A Retrospective Assessment of Antecedent Pre-Exposure Prophylaxis Eligibility of HIV-Positive Women in the South

Introduction

The current domestic HIV epidemic is well seated in the southeast region of the nation. ¹ Among the 37,600 new HIV infections in the United States in 2014, half of them were in the South. ¹ Moreover, of the 6000+ people who died of HIV-related complications in 2014, 53% of them resided in the South. ¹ African American women are significantly impacted by HIV and disproportionately shoulder the majority of HIV infections among women. ² This impact is especially experienced in the South. HIV pre-exposure prophylaxis (PrEP) is recognized as an effective prevention approach for individuals at higher risk of HIV acquisition. ^{3 –5} Despite its acceptance and utility among other societal groups, studies indicate low use among women, particularly among African American women. ^6,7

Most approaches to HIV prevention have employed established indicators of HIV risk among heterosexual women, namely having >1 concurrent sexual partners and/or a sexual relationship with a partner(s) of known HIV-positive status, known bisexual orientation, or known injection drug use history. The quest to identify PrEP-eligible individuals in some districts has utilized algorithms of expanded criteria, such as sexually transmitted infections history, hepatitis B or C coinfections, requests for anal cytology and prescriptions for antedotes to illicit drugs. ^4,8,9 These studies demonstrate efforts to enhance PrEP delivery to those at higher risk of HIV infection and illuminate the need for expansion of the Centers for Disease Control and Prevention's (CDC) PrEP eligibility criteria with questions about violence, transactional sex, incarceration, or noninjection drug use.

Although these measures of HIV risk are insightful and reasonable, it is hypothesized here that these indicators for PrEP use do not sufficiently approximate risk in women who may personally engage in low-risk behaviors. Indeed, many women remain at significant risk of HIV acquisition solely because of the activities of their partners. It is, therefore, postulated that many African American women remain vulnerable to HIV acquisition, yet meet none of the established criteria for PrEP eligibility. These are women who have only one sexual partner and who have low suspicion and no knowledge of their partner's bisexual orientation, HIV-positive status, or injection drug use history. Because of this breach of risk approximation, many women who are presently HIV positive likely fulfilled none of the established indications for PrEP at the time of their HIV acquisition. It is reasonable to suppose that their HIV infections may have been averted if risk had been better estimated and appropriate strategies for HIV prevention employed.

Materials and Methods

In an effort to assess the fitness of current PrEP indications for estimating HIV risk in heterosexual women, 102 HIV-positive women in Atlanta, GA, were queried about their HIV risk awareness and behaviors in the time period before their HIV infection. Study participants provided voluntary and anonymous responses to an eight-item questionnaire designed to retrospectively assess risk of HIV according to established 2014 and revised 2017 CDC clinical recommendations. ^3,4 The CDC's recommendations for PrEP use in heterosexual adults target HIV-negative adult women who are not in a monogamous partnership with a recently tested HIV-negative partner and either infrequently use condoms during sex with a partner who is bisexual or uses IV recreational drugs, is in an ongoing sexual relationship with an HIV-positive partner, or has been diagnosed with a bacterial sexually transmitted infection in the past 6 months. ^3,4 The items of the questionnaire are outlined in Table 1. Women were invited to participate in the survey by a peer educator for the Heather Ivy Society, a local support group for women who are impacted by HIV. The study enrollment period was from August 27 to November 27, 2018. The time period between HIV diagnosis and data collection was not directly assessed in the questionnaire. However, respondents had been living with an awareness of their HIV infection for ∼1–20 years before study participation. The peer counselor explained the risks, benefits, and methods of participating in the survey. Verbal consent was obtained and surveys were self-administered. No personal identifying information was collected during the survey administration. Study data were collected and managed using an online data capture tool. Upon completion of data collection, descriptive statistics were used to summarize the results.

Results

A total of 102 women completed the questionnaire. The majority of the respondents were black, with 86% of the surveyed population identifying in this ethnic group. Approximately 8% of the respondents were white and <1% identified as Latina or Asian. About 4% self-categorized as other. No respondent identified as Native American.

When women were queried about the number of sexual partners they had at the time of their HIV infection or diagnosis, >65% reported having only one partner. In addition, 64% of the women reported having sex four or more times with the sexual partner from whom they acquired HIV, suggesting sexual relations in the context of a presumed monogamous partnership. Slightly >90% of the respondents reported no knowledge or suspicion of their partners' bisexual orientation or HIV-positive status, respectively (Table 2).

Discussion

African American women, particularly in the South, remain disproportionately impacted by high rates of HIV infections, although with low utilization of PrEP despite its known efficacy in preventing HIV transmissions. Indeed, data from US pharmacies between 2013 and 2016 showed that women were dispensed only 14% of PrEP prescriptions with African American women representing a paucity of the prescriptions to women. ¹⁰ Underutilization of PrEP by African American women has been shown to be a function of limited awareness of PrEP, low perceived risk of HIV infection among women, stigma associated with the use of antiretrovirals, difficulty in broaching sensitive discussions of sexuality with providers, medication costs, and miscalculation of risk by clinicians when relying upon accepted risk assessment criteria. ^{10 –13} Studies of the perspectives of African American women regarding PrEP have shown that most women expressed an interest in utilizing it, even expressing frustration for having limited awareness of or access to PrEP before their participation in the studies. ^14,15 Such social and structural barriers to PrEP, particularly narrow eligibility standards for PrEP consideration, impede women's use of it despite a self-reported interest in HIV prophylaxis. ¹⁵

The findings here demonstrate an incongruence in the actual risk of HIV acquisition among African American women in Atlanta, GA, and the expected risk based upon self-reported behavioral factors. The study demonstrates that the recommended indications for PrEP use do not fully incorporate heterosexual women who personally engage in lower risk behaviors, yet remain at significant risk of HIV acquisition. When current indications for PrEP were retrospectively applied to women who are now HIV positive, the majority of them fell outside of the consideration limits for PrEP. The majority of the women were engaged in sexual relations with a single partner and had no knowledge or suspicion of their partners' HIV-positive status or bisexual orientation. Their reported sexual activity occurred in what is even suggested to be a monogamous partnership from the perspective of the female respondent.

The results of this study demonstrate an apparent shortfall of the recommendations to approximate HIV risk in heterosexual African American women and elucidate a necessity to expand or revise the recommended indications for PrEP use in this population. ^3,4 As demonstrated, heterosexual women who self-report having a single sexual partner and/or no awareness or suspicion of their partners' HIV-positive status or bisexual orientation remain vulnerable to HIV infection. These findings highlight the limitations of relying solely on patient characteristics to inform PrEP eligibility. An algorithm that appraises the behaviors of the sexual partners of heterosexual women or that uses residency details may provide a more relevant risk assessment focus. For example, recommendations that employ information on whether heterosexual partners reside in a shared residence or whether there is prior evidence of or a strong suspicion of sexual infidelity in the partnership may prove highly impactful. Likewise, PrEP eligibility justified by a high prevalence of HIV infections in the community in which a patient and/or her sexual partner(s) resides may offer a meaningful preventive approach. ¹⁰

Because of profound health disparities in HIV diagnoses among African American women and the missed opportunities for prevention demonstrated in this survey, a call upon health care to expand the scope of PrEP eligibility is paramount to altering the course of the epidemic. Estimation of HIV risk in a one-size-fits-all approach is faulty and a selective application of PrEP often exacerbates issues of stigma around HIV prevention. Instead, a more routine and partner-focused approach to PrEP in adult women may destigmatize PrEP and bolster its acceptance and utility among populations who may benefit from it most. ¹⁶

An acknowledged limitation of this study is its inability to assess alternative or expanded factors by which PrEP eligibility may be determined. Future areas of inquiry might include assessments of women's geographic place of employment or recreation and the local prevalence of HIV infections to determine PrEP eligibility. Additional risk assessment studies that are informed by the sexual behaviors of the male partners of women are warranted. ¹⁷ A risk-evaluation strategy that assimilates features of the three Ps, namely personal participation in established high-risk behaviors, partner participation in established high-risk behaviors, and local HIV prevalence rates in a woman's city or region of residence or employment may offer a more meaningful approach to PrEP eligibility.