A Systematic Review and Narrative Synthesis of Factors Affecting Pre-exposure Prophylaxis Willingness Among Black Women for HIV Prevention

Abstract

Pre-exposure prophylaxis (PrEP) can significantly reduce human immunodeficiency virus (HIV) transmission among Black women in the United States (U.S.), a group disproportionately affected by HIV. However, PrEP uptake in this HIV-vulnerable population is low. This review analyzes the factors influencing Black women's PrEP willingness using the Behavioral Model for Vulnerable Populations (BMVP). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Population, Intervention, Comparison, Outcome, Study Design (PICOS) framework, we conducted a systematic literature search and selected 24 peer-reviewed studies on PrEP willingness. Narrative synthesis revealed a heterogeneous landscape of the determinants affecting PrEP willingness among Black women, categorized into three main domains. Predisposing demographic and social factors included younger age, unmarried status, higher education, sexual or gender minority identity, trust in healthcare providers, and perceived HIV risk. Predisposing behavioral factors included condomless sex, multiple partners, and engagement in sex work. Socioeconomic status, health insurance, healthcare access, support systems, and structural challenges were identified as enabling factors influencing Black women’s PrEP willingness. Finally, the perceived need domain and health-related factors influencing the perceived need for PrEP included a history of sexually transmitted infections (STI), intimate partner violence (IPV), and birth control interference. This study emphasizes the complexity of the barriers and facilitators of PrEP uptake and, thus, the need for tailored interventions and health strategies to promote its use. Addressing the interconnected individual, interpersonal, and structural determinants of PrEP access is crucial for improving PrEP willingness and thereby advancing health equity in this population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10461-024-04491-z.

Introduction

HIV Diagnoses and Perception of Infection Risk

Despite ongoing efforts, Black individuals in the U.S. remain disproportionately affected by HIV [1], accounting for 45% of diagnoses, notably through heterosexual contact, which represents 91% of HIV cases in Black individuals from 2015 to 2019 [2–4]. Black women, constituting 13% of the U.S. female population, disproportionately represent 55% of HIV diagnoses, with significant concentrations in the southern states [2, 5]. Their lifetime HIV risk is markedly higher than that of other groups (e.g., 17 times that of White women), underscoring ongoing racial disparities in HIV prevention access [6–8]. Risk factors, such as men who have sex with men (MSM) and partners with undisclosed HIV status, along with socio-cultural issues, contribute to this trend. These socio-cultural issues include intimate partner violence (IPV), sexual coercion, gender inequality, and racial discrimination [9–14]. Additionally, cisgender (cis) Black women may minimize HIV risk due to stigma and non-disclosure by partners living with HIV [12, 15, 16].

Biomedical Intervention Using PrEP

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy that offers antiretroviral drugs to HIV-negative individuals in cases of exposure [5, 17–20]. Clinical trials of PrEP among MSM and other high-risk populations have demonstrated its effectiveness in reducing HIV infection [17, 18, 21–25]. Despite its efficacy [17, 18, 21, 24, 26], the Joint United Nations Program on HIV/AIDS (UNAIDS) reported only 626,000 of the 3 million targeted PrEP users by 2020 [27]. The Global AIDS Strategy 2021–2026 emphasizes reducing inequalities to eliminate AIDS by 2030, highlighting the need for integrated PrEP services for women [2, 28, 29].

The Food and Drug Administration (FDA) approval of Truvada (emtricitabine/tenofovir disoproxil fumarate (TDF-FTC)) in 2012 and Descovy (emtricitabine/tenofovir alafenamide (TAF-FTC)) in 2019, both fixed-dose oral combinations of emtricitabine/tenofovir for PrEP, provided significant milestones in biomedical HIV prevention [30, 31]. It is important to note that the FDA's approval of Descovy explicitly excludes individuals who have receptive vaginal sex, including cisgender women and many transgender (trans) men. Recently, the introduction of long-acting injectable (LAI) PrEP, Cabotegravir [32], has offered a new alternative for individuals facing challenges with daily oral PrEP use [33, 34]. LAI PrEP has demonstrated superior efficacy for preventing HIV in trans and cis women [35, 36] and greater preference among Black women engaging in inconsistent condom use and sex with multiple partners [37]. LAI PrEP represents a significant advancement in HIV prevention by providing a treatment option that can be tailored to individual lifestyles and sexual health needs, potentially increasing adherence and effectiveness of PrEP regimens [27, 32, 33, 35, 37, 38].

In June 2024, Gilead Sciences announced that the twice-yearly injectable HIV-1 capsid inhibitor lenacapavir demonstrated 100% efficacy in preventing HIV in cisgender women during the Phase 3 PURPOSE 1 trial [138]. The trial results showed the superiority of lenacapavir over daily oral Truvada (emtricitabine/tenofovir disoproxil fumarate), making it the most durable HIV prevention method proven effective in this population [138]. Based on these findings, the independent Data Monitoring Committee (DMC) recommended stopping the blinded phase of the trial and offering open-label lenacapavir to all participants [138]. This significant milestone in HIV prevention holds the potential to enhance adherence and outcomes for at-risk populations, particularly those facing barriers to daily pill-taking.

PrEP Use Disparities and Barriers to PrEP Uptake

Despite the availability of PrEP since 2012, notable disparities in its uptake have persisted along racial and gender lines [39–42]. Black individuals receive fewer PrEP prescriptions and are less likely to begin treatment than White individuals, with Black PrEP users constituting only 11% of the total PrEP-using population versus 69% for White users in 2016 [43–45]. Cisgender and transgender Black women are also underrepresented among PrEP users [46], with a five-fold lower PrEP-to-need ratio than men [47] and a lower prescription rate than White women, highlighting significant gender and racial gaps [31, 45, 48]. Key barriers to PrEP use in Black populations include low awareness [49, 50], perceived risk [51, 52], and medication safety concerns compounded by social stigma, especially in transgender women [11, 36, 53–59]. Structural issues such as cost, healthcare access, and the necessity for regular medical follow-ups present further challenges, although insurance often covers PrEP [38, 60–64]. The underutilization of PrEP is attributed to multifaceted barriers [65, 66] along the PrEP care continuum, impacting the willingness and ability to maintain PrEP regimens [64, 67–75].

PrEP Willingness

Poteat et al. (2019) emphasized exploring the later stages of the PrEP care continuum to boost uptake and adherence [76]. The PrEP continuum model by Kelley et al. (2015) [77] underscores the journey from awareness [49] to adherence, pinpointing the pivotal role of willingness in transitioning from awareness to actual use [76, 78, 79]. Research has identified key predictors of willingness to use PrEP, such as socioeconomic factors, individual risk behaviors, healthcare provider input, desire for HIV protection, trust in partners’ HIV status disclosure [80], being single, PrEP knowledge [81, 82], younger age [11, 83], and having a partner with HIV [62]. Effective PrEP implementation for Black women requires an in-depth understanding of the barriers and facilitators affecting their uptake. While some research has suggested that knowledge tends to enhance PrEP willingness in studies with predominantly White samples [11, 62, 84–86], this increase in awareness does not consistently lead to a willingness to use PrEP among substance-using cis Black women [87–89]. This discrepancy underscores the complexity of influencing Black women's attitudes [90] toward PrEP and highlights the need for nuanced education strategies. These approaches should address both advantages and concerns, aligned with women's intrinsic motivations for a balanced and informed decision-making process regarding PrEP [89, 91].

Underlying Conceptual Framework

This review used the Behavioral Model for Vulnerable Populations (BMVP) to examine the factors influencing PrEP willingness in Black women [92, 93]. The BMVP is an extension of the original Behavioral Model of Health Services Utilization developed by Andersen and Newman in 1973 [92]. This model, which has undergone numerous revisions to adapt to changing research interests and healthcare environments [92, 93], categorizes the individual determinants into predisposing, enabling, and need factors [92, 93]. The BMVP, developed by Gelberg, Andersen, and Leake, introduces additional domains to address the health and healthcare challenges faced by vulnerable populations [93]. This model emphasizes the importance of social structure and enabling resources, which are particularly relevant for understanding the health behaviors of vulnerable groups. We explored predisposing elements, such as socio-demographics, substance use, sociocultural vulnerabilities, and enabling factors, such as individual resources and health service support. Need-related factors such as health beliefs and perceived risks were also assessed. This framework underpins narrative synthesis and provides a structured approach that allows for a comprehensive understanding of the nuances of PrEP willingness.

Systematic Review Question

What factors are currently known to be associated with Black women’s willingness to take PrEP for HIV prevention?

Rationale

Although research on PrEP willingness is growing [94–99], studies that specifically examine Black women's willingness and interest in initiating PrEP for HIV prevention remain scarce [86, 100–102]. Much of the existing research predominantly focuses on MSM populations or includes only a small number of Black female participants [103, 104]. This comprehensive review of existing willingness-related findings in the U.S. highlights the need to fill these gaps, target unique barriers, and identify facilitators affecting readiness and motivation to initiate PrEP use. The findings from this review offer insights to inform integrating the 'willingness' stage of the PrEP continuum to shape future behavioral research interventions for this vulnerable demographic with imperative reasons for PrEP use.

Objectives

This systematic review aimed to assess recent U.S. findings related to Black women’s willingness to use PrEP and use an overarching conceptual model (BMVP) [93] to organize the factors associated with willingness to take PrEP for HIV prevention.

Methods

This systematic review was a narrative synthesis reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [105]. Additional details are provided in Online Resource 1 of the PRISMA Checklist for preferred reporting items.

Eligibility Criteria

Table 1 presents the eligibility criteria used to select the studies for inclusion in the systematic review, detailing the requirements for language, publication type, population focus, subject matter, publication date range, and geographical scop.

Table 1.

Eligibility criteria for systematic review studies

Study Inclusion Criteria
Criteria	Description
Language and Publication	Articles must be in English and published in peer reviewed journals
Population Focus	Studies must include Black or African American women, or both genders with separate analysis for women
Subject Matter	Articles must report on willingness to use oral or long-acting, extended-release injectable PrEP, specifically at the uptake/use stage of the PrEP care continuum
Publication Date Range	Studies published from January 1, 2012, to December 31, 2022
Geographical Scope	Research must be conducted in the U.S. to reflect the U.S.-specific context of PrEP implementation and historical response to HIV/AIDS

Specific eligibility criteria used to select the studies for this systematic review

Information Sources

A comprehensive literature search was conducted in May 2023 across five databases: PubMed (MEDLINE), CINAHL, EMBASE, Web of Science, and PsycINFO, covering studies from January 1, 2012, to May 24, 2023. The starting point of 2012 marked the FDA's approval of Truvada (emtricitabine/tenofovir disoproxil fumarate) for PrEP, which catalyzed extensive research into PrEP's efficacy, acceptability, and implementation [30]. Subsequent years saw significant advancements, including the approval of Descovy (emtricitabine/tenofovir alafenamide) in 2019 and Apretude (cabotegravir) in 2022 [31, 32], broadening the scope of PrEP-focused research and the potential impact on diverse populations. The endpoint of 2023 ensures that it encompasses the most recent and relevant research. Thus, the 2012–2023 window allowed us to capture the trajectory of PrEP implementation and its evolving impact on public health. Additionally, the search focused on original US-based research pertinent to PrEP willingness, excluding summary articles, non-empirical studies, editorials, epidemiological reports, commentaries, case reports, and articles on HIV treatment rather than prevention.

