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. Author manuscript; available in PMC: 2020 Apr 1.
Published in final edited form as: J Acquir Immune Defic Syndr. 2019 Apr 1;80(4):386–393. doi: 10.1097/QAI.0000000000001935

Social networks and its impact on women’s awareness, interest, and uptake of HIV pre-exposure prophylaxis (PrEP): Implications for women experiencing intimate partner violence

Tiara C Willie *, Jamila K Stockman 1, Danya E Keene 2, Sarah K Calabrese 3, Kamila A Alexander 4, Trace S Kershaw 5
PMCID: PMC6408934  NIHMSID: NIHMS1516021  PMID: 30570528

Abstract

Background:

In the U.S., women represent less than 5% of all pre-exposure prophylaxis (PrEP) users. Social networks may promote and/or inhibit women’s PrEP awareness, which could influence PrEP intentions. Further, women experiencing intimate partner violence (IPV) may have smaller, less supportive networks, which could deter or have no impact on PrEP care engagement. This study examined associations between network characteristics and women’s PrEP awareness, interest, uptake, and perceived candidacy; and analyzed IPV as an effect modifier.

Setting/Methods:

From 2017 to 2018, data were collected from a prospective cohort study of 218 PrEP-eligible women with (n=94) and without (n=124) IPV experiences in Connecticut. Women completed surveys on demographics, IPV, social networks, and PrEP care continuum outcomes.

Results:

Adjusted analyses showed that PrEP awareness related to having more PrEP-aware alters. PrEP intentions related to having more alters with favorable opinions of women’s potential PrEP use and a smaller network size. Viewing oneself as an appropriate PrEP candidate related to having more PrEP-aware alters and more alters with favorable opinions of women’s potential PrEP use. IPV modified associations between network characteristics and PrEP care. Having members who were aware of and/or used PrEP was positively associated with PrEP care engagement for women without IPV experiences, but had either no effect or the opposite effect for women experiencing IPV.

Conclusion:

Improving PrEP attitudes might improve its utilization among women. Social network interventions might be one way to increase PrEP uptake among many U.S. women, but may not be as effective for women experiencing IPV.

Keywords: social networks, pre-exposure prophylaxis, women, intimate partner violence, HIV

INTRODUCTION

In the U.S., women who contract HIV through heterosexual contact are recognized as one of the most-affected subpopulations for HIV diagnoses.1 In 2016, women represented 19% of all new HIV diagnoses in the U.S., and heterosexual contact accounted for 87% of HIV diagnoses among women.1 In 2012, the FDA approved the dissemination of pre-exposure prophylaxis (PrEP), a daily oral medication HIV-negative persons can take to reduce their risk of HIV acquisition.2 In the U.S., only 4.6% of national PrEP users are women.3 Despite being one of the most innovative HIV prevention strategies to date, PrEP is underutilized by U.S. women. There is a clear need for research that investigates factors influencing women’s decisions and engagement surrounding PrEP in order to protect women’s sexual health.

Although largely unexplored, women’s social networks may shape their interest, awareness, and uptake of PrEP. Research literature suggests that an individual’s beliefs and behaviors can be shaped by the social norms, behaviors, and reward system of their social network members.4 In the context of HIV prevention, existing research among men indicates that characteristics of one’s social network can impact whether an individual engages in the PrEP care continuum (i.e., awareness, uptake, adherence and retention).5,6 For example, Kuhns et al.5 found that having a large network size was associated with PrEP uptake among young men who have sex with men. Similarly, Schneider et al.6 found that, among Indian truck drivers, having at least one close friend was associated with high PrEP acceptability compared to having no close friends. Together, these studies show preliminary evidence that structural characteristics (e.g., network size – number of network members) and ego attributes (e.g., closeness – how close a participant is to all other individuals in their network) impact men’s PrEP acceptability and uptake. Though previous research suggests that networks can shape PrEP engagement among men, very little research has examined this relationship among heterosexual women is sparse. This sparse research is problematic because the same social network characteristics that are associated with women’s HIV risk behaviors,7 could also affect women’s PrEP engagement. Social network analysis may be a key strategy for understanding women’s underutilization of PrEP, as this method affords an in-depth investigation of how social networks influence women’s PrEP awareness, interest, and uptake.

