Women’s Decision-Making about PrEP for HIV Prevention in Drug Treatment Contexts

Abstract

Despite pre-exposure prophylaxis’s (PrEP) efficacy for HIV prevention, uptake has been low among women with substance use disorders (SUDs) and attributed to women’s lack of awareness. In semistructured interviews with 20 women with SUD and 15 key stakeholders at drug treatment centers, we assessed PrEP awareness and health-related decision-making. Women often misestimated their own HIV risk and were not aware of PrEP as a personally relevant option. Although women possessed key decision-making skills, behavior was ultimately shaped by their level of motivation to engage in HIV prevention. Motivation was challenged by competing priorities, minimization of perceived risk, and anticipated stigma. Providers were familiar but lacked experience with PrEP and were concerned about women’s abilities to action plan in early recovery. HIV prevention for women with SUD should focus on immediately intervenable targets such as making PrEP meaningful to women and pursuing long-term systemic changes in policy and culture. Efforts can be facilitated by partnering with drug treatment centers to reach women and implement PrEP interventions.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

“…The barriers identified were (1) perceived HIV risk, (2) concerns about medication side effects or interactions, (3) housing insecurity and travel, (4) co-occurring health-related conditions and appointments, and (5) caregiving responsibilities. We chose not to focus on caregiving as that has already been established in the literature [ 67 – 70 ].…”

“…Although past research with cisgender and transgender women has highlighted the need for gender affirming care, bundling referrals to other needed health and social services [ 80 ] along with the importance of peers [ 54 ], these are not sufficient; ultimately, women faced barriers that made attending PrEP appointments challenging. Barriers, such as competing priorities, travel, and other health-related conditions were significant [ 70 ]. The norm in healthcare of referring patients to services is a suboptimal approach to engaging women at risk.…”

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

“…Given that PWID may have competing priorities, including basic needs (e.g., food, housing, employment, etc. ), limiting the number of visits required for PrEP initiation and maintenance could significantly reduce PrEP care continuum drop off [ 121 ]. Importantly, PrEP initiation is only one step in the care continuum and later steps such as persistence and retention will need support [ 86 ].…”

No Longer the Exception, but the Standard: Integrating Trauma-Informed Policy and Pre-exposure Prophylaxis Implementation for Women

“…Promoting autonomy among women during the PrEP decisionmaking process is critical to successful programming. Shared decision aid tools can help women to assess HIV risks and explain potential HIV prevention options (Qin et al, 2020). Providers should consider incorporating such tools into patientprovider conversations during PrEP education and counseling.…”