Self-Perception of HIV Risk and Interest in Pre-Exposure Prophylaxis in a General Obstetrics and Gynecology Clinic Population

Abstract

Background:

Pre-exposure prophylaxis (PrEP) for HIV is underutilized, particularly among attendees of obstetrics and gynecology (Ob/Gyn) clinics. Lack of self-perception of HIV risk is a barrier to PrEP utilization, and a lack of understanding of community risk factors for HIV may contribute to that lack of self-perception of risk.

Methods:

Attendees of general Ob/Gyn clinics in New Orleans completed a survey assessing HIV knowledge, self-perception of HIV risk, and interest in PrEP. They reviewed a brief written educational intervention on demographic and behavioral risk factors for HIV and availability of PrEP. HIV knowledge, self-perception of HIV risk, and interest in PrEP were reassessed after the intervention.

Results:

One-hundred seventy individuals completed the survey. Eighty-five participants (50%) expressed initial interest in PrEP. Self-perception of risk of HIV acquisition was associated with interest in PrEP. Ten of 11 (90.9%) respondents who had high self-perceived risk of HIV were interested in PrEP, compared with 75 of 159 (47.2%) of those who had low self-perceived risk (p = 0.01). The association remained significant in a multivariate analysis. After the intervention, the number of those who perceived themselves to be at risk of HIV increased from 11 to 25 individuals (p < 0.01) and 20 of these (80%) were interested in PrEP. Knowledge of HIV risk factors increased (p < 0.01). The intervention did not significantly alter interest in PrEP.

Conclusions:

Self-perception of HIV risk was associated with interest in PrEP. A brief written educational intervention increased knowledge of HIV risk factors and increased self-perception of risk of HIV. The intervention did not translate to increased interest in PrEP.

Introduction

While 38% of the U.S. population lives in the South, the region accounts for an estimated 51% of new HIV cases.¹ In 2019, Louisiana had the fourth highest rate of incident HIV infections in the United States with 22.8 cases per 100,000 people, nearly double the national rate of 13.2 per 100,000 people.² In 2019, 16% of all new HIV cases were among heterosexual cisgender women.³ Although Black women account for 13% of the female U.S. population, they accounted for 55% of the HIV diagnoses among females in 2019.²

In 2019, the Department of Health and Human Services released Ending the HIV Epidemic: A Plan for America, with the goal of reducing new HIV infections by 75% by 2025 and at least 90% by 2030.⁴ Increasing pre-exposure prophylaxis (PrEP) use among those at risk for HIV is a core component of the plan.⁴ In 2021, the Centers for Disease Control and Prevention (CDC) published an update to the clinical practice guideline for PrEP prescribing, which recommends that all sexually active adults and adolescents be informed about PrEP.

The intervention should be offered to any person who is at substantial risk of HIV acquisition and to anyone else who requests it, even in the absence of specific reported risk behaviors.³ Those at substantial risk of acquiring HIV are adults or adolescents who have had vaginal or anal sex in the past 6 months and any of the following: HIV-positive sexual partner, recent bacterial sexually transmitted infection, or history of inconsistent or no condom use with a partner of unknown HIV status.

The American College of Obstetricians and Gynecologists (ACOG) issued a practice advisory in 2022, recommending that obstetrician–gynecologists discuss PrEP with all sexually active adolescent and adult patients as part of routine care.⁵ Obstetrician–gynecologists are well versed in provision of sexual health care, and attendees of obstetrics and gynecology (Ob/Gyn) clinics believe these to be excellent venues for PrEP prescribing.^6,7

However, despite high levels of HIV transmission, and FDA approval for over a decade, utilization of PrEP both nationwide and in the U.S. South has been limited.⁸ Of the 1.2 million Americans who could benefit from PrEP, 25% report using it. PrEP use among those living in the South accounts for only 27% of total use, despite the region accounting for over half of the new annual HIV cases.¹ According to pharmaceutical prescription data, in 2021, only 8% of PrEP users in the United States were women.⁹