Further understanding of how intimate partner violence (IPV) can impact the relationship between social networks and women’s PrEP engagement behaviors is pivotal. IPV is an important predictor of women’s HIV susceptibility. Women with IPV experiences may have been sexually assaulted by a risky male partner.8,9 IPV can also interfere with women’s ability to negotiate safe sex practices with abusive partners.8,9 Optimizing women-controlled HIV prevention methods is key for this vulnerable population. Women with IPV experiences have a higher odds of reporting interest in PrEP, but are also concerned about their partner controlling their PrEP.10 Given women’s concerns about controlling partners, it is possible that abusive partners might discourage women from engaging in HIV prevention such as PrEP. A recent study found that the social networks of women experiencing IPV were smaller and offered less social support than the social networks of women not experiencing IPV.11 Therefore, if abusive partners are discouraging women’s engagement in the PrEP care continuum, it is possible that women have limited access to supportive social network members. In addition to abusive partners, some PrEP research found that family and friends could have positive and/or negative influences on PrEP adherence.12,13 Women experiencing IPV may face additional difficulties accessing PrEP and less support from their social network, however, no study has examined IPV as an effect modifier on the association between women’s social networks and the PrEP care continuum. A growing number of PrEP engagement interventions are leveraging social networks among men who have sex with men,14,15 but this intervention delivery format may only enhance PrEP engagement among those with supportive social networks. Empirically investigating IPV as an effect modifier may reveal some important insights for the development and implementation of social network-based interventions aimed at promoting PrEP awareness, interest, and uptake among U.S. women and those who experience IPV in particular.

The current study aimed to: (1) examine the association between social network characteristics and multiple outcomes along the PrEP care continuum (i.e., awareness, interest, intentions, and perceived candidacy); and (2) examine how IPV experiences modify the association between social network characteristics (characteristics of social network members; composition of the overall social network) and multiple outcomes along the PrEP care continuum. We hypothesize that having more social network members who are aware of PrEP, are using PrEP, and think favorably of women’s potential PrEP use will be positively associated with PrEP awareness, interest, intentions, and perceived candidacy. We also hypothesize that higher closeness and density will be positively associated with PrEP awareness, interest, intentions, and perceived candidacy. Finally, we hypothesize that these associations will be modified by IPV, such that they would be attenuated for women experiencing IPV than those without these experiences.

METHODS

Participants

Women were eligible for the study based on the following criteria: 1) between the ages of 18 and 35, 2) reported at least one of the sexual risk indicators for PrEP candidacy in the past six months according to the 2014 CDC clinical summary guidelines16 (i.e., unprotected sex with a male partner, HIV-positive sexual partner, recent STI, two or more sexual partners, transactional sex), 3) spoke English and/or Spanish, and 4) resided in Connecticut. Women were not asked to report their HIV status during the screening process, however, women were asked to report this information during the baseline interview. All of the women reported being HIV-negative in the baseline interviews.

This study oversampled women experiencing IPV in order to gain a better understanding of how recent IPV impacted women’s health. Therefore, the prevalence of recent IPV is higher in this sample than the general population of U.S. women.

Procedures

Two hundred and eighteen women were recruited from August 2017 to April 2018 to participate in a prospective cohort study exploring factors influencing engagement in the PrEP care continuum among women with and without IPV experiences. Participants were recruited online (n=185) and throughout the community (n=23). Flyers were posted online on Craigslist and Facebook, and throughout the community in beauty salons and community health clinics. Participants had the option to be screened for eligibility either via online survey or over the phone.

