrEP’s side effects | 19 | ||
Perception that PrEP is for people who inject drugs | 13 | ||
Perception that PrEP is for people who inject drugs | 13 | ||
Research participation serving as access to PrEP knowledge | 12 | ||
Perception that PrEP is for risky lifestyles | 11 | ||
Concern about PrEP’s side effects with pre-existing conditions | 9 | ||
Perception that taking PrEP promotes risky behavior | 4 | ||
Personal knowledge that PrEP is for women | 3 | ||
Concern for PrEP not being studied in cis women | 1 | ||
Awareness of lack of knowledge on PrEP may prompt willingness to learn more | 4 | ||
PrEP Willingness | 6 codes | ||
Stigma around PrEP uptake | 10 | ||
Reasons women might be hesitant towards taking PrEP | 8 | ||
Reasons why cis Black women might be willing to take PrEP | 6 | ||
Awareness of lack of knowledge on PrEP may prompt willingness to learn more | 4 | ||
Self-awareness of lack of knowledge on PrEP | 2 | ||
Certainty that PrEP is not an option | 2 | ||
Knowledge of PrEP as a prevention tool | 8 codes | ||
Perception that PrEP offers safety | 29 * | ||
PrEP empowers ability to control personal sexual health | 20 * | ||
Perception that PrEP offers freedom | 19 | ||
Knowledge of PrEP as preventing HIV | 17 | ||
Research participation serving as access to PrEP knowledge | 12 | ||
Personal experience with taking PrEP | 3 | ||
Understanding that PrEP can prevent HIV risk to others | 3 | ||
Knowledge that PrEP helps with HIV transmission | 2 | ||
Awareness of sexual risk | 11 codes | ||
Awareness of HIV risk within sexual relationships | 28 * | ||
Perception of elevated HIV risk with new partner | 8 | ||
Personal investment in knowing one’s personal HIV status | 6 | ||
Perception that PrEP is for risky lifestyles | 11 | ||
Awareness of HIV risk | 11 | ||
Perception that taking PrEP promotes risky behavior | 4 | ||
Awareness of changes in sexual risk over time | 4 | ||
Awareness of STI risk within sexual relationships | 2 | ||
Perception of elevated HIV risk with multiple partners | 1 | ||
Acceptance of risk for getting STDs | 1 | ||
Perceived facilitators of the decision to use PrEP | 6 codes | ||
Perception that varied PrEP messaging can bring awareness | 19 | ||
Willingness to take PrEP | 15 | ||
Perception that awareness and education of PrEP prompts willingness to take PrEP | 8 | ||
Perception that PrEP will not impact their sexual intimacy | 8 | ||
Willingness to take PrEP as an injection | 4 | ||
Perception that PrEP can reduce personal risk of getting HIV | 2 | ||
Factors that inform the choice for or against PrEP use among cis Black women | 2 codes | ||
Reasons why cis Black women might be willing to take PrEP | 6 | ||
Scientific data are not always reflective of cis Black women | 4 | ||
Willingness for self-advocacy with healthcare provider | 2 codes | ||
Willingness to take PrEP | 15 | ||
Willingness to advocate for self with healthcare provider | 4 | ||
Willingness to educate others on PrEP | 1 | ||
Acceptance of PrEP as approved | 2 codes | ||
Acceptance of side effects with PrEP | 3 | ||
Acceptance of longevity of PrEP regimen | 1 | ||
Awareness of HIV risk with drug use | 2 codes | ||
Awareness of HIV risk due to personal drug use | 1 | ||
Awareness of personal HIV risk due to previous drug use | 1 | ||
Perceived HIV knowledge | 1 code | ||
Awareness of HIV transmission routes | 1 |
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Hill, M.J.; Sapp, S.; McCants, S.; Campbell, J.; Taylor, A.; Stockman, J.K.; Santa Maria, D. An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP). Int. J. Environ. Res. Public Health 2024, 21, 1084. https://doi.org/10.3390/ijerph21081084
Hill MJ, Sapp S, McCants S, Campbell J, Taylor A, Stockman JK, Santa Maria D. An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP). International Journal of Environmental Research and Public Health. 2024; 21(8):1084. https://doi.org/10.3390/ijerph21081084
Chicago/Turabian StyleHill, Mandy J., Sarah Sapp, Shadawn McCants, Jeffrey Campbell, Akeria Taylor, Jamila K. Stockman, and Diane Santa Maria. 2024. "An Examination of Perceptions among Black Women on Their Awareness of and Access to Pre-Exposure Prophylaxis (PrEP)" International Journal of Environmental Research and Public Health 21, no. 8: 1084. https://doi.org/10.3390/ijerph21081084