Search Strategy

The search strategy for this systematic review was developed using a 'building block' approach, dividing the search topic into key concepts to efficiently navigate the literature [106]. The primary concepts identified were HIV, PrEP, willingness to use PrEP, and Black women (Figure 1). A relevant set of synonyms and related terms was compiled to correspond to each concept, ensuring alignment with medical subject headings specific to each database. Search queries were iteratively refined to optimize retrieval of relevant articles. Details of the search strategy and search terms are provided in the Supplemental Appendix in the study protocol.

Fig. 1.

Systematic Review Building Block Database Search Strategy. The 'building block' approach used to develop the search strategy visually representing the key concepts central to the review. This figure illustrates the 'building block' approach used in developing the search strategy for this systematic review. It visually represents the key concepts in the square boxes central to the review: HIV, PrEP, willingness to use PrEP, and Black women. The diagram also shows the associated synonyms and related terms used to enhance the search across various databases. *This figure was created using Microsoft word

Definition and Operationalization of Willingness

In the context of this systematic review, willingness to use PrEP for HIV prevention was defined as an individual's openness to initiate PrEP. Behavioral willingness is a component of readiness to change that is predictive of future intentional behavior change [139, 140] and is a stronger predictor of behavior than intentions or implicit attitudes [141]. It captures the spontaneous, situational aspect of decision-making, reflecting an individual's readiness to engage in behavior given the right circumstances [141]. In the included studies, willingness to use PrEP was operationalized using various measures, including self-reported future likelihood, PrEP acceptability scores, hypothetical scenarios, and attitudinal measures. Table 2 presents the key willingness measures used in each study.

Table 2.

Study characteristics

Author (Year)	Title	Method	Population characteristics	Study design data source	Key measures	PrEP willingness study findings
Arnold (2018)	Preliminary investigation evaluating college students’ willingness and need for PrEP	Quantitative study	Sample size n = 147. AA women were 89.1% of college students	Exploratory research w. survey questionnaires	Willingness to use PrEP, beliefs about medication, and perceived risk of HIV	88% of females were PrEP-willing if they knew it would lower the chance of HIV, 85% were if they knew their partner was HIV + , and 88% were high risk for HIV
Ayangeakaa (2023)	Understanding Influences on Intention to Use PrEP Among African American Young Adults	Qualitative Study	63 African American young adults aged 18–29 years old in Louisville, Kentucky	Two focus groups of cis heterosexual women	The focus group guide measured oral and long-acting injectable (LAI) PrEP awareness, knowledge, perceived risk, perceived need, attitudes, barriers, and facilitators to PrEP use	Participants found oral PrEP acceptable for HIV prevention and were willing. Some participants were concerned about the long-term effects and stigma. Some expressed interest in long-acting injectable options
Braksmajer (2019)	Feasibility and acceptability of PrEP use among women in violent relationships	Qualitative Study	A sample size of 26 women (21 or 81% of whom were AA/Black) who experienced intimate partner violence and were eligible for PrEP	Semi-structured interviews using directed content analysis	Attitudes, beliefs, and experiences of women in violent relationships toward PrEP use	All women were willing to use PrEP, but some women expressed uncertainty or ambivalence, while others expressed a willingness to try it if an HCP recommended it or if they felt that their risk of HIV was high
Braksmajer (2018)	Willingness To Take PrEP for HIV Prevention: The Effects of Race/Ethnicity and Provider Trust	Quantitative study	N = 447 individuals (110 Black women) with HIV risk and visited a PCP in the past year in a mid-size city located in western New York	Cross-sectional web-based survey	A dichotomous measure of PrEP willingness, race/ethnicity, and PCP trust. Other measures: condom use, HIV-risk behaviors, HIV knowledge, and potential barriers to PrEP use	This study found a significant association between PCP trust and PrEP willingness, with those with greater trust having 3.24 times the adjusted odds of being willing to try PrEP
Chandler (2022)	Let Me Prep You to PREP Me: Amplifying Voices of Black Women and Their Providers to Consider PrEP for HIV Prevention Option	Qualitative Study	Cis Black women (n = 15) who were established patients at an outpatient community-based clinic located in Atlanta, Georgia	Descriptive study semi-structured in-depth interviews using Atlas.ti software	The interview guide was developed through an extensive search on the perceptions/ ideations of PrEP use among cis Black women. Interview questions concerned PrEP knowledge, awareness, benefits, and harms of PrEP use	Black women exhibited low PrEP willingness, but most were unwilling to use it, except when perceiving HIV risk. Higher acceptability is linked to better PrEP knowledge and recent education
Elopre (2022)	PrEP service delivery preferences of Black Cis-gender women living in the Southern United States	Quantitative study	795 Black cis-gender women living in Alabama	Cross-sectional survey that used a discrete choice experiment (DCE)	Measures: PrEP willingness and PrEP service delivery preferences (oral vs. long-acting injectable). racism, social support, HIV knowledge, IPV, stigma of HIV + people	PrEP Willingness was higher among younger women, those with greater HIV knowledge, those who perceived a need for PrEP, and those with more recent sex partners
Garfinkel (2017)	Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients	Quantitative study	Young adult female family planning patients (n = 146) between the ages of 18–35 seeking services at two publicly funded clinics in greater Baltimore, Maryland	Clinic-based survey via Audio Computer Assisted Survey Instrument (ACASI)	PrEP acceptability/willingness, HIV risk perception, lifetime history of partner violence, demographics, healthcare-seeking patterns, sexual behavior, violence, and access to local support services	Black women were more likely than women of other races with PrEP acceptability. Over 70% of Black women would consider PrEP. PrEP willingness was associated with younger age, Black race, sex trade history, & higher HIV-related risk perception
Haider (2022)	Knowledgeable, aware & interested: Young Black women’s perceptions of pre-exposure prophylaxis	Quantitative study	N = 100 young Black women from two women's health clinics in Chicago	Cross-sectional, survey & 4 structured open-ended questions	Sexual health and behavior, PrEP attitudes, stigma, knowledge, awareness, willingness, barriers and facilitators to uptake, and demographic and behavioral domains	One-half expressed interest in starting PrEP in the next three months. PrEP willingness was moderate, and participants who reported high PrEP willingness had 13 times the odds of interest in starting PrEP
Hill (2023)	A survey with interventional components delivered on tablet devices versus usual care to increase pre-exposure prophylaxis uptake among cisgender Black women: a pilot randomized controlled trial	Quantitative intervention study	N = 40 cisgender Black women who presented to two urban emergency departments (EDs) in Houston, TX	Pilot randomized controlled trial Compared a survey w. interventional component (iPrEP) versus. usual care	The Pre-test and post-test assessments measured socio-demographics, sexual behaviors, substance use, and PrEP willingness. The iPrEP intervention survey used hypothetical scenarios to evaluate PrEP willingness and reasons for PrEP use. Follow-up assessments at 1, 3, and 6 months measured the frequency and persistence of condomless sex and substance use	The iPrEP intervention was feasible and acceptable among cisgender Black women. The iPrEP intervention was associated with increased willingness to take PrEP, with a mean score of 3.9 out of 5 at six months
Johnson (2020)	Awareness and Intent to Use Pre-exposure Prophylaxis Among African American Women in Family Planning Clinic	Mixed Methods	109 African American or Black cisgender women attending a family planning clinic at the University of Chicago	Cross-sectional survey via REDCap. Open-ended questions via Dedoose	Awareness of PrEP and intent to take PrEP were the main outcome variables. Demographic characteristics, medical history (STI testing), social needs, sexual behavior, HIV status of sexual partners, and condomless sex	Among the 109 participants, 35% were aware of PrEP, and 74% reported that they would likely take PrEP. The study found no significant associations between demographic and behavioral factors and awareness of or willingness to use PrEP
Kerr (2022)	A Qualitative Exploration of Stigmas Impacting HIV PrEP Use among African American Young Adults	Qualitative Study	63 AA young adults (age 18–29) self-identifying as transgender women and heterosexual women in Louisville, Kentucky	Focus group discussions	PrEP awareness, attitudes towards PrEP, barriers and facilitators to PrEP uptake and norms regarding PrEP	The study found that some participants were willing to use PrEP to prevent HIV, while others expressed reservations about PrEP for fear of being shamed, judged, or criticized
Ojikutu (2019)	Spatial Access and PrEP Willingness Among Black/African American Individuals in the US: Cross-Sectional Survey	Quantitative study	868 Black/African American individuals aged 18–50 years from The National Survey on HIV in the Black Community (U.S.)	A self-administered online cross-sectional survey	PrEP Willingness (outcome), demographic (age, gender, education, geographic location), socioeconomic (income, insurance status, healthcare utilization), and health-related characteristics (HIV risk behaviors)	26% were willing to use PrEP. Spatial access to PrEP-prescribing clinics was positively associated with PrEP willingness. Those who lived in ZIP codes with a higher density of PrEP clinics were likelier to report willingness to use PrEP
Ojikutu (2020)	HIV-related Mistrust and Willingness to Use PrEP Among Black Women in the United States	Quantitative study	Sample Size was 522 Black women in the U.S	Cross-sectional online survey from a web panel	HIV-Related Medical Mistrust or Belief in “HIV Conspiracy Theories,” PrEP awareness, PrEP willingness, demographic (age, education, income), and HIV behavioral risk factors	Of the 347 women with expanded PrEP indications, 30.8% were willing to use PrEP once they were made aware of it. women with high HIV conspiracy belief scores were more willing to use PrEP
O'Malley (2021)	Intimate Partner Violence, PrEP Acceptability, and Attitudes: Perspectives of Women Seeking Care at a Family Planning Clinic	Mixed Methods	145 female participants (16% Black or African American women) who sought care at a family planning clinic in Pittsburgh, Pennsylvania	Mixed-methods survey (close-ended and open-ended questions) using Nvivo 12	PrEP acceptability was measured through a single item of willingness to use PrEP. IPV experience, HIV risk behaviors (condom use, numerous male sex partners), and demographics (age, race, ethnicity, education)	Over 80% of participants reported being willing to use PrEP, with 60% indicating they would be willing to use it daily. Common reasons for PrEP's willingness were protection against HIV and peace of mind
Patel (2019)	PrEP Eligibility Among At-Risk Women in the Southern US: Associated Factors, Awareness, and Acceptability	Quantitative study	225 HIV-negative women (83% Black) in women's Interagency HIV Study (Atlanta, GA, Birmingham, AL, Chapel Hill, NC, Jackson, MS, Miami, FL)	Cross-sectional analysis of data collected from a PrEP-related questionnaire	Key measures -PrEP awareness and PrEP acceptability/willingness. Also, demographic, socio-behavioral, and clinical characteristics of the participants	77% of participants expressed PrEP willingness, including (88%) who were PrEP-eligible, with the most common indicator being condomless sex. The reasons for willingness were more control/protection from HIV, inability to trust sexual partners, and offered by an HCP
Poteat (2019)	A Gap Between Willingness and Uptake: Findings from Mixed Methods Research on HIV Prevention among Black and Latina Trans Women	Mixed Methods	201 Black and Latina transgender women (BLTW). Of these, 125 (62.2%) identified as Black or African American in Baltimore, Maryland, and Washington, DC	Sequential exploratory design (mixed methods)	Participants who reported being HIV-negative and had never taken PrEP were asked if they would be ‘willing’ to take it. Participants who were PrEP unwilling were asked reasons for unwillingness from a list of potential reasons	66% of participants had heard of PrEP, and 43% reported willingness to take PrEP. The most reported reasons for unwillingness to take PrEP were concerns about side effects (44%) and not feeling at risk for HIV (42%) (qualitative), lack of trust in healthcare providers, costs, and the need for frequent medical visits
Ransome (2020)	Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South	Quantitative study	The sample size was 114 Black women out of 169 total Black/African American participants	Cross-sectional survey from a probability-based web panel	The primary exposure variable was willingness to use PrEP; individual-level variables were age, Gender, Education, Individual HIV risk, and Awareness of PrEP	Participants living in ZIP codes with increases in new HIV diagnoses were twice as likely to be PrEP-willing. However, the association between area-level HIV risk and willingness to use was no longer significant after adjusting for socioeconomic disadvantage and income
Restar (2018)	Acceptability of Antiretroviral Pre-Exposure Prophylaxis from a Cohort of Sexually Experienced Young Transgender Women in Two U.S. Cities	Quantitative study	N = 300 young transgender women (YTW), 42% Black/African American in Boston, MA	Cross-sectional survey using data from larger RCT for a PrEP intervention (secondary data analysis)	Four items measured healthcare utilization, STI diagnoses, and awareness of PrEP. The PrEP willingness scale was a 10-item measure that assessed how likely the participants were to take PrEP in various situations, including different dosing frequencies and types of partnerships	The mean score for PrEP acceptability was 23.4, suggesting moderate willingness among YTW across scenarios. The main reasons for disinterest were medication concerns (20.5%) and provider/researcher mistrust (16.7%)
Towe (2020)	Examining the potential of PrEP for HIV prevention in a community sample of persons who use stimulants living in the Southern U.S	Quantitative study	352 participants who use stimulants, 162 women (75 Black/African American)	Cross-sectional using clinical interviews and computerized questionnaires	PrEP awareness, knowledge, and willingness to take PrEP using a 10-point scale for the question: "If PrEP were available to you for free, how willing would you be to take PrEP to protect yourself from HIV?"	Overall, participants expressed willingness to take PrEP, with women reporting average ratings above seven on the 10-point willingness scale. PrEP Willingness was positively correlated with perceived HIV risk but not significantly associated with age
Troutman (2021)	African American Women’s Knowledge, Perceptions, and PrEP Willingness for HIV Prevention in the South	Mixed Methods	Sample of 27 (ages ranging between 20–67 years) of HIV-negative Black or African American women in Columbia, South Carolina	Focus groups and quantitative survey	Focus group topics focused on awareness, perceptions, and potential use of PrEP. Also, demographics, sexual risk behaviors, PrEP Willingness, likelihood of PrEP uptake, PrEP knowledge, and perceptions	16 out of 27 participants were willing to take PrEP, and many stated they were eager to start taking PrEP immediately if it was available and covered by insurance. However, eleven participants were not willing to start using PrEP for HIV prevention
Uzoeghelu (2022)	HIV Risk Behaviors and PrEP Willingness Among Black Americans with Arrest History	Quantitative study	868 Black/African American participants with an arrest history recruited from a national web panel	Cross-sectional survey from a national web panel	PrEP willingness (“If a pill that could prevent HIV from an infected sex partner to an uninfected partner were available, I would take it. Demographic, sexual risk, arrest history	Individuals with a history of arrest had a higher PrEP willingness if they reported a history of multiple sexual partners. PrEP willingness was associated with younger age, higher education level, and a history of STDs
Villaalba (2022)	Understanding the Impact of Intimate Partner Violence Type and Timing on PrEP Knowledge, Acceptability, Sexual Behavior, and Gender Roles in Women of Color	Quantitative study	101 women with a history of IPV, 72% were Black women from four community-based organizations located in densely populated, multicultural, low-income urban areas in South Florida	Cross-sectional self-administered survey questionnaire with Likert-type scales	Measures include sociodemographic characteristics, HIV risk behaviors, IPV experiences, attitudes towards PrEP, and PrEP acceptability. PrEP willingness/acceptability was assessed using two questions: "Will take PrEP if recommended by the doctor" and "Will use PrEP if encountering minor side effects."	Women who reported experiencing physical IPV in the past year had lower PrEP knowledge and willingness/acceptability. Also, being subordinate to others was significantly associated with lower PrEP willingness/acceptability
Willie (2017)	Intimate Partner Violence and PrEP Acceptability in Low-Income, Young Black Women: Exploring the Mediating Role of Reproductive Coercion	Quantitative study	147 Black/African American women ages 18–25 from six sites (two youth educational and employment programs, three women, Infants, and Children’s Programs (WIC))	Cross-sectional survey questionnaire	PrEP acceptability was measured via a single question, “Would you consider taking a pill every day if you could protect yourself from getting HIV during sex?” Also measured were IPV and reproductive coercion and demographic characteristics	77% (n = 114) of the participants reported willingness to use PrEP. The study found that young Black women who reported IPV and reproductive coercion were more likely to be willing to use PrEP. Specifically, women who reported birth control sabotage and pregnancy coercion were more likely to report PrEP acceptability
Wingood (2013)	Racial Differences and Correlates of Potential Adoption of Pre-exposure Prophylaxis: Results from a National Survey	Quantitative study	The sample size was 1,509 women, including 1,068 Black/African American and 441 White women	Cross-sectional survey, computer-assisted phone interviewing	Potential PrEP uptake (Willingness to use PrEP if available) sociodemographic factors, sexual behaviors, and social influences	Women at higher risk of HIV were more likely to report potential use of PrEP. Specifically, women of lower socio-economic status, such as those with less education and those who were unemployed, had higher odds of potential PrEP uptake