Women provided written informed consent and were asked to complete a baseline survey administered through Qualtrics either in-person at the research office or online. The baseline interview contained an egocentric social network assessment. At the end of the baseline interview, participants were compensated $25 and provided a list of community resources (e.g., health clinics administering PrEP, domestic violence agencies). The Yale University’s IRB approved all study procedures.

Measures

Individual Characteristics

Intimate Partner Violence (IPV).

IPV was assessed using the physical assault subscale of the Conflict Tactics Scale-2 (CTS-2)17 and the Sexual Experiences Survey (SES).18 Women were asked if they experienced physical and sexual forms of partner violence in the past six months by a romantic and/or sexual partner. Examples of physical partner violence includes “hitting, pushing, and/or being shoved” and sexual partner violence includes “kissed or touched in a sexual way when you did not want to.” A summary, binary variable was created: recent IPV (affirmative response to any form of physical and/or sexual IPV in the past six months vs. none).

PrEP Care Continuum Outcomes (Awareness, Interest, Intentions, and Perceived Candidacy).

PrEP awareness was assessed by asking participants, “Before participating in this survey, had you ever HEARD OF a daily pill that an HIV negative person can take to prevent HIV BEFORE being exposed to the HIV virus (for example, before having sex with someone who is HIV positive)? This pill is also called HIV pre-exposure prophylaxis, PrEP, and Truvada®.”19 PrEP awareness was coded as Yes vs. No. Before completing the other PrEP measures, all women were provided with background information about PrEP (see Measures, Supplemental Digital Content 1). PrEP Interest was assessed by asking participants to rate their interest in learning more about PrEP on a 5-point Likert scale: Not at all interested (1) to Extremely interested (5). PrEP interest was dichotomized as “Not at all interested or A little bit interested” vs. “Somewhat interested, Very interested, or Extremely interested.” PrEP Intentions was assessed by asking participants if they plan to begin PrEP.20 Response options were “Yes I will definitely begin taking PrEP” or “No, I definitely will not begin taking PrEP”. PrEP intentions was coded as Yes vs. No. Perceived PrEP Candidacy was assessed by asking participants if they viewed themselves as an appropriate candidate for PrEP.20 Response options were “Yes, I am definitely an appropriate candidate” and “No, I am definitely not an appropriate candidate.” Appropriate PrEP candidate was coded as Yes vs. No.

Sociodemographic Characteristics.

Participants were asked to self-report socio-demographics. The following characteristics were assessed: age, gender, race and ethnicity, years of education, and annual income.

Social Network Characteristics

Alter Listing.

We assessed individuals’ egocentric network using the following name generator question: “How many people are you very close to?” Participants were able to choose up to 7 people. Participants were then asked to list the initials and answer questions about the first person that they were “closest” to, followed by persons who they were “next closest to and so forth.” A maximum of 7 social network members could be listed by the participant. A network size variable was created from this question.

Alter Attributes.

Participants were asked, to the best of their knowledge, to describe each alter’s awareness of PrEP (Yes vs. No), whether the alter would be supportive of the participant if they were using PrEP (Very unfavorable, Unfavorable, Somewhat unfavorable, or Neutral vs. Somewhat favorable, Favorable, or Very Favorable), and whether the alter had ever used PrEP (Yes vs. No). Summary indicators for alter attributes were created to represent the number of network members with a specific attribute (e.g., percentage of PrEP-aware network members).

Density and Closeness.

Network characteristics was assessed using two approaches. First, participants (i.e., ego) were asked about their level of closeness to each alter listed and were able to respond on a 7-point Likert scale. Next, participants were asked about the level of closeness between each pair of alters listed and were able to respond on a 7-point Likert scale. Individuals were considered “close” if the participant selected a value of 2+ on the 7-point Likert scale [Not at all close (1) to Very close (7)]. These questions were used to derive density (the percentage of possible relationships that were actually present in the ego’s network, excluding the ego) and closeness (a measure of the ego’s distance to alters).