While the renewed call for PrEP prescribing may provide a boost in interest for PrEP among health care providers, another major barrier to PrEP utilization is lack of self-perception of HIV risk among patients, even if they engage in high-risk sexual practices.^10,11 In our group's prior study of PrEP interest among urban attendees of Ob/Gyn clinics, 84.7% considered themselves at low risk for acquiring HIV, although only 41.0% used condoms.⁶ Underestimation of risk of HIV acquisition may contribute to low interest in PrEP.⁶

Beyond individual risk behaviors, multiple levels of factors play a role in a person's vulnerability to HIV, including community, network, and partner factors.¹² The 2017 guidelines listed “high HIV prevalence area or network” as an indication for PrEP use, but what constituted a high prevalence area or network was not specifically defined.⁸ Prior investigations have demonstrated that individuals do consider the HIV risks of their community or network when assessing their own risk of HIV acquisition.¹³ It is unknown if simply presenting demographic data as they pertain to HIV risk could alter a person's perception of their own HIV risk.

We aimed to characterize self-perceived risk of HIV acquisition among attendees of general Ob/Gyn clinics based at academic centers in New Orleans, Louisiana, using a self-administered survey, and assess how self-perceived risk of HIV relates to interest in PrEP. Furthermore, we evaluated whether a brief written educational intervention that presents demographic and behavioral factors associated with HIV can alter HIV knowledge, self-perception of HIV risk, and interest in PrEP.

Methods

Patients were recruited from September 2020 through August 2021 during normal clinic hours from two Tulane University-affiliated general Ob/Gyn clinics located in the New Orleans metropolitan area. Eligible patients included sexually active individuals who were 18 years or older, English speaking, nonpregnant, and not known to be living with HIV. Patients who were currently breastfeeding or incarcerated were excluded from participating. Participants were provided with a link to access a survey via their cell phones and completed the survey on their personal devices while waiting during clinic visits.

The survey collected data on demographic information (age, gender, sexual orientation, education level, and income), sexual history in the prior 6 months, self-perception of HIV risk, and knowledge of HIV transmission and assessed interest in PrEP. Self-perception of HIV risk was assessed by asking: “Please indicate the extent to which you agree or disagree with the following statement: I am at risk of getting HIV this year.” Answer choices included strongly agree, agree, disagree, strongly disagree, and decline to answer.

Interest in PrEP was assessed by asking: “If PrEP were available to you, how likely would you be to use it to prevent HIV?” Participants were also asked, “If your healthcare provider recommended PrEP, would you be willing to try it?” Answer choices to both questions included very likely, likely, unlikely, very unlikely, undecided, and decline to answer.

A brief (4-page) written educational intervention was delivered to participants via the survey. The educational intervention is provided as Supplementary Data. It consisted of infographics on modes of HIV transmission and risk factors and presented HIV incidence rates among women, in the U.S. South, and among racial groups. It also included a patient information sheet on PrEP. The educational intervention materials were created using patient education materials published by governmental and nonprofit groups.^{8,14

–21} Participants then completed a postintervention section of the survey, which repeated questions regarding self-perception of HIV risk, knowledge of HIV transmission, and interest in PrEP.

The number of individuals who were at substantial risk of acquiring HIV was calculated using the definition of PrEP eligibility from the United States Public Health Service 2017 Clinical Practice Guidelines, which were in use at the time of data collection.⁸ This substantial-risk subgroup included participants who reported being sexually active in the past 6 months and at least one of the following: having an HIV-positive sexual partner, having a bacterial sexually transmitted infection, more than one sexual partner, inconsistent or no condom use, or commercial sex work within the past 6 months.

Chi-squared analysis was used to determine if demographic factors were associated with interest in PrEP. Chi-squared analysis was used to determine if self-perception of HIV risk was associated with interest in PrEP among the total population and among individuals in the substantial-risk subgroup, both before and after the educational intervention. Fisher's exact test was used when cell counts were less than five. A multivariate analysis using logistic regression was then performed to assess whether self-perception of HIV risk was associated with interest in PrEP; demographic factors found to be associated with interest in PrEP were included in the model.

The Wilcoxon signed rank test was used to determine if the educational intervention altered self-perception of HIV risk, interest in PrEP among the total population, and interest in PrEP in the substantial-risk subgroup. Knowledge of risk factors for HIV acquisition was compared before and after the intervention by creating pretest and post-test knowledge scores and comparing them using the Wilcoxon signed rank test.

A power analysis was performed. A sample of 155 would provide 80% power to detect a 15% increase in self-perception of HIV risk, from a projected baseline of 15% to 30% after the educational intervention. An earlier study of PrEP interest in this patient population demonstrated that 15% of participants had a high self-perceived risk of HIV.⁶ Given an anticipated dropout rate from the survey of about 20%, we aimed to enroll 200 participants.

The study was approved by the Tulane University Institutional Review Board (Protocol No. 2020–1345). Verbal informed consent was obtained by study staff members using an approved verbal consent script. The need for written informed consent was waived by the IRB as no identifying information was collected on participants. All study activities and data collection procedures, including the brief educational intervention, were administered and stored electronically using Qualtrics survey software. Data analysis was conducted using SAS Studio^® software (SAS Institute, Cary, NC).

Results

Demographics

Of the 295 patients invited to take the survey, 201 agreed to participate and started the survey. One hundred seventy had sufficient data to be included in the analysis; 31 participants were excluded due to selecting “decline to answer” to either of the following: “Please indicate the extent to which you agree or disagree with the following statement: I am at risk of getting HIV this year” or “If PrEP were available to you, how likely would you be to use it to prevent HIV?” These questions were necessary to evaluate initial self-perception of HIV risk and interest in PrEP. The demographic characteristics of the 31 participants who were excluded from the analysis did not differ significantly from those who were included.

Among the 170 participants included, 80 (47.1%) were aged 30 years or younger (Table 1). One hundred participants (58.8%) described themselves as Black. One hundred sixty-nine participants (99.4%) identified as female. One hundred forty-one participants (82.9%) identified as heterosexual/straight. Sixty-four participants (37.7%) had an annual income of $20,000 or less. Seventy-four participants (43.5%) cited high school/GED or less for education level and 51 (30%) had some college education.

Table 1.

Cohort Demographic Characteristics

	All included participants (N = 170)	Subgroup at substantial risk of acquiring HIV ^a (N = 13)
Age
Less than 20 years	10 (5.9%)	2 (15.4%)
Between 21–30 years	70 (41.2%)	8 (61.5%)
Between 31–40 years	30 (17.6%)	—
Between 41–50 years	32 (18.8%)	3 (23.1%)
Between 51–60 years	17 (10.0%)	—
Greater than 60 years	11 (6.5%)	—
Race
Black	100 (58.8%)	9 (69.2%)
White	54 (31.8%)	2 (15.4%)
Asian or Pacific Islander	1 (0.6%)	—
Native American	1 (0.6%)	—
Other	9 (5.3%)	2 (15.4%)
Decline to answer	6 (3.5%)	—
Hispanic ethnicity
Hispanic	16 (9.4%)	2 (15.4%)
Not Hispanic	151 (88.8%)	11 (84.6%)
Decline to answer	3 (1.8%)	—
Gender
Female	169 (99.4%)	13 (100%)
Other	1 (0.6%)	—
Sexual orientation
Heterosexual/straight	141 (82.9%)	8 (61.5%)
Homosexual/lesbian/gay	4 (2.4%)	—
Bisexual	16 (9.4%)	5 (38.5%)
Other	6 (3.5%)	—
Decline to answer	3 (1.8%)	—
Annual income
Less than $20,000/year	64 (37.7%)	10 (76.9%)
$20,000–$50,000/year	56 (32.9%)	1 (7.69%)
$50,000–$100,000/year	22 (12.9%)	1 (7.69%)
More than $100,000/year	13 (7.7%)	—
Decline to answer	15 (8.8%)	1 (7.69%)
Highest education
Less than high school	8 (4.7%)	—
High school/GED	66 (38.8%)	7 (53.9%)
Some college	51 (30.0%)	4 (30.8%)
Associate's degree	12 (7.1%)	1 (7.69%)
Bachelor's degree	19 (11.2%)	1 (7.69%)
Some graduate school	6 (3.5%)	—
Completed graduate school	8 (4.8%)	—

PrEP eligible by 2017 guidelines.

PrEP, pre-exposure prophylaxis.

Thirteen (7.6%) participants were at substantial risk of acquiring HIV infection. In the substantial-risk subgroup, 10 (76.9%) participants were aged 30 years or younger, 9 (69.2%) described themselves as Black, 13 (100%) identified as female, 8 (61.5%) were heterosexual/straight, 10 (76.9%) had an income of less than $20,000 per year, and 7 had high school/GED as the highest level of education (53.9%) (Table 1).

PrEP interest

Participants were categorized as initially interested in PrEP if they answered the question “If PrEP were available to you, how likely would you be to use it to prevent HIV?” with “very likely” or “likely” on the preintervention survey. A total of 85 participants (50.0%) were interested in PrEP, 54 (31.8%) were not interested in PrEP (answered “unlikely” or “very unlikely”), and 31 (18.2%) were undecided. For the remainder of the analysis, participants who answered “unlikely,” “very unlikely,” or “undecided” were grouped and considered not interested in PrEP. In the substantial-risk subgroup, 7 of 13 (53.8%) participants were interested in PrEP.

Of the participants who identified as Black, 59 (59.0%) were interested in PrEP versus 20 (37.0%) of those who identified as White (p = 0.04). Interest in PrEP was higher in participants with a lower income. Of those reporting an income of less than $20,000/year, 41 (64.1%) were interested, compared with 26 (48.4%) of those with an income of $20,000–$50,000 and 12 (34.3%) with an income of $50,000 or more (p = 0.02). Age (p = 0.31), sexual orientation (p = 0.28), and education level (p = 0.36) were not associated with interest in PrEP.

Responses to the preintervention question regarding self-perception of HIV were consolidated: “Strongly agree” and “agree” were grouped together and “disagree” and “strongly disagree” were grouped together. Self-perception of HIV risk was found to be associated with interest in PrEP (Table 2). Eleven (6.5%) of all respondents perceived themselves to be at risk of HIV. Ten of those 11 individuals (90.9%) were interested in PrEP, while 1 person was undecided. This differed significantly from those who did not perceive their risk of HIV to be high; of those with low self-perceived risk of HIV, 75 (47.2%) were interested in PrEP (p = 0.01).

Table 2.

Association of Self-Perception of HIV Risk with Interest in Pre-exposure Prophylaxis

	Interested in PrEP ^a	Not interested in PrEP or undecided	Total
High self-perceived risk of HIV^a	10	1	11
Low self-perceived risk of HIV	75	84	159
Total	85	85	170

Association remained significant after adjusting for race and income (p = 0.02).

The association remained significant in the multivariate analysis that included race and income, which were included as these factors were independently associated with interest in PrEP. In the substantial-risk subgroup, there was no statistically significant association between self-perceived HIV risk and PrEP interest: 3 (100%) of those with high self-perceived HIV risk were interested, compared with 4 of 10 (40.0%) of those with low perceived risk of HIV (p = 0.39). The lack of an association was likely due to a small number of participants in this subgroup.

Impact of the educational intervention

After the intervention, the number of those who perceived themselves to be at risk of HIV increased significantly from 11 (6.5%) to 25 (14.9%) individuals (p < 0.01). Despite this, the intervention did not alter interest in PrEP in the overall population (87 of 168; 51.8%, compared with 50.0% preintervention) or in the substantial-risk subgroup (7 of 13; 53.8%, unchanged from preintervention) (Table 3).

Table 3.

Pre- and Postintervention Interest in Pre-exposure Prophylaxis

	Preintervention interest	Postintervention interest	p
If PrEP were available to you, how likely would you be to use it to prevent HIV?
	N = 170	N = 168	0.78
Likely/very likely	85 (50%)	87 (51.8%)
Unlikely/very unlikely	54 (31.8%)	52 (31.0%)
Undecided	31 (18.2%)	29 (17.2%)
If your health care provider recommended that you take PrEP, would you be willing to try it?
	N = 170	N = 166	0.75
Likely/very likely	96 (55.9%)	98 (59.0%)
Unlikely/very unlikely	40 (23.5%)	37 (22.3%)
Undecided	35 (20.6%)	31 (18.7%)

Interest in PrEP remained associated with self-perception of HIV risk: 20 of 25 (80%) participants who perceived themselves to be at risk of HIV were interested in PrEP, compared with 67 of 142 (47.2%) participants who did not perceive themselves to be at risk (p < 0.01). In the substantial-risk subgroup, interest in PrEP was not associated with self-perception of HIV risk after the intervention (p = 0.59); this was unchanged from before the intervention.

Baseline knowledge of HIV transmission pathways was high in this population, with 164 (96.5%) participants knowing that HIV can be transmitted via sex without a condom, 136 (80.0%) knowing that it can be passed during childbirth, and 153 (90%) aware that it can be transmitted by sharing injecting equipment (Table 4). Using the composite pre- and postintervention score, the educational intervention was found to be associated with a significant change in knowledge of HIV risk factors (p < 0.01).

Table 4.

Pre- and Postintervention HIV Risk and Knowledge Assessment

	Preintervention	Postintervention
I am at risk of getting HIV this year
Strongly agree	2 (1.2%)	8 (4.7%)
Agree	9 (5.3%)	17 (10.0%)
Disagree	40 (23.5%)	48 (28.2%)
Strongly disagree	119 (70.0%)	96 (56.5%)
Decline to answer	—	1 (0.6%)
Women are at risk of getting HIV
Strongly agree	57 (33.5%)	77 (45.3%)
Agree	92 (54.1%)	80 (47.1%)
Disagree	10 (5.9%)	10 (5.9%)
Strongly disagree	9 (5.3%)	2 (1.2%)
Decline to answer	2 (1.2%)	1 (0.6%)
Having more sexual partners increases the risk of getting HIV
Strongly agree	109 (64.1%)	116 (68.2%)
Agree	46 (27.1%)	48 (28.2%)
Disagree	8 (4.7%)	2 (1.2%)
Strongly disagree	5 (2.9%)	1 (0.6%)
Decline to answer	2 (1.2%)	3 (1.8%)
Having or having had a sexually transmitted infection increases the risk of getting HIV
Strongly agree	47 (27.7%)	88 (51.8%)
Agree	79 (46.5%)	58 (34.1%)
Disagree	27 (15.9%)	12 (7.1%)
Strongly disagree	9 (5.3%)	7 (4.1%)
Decline to answer	8 (4.7%)	5 (2.9%)
Do you think you live in a region with a large number of cases of HIV?
Yes, I do	95 (55.9%)	125 (73.5%)
Not sure	67 (39.4%)	36 (21.2%)
No, I don't	7 (4.1%)	7 (4.1%)
Decline to answer	1 (0.6%)	2 (1.2%)
Do you think you are in a racial/ethnic group that is at higher risk of being diagnosed with HIV?
Yes, I do	52 (30.6%)	78 (45.9%)
Not sure	70 (41.2%)	46 (27.1%)
No, I don't	44 (25.9%)	41 (24.1%)
Decline to answer	4 (2.4%)	5 (2.9%)
Please select all of the ways that HIV is spread
Sex without a condom	164 (96.5%)	168 (98.8%)
Passed from mother to baby	136 (80.0%)	148 (87.1%)
Sharing injecting equipment	153 (90.0%)	156 (91.8%)
Contaminated blood transfusions and organ transplants	143 (84.1%)	150 (88.2%)
Sitting on public toilet seats	20 (11.8%)	22 (12.9%)
Sharing food or drinks with someone who has HIV	30 (17.6%)	28 (16.5%)
Decline to answer	3 (1.8%)	2 (1.2%)

Notably, those who believed that women are at risk of getting HIV increased from 57 (33%) to 77 (45.3%), those who believed that having a sexually transmitted infection increases your chances of getting HIV increased from 47 (27.7%) to 88 (51.8%), and those who considered themselves to be living in a region with a large number of cases of HIV increased from 95 (55.9%) to 125 (73.5%) (Table 4).

Impact of health care provider recommendation

The impact of a health care provider's recommendation for PrEP was assessed using the question: “If your healthcare provider recommended that you take PrEP, would you be willing to try it?” Before the educational intervention, there was a nonsignificant increase from 85 (50%) who were interested in PrEP to 96 (55.9%) who would be willing to try it if recommended by a health care provider.

Similarly, after the educational intervention, a nonsignificant increase was noted from 87 (51.8%) who were interested in PrEP to 98 (59%) who would be willing to try it if recommended (Table 3).

Discussion

Self-perception of HIV risk was independently associated with interest in PrEP at baseline and after the educational intervention. Enebeli et al. similarly found that an individual's perception of their risk of HIV acquisition was associated with interest in PrEP in sexual health clinics in Canada.²² Hill et al. proposed that self-perception of HIV risk is a key precursor to considering use of PrEP.²³ Efforts to increase PrEP uptake could focus on raising awareness of HIV risk factors and increasing patients' self-perception of HIV risk if they fall into high-risk groups.

This study demonstrates that a brief written educational intervention highlighting demographic and behavioral risk factors for HIV significantly increased knowledge among participants, even in this population with high baseline knowledge. Knowledge of the high risk of HIV in their community notably increased participants' own self-perception of HIV risk. Although the intervention did not result in increased interest in PrEP, it is possible that additional information about PrEP, or a conversation with a health care provider, could help translate increased self-perception of HIV risk into increased interest in PrEP.

Knowledge of and interest in PrEP among clinic attendees have increased since the medication became available. While fewer than 10% of women had heard of PrEP in 2013, 30% of women in clinics and emergency departments in Chicago in 2018 had heard of PrEP and 25% were interested in using it.^24,25 In our prior work in this clinic population in New Orleans in 2018, 37.5% of women considered using PrEP.⁶ In a Houston investigation in 2019–2021, 52.5% of cisgender Black women considered using PrEP at baseline.²³

In the current investigation, a total of 50% of the population was interested in PrEP before the intervention. Even in those who had a low self-perceived risk of HIV, the interest in PrEP was substantial (47.2%), indicating a general openness to PrEP in this population and confirming that PrEP use is becoming more acceptable over time.

Despite the increasing interest in PrEP, recognition among patients that Ob/Gyn offices are prime locations for PrEP prescribing, and clear national guidelines, Ob/Gyn health care providers often provide inadequate counseling regarding the availability PrEP, and PrEP is severely underutilized in these settings.^11,26
–28 In one study of over 13,000 women who tested positive for gonorrhea or syphilis, none were prescribed PrEP.²⁹

In this study, the subgroup of participants found to be at substantial risk of acquiring HIV (n = 13) was small and represented only 7.6% of the sample. This highlights the difficulty of identifying the highest risk patients in clinic settings, even when the clinic is located in a high prevalence region and serves a demographically high-risk population. The relative rarity of these individuals may contribute to reluctance of Ob/Gyn providers to routinely discuss PrEP with their patients.

Additional reasons for the implementation gap are lack of knowledge among health care providers; competing priorities at clinic visits; and lack of a streamlined process for PrEP prescribing, payment, and monitoring in most clinic settings.²⁸ Addressing these provider- and system-level barriers will be crucial to increasing PrEP prescribing and utilization. Additional patient-level barriers to utilization of PrEP have also been identified. HIV and PrEP stigma, mistrust in the health care system, difficulties with PrEP initiation, monitoring, and adherence must be addressed.²⁵

Although interest in PrEP does demonstrate some demographic trends in this study, these trends should not be used to guide PrEP counseling and prescribing as members of many demographic groups were found to be at substantial risk of HIV infection and/or expressed interest in PrEP. The importance of avoiding risk stratification by demographic characteristics has been echoed by other authors as it could lead to inequitable prescribing and denial of this potentially lifesaving medication to some individuals at risk.^7,28

The CDC and ACOG recommend that health care providers routinely take a sexual history at all well-person visits and discuss PrEP with all sexually active persons, rather than having the conversation only with those whom they consider high risk.⁵ This universal approach could also help reduce any perceived stigma associated with PrEP.

A strength of this investigation was the use of a recruitment strategy that engaged HIV-vulnerable populations in a manner that did not interrupt clinical care or patient flow. This study did have several limitations. Social desirability bias may have resulted in under-reporting of self-perceived HIV risk or risk behaviors. However, we attempted to minimize this bias by allowing participants to complete the surveys in private on their own devices. The study did not address the issue of HIV risk stemming from a partner who is nonmonogamous (even if the patient is monogamous with this partner).

The survey was offered exclusively in English, thus requiring English fluency for inclusion. This limitation may significantly impact the findings; an analysis of National Health Behavior Survey data indicated that PrEP awareness increases with English proficiency.³⁰ Additionally, while 201 patients originally agreed to participate in the study and started the survey, only 170 (84.6%) of those had sufficient data to be included in the analysis. This is comparable with the survey completion rate seen in other similar studies.^11,22

Data collection was limited to the two clinic sites at which we conducted our study. These clinics represent a predominantly urban population seeking care at academically affiliated Ob/Gyn clinics. Individuals seeking medical care in other settings were not included and those not engaged in medical care, who may be at greatest risk of HIV acquisition, are not represented in this study.

Future directions include examining ways in which to increase interest in PrEP among patients, increase PrEP prescribing among health care providers, and remove system-level barriers for individuals initiating and remaining in PrEP care. Specifically, further research could explore the impact of discussion of partners' sexual practices on self-perception of HIV risk. Counseling strategies to help translate self-perception of HIV risk into interest in PrEP are needed.

Additionally, although our study showed a trend toward increased willingness to use PrEP following a health care provider's recommendation, the change was not significant; further study is needed to determine the impact of a strong recommendation from a health care provider on PrEP uptake. At the provider level, tools to aid in the identification of patients at substantial risk of HIV infection in their clinics would allow targeting discussion of PrEP to those at highest risk. A patient survey embedded in the electronic medical record modeled on our survey, for example, could flag individuals for the discussion.

At a system level, developing an effective practice model that could streamline laboratory ordering, result reviewing, and PrEP prescribing would be of benefit.

Conclusions

The level of interest in PrEP is increasing among patients over time and was demonstrated to be 50% in this study at baseline. Self-perception of HIV risk was associated with interest in PrEP. A brief written educational intervention increased knowledge of HIV risk factors and increased self-perception of risk of HIV. The intervention did not translate to increased interest in PrEP in this investigation, but self-perception of HIV risk is a known precursor to interest in PrEP.

To reduce the incidence of HIV in the United States, particularly in the South, it behooves health care providers to increase prescription of PrEP and improve delivery of PrEP-related care to eligible patients. PrEP prescribing aligns seamlessly with the Ob/Gyn priorities of reproductive and sexual health, and obstetrician–gynecologists are naturally positioned to become leaders in PrEP prescribing and reducing the transmission of HIV.

Footnotes

Acknowledgments

The authors of this study thank participating clinic patients in New Orleans, Louisiana, for their time and contribution to advancing the field of HIV prevention.

Authors' Contributions

B.A.B. was involved in investigation, data curation, and writing—original draft. R.A.R., S.A.L., M.E.W., and V.M.M. were involved in investigation, data curation, and writing—review and editing. C.M.M. was involved in formal analysis. A.N. was involved in conceptualization, methodology, data curation, writing—review and editing, and supervision.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Data

References

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