Overview of the characteristics of the 24 studies included in the systematic review, including each study's title, method, population characteristics, study design, data sources, key measures, willingness to use PrEP, and significant findings

Selection Process, Screening, and Data Extraction

A systematic search yielded 1,861 records across the five databases. After deduplication, 1,598 unique citations were managed using RefWorks, Excel, and RAYYAN [107]. The remaining articles were screened by three reviewers (NP, SC, and ASH) using a two-phase process. Initially, the article titles, abstracts, and descriptors were inspected against the inclusion/exclusion criteria. Subsequent full-text reviews resulted in 65 studies, of which 24 required consensus through discussion. Data abstraction included the following key elements: authorship, publication year, methodology, population, design, data sources, and outcomes relevant to PrEP willingness.

Evaluation of Methodological Quality

We employed the Risk of Bias in Non-randomized Studies—of Exposure (ROBINS-E) tool [108] to appraise methodological biases across six domains: confounding, exposure measurement, participant selection, missing data, outcome measurement, and reporting. Signaling questions guided the appraisal by categorizing the bias as low, moderate, or high. The leading reviewer synthesized these evaluations into overarching bias judgments for each study.

Certainty Assessment of Evidence Quality

Quality appraisal of eligible studies was conducted using a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach [109]. The certainty of evidence for each key outcome was gauged using the PICOS framework [110]. The GRADE methodology began with the study design, adjusting for five downgrading factors (risk of bias, imprecision, inconsistency, indirectness, and publication bias) and two upgrading factors (large effect size and plausible confounding). Certainty levels were designated as high, moderate, or low, corresponding to strong, reasonable, or weak confidence in the evidence, respectively. Further details are provided in Online Resource 6.

Narrative Synthesis

The synthesis of data on PrEP willingness among Black women adhered to the narrative synthesis framework of Popay et al. [111]. It uses the Behavioral Model for Vulnerable Populations (BMVP) [93] to categorize factors as predisposing, enabling, or need-based. The initial synthesis included a quantitative exploration of willingness outcomes from studies, while qualitative data provided contextual depth through participants' quotes, illuminating influential factors [112].

Thematic Analysis

Thematic analysis [113–115] was employed to code and arrange the data into key themes that inform the domains of the model. This approach combines deductive (theory-driven) and inductive (data-driven) methods to ensure a comprehensive understanding of the factors that influence PrEP willingness. For the coding process, data from the studies were independently coded using a predefined coding framework based on the BMVP domains. During theme development and framework application, coded data were grouped into themes aligned with the predisposing, enabling, and need domains of the model.

While the initial coding and categorization were guided by the BMVP (deductive approach), the analysis also incorporated inductive elements. As themes emerged from the data, they were refined and expanded based on the specific contexts and nuances presented in the studies. This combination of deductive and inductive methods allowed for a more robust and comprehensive synthesis that captured both the theoretical constructs of the BMVP and the empirical realities reflected in the qualitative data.

Results

Overview of Study Selection

Figure 2 displays the PRISMA 2020 flow diagram [116] outlining the selection process and the inclusion criteria. The final sample included 24 relevant studies on PrEP willingness that met the eligibility criteria. During the full-text assessment, nine studies were excluded for utilizing outcome measures that were incompatible with our review criteria. Furthermore, 28 studies failed to provide data specific to Black women’s PrEP willingness and were excluded. An additional four studies were omitted due to irrelevance to the targeted study population and inappropriate study type. The comprehensive records of the excluded studies are presented in Online Resource 4.

Fig. 2.

PRISMA 2020 flow diagram [116]. The PRISMA flow diagram summarizing the study selection process. This figure presents the PRISMA flow diagram, summarizing the study selection process for the systematic review. It traces the progression from initial record identification to the final inclusion of 24 studies focused on PrEP willingness in Black Women, detailing reasons for exclusions at various stages. *This figure was created using Microsoft word

Study Characteristics

From 2014 to 2023, the included studies had an average sample size of 251, employing a variety of research designs, including survey questionnaires (Arnold 2018; Braksmajer 2018; Elopre 2022; Garfinkel 2017; Haider 2022; Patel 2019; Ojikutu 2019; Ojikutu 2020; Ransome 2020; Restar 2018; Towe 2020; Uzoeghelu 2022; Villaalba 2022; Willie 2017; Wingood 2013). Others utilized randomized controlled trial survey interventions (Hill, 2023), semi-structured interviews (Braksmajer, 2019; Chandler, 2022), and focus groups (Ayangeakaa, 2023; Kerr, 2022). O'Malley et al. (2021) and Johnson et al. (2022) used cross-sectional surveys with open-ended questions; Troutman (2021) used focus groups and quantitative surveys; and Poteat (2019) used a sequential exploratory design for qualitative data, followed by quantitative survey data. Only Ayangeakaa (2023) and Elopre (2022) compared oral and LAI PrEP modalities, with the former examining preferences qualitatively and the latter examining them quantitatively. Comprehensive data profiling of the study populations in the included studies are provided in Online Resource 2. (Table 2).

Risk of Bias Assessment Results

Bias assessment revealed moderate (n = 14) to high-risk (n = 10) biases across the studies (Table 3). Predominant biases included confounding due to uncontrolled variables, exposure classification potentially leading to social desirability effects, and selection bias from nonrandom sampling methods. Incomplete data further compromised 11 studies, with the pandemic exacerbating this issue. Outcome measurement and reporting biases were noted in ten studies, which can be attributed to subjective data interpretation and the inherent limitations of self-reporting. Refer to Online Resource 5 for the rationale for the overall risk of bias from the ROBINS-E Assessment and Online Resource 7 for the risk of bias visualization (robvis) [117].

Table 3.

ROBINS-E risk of bias assessment

Author (Year)	Confounding bias	Bias in participant selection	Exposure classification bias	Missing data bias	Outcome measurement bias	Bias in selection of reported result	Overall risk of bias
Arnold (2018)	Low	Some concerns	Some concerns	Unclear/no information	Unclear/no information	Unclear/no information	High
Ayangeakaa (2023)	Unclear/no information	Some concerns	Some concerns	Some concerns	Low	Some concerns	High
Braksmajer (2019)	Some concerns	Some concerns	High	Unclear/no information	Unclear/no information	Unclear/no information	Moderate
Braksmajer (2018)	Some concerns	Some concerns	Some concerns	Some concerns	Unclear/no information	Unclear/no information	Moderate
Chandler (2022)	Unclear/no information	Unclear/no information	Unclear/No information	Unclear/no information	Unclear/no information	Unclear/no information	High
Elopre (2022)	Unclear/no information	Unclear/no information	Some concerns	Some concerns	Unclear/no information	Unclear/no information	High
Garfinkel (2017)	Unclear/no information	Unclear/no information	Some concerns	Some concerns	Some concerns	Unclear/no information	High
Haider (2022)	Unclear/no information	Unclear/no information	Some concerns	Unclear/no information	Unclear/no information	Unclear/no information	High
Hill (2023)	Low	Unclear/no information	Some concerns	Some concerns	Unclear/no information	Some concerns	Moderate
Johnson (2020)	High	Unclear/no information	Some concerns	Some concerns	Some concerns	Some concerns	High
Kerr (2022)	Some concerns	Unclear/no information	Unclear/No information	Some concerns	Unclear/no information	Some concerns	Moderate
Ojikutu (2019)	Low	Some concerns	Some concerns	Some concerns	Some concerns	Unclear/no information	High
Ojikutu (2020)	Unclear/no information	Some concerns	High	Some concerns	Low	Some concerns	Moderate
O'Malley (2021)	Some concerns	Unclear/no information	Some concerns	Unclear/no information	Low	Unclear/no information	Moderate
Patel (2019)	Unclear/no information	Low	Some concerns	Unclear/no information	Some concerns	Unclear/No information	Moderate
Poteat (2019)	Unclear/no information	Unclear/no information	Some concerns	Some concerns	Some concerns	Unclear/no information	Moderate
Ransome (2020)	High	Unclear/no information	Some concerns	High	Unclear/no information	Some concerns	High
Restar (2018)	High	Some concerns	Some concerns	Some concerns	Some concerns	Some concerns	Moderate
Towe (2020)	Unclear/no information	Some concerns	Some concerns	Unclear/no information	Some concerns	Some concerns	Moderate
Troutman (2021)	Some concerns	Unclear/no information	High	Unclear/no information	Unclear/no information	Some concerns	Moderate
Uzoeghelu (2022)	Some concerns	High	High	Unclear/no information	Some concerns	Unclear/no information	High
Villaalba (2022)	Some concerns	Unclear/no information	Some concerns	Unclear/no information	Some concerns	Unclear/no information	Moderate
Willie (2017)	Unclear/no information	High	Some concerns	Low	Unclear/no information	Unclear/no information	Moderate
Wingood (2013)	Some concerns	Unclear/no information	Some concerns	Low	Some concerns	Unclear/no information	Moderate

Summary of the risk of bias assessment for the 24 studies, as categorized using the ROBINS-E tool

Certainty Appraisal Results

The evaluation of certainty of evidence from the 24 studies included in this systematic review is summarized in Table 4. The certainty of evidence varies between moderate and high levels, as determined by the GRADE assessment [118, 119]. This variation is influenced by factors such as inconsistent findings, imprecise results, potential publication bias, and contextual differences in study settings. The moderate-to-high certainty ratings were mainly due to the limited number of studies with a high risk of bias, inconsistency in the reported results, and imprecise effect estimates. However, the relatively small sample sizes in many studies have raised concerns about the generalizability of the findings. Inconsistencies in effect sizes and heterogeneity across studies also affected overall confidence in the evidence. See Online Resource 6 for more information on the GRADE level of evidence for each rating applied to the reviewed studies.

Table 4.

GRADE assessment of the certainty of evidence

Author (Year)	Risk of bias	Inconsistency	Indirect evidence	Imprecision	Publication bias	Overall rating
Arnold (2018)	High	Low	High	Moderate	Low	High
Ayangeakaa (2023)	High	Low	Low	Moderate	Low	High
Braksmajer (2019)	Moderate	Moderate	High	Low	Low	Moderate
Braksmajer (2018)	Moderate	Moderate	Low	Moderate	Low	Moderate
Chandler (2022)	Low	High	Low	Moderate	Low	Moderate
Elopre (2022)	High	Low	Low	Moderate	Low	High
Garfinkel (2017)	High	Low	Moderate	Moderate	Low	High
Haider (2022)	High	Low	Moderate	Moderate	Low	High
Hill (2023)	Moderate	Moderate	High	Moderate	Low	Moderate
Johnson (2020)	High	Low	Moderate	Moderate	Low	High
Kerr (2022)	Moderate	Moderate	Moderate	Moderate	Low	Moderate
Ojikutu (2019)	Moderate	Moderate	High	High	Low	High
Ojikutu (2020)	Moderate	Moderate	Low	Moderate	Low	Moderate
O'Malley (2021)	Moderate	Moderate	Moderate	Moderate	Low	Moderate
Patel (2019)	Moderate	Moderate	Moderate	Moderate	Low	Moderate
Poteat (2019)	Moderate	Moderate	Low	High	Low	Moderate
Ransome (2020)	High	Low	Moderate	Low	Low	High
Restar (2018)	Moderate	Moderate	Low	Moderate	Low	Moderate
Towe (2020)	Moderate	Moderate	Moderate	Moderate	Low	Moderate
Troutman (2021)	Moderate	Moderate	Low	Low	Low	Moderate
Uzoeghelu (2022)	Moderate	Moderate	High	High	Low	High
Villaalba (2022)	Moderate	Moderate	Low	Moderate	Low	Moderate
Willie (2017)	Moderate	Moderate	Moderate	Moderate	Low	Moderate
Wingood (2013)	Moderate	Moderate	High	Moderate	Low	Moderate

GRADE assessment results for certainty of evidence from the 24 studies included in the systematic review

Narrative Synthesis by Underlying Conceptual Framework

Narrative synthesis revealed various determinants of Black women’s willingness to use PrEP. The review findings were organized according to the overarching domains of the BMVP [93], with each including specific thematic groups and corresponding subcategories (Table 5).

Table 5.

Organization of themes from narrative synthesis by BMVP

Organization of Themes for Predisposing Factors	Organization of Themes for Enabling Factors	Organization of Themes for Need Factors
1) Demographic Factors: - Age - Marital status - Education - Sexual orientation 2) Health/Healthcare Belief Factors: - Provider-patient relationships - Perceived HIV risk/likelihood of HIV 3) Behavioral Factors: - Sexual behaviors - History sex work - Alcohol/substance use behaviors 4) Cultural and Social Factors: - Traditional gender roles - Limited partner communication & distrust - Socio-cultural norms 5) PrEP-related Attitudes/Intentions: - HIV knowledge - PrEP knowledge - Perceived benefits/harms of PrEP use	1) Demographic Factors: - Structural challenges - Health insurance coverage - Employment status 2) Healthcare Accessibility Factors: - Accessibility to PrEP & transportation - Geographic region - Availability of social services/resources - PrEP modality preferences 3) Support System Factors: - Supportive social environment - Access to culturally sensitive providers	(No sub-categories): - Perceived need - History of STI diagnosis - Currently experiencing IPV or non-monogamous relationships - Birth control sabotage & partner interference

Categorization of the determinants of Black women’s PrEP willingness as identified in the narrative synthesis organized according to the domains of the BMVP [93] framework

Predisposing Factors

The predisposing factors influencing PrEP willingness were categorized into the following thematic groups, each of which had corresponding subcategories: (1) demographic, (2) health beliefs, (3) behavioral, (4) cultural and social factors, and (5) attitudes/intentions related to PrEP.

Demographic Predisposing Factors

Age

Age has emerged as a key demographic predisposing factor, with studies indicating that younger Black women are more willing to use PrEP, possibly because of their active engagement in sexual behaviors linked to HIV transmission and heightened risk perception (Garfinkel, 2017; Ojikutu, 2019, 2020; Johnson, 2020; Elopre, 2022). Restar (2018) reported that younger Black transgender individuals (21–25 years) in the study had significantly lower PrEP acceptability scores (β =  − 2.0, SE = 0.8, 95% CI [− 3.6, − 0.4], p = 0.01) and thus were less likely to accept PrEP than older transgender individuals (26–27 years), suggesting that the impact of age on PrEP willingness varies by context. Ayangeakaa (2023) captured the essence of this variation qualitatively, illustrating that participants believed HIV risk behaviors decreased with age, as one participant stated, ‘At this point in my life I would not get on [PrEP], at 28…if I knew about it when I first to college, that probably would have been something I did or I was on because I was high risk’ (Ayangeakaa 2023). To foster early willingness, Troutman (2021) recommended promoting PrEP to younger cohorts, specifically high school and college students.

Marital Status

Ojikutu (2020) found that Black women who were single, widowed, divorced, or separated are significantly more willing to use PrEP (AOR = 2.47, 95% CI [1.4, 4.37], p = 0.002), suggesting that a single relationship status may be associated with a higher perceived HIV risk in influencing PrEP willingness. Similarly, Uzoeghelu (2022) reported that single Black women (with no arrest history) were more willing to uptake PrEP (adjusted prevalence ratio (aPR) = 1.69, 95% CI [1.1, 2.5]), p = 0.011). Despite this, some Black women underestimated their risk due to the presumption of monogamy, with statements like, “I wouldn’t take [PrEP] now because I’m in a monogamous relationship” and” If I have one partner and we’re faithful… I don’t feel it’s for my situation’ (Ayangeakaa 2023). Braksmajer (2019) noted cases in which Black women unknowingly engaged in unprotected sex with unfaithful partners. In these cases, relationship status was a pivotal factor in Black women’s reluctance to consider PrEP, as illustrated by a participant's remark, "I was worried about [HIV], but now that I got checked and did not have it, I am not worried. If he does go out and [have sex], I don’t think he’d do it like that [have condomless sex] because would I not have it by now?" (Braksmajer 2019).

Education

The level of education among Black women had a nuanced influence on PrEP willingness. Braksmajer (2019) identified higher education as a significant predictor of willingness to use PrEP in interviews with women experiencing intimate partner violence within the last 6 months. However, Ojikutu (2019) and Ojikutu (2020) reported an inverse relationship, where Black women with less education demonstrated greater interest in PrEP (Ojikutu 2019: aPR = 0.60, 95% CI [0.4, 1.0]), p < 0.050; Ojikutu 2020: OR = 2.22, 95% CI]1.1, 4.3], p = 0.018). This finding implies that Black women with more education might perceive lower HIV risk, potentially diminishing PrEP willingness and interest in uptake.

Sexual Orientation

Sexual orientation influences Black women's perceptions of PrEP need and willingness. Sexual and gender minority participants, who were aware of their HIV risk, expressed a clear willingness to use PrEP. A transgender woman affirmed, "I’m sexually active, and it can help me prevent HIV; why would I not take it?" (Ayangeakaa 2023). Conversely, heterosexual Black women often harbored misconceptions about PrEP's applicability, with some believing it was solely for LGBTQ + individuals, as reflected in Ayangeakaa’s findings: "I wasn’t aware that it was also for straight people" (2023). Chandler (2022) encountered similar misinformation, with participants incorrectly assuming PrEP was exclusive to MSM, echoed by a young mother: "No [I would not take it] … I thought it was strictly for homosexuals.” Additionally, some Black women viewed heterosexuality as a protective factor against HIV, a misconception that O'Malley (2020) suggested could be rectified with increased awareness: "Most straight women are not fully aware of their HIV risk. If more women learn about their risks, it would be good for society as more people are protected” (O'Malley, 2020).

Health/Healthcare Beliefs Predisposing Factors

Provider–Patient Relationships

Trust in and familiarity with healthcare providers have been identified as key factors in Black women's willingness to adopt PrEP. Studies have demonstrated a significant association between having a medical provider who meets health needs and greater PrEP willingness (Restar, 2019; β = 2.9, SE = 0.8, 95% CI [1.3, 4.4], p < 0.001), a greater likelihood of engaging in PrEP services upon provider recommendation (Towe, 2021; 30% of participants), and higher trust levels associated with increased willingness (Braksmajer, 2018; b = 1.27, aOR = 3.55, p = 0.020). Conversely, a lack of provider engagement (last seen doctor more than one year ago) (OR = 0.36, 95% CI [0.18, 0.7]; p = 0.005) (Ojikutu, 2020) has been shown to deter willingness to use PrEP. Wingood (2013) also supports this, noting an increased consideration for PrEP with trusted providers' recommendations (aOR = 13.2, 95% CI [7.5, 23.1], p < 0.001), yet embarrassment can be a barrier. Troutman (2021) highlights the impact of missed opportunities when providers fail to recommend PrEP [120], with a participant remarking, ‘If my provider would have shared this information, I probably would have known about PrEP, and would have at least used it to know what it’s like.”

Perceived HIV Risk and Likelihood of Infection

PrEP willingness was linked to HIV risk perception, as studies by Ransome (2020), Chandler (2022), and Arnold (2018) consistently revealed that Black women who self-reported greater HIV risk were significantly more willing to use PrEP. Ransome (2020) found that individual HIV risk was associated with a higher likelihood of PrEP willingness (aPR = 2.56, 95% CI [1.7, 3.9], p = 0.03). A participant in Chandler (2022) expressed willingness to use PrEP “for HIV to protect herself.” Arnold (2018) found a notable willingness to use PrEP if it was known to lower HIV risk; however, perceived risk for HIV did not strongly influence willingness to use PrEP (F (1, 146) = 11.72, p = 0.718). Ayangeakaa (2023) provided contextual insight into Black women’s awareness of sexual risk behaviors associated with HIV in their communities, reinforcing the importance of self-protection through PrEP. A Black woman emphasized this, stating, "It’s a lot of funny business going around, [you] have to protect yourself because…some people are secretive about their sex life” (Ayangeakaa 2023). Correspondingly, Towe (2021) highlighted the prevalence of HIV acquisition concerns, with 60% of participants agreeing with "I am scared of contracting HIV" and 54% with "It would help me protect myself against HIV."

Behavioral Predisposing Factors

Sexual Behaviors

Inconsistent condom use and recent condomless sex have significantly predicted Black women's willingness to adopt PrEP (Johnson 2020; O’Malley 2021). One-third of the participants in Towe's study (2021) recognized the superior protection offered by combining PrEP with condoms. Personal risk behavior acknowledgment, particularly inconsistent condom use and multiple sexual partners, prompted an interest in PrEP. For example, one participant admitted, ‘I would be willing to use [PrEP] because of [my] inconsistent use of condoms and the number of partners in the past 12 months’ (O’Malley, 2021). Another highlighted PrEP's importance for safety when involving men who have male partners: 'I am very interested in protecting myself. I want to be as safe as possible’ (O’Malley, 2021). The relevance of PrEP is further emphasized in contexts involving abusive partners who oppose condom use, where women may avoid using them to avoid conflict (Braksmajer, 2019; O’Malley, 2021). Furthermore, studies have shown that women with more sexual partners (Wingood, 2013: aOR 1.8, 95% CI [1.1, 2.7], p < 0.01; Uzoeghelu, 2022: aPR 2.61, 95% CI [1.8, 3.9], p < 0.001) and those engaging in anal sex (Uzoeghelu, 2022: aPR = 1.46, 95% CI [1.0,2.1], p = 0.043) have heightened HIV risk perceptions, and a consequent increase in interest in PrEP.

History of Exchange in Sex Work

Involvement in sex work has emerged as a predisposing factor for PrEP willingness. Participants with a history of trading sex in Garfinkel (2017) were almost five times more likely to consider taking PrEP than those without such a history (AOR = 4.94, 95% CI [2.0,12.2], p < 0.001). Towe (2021) suggests that this trend is driven by selling sex for money. Studies have consistently found that Black women with a history of sex trade demonstrated significantly higher PrEP willingness (Wingood 2013, aOR = 4.1, 95% CI [1.6, 10.5], p < 0.01; Poteat 2019, aOR = 5.79, 95% CI [1.0, 33.7], p = 0.050), likely because of increased HIV risk and viewing PrEP as a strategy to mitigate vulnerability. However, Restar (2018) found that transgender women reporting transactional sex in the past 4 months were associated with lower PrEP acceptability (β = -1.5, 95% CI [-3.0, -0.1], p = 0.040). Kerr (2022) provided further insight, suggesting the need to detach PrEP from the stigma associated with "high-risk" sexual behaviors such as sex work for income. They argued that removing such stigmas could encourage more individuals involved in sex work to be empowered to protect themselves with PrEP instead of feeling shame (Kerr, 2022).

Alcohol/substance Use Behavior

Substance use was prevalent among the participants in Towe (2021). Notably, PrEP candidates reported more frequent and problematic stimulant use, endorsed more stimulant use disorder symptoms, and were more likely to use alcohol and heroin than non-candidates. Although the participants in this study had limited knowledge about PrEP and concerns about its side effects, their willingness to take PrEP was high and correlated with perceived HIV risk due to substance use. These findings suggest that women who use stimulants and alcohol may particularly benefit from PrEP for HIV prevention.

Cultural and Social Predisposing Factors

Traditional Gender Roles

Traditional gender roles have a significant impact on willingness to and commitment to PrEP uptake. Villaalba (2022) found that subordination (aOR = 1.5, 95% CI [1.2,2.4], p = 0.05) and self-silencing among Black women (aOR = 1.6, 95% CI [0.5, 2.3], p = 0.05) were associated with lower PrEP acceptability. Braksmajer (2019) highlighted the importance of partner support in health protection choices, with some Black women expressing that their well-being was paramount, even if it meant facing partner objections to PrEP use. One participant stated, ‘If you’re with someone that is … going to be mad that you’re taking a pill that’s going to affect your life in the long run if anything was to happen then, obviously, they don’t care about your life so, yeah no’ (Braksmajer, 2019). This finding underscores the belief that sexual partners should understand the measures taken to protect their own health.

Limited Partner Communication and Distrust

Communication difficulties and mistrust regarding partners' fidelity are also key predisposing factors that motivate PrEP use among Black women. O'Malley (2021) observes that PrEP provides a sense of control for those who face challenges in discussing sexual histories with partners, as one participant shared: 'I do not always talk to my partners about their sexual history… I would feel more in control of my health by taking PrEP.' Chandler (2022) echoed this sentiment, with a participant noting that PrEP’s benefits in relationships affected by infidelity: 'Women get [HIV] from their boyfriends or husband because he has been sleeping around, so I think it would be good for someone… who believes their partner has cheated.' Fear of negative partner reactions to PrEP use is also common, with some women being concerned about skepticism or offenses (Braksmajer, 2019; Troutman, 2021). However, Ayangeakaa (2023) highlights the inherent uncertainty in relationships as a rational basis for PrEP, with a poignant remark: 'You can’t say you’re not at risk for HIV… you just never know what your partner is doing’, underlining the issue of partner distrust.

Socio-cultural Norms

Discrimination and strong religious beliefs are linked to PrEP willingness, in which personal convictions and fear of family judgment play a role. Elopre (2022) found that participants who were willing to use PrEP had significantly (p < 0.01) fewer experiences of discrimination, with a mean score of 38.44 (SD = 9.2). A participant from Kerr's study (2022) voiced concerns about family members questioning HIV medications: 'I live with my mom, so I know if I have HIV medication in the house, she’d be like, “what’s going on?”, It would be bad.' Moreover, PrEP could be perceived as indicative of infidelity, causing mistrust in relationships, with a participant stating, 'If you’re with someone and it’s supposed to be just you two, and you’re taking an HIV pill, they may be offended' (Kerr, 2022). Troutman (2021) also emphasizes the effectiveness of relatable and inspirational "PrEP spokespersons" in the community, such as pastors' wives, who could influence Black women’s acceptance [121]. One participant said, ‘If you went to my pastor’s wife and she received it well, everyone would get on board."

PrEP-Related Attitudes/Intentions in the Predisposing Domain

HIV Knowledge

HIV knowledge has emerged as a pivotal factor influencing PrEP willingness, with Elopre (2022) noting that individuals with more HIV knowledge are more inclined to use PrEP (mean score 13.32, (SD = 3.5) p < 0.01). Ojikutu (2020) highlighted a notable association between Black women's beliefs in HIV conspiracy theories and PrEP willingness (OR = 1.09, 95% CI [1.03,1.16], p < 0.001). While it may seem counterintuitive, Ojikutu (2020) suggested that this belief could represent a form of self-preservation in a society with a history of discriminatory practices, where skepticism towards healthcare may actually be a rational protective response, thereby potentially increasing empowerment and the willingness to protect themselves with PrEP (Ojikutu, 2020). In contrast, Poteat (2021) found that low HIV knowledge was significantly associated with PrEP willingness among Black women (aOR = 0.32, 95% CI [0.1, 1.0], p = 0.050). This suggests that individuals who are well versed in HIV [122] may prefer other prevention methods. Kerr (2022) proposed that insufficient knowledge about HIV transmission, influenced by PrEP stigma, could lead to fear of PrEP's safety, exemplified by a participant's quote: "I’m scared that it might backfire. What if instead of preventing AIDS, it gives you AIDS?".

PrEP Knowledge

PrEP knowledge has a nuanced predictability of Black women’s PrEP willingness [115], with some studies highlighting its varied influence across different contexts. Haider (2022) identified prior PrEP knowledge as a significant predictor of future willingness to use PrEP (aOR = 0.4, 95% CI [0.1, 0.9], p < 0.05). However, Ojikutu (2020) and Hill (2023) found that increased PrEP knowledge did not necessarily correlate with Black women's willingness to use PrEP. Furthermore, a college-aged Black women from Chandler (2022), who researched PrEP, expressed a positive view and subsequent readiness to use it if offered, saying, "[PrEP] is actually very good and accurate, and if offered, [it is] something that I need and would definitely use.”

Conversely, another participant from the same study declined PrEP usage due to insufficient information, stating, ‘I [do] not know enough about the medication’ (Chandler, 2022). Additionally, a Troutman (2021) participant articulated a newfound awareness and a cautious but open willingness to explore PrEP further:’ I feel like I have learned something. I think it’s very useful, and I want to tell more people about it. I’m hesitant, but I’m willing and open.”

Perceived Benefits and Harms of PrEP

Studies have shown that positive beliefs about PrEP's effectiveness correlate with increased willingness, underscoring how Black women’s perceptions of the benefits or potential harms of PrEP may shape attitudes toward its use. Black women with favorable attitudes toward PrEP were more likely to be willing to use it (Kerr, 2022), further illustrated by a Black woman from Ayangeakaa (2023) stating,’ I feel like having PrEP would prevent the chances of many people catching HIV. So, PrEP is a big thing.” Kerr (2022) highlighted the preventive benefits of PrEP, with one Black woman stating, ‘I just think about unprotected sex.’ [PrEP] seems like a good idea to me." Another participant acknowledged the relevance of PrEP use when perceived risk is higher: “Did I need [PrEP] at one point? Yes. Would I have taken it? Definitely, because sometimes I used condoms, but sometimes I did not. [It] would have been perfect at those times’ (Kerr, 2022). Similarly, a trans woman also recognized PrEP's role in the broader context of HIV research, expressing optimism for future advancements: "It’s awesome, with all of the research and money put into the HIV thing, it should be some progress like that, even be a cure somewhere around the corner’ (Kerr, 2022). Troutman (2021) captured the sentiment of empowerment that PrEP offers Black women, with participants commenting, "I think [PrEP] is strictly just taking care of yourself" and likening it to "a vitamin for HIV prevention."

Enabling Factors

The enabling factors influencing PrEP willingness were categorized into thematic groups, each with corresponding subcategories:1) socioeconomic, 2) healthcare accessibility, and 3) support system factors for PrEP.

Socio-economic Enabling Factors

Structural Challenges

Lower income levels emerged as a notable determinant of PrEP willingness among Black women in this review, but this relationship was complex. Ojikutu (2020) reported that individuals with lower income and expanded PrEP indications displayed significantly greater willingness to consider PrEP (OR = 1.89, 95% CI [1.1,3.2], p = 0.020), highlighting how PrEP is a valuable resource among Black women with fewer economic resources. Wingood (2013) observed a similar inclination towards PrEP among Black women of lower socioeconomic status, as women were less willing to use PrEP if the cost was $200/year (aOR = 0.60, 95% CI [0.4, 1.0], p < 0.01). However, Braksmajer (2018) indicated that a higher income was linked to a greater willingness to take PrEP, suggesting that economic stability may also play a role in PrEP adoption decision-making.

Health Insurance Coverage

Towe (2021) reported that, despite a general willingness to use PrEP, 73% of potential users were uncertain about PrEP access and affordability. Troutman (2021) reiterated this sentiment, finding that insurance coverage was a pivotal factor for women considering PrEP, with one participant emphasizing the need for affordability: "You can’t pay for the medicine or the doctor… just make PrEP affordable." Additionally, cost-effectiveness concerns were particularly pronounced among women who experienced IPV, with the price of PrEP, insurance coverage, and inconsistent healthcare being crucial issues (O'Malley, 2021), suggesting the importance of financial factors in the PrEP decision-making process of Black women.

Employment Status

In this study, employment status appeared to influence Black women’s PrEP willingness, with Wingood’s (2013) finding that unemployed women were significantly more likely to consider PrEP adoption (aOR = 1.8, 95% CI [1.2, 2.6], p < 0.01) than Black women employed full-time. Despite this, insured Black women who are employed still expressed financial challenges in accessing PrEP, stating, ‘If you want to start and pick a target population, start where people have jobs, with insurance, that can afford PrEP, without a barrier’ (Troutman, 2021). This underscores that, while employment can facilitate insurance coverage, it does not automatically resolve the financial hurdles associated with PrEP, pointing to the need for broader measures to enhance PrEP affordability and access.

Healthcare Accessibility Enabling Factors

Accessibility of PrEP Services and Transportation

Transportation barriers significantly impact access to PrEP services and consequently Black women’s willingness to use PrEP. Ojikutu (2019) found spatial access to PrEP clinics as a key enabling factor influencing Black women’s PrEP willingness (aPR = 1.16, 95% CI [1.0, 1.3], p < 0.050), as those living in areas with higher PrEP clinic density showed greater inclination for its use. However, 40% of the participants still commute to these facilities for over an hour (Ojikutu, 2019). O'Malley (2021) also highlighted the transportation challenges related to frequent medical appointments, with one IPV survivor noting, ‘My willingness to take PrEP may be affected by the number of times I would need to see a doctor,’ thus underscoring the influence of transportation challenges on PrEP uptake and adherence among Black women (O'Malley, 2021).

Geographic Region

The geographic region in which one lived appeared to shape PrEP willingness among Black women, with particular attention needed in rural and southern areas in the U.S. In states such as Alabama, for instance, known for its rural HIV challenges, Elopre (2022) suggested that online PrEP services are a viable option for cisgender women facing challenges in accessing PrEP in clinical settings. Ojikutu (2019) found that residing in the Western U.S. (aPR = 2.04, 95% CI 1.1, 3.9], p < 0.050) (versus the Northeast U.S.) and self-reporting of high HIV risk were correlated with increased PrEP willingness. Ransome (2020) further emphasized the significant impact of area-level HIV risk on PrEP willingness (aOR = 2.03, p = 0.030), highlighting the need to consider broader contextual factors of local HIV epidemiology. Moreover, Ayangeakaa (2021) noted that exposure to PrEP information “depends on your location,” with participants asserting that those in southern, conservative states might have more opportunities to learn about PrEP and ultimately have greater willingness than those in other geographic regions.

Availability of Financial Assistance, Public Social Services, and Community Resources

Various studies have emphasized the need to integrate HIV services with social programs tailored to community needs [123], including violence prevention, employment, and housing (Poteat, 2019). In Poteat (2019), transgender women expressed concerns that the emphasis on treating those living with HIV overshadows the need to promote PrEP. A telling quote illustrates this gap: “for the longest time, I haven’t been able to get services unless I have HIV… even as a homeless transgender senior with a disability’ (Poteat 2019). The study also identified provider-related barriers to PrEP provision such as discomfort in discussing sexual health, concerns about risk compensation compounded by racism, and PrEP stigma. Troutman (2021) found that PrEP use could be stigmatized as indicative of infidelity or promiscuity, as one participant remarked: “Yeah, they love to have sex with everybody.” To mitigate this stigma, some of the included studies called for PrEP services to be offered in non-traditional settings, such as harm reduction and syringe exchange programs, to broaden the reach of PrEP among Black women (Troutman, 2021; Towe, 2021; Poteat, 2019).

PrEP Modality Preferences

Black women show a preference for various PrEP modalities beyond daily oral pills, with many favoring long-acting injectable options (Elopre 2022; Ayangeakaa 2023; O’Malley 2021). Elopre (2022) reported that 69% of participants preferred non-pill forms, such as LAI, particularly among those who were more knowledgeable about HIV. Pill aversion and adherence challenges contribute to this preference, as one woman explained her difficulty with pills: 'I don’t like pills. I don’t know how to take pills' (Ayangeakaa, 2023), and another expressed a preference for injectable PrEP: 'I would be more willing to use [PrEP] if it was a shot' (O’Malley, 2021). The convenience of LAI is appealing, with one participant advocating for monthly shots: 'I think you should take the PrEP [as] a shot…they ain’t going to remember to take no pill.' Another highlights its ease: 'If you get a [PrEP shot] once a month…you ain’t got to worry about it' (Ayangeakaa 2023). The call for diverse PrEP options is clear, with a recognition of different needs: 'Some people are good with pills, and some people fear needles, so they need different things' (Ayangeakaa, 2023), indicating that PrEP acceptability may increase with more available options.

Support System Enabling Factors

Supportive Social Environment

A supportive social environment is a key enabler of PrEP willingness among Black women. Wingood (2013) found that Black women were more willing to consider PrEP if they believed that their peers would also use it, with recommendations from healthcare providers notably increasing their potential for PrEP uptake. The impact of influential peers, particularly other women, on Black women's PrEP adoption was significant (aOR = 8.3, 95% CI [4.8, 14.2], p < 0.001). Poteat (2019) observed that transgender Black women valued “receiving services from other transgender women, with one participant noting the community’s anticipation for such support, stating, “In fact, I think some people have been waiting to see that.” Additionally, Braksmajer (2019) identified that engaging in comprehensive HIV discussions with partners was a supportive enabling factor in increasing Black women's willingness to use PrEP.

Access to Culturally Sensitive Providers: Curbing Healthcare Discrimination

Access to culturally sensitive providers is crucial for Black women's PrEP uptake [120], with increased willingness observed when informed providers address their health needs (β = 2.9, p < 0.001; Restar, 2018). However, there is a notable gap in provider education on PrEP for Black women (Chandler, 2022) and the perception that conversations about PrEP are less frequent with heterosexual individuals than with MSM, as one woman noted: “It seems like providers mainly… talk about PrEP with MSM. They don’t talk about promoting it with heterosexuals” (Troutman, 2021). Skepticism, due to historically unethical medical practices, also plays a role, particularly in the transgender community (Poteat, 2019). Discrimination experiences further diminish PrEP willingness (Elopre, 2022), compounded by systemic issues, such as racial bias and stigma (Ransome, 2020). Judgment faced by Black women over medication use is emblematic of the broader stigma, with a participant reflecting, 'There’s just so much judgment with any medication. I always feel like I have to defend myself when talking about it' (Ayangeakaa, 2022), highlighting the need for stigma reduction in healthcare.

Need Factors

The themes found in the need factor domain were organized into themes of perceived need, history of STIs, current experience of IPV/non-monogamous relationships, and birth control sabotage/partner interference.

Perceived Need

'Perceived Need' in this context denotes the individual's recognition and assessment of their HIV risk and its influence on their willingness to use PrEP. Ayangeakaa (2023) and Braksmajer (2018) found a strong association between perceived HIV risk and willingness to initiate PrEP (Braksmajer: aOR = 22.1 p < 0.001). Arnold (2022) and Elopre (2022) observed that willingness is linked to the frequency of self-acknowledged risk behaviors. Ojikutu (2019) reported that individuals who saw themselves as being at higher risk due to risky behaviors were more open to PrEP (aPR = 1.70, 95% CI [1.27, 2.27]). Similarly, Patel (2019) found that those who recognized a high risk of HIV infection (OR = 6.76, 95% CI [3.3, 14.1]) or were aware of their partners’ positive status were more likely to consider PrEP. Towe (2020) also noted that awareness of PrEP's risk-reduction potential increased their willingness to use it (r = 0.190, p = 0.006). These findings highlight that personal risk assessment is a critical determinant of the perceived need for PrEP and adoption of preventive measures (Ojikutu, 2020; Troutman, 2021).

History of STI Diagnosis

Women with a history of STIs are more willing to consider PrEP (Chandler 2022; Haider 2022). Johnson (2020) reported that Black women with recent STI diagnoses showed increased PrEP willingness, a finding echoed by Ojikutu (2020), who noted a significant link between STI history and PrEP willingness (OR = 1.8, p = 0.010). O'Malley (2021) found that 70% of PrEP-willing participants cited past negative sexual health outcomes such as STIs as motivators for their willingness. One participant illustrated this concern: "I am someone who usually participates in unprotected sex. He had recently cheated and developed gonorrhea. Therefore, I worry about my health. Before reading the information about HIV, I never really thought about my chances of getting it." These insights highlight the impact of recognizing personal HIV risks informed by past STI experiences on the perceived need for PrEP (O'Malley, 2021).

IPV Experiences and Non-monogamous Relationships

Villaalba (2022) discovered that physical IPV experiences in the past year were significantly associated with Black women's willingness to use PrEP (aOR = 1.9, 95% CI [1.7, 4.3], p = 0.050). In contrast, Garfinkel (2017) found that women with a lifetime history of IPV were less likely to consider taking PrEP than those without a history of IPV (aOR = 0.71, 95% CI [0.6, 0.9], p = 0.004). Braksmajer (2019) noted that about half of women would have considered PrEP had they stayed in abusive relationships, indicating the influence of relationship dynamics on PrEP consideration. Troutman (2021) found that many participants viewed PrEP as a viable HIV prevention method for women in non-monogamous relationships, suggesting that PrEP is a safeguard against the knowledge of partners' additional sexual activities. One participant stated, "Even if you’re not high risk, you still want to take it [PrEP] because you may be monogamous, but your partner may not be; because you got a lot of men that like to do that…undercover,” (Troutman, 2021). The perception that most relationships lack monogamy led participants to endorse PrEP as a protective measure for women with concerns about their partners' fidelity, with one woman saying, "Some women know their partners cheating, but they still want that person” (Troutman, 2021). This sentiment was echoed by Chandler (2022), in which a participant suggested PrEP for those in committed relationships but aware of their partner's infidelity: “I know a lot of times women get [HIV] from their boyfriends or husband because he has been sleeping around so I think it would be good for someone who is in a committed relationship, and they know that their partner has cheated before.”

Birth Control Sabotage and Partner Interference

Willie (2017) also found that women who experienced birth-control sabotage were more likely to be willing to use PrEP. The path analysis model showed that birth control sabotage was directly related to PrEP acceptability (b = 0.19, t = 1.98, p < 0.05) and the total indirect effect from IPV to PrEP acceptability through birth control sabotage was significant (indirect effect = 0.08, p < 0.050) (Willie, 2017). One participant from Braksmajer (2019) expressed the difficulty of adhering to birth control due to an abusive and controlling partner, stating, “I wouldn’t take PrEP … I had no control over my own life. My body was his body.” Partner interference also posed a significant barrier to PrEP use, with one-third of Black women reporting IPV as an obstacle (Braksmajer, 2019). The fear of partners' violent reactions to PrEP use was also a concern, with one woman sharing, “He might want to kill her thinking that she might have HIV” (Braksmajer, 2019). Additionally, the fear of violence upon discovery of covert PrEP use was prevalent, as other women explained, “He’s gonna flip even more because he’s gonna be like ‘well you had something to hide; you must have HIV, that’s why you’re taking it’ or ‘you’re sleeping with somebody who has it” (Braksmajer, 2019). These findings highlight the complex interplay between IPV and PrEP willingness, where the desire for autonomy in health decisions is often countered by the fear of partner retaliation. Table 6 provides a comprehensive summary of the factors associated with PrEP willingness.

Table 6.

Summary of factors associated with willingness to use PrEP by theoretical domain

Authors	Domain	Factors	Qualitative source/sample statistic	Sample statistic value	p-value
Arnold 2018	Predisposing	Beliefs about medication	Pearson’s r	.217	< .050
	Enabling	–	–	–	–
	Need	–	–	–	–
Ayangeakaa 2023	Predisposing	–	–	–	–
	Enabling	–	–	–	–
	Need	Perceived HIV risk	Focus groups	–	–
		Perceived need for PrEP (behavioral beliefs)	Focus groups	–	–
Braksmajer 2019	Predisposing	Higher education	Interviews	–	–
		Reproductive coercion	Interviews	–	–
		Negative partner reactions	Interviews	–	–
		Fear of partner interference	Interviews	–	–
		Concerns about side effects	Interviews	–	–
	Enabling	Discussion of HIV with partner	Interviews	–	–
	Need	–	–	–	–
Braksmajer 2018	Predisposing	Trust primary care provider	aOR	3.55	.020
	Enabling	–	–	–	–
	Need	Perceived HIV risk	aOR	22.10	.001
Chandler 2022	Predisposing	Misinformation	Interviews	–	–
		Stigma	Interviews	–	–
	Enabling	Comprehensive PrEP education	Interviews	–	–
	Need	History of STIs	Interviews	–	–
Elopre 2022	Predisposing	Younger age	Mean (SD)	33 (10.7)	< .01
		Higher HIV knowledge	Mean (SD)	13.32 (3.5)	< .01
		Higher Mean Number of Sexual Partners	Mean (SD)	1.32 (1.0)	< .05
		Lower intrinsic religiosity	Mean (SD)	2.42 (1.5)	< .05
		Perceived social support–significant others	Mean (SD)	5.73 (1.5)	< .05
		Lower experiences of discrimination	Mean (SD)	38.44 (9.2)	< .01
	Enabling	–	–	–	–
	Need	Perceived HIV risk	N (%)	93 (40%)	< .01
		Higher perceived need for PrEP (Yes vs. No)	N (%)	43 (18%)	< .01
Garfinkel 2017	Predisposing	Sex trade history	aOR [95% CI]	4.94 [2.0, 12.2]	< .001
	Enabling	–	–	–	–
	Need	Lifetime history of IPV	aOR [95% CI]	0.71 [0.6, 0.9]	.004
Haider 2022	Predisposing	Prior PrEP knowledge	aOR [95% CI]	0.40 [0.1, 0.9]	< .05
		PrEP acceptability	aOR [95% CI]	13.7 [1.4, 130.9]	< .05
	Enabling	–	–	–	–
	Need	–	–	–	–
Hill 2023	Predisposing	–	–	–	–
	Enabling	–	–	–	–
	Need	–	–	–	–
Johnson 2020	Predisposing	Younger age	N (%)	16 (67%)	–
		Condomless vaginal sex, previous 3 months	N (%)	52 (73%)	–
	Enabling	–	–	–	–
	Need	STI test, previous 3 months	N (%)	56 (78%)	–
Kerr 2022	Predisposing	PrEP knowledge	Focus groups	–	–
		Positive PrEP attitudes	Focus groups	–	–
		PrEP stigma	Focus groups	–	–
	Enabling	–	–	–	–
	Need	–	–	–	–
Ojikutu 2019	Predisposing	Lower education (less than high school)	aPR [95% CI]	0.60 [0.4, 1.0]	< .050
	Enabling	Density of PrEP clinics per 10,000 people	aPR [95% CI]	1.16 [1.0,1.3]	< .050
		Census Region (West vs. Northeast)	aPR [95% CI]	2.04 [1.1, 3.9]	< .050
	Need	Perceived HIV risk	aPR [95% CI]	1.70 [1.3, 2.3]	< .050
Ojikutu 2020	Predisposing	Less education (Did not finish college)	OR [95% CI]	2.22 [1.1, 4.3]	.018
		Last Seen Doctor More Than 1 Year Ago	OR [95% CI] AOR, [95% CI]	0.36 [0.2, 0.7] 0.28, [0.13, 0.2]	.005 0007
		HIV–Related Medical Mistrust Scale	OR [95% CI] aOR, [95% CI]	1.09 [1.0, 1.2] 1.08, [1.01, 1.14]	.003 .020
		HIV conspiracy beliefs (There is a cure for HIV but the government is withholding it from the poor)	aOR [95% CI]	2.81 [1.6, 4.9]	< .001
		Unmarried/non–cohabitating (single, widowed, divorced, separated)	OR [95% CI] AOR, [95% CI]	2.76 [1.7, 4.6] 2.47, [1.43, 4.27] <  <	< .001 0.0017
	Enabling	Lower income	OR [95% CI]	1.89 [1.1, 3.2]	.204
	Need	–	–	–	–
O'Malley 2021	Predisposing	HIV worry	OR [95% CI]	3.98 [1.5, 10.2]	.014
		More sex partners	OR [95% CI]	0.40 [0.2, 0.8]	.014
	Enabling	–	–	–	–
	Need	–	–	–	–
Patel 2019	Predisposing	Having more control/protection from HIV	N (%)	155 (89.8%)	–
		Inability to trust sexual partners	N (%)	96 (55.6%)	–
		Offered by a health care provider	N (%)	61 (35.6%)	–
	Enabling	–	–	–	–
	Need	HIV Positive sexual partner	N (%)	60 (35.1%)	–
Poteat 2019	Predisposing	Low HIV knowledge	aOR [95% CI]	0.32 [0.1, 1.0]	.050
		History of exchange sex	aOR [95% CI]	5.79 [1.0, 33.7]	.050
	Enabling	–	–	–	–
	Need	HIV risk perception	aOR [95% CI]	1.86 [1.1, 3.2]	.020
Ransome 2020	Predisposing	Individual HIV risk	aPR [95% CI]	2.56 [1.7, 3.9]	.030
	Enabling	High area–level HIV risk (Upper 25th percentile)	aPR [95% CI]	2.03 [1.0, 4.0]	.030
	Need	–	–	–	–
Restar 2018	Predisposing	Younger ages (ages 21–25)	β (SE) [95% CI]	–2.0 (0.8) [-3.6, –0.4]	.010
		History of transactional sex < 4 months	β (SE) [95% CI]	–1.5 (0.8) [-3.0, –0.1]	.040
		PrEP interest	β (SE) [95% CI]	3.7 (0.8) [2.2, 5.2]	< .001
	Enabling	Provider meets health needs	β (SE) [95% CI]	2.9 (0.8) [1.3, 4.4]	< .001
	Need	–	–	–	–
Towe 2020	Predisposing	–	–	–	–
	Enabling	–	–	–	–
	Need	Perceived HIV risk	Pearson’s r	0.19	.006
Troutman 2021	Predisposing	–	–	–	–
	Enabling	–	–	–	–
	Need	Perceived HIV risk	Focus groups	–	–
Uzoeghelu 2022	Predisposing	Single marital status (no arrest history)	aPR [95% CI] AP, [95% CI]	1.69 [1.1, 2.5] 1.69[1.13, 3.53]	.011 0.013
		Multiple sex partners in past 3 months (with arrest history) (with an arrest history)	aPR [95% CI] aP, [95% CI]	2.61 [1.8, 3.9] 2.61, [1.77, 3.85]	< .001  < 0. 001
		Multiple sex partners in past 3 months (no arrest history) (no arrest history)	PR [95% CI]	1.79 [1.1, 3.0]	.023
		Lifetime history of anal sex (no arrest history)	aPR [95% CI] APR, [95% CI]	1.46 [1.0, 2.1] 1.46, [1.01, 2.12]	.043 0.0429
	Enabling	–	–	–	–
	Need	–	–	–	–
Villaalba 2022	Predisposing	Lifetime psychological IPV experiences	aOR [95% CI]	2.2 [1.1, 4.8]	.05
		Being subordinate to others	aOR [95% CI]	1.5 [1.2, 2.4]	.05
		Self–silencing	aOR [95% CI]	1.6 [0.5, 2.3]	.05
	Enabling	–	–	–	–
	Need	Past year physical IPV experiences	aOR [95% CI]	1.9 [1.7, 4.3]	.05
Willie 2017	Predisposing	–	–	–	–
	Enabling	–	–	–	–
	Need	Birth control sabotage	b | t | Indirect Effect	0.19 | 1.98 | 0.08	< .050
Wingood 2013	Predisposing	Provider Recommendation	aOR [95% CI]	76% | 13.2 [7.5, 23.1]	< .001
		More lifetime sexual partners	aOR [95% CI]	65% | 1.8 [1.1, 2.7]	< .01
		Sex for money or drugs	aOR [95% CI]	89% | 4.1 [1.6, 10.5]	< .01
		Less educated	aOR [95% CI]	71% | 1.8 [1.2, 2.9]	< .01
		Influence of female peers	aOR [95% CI]	77% | 8.3 [4.8, 14.2]	< .001
	Enabling	Unemployment status	aOR [95% CI]	69% | 1.8 [1.2, 2.6]	< .01
	Need	–	–	–	–

Categorization of the key factors influencing willingness to use pre–exposure prophylaxis (PrEP) as identified in each of the 24 review studies. Factors are grouped as predisposing (individual beliefs and characteristics), enabling (external conditions facilitating or hindering PrEP use), and need (perceived or actual risk of HIV infection) factors

OR odds ratio, aOR adjusted odds ratio, aPR adjusted prevalence ratio, Β standardized regression coefficient, r Pearson’s correlation coefficient, SE standard error, CI confidence interval

Gender-Specific Barriers and Facilitators to PrEP Willingness

Cisgender Women

We found that common barriers to PrEP uptake among cisgender women include stigma, medical mistrust, and low HIV risk perception (Ojikutu, 2019). Despite a high level of awareness about PrEP, many cisgender women had misconceptions about the drug, such as believing it was only for men who had sex with men (Ojikutu, 2019). Significant barriers also include concerns about side effects and fear of being judged or shamed by peers and family members for taking PrEP (Johnson, 2020; Braksmajer, 2018). Facilitators of PrEP uptake include receiving accurate information, support from healthcare providers, and understanding the protective benefits of PrEP against HIV (Johnson, 2020). Some women recognized the potential benefits of PrEP in situations where they lacked control over their partner's behavior and preferred alternative PrEP modalities, such as injectables (Ayangeakaa, 2023).

Transgender Women

PrEP acceptability among young transgender women (ages 16–29) is influenced by factors such as PrEP interest, having a medical provider who meets their health needs, younger age, and recent engagement in transactional sex (Restar, 2018). Barriers include concerns about side effects, medical mistrust, high levels of stigma, discrimination, and concerns about PrEP's interaction with hormone therapy (Restar, 2018; Johnson, 2020; Braksmajer, 2018). Structural barriers such as economic marginalization and inadequate healthcare further complicate PrEP uptake (Restar, 2018). Facilitators include targeted educational campaigns, supportive healthcare environments, and interventions that address intersectional stigma (Johnson, 2020). Transgender women demonstrated higher awareness and knowledge of PrEP due to targeted advertisements and community outreach (Ayangeakaa, 2023).

Discussion

This systematic review, guided by the BMVP, identified multiple factors affecting PrEP willingness among Black women, elucidating how these determinants can be leveraged to mitigate HIV risk and foster health equity. Key demographic variables, such as age, marital status, and education, emerged as significant factors, corroborating previous studies [30, 124–126]. Notably, the dual influence of education level on PrEP willingness underscores the complex interplay between knowledge and health behaviors [102, 125, 127]. Perceptions of high HIV risk also markedly increased PrEP willingness, consistent with existing research [128, 129]. The inverse relationship between substance use and PrEP willingness highlights the critical role that PrEP could play in behaviors that increase HIV risk. Cultural dynamics encompassing traditional gender roles and religiosity are pivotal in shaping attitudes toward PrEP. These findings highlight the need for culturally tailored interventions adapted to better resonate with the lived experiences of Black women.

Socioeconomic status and healthcare access were the dominant factors affecting PrEP willingness. Our synthesis highlights how financial constraints and inadequate insurance perpetuate disparities, echoing the literature's call for more inclusive healthcare policies [31, 130–132]. The significance of culturally competent providers as facilitators of PrEP acceptance [59, 120, 127, 133–135] reinforces the provider-patient relationship's centrality in healthcare delivery. However, provider bias and stigma remain formidable barriers, emphasizing the need for interventions aimed at provider education and mitigating bias [136]. This review also provides initial insights into the acceptance of LAI PrEP (Apretude) as an alternative to oral PrEP. However, only two studies in this review focused on this new modality, in contrast to 22 studies that only examined oral PrEP. Despite the limited data, the preference for more options (including LAI PrEP) suggests a positive reception among Black women owing to its perceived effectiveness, convenience, and confidentiality [Elopre, 2022; Ayangeakaa, 2023]. Thus, future research should incorporate a broader exploration of LAI PrEP, as it becomes more established in the market.

Implications for PrEP Use Among Cisgender and Transgender Women

Our review highlights distinct differences in PrEP use and associated factors between cisgender and transgender women. For cisgender women, key barriers include stigma, medical mistrust, and low HIV risk perception, while facilitators involve accurate information, support from healthcare providers, and understanding of the protective benefits of PrEP (Ojikutu, 2019; Johnson, 2020; Braksmajer, 2018; Ayangeakaa, 2023). In contrast, transgender women face unique challenges such as high levels of stigma, discrimination, and concerns about hormone therapy interactions. Facilitators of this group include targeted educational campaigns and supportive healthcare environments (Restar, 2018; Johnson, 2020; Braksmajer, 2018; Ayangeakaa, 2023).

These differences underline the need for tailored interventions to address the unique needs of each group effectively. For cisgender women, increasing PrEP uptake requires addressing prevalent misconceptions and stigma as well as improving communication and education strategies used by healthcare providers (Ojikutu, 2019). For transgender women, interventions must address specific forms of stigma and discrimination, provide safe and supportive healthcare environments, and enhance provider training on transgender health issues (Restar, 2018; Johnson, 2020).

Strengths

The strengths of this systematic review are evident through its rigorous methodology, guided by the PICO model, and adherence to the PRISMA guidelines, which underscores its transparency and credibility. A comprehensive search across five databases and a building block strategy notably reduced selection bias. By covering studies from 2013 to 2023, we captured the evolving landscape of PrEP willingness for HIV prevention among Black women. Methodological quality was assessed using the ROBINS-E tool [108], whereas the BMVP framework provided a solid conceptual base. A narrative synthesis approach facilitated thorough data exploration, and a modified GRADE assessment ensured a robust evidence evaluation. The inclusion of various study designs enriched the analysis of factors affecting PrEP willingness among Black women.

Limitations

The limitations of this review include moderate bias across studies, which affects the reliability of the conclusions. The heterogeneity of the study designs and lack of uniform measures prevented the use of meta-analysis, necessitating narrative synthesis. The small sample sizes in some studies might restrict the generalizability of the findings, with broad confidence intervals affecting the precision of the data. Despite the inclusion of studies published up to 2023, recent research may not have been captured. Furthermore, it is important to note that many of the included studies were not designed to be generalizable. Specifically, qualitative studies and those focusing on regional or specific populations of Black women often aim to provide in-depth insights rather than broadly applicable results. These studies contribute valuable contextual and detailed understanding of PrEP willingness among Black women, but their findings may not be widely applicable to all Black women across different regions and settings.

Despite these constraints, the review's methodological rigor is a counterbalancing strength. The Behavioral Model for Vulnerable Populations (BMVP) provides a structured framework for synthesizing diverse findings. However, it acknowledges the issues of bias, generalizability, data precision, and reliance on a singular behavioral model. Recognizing these limitations, we emphasize the need for further research with larger, more diverse samples and standardized measures to enhance the generalizability and robustness of future findings.

Practice, Policy, and Future Research Implications

This study highlights the need for healthcare providers to enhance cultural sensitivity in PrEP discussions with Black women, suggesting the development of tailored training programs to effectively communicate its benefits and risks. Ensuring that Black women communities receive clear and accurate information about PrEP is crucial for informed decision-making regarding HIV prevention. Policywise, there is a call for increased PrEP affordability and the inclusion of Black women's experiences in policy development to address unique challenges, such as contraceptive coercion. Future research should examine the barriers and facilitators of PrEP use, particularly oral and long-acting injectable forms, in larger cohorts of substance-using Black women to gain a deeper understanding of their needs and perceptions.

Conclusion

This review methodically evaluates the variables affecting PrEP willingness in Black women guided by the BMVP framework. It identified demographic aspects, trust in healthcare, perceived HIV risk, behavior, cultural and societal contexts, knowledge, attitudes, socioeconomic factors, social support, and perceived necessity as crucial in promoting PrEP uptake among Black women. These insights should shape customized interventions and policymaking to bolster PrEP usage with the aim of lowering HIV rates and improving sexual health within this population. Collaborative efforts among healthcare professionals, policymakers, and researchers are vital for promoting HIV prevention and fostering healthcare equity among Black women.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

PrEP

Pre-exposure prophylaxis

HIV

Human immunodeficiency virus

CIS

Cisgender

Trans

Transgender

PRISMA

Preferred reporting items for systematic reviews and meta-analyses

PICOS

Population, intervention, comparison, outcome, study design framework

TDF-FTC

Truvada, a fixed-dose oral combination of emtricitabine/tenofovir disoproxil fumarate

FTC/TAF

Descovy, a fixed-dose combination of emtricitabine/tenofovir alafenamide

LAI-PrEP

Apretude (cabotegravir extended-release injectable suspension), long-acting injectable PrEP

BMVP

Behavioral model for vulnerable populations

STI

Sexually transmitted infection

IPV

Intimate partner violence

ROBINS-E

The risk of bias in non-randomized studies of exposure tool

GRADE

Grading of recommendations assessment, development and evaluation approach

Author Contributions

Alexis S. Haynes: Contributed to study conceptualization and design; wrote the study protocol; conducted methodology, literature search, primary and secondary screening of studies, and conflict resolution; performed data extraction, formal analysis, and investigation; interpreted the data; and was involved in writing—original draft preparation, review, and editing per PhD dissertation requirements. Mandy J. Hill: Provided supervision, participated in conceptualization and design, reviewed, and edited the manuscript, and conducted critical manuscript revisions for important intellectual content. Christine Markham: Participated in the conceptualization and design, reviewed, and edited the manuscript, and conducted critical manuscript revisions for important intellectual content. Vanessa Schick: Engaged in conceptualization and design, reviewed, and edited the manuscript, and carried out critical manuscript revisions for important intellectual content. Robert Suchting: Involved in conceptualization and design, reviewed, and edited the manuscript. Nivedhitha Parthasarathy and Sumaita Choudhury: Responsible for primary and secondary screening of the studies. CM, MH, VS, and RS: Offered critical insights and recommendations based on expertise. All authors have read and approved the final manuscript.

Funding

This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sector. The authors acknowledge the support of the University of Texas Health Science Center at Houston (UTHealth Houston) and its Member Institutions for providing Open Access funding, which was enabled and organized by the UTHealth Houston Department of Health Promotion and Behavioral Sciences.

Data Availability

All the data analyzed in this study were obtained from publicly available sources. The data extracted from these sources are included in the supplementary tables.

Code Availability

Not applicable. No new software applications or custom codes were used during the preparation of the manuscript.

Declarations

Conflict of interest

The authors declare no conflicts of interest relevant to this article. There are no competing financial or nonfinancial interests that could potentially influence the work presented in this manuscript.

Ethical approval

This was an observational review study; thus, no ethical approval was required. The authors adhered to the minimum standards and reporting guidelines for systematic review articles by systematic reviews and meta-analyses (PRISMA), and protocols (Prisma-P).

Research Involving Human and Animal Rights

This article does not contain any studies involving human participants or animals performed by any of the authors. Consequently, this study was exempt from Institutional Review Board (IRB) review and ethics approval.

Informed Consent

Informed consent was not obtained for this study. This systematic review did not involve human participants; therefore, consent for participation was not required.

Consent for Publication

The authors consent to the publication of the data and images submitted in this manuscript.