Analysis

Sample demographics, prevalence, and bivariate associations with the PrEP care continuum outcomes were examined. Chi-square and t tests were used to assess bivariate associations between socio-demographics and outcomes.

Logistic regression models were conducted to examine whether social network characteristics were associated with the outcomes, while controlling for covariates. Only covariates that were significantly associated with an outcome at the bivariate level (p<.05) were controlled for in the adjusted models. Next, IPV and an interaction term between IPV and social network characteristics was entered into the logistic regression model to test for effect modification.

Of the 218 women who participated in the baseline interview, only the women who had completed social network data were included in the current analyses. This restriction resulted in a final sample of 191 women. All analyses were conducted using SPSS 24.21

RESULTS

Table 1 displays the sample characteristics for 191 women. 24.4% of women reported being PrEP-aware, 37.6% were interested in learning more about PrEP, 34.1% of the participants intended to use PrEP, and 2.4% reported using PrEP before. Women experiencing IPV had the highest prevalence of PrEP interest (44.7% vs. 30.2%; χ2=4.3, p=.03), intentions (42.4% vs. 28.3%; χ2=4.1, p=.04), and perceived candidacy (47.1% vs. 26.4%; χ2=8.8, p=.003) than women without IPV experiences.

Table 1.

Sample Characteristics and Differences by Women's PrEP Care Continuum Outcomes

Women's PrEP Care Continuum Outcomesb
N (%)a Awareness, N
(%)		 p Interest, N
(%)		 p Intentions, N
(%)		 p Appropriate
Candidate, N
(%)		 p
Overall 191 (100) 48 (25.1) 70 (37.6) 66 (34.6) 68 (35.6)
Race and Ethnicity 0.20 0.88 0.06 0.13
 Non-Hispanic Black 45 (22.0) 12 (27.9) 18 (41.9) 18 (41.9) 20 (46.5)
 Non-Hispanic White 89 (43.4) 25 (30.1) 29 (34.9) 22 (26.5) 23 (27.7)
 Hispanic 50 (24.4) 6 (13.3) 16 (35.6) 21 (46.7) 19 (42.0)
 Non-Hispanic Other Race 21 (10.2) 5 (25.0) 7 (35.0) 5 (25.0) 6(30.0)
Education Completed 0.46 0.25 0.14 0.40
 <High School 9 (4.4) 2 (28.6) 2 (28.6) 3 (42.9) 2 (28.6)
 High School or GED 45 (22.0) 6 (15.4) 18 (46.2) 17 (43.6) 13 (33.3)
 Some College 75 (36.6) 19 (26.4) 29 (40.3) 28 (38.9) 31 (43.1)
 College or Graduate School 76 (37.1) 21 (28.8) 21 (28.8) 18 (24.7) 22 (30.1)
Employment 0.57 0.94 0.18 0.35
 Unemployed 73 (39.5) 20 (27.4) 27 (37.0) 21 (28.8) 23 (31.5)
 Employed 118 (60.5) 28 (23.7) 43 (36.4) 45 (38.1) 45 (38.1)
Relationship Status 0.87 0.14 0.64 0.27
 In a relationship 174 (91.1) 44 (25.3) 61 (35.1) 61 (35.1) 64 (36.8)
 Not in a relationship 17 (8.9) 4 (23.5) 9 (52.6) 5 (29.4) 4 (23.5)
Sexual Orientation 0.14 0.51 0.74 0.40
 Heterosexual 139 (72.8) 31 (22.3) 49 (35.3) 49 (35.3) 47 (33.8)
 Lesbian, Bisexual, Queer, Asexual, Other 56 (27.2) 17 (32.7) 21 (40.4) 17 (32.7) 21 (40.4)
Income Status 0.83 0.23 0.26 0.95
 >$30,000 82 (42.9) 20 (24.4) 34 (41.5) 32 (39.0) 29 (35.4)
$30,000+ 109 (57.1) 28 (25.7) 36 (33.0) 34 (31.2) 39 (35.8)
IPV .90 .03 .04 .003
Yes 85 (44.5) 21 (24.7) 38 (44.7) 36 (42.4) 40 (47.1)
No 106 (55.5) 27 (25.5) 32 (30.2) 30 (28.3) 28 (26.4)
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a

Column percentages are shown.

b

Row percentages are shown. p-values derived from chi-square tests.

Figure 1 displays differences in social network characteristics by IPV status. Women experiencing IPV had less favorable support of potential PrEP use across their network (10.48 vs.13.48, t=2.33, p=.02) and smaller networks (3.08 vs. 4.02, t=3.44, p=.001) than women without these experiences.

Figure 1. Social Network Characteristics of Women’s Social Networks By IPV Status.

Figure 1.

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**Indicates that this relationship was significantly different between women with and without IPV experiences based on t-tests.

Table 2 presents adjusted effects of social network characteristics on PrEP outcomes. Lower PrEP awareness was associated with being Hispanic (vs non-Hispanic) and having a lower percentage of PrEP-aware alters. Stronger intentions to use PrEP was associated with being Hispanic women (vs non-Hispanic), having more network members with a favorable opinion of women’s potential PrEP use, and having a smaller network size. Perceiving oneself as an appropriate PrEP candidate was associated with having a lower percentage of PrEP-aware alters, having more network members with a favorable opinion of women’s potential PrEP use, and having a smaller network size.

Table 2.

Associations between Social Network Characteristics and PrEP Care Continuum Outcomes

PrEP Care Continuum Outcomes
Awareness Interest Intentions Appropriate Candidate
aOR (95% CI) p aOR (95% CI) p aOR (95% CI) p aOR (95% CI) p
Race and Ethnicity
 Non-Hispanic Black .84 (.33, 2.10) 0.70 1.12 (.51, 2.49) 0.76 1.83 (.77, 4.36) 0.17 2.09 (.89, 4.90) 0.08
 Hispanic .23 (.07, .82) 0.02 .80 (.36, 1.79) 0.58 2.54 (1.01, 5.83) 0.02 1.37 (.58, 3.23) 0.47
 Non-Hispanic Other Race .91 (.27, 3.09) 0.87 .86 (.29, 2.52) 0.78 .72 (.21, 2.47) 0.60 .86 (.27, 2.79) 0.80
 Non-Hispanic White REF REF REF REF
Social Network Characteristics
 PrEP Awareness 1.05 (1.03, 1.08) <.001 1.00 (.98, 1.02) 0.82 .99 (.98, 1.01) 0.51 .98 (.96, .99) 0.04
 PrEP Use .96 (.89, 1.04) 0.27 .99 (.95, 1.03) 0.69 1.02 (.96, 1.07) 0.54 1.02 (.97, 1.08) 0.42
 Favorable Opinion of PrEP Use .98 (.92, 1.04) 0.44 .99 (.97, 1.07) 0.51 1.07 (1.01, 1.15) 0.03 1.07 (1.01, 1.14) 0.03
 Network Size 1.15 (.79, 1.67) 0.47 .83 (.61, 1.13) 0.23 .55 (.36, .83) 0.004 .53 (.36, .77) 0.001
 Density .99 (.96, 1.10) 0.27 .98 (.97, 1.04) 0.20 .98 (.97, 1.01) 0.22 .99 (.97, 1.00) 0.34
 Closeness .73 (.38, 1.40) 0.35 1.10 (.72, 1.67) 0.67 .93 (.50, 1.75) 0.83 1.27 (.79, 2.04) 0.33
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Bolded values are statistically significant.

Effect Modification

IPV significantly modified the effect of social network characteristics on 3 of the 4 PrEP outcomes: interest, intentions, and perceived candidacy. Figure 2 shows that a higher percentage of PrEP-aware alters was positively associated with interest in PrEP for women without IPV experiences, but associated with lower PrEP interest for women experiencing IPV (B=−.04, SE= .01, p =.02). Figure 3 shows that a higher percentage of PrEP-aware alters was positively associated with intentions to use PrEP for women without IPV experiences, but associated with lower PrEP intentions for women experiencing IPV (B=−.05, SE= .02, p =.01). Also, a higher percentage of PrEP-use alters was positively associated with women’s perceived PrEP candidacy for women without IPV experiences, but was not related to PrEP candidacy for women experiencing IPV (B=−.12, SE= .06, p =.03, see Figure, Supplemental Digital Content 2, which depicts this interaction in graphic form).

Figure 2.

Figure 2.

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Percentage of Alters who were PrEP-aware by IPV interaction for women’s interest in PrEP.

Figure 3.

Figure 3.

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Percentage of Alters who were PrEP-aware by IPV interaction for women’s intentions to use PrEP.

DISCUSSION

To our knowledge, the present study is the first to examine the ways that social networks shape women’s engagement in the PrEP care continuum. Consistent with our hypotheses, our findings indicate that social network members can influence women’s engagement in PrEP. These findings add to the burgeoning literature on social networks and PrEP, which has primarily focused on men.13–15,22,23 These findings also have important implications for the development and implementation of social network-based approaches to HIV prevention for women, particularly women experiencing IPV.

Extant research indicates low PrEP awareness among women,10,24–26 and our study found that having more PrEP-aware network members may increase women’s awareness of PrEP. Social networks are an important vehicle for information and resource exchange among individuals and groups.27 Therefore, women who have a larger number of PrEP-aware network members might have more opportunities to converse with members about PrEP. These interactions may function as a form of information exchange between women and their social networks, leading to an increase in women’s PrEP awareness.

PrEP intentions could be an important precursor to actual uptake. Our findings suggest that women had stronger intentions to use PrEP if network members were perceived as viewing the woman’s use of PrEP favorably. Having several network members who think favorably about PrEP use may make women feel as though they have social support from these same network members, if they decide to use PrEP. As a result, women who have access to this form of social support may have a stronger motivation and/or less social barriers to receive PrEP in the future. Further, women with smaller networks tended to have stronger PrEP intentions. It is possible that women with smaller networks have stronger, closer relationships than women with larger networks. Thus, women with smaller networks may experience more support and less stigmatizing reactions to their PrEP intentions. Future research should examine the impact of the strength of relationships on women’s PrEP care continuum outcomes among women with varying levels of network size.

Women’s perceived PrEP candidacy was related to two alter attributes. Having several network members who think favorably about PrEP use was associated with women viewing themselves as appropriate candidates for PrEP, but having more PrEP-aware network members related to not viewing oneself as a PrEP candidate. The social processes that underlie the exchange of opinions among network members might be affecting women’s perceived HIV risk and PrEP candidacy. Specifically, women may believe that they are a good candidate for PrEP because they have network members that will support their PrEP use and engagement in care. However, women might be comparing their HIV-related sexual risk to network members who are aware of PrEP. If this comparison is incongruent, women may feel that their HIV risk is insufficient for PrEP. Also, PrEP-aware network members may have discussed negative and skeptical PrEP attitudes with women, which could result in women’s disbelief in being an appropriate PrEP candidate. Together, these findings suggest that leveraging women’s social networks by increasing positive PrEP attitudes, not just awareness may help facilitate women’s access to PrEP.

Consistent with previous research,11 our study found that social networks among women experiencing IPV differed from women without these experiences. Women experiencing IPV had smaller networks than women without these experiences. Abusive partners use emotional and physical tactics to isolate women from their family and friends.28 Thus, women experiencing IPV might have smaller networks because they are experiencing social isolation. Additionally, women experiencing IPV tended to have less support for their potential use of PrEP among their network than women without these experiences. These findings are similar to Katerndahl et al.11 who found that the social networks of women experiencing IPