Arrendamientos operativos

Women make up nearly one-fifth of new HIV infections in the US, yet few are being informed about PrEP. Many WOC reported that they had heard about PrEP for MSM, but they did not know that PrEP was an option for themselves. This lack of awareness caused women to feel frustrated and unvalued. Despite the many potential barriers to PrEP uptake, WOC generally find PrEP acceptable and identify it as a

potentially powerful tool for HIV prevention. Particularly in high incidence areas, efforts are needed to inform women that PrEP can be part of their HIV prevention options. Providing this information could also build trust with their providers, reduce the stigma associated with PrEP, and allow women to better understand side effects and their HIV risk.

Providers may be under-equipped to prescribe PrEP. Awareness of PrEP has increased in the last several years, but this has not resulted in changes in clinical practice. This may be because providers – both HIV and non-HIV providers - require more

training on topics related to PrEP such as medication side effects and toxicities. In particular, there is a need for more providers to learn how to take sexual histories and to provide adherence and risk reduction counseling, especially to reach all women at substantial risk across different care settings.

WOC voiced a lack of trust in the medical system as a major concern. Abuse and racism within the US medical system against people of color are well-documented (126– 130). WOC have been forcibly sterilized and forced to undergo medical procedures without their informed consent or against their wishes (131–134). Kaiser Family

Foundation’s 2009 report of state-level health indicators found that WOC fared worse than White women in almost every state, with some of the largest disparities seen in rates of new AIDS diagnoses and lack of prenatal care (135). The Institute of Medicine’s 2003 review Unequal Treatment reported that providers’ bias in decision-making (such as prescribing fewer medications and providing lower levels of treatment to people of color compared to White people) is a significant contributor to racial and ethnic disparities in health care for both men and women, citing treatment differences in cancer, coronary heart disease, and HIV/AIDS (130). Though there is not much research on provider PrEP prescribing practices, the limited research shows that there may be racially discriminatory prescribing practices (125). The lack of knowledge about PrEP and the low uptake of PrEP among WOC may also be a result of provider bias or assumptions regarding who is eligible for PrEP. One practice that may decrease the disparity in PrEP prescribing and counteract potential provider bias would be routinizing PrEP for women; that is,

incorporating PrEP education and counseling into all women’s routine health care visits. Medical providers and WOC identified some similar concerns about PrEP, namely cost, adherence, and the possibility of risk disinhibition. The cost of PrEP may indeed be a significant barrier as Truvada costs nearly $2,000 per month, in addition to costs for laboratory tests and office visits prior to initiation and during care (136,137). Medicaid covers PrEP, but for those with private insurance, out-of-pocket expenses for laboratory tests, clinic visits, and medication vary and be burdensome (136,138). Although private insurance typically provides at least some coverage for PrEP, several insurance plans have large deductibles or copays (111). Some states have developed

patient assistance programs or care support programs, but these may not cover the cost of the drug and care (111). Gilead Sciences has a medication assistance program for patients making less than 500% of the federal poverty line (139). Even with these programs, the reimbursement process requires significant documentation and the ability to negotiate a complex process, often over the course of multiple office visits (111). In DC, the DOH offers a drug assistance program (DAP) for PrEP for insured and uninsured DC residents (140). PrEP DAP pays the monthly co-pay and deductible for the medication, but funding is limited and does not cover laboratory work or office visits (140). Patients and their provider must complete an application form that includes indicating HIV risk behavior (e.g., “a sexual relationship with a person living with HIV”), which some patients may find stigmatizing (140). However, the US Preventive Services Task Force’s recent grade A recommendation of PrEP will require insurance plans to provide PrEP at no cost- sharing for patients beginning in 2021 (141).

Adherence is also a significant barrier. As clinical trials indicate, women need to maintain at least 75% daily adherence in order for PrEP to be effective (53). Adherence support requires thoughtful, patient-centered, ongoing discussions between women and providers on how women can feasibly integrate PrEP into their lives. Regarding the concern that PrEP use will lead to an increase in risky behaviors, cited by both WOC and providers, most evidence does not support this concern. The TDF2 clinical trial, which was exclusively women, did not find evidence of increased risky behaviors (49). A 2016 systematic review found that there was no change in condom use or an increase in condom use over time when comparing PrEP users to non-PrEP users (142). Similarly,

this review found that the number of sexual partners either did not change or decreased from baseline when comparing PrEP users to non-PrEP users (142). However, though the Partners PrEP trial showed a decrease in risky behaviors, there was an increase in number of non-primary sexual partners after participants were unblinded (143). Notably, these studies typically included risk reduction counseling. As these results may not be generalizable to WOC in the US, more research in this area is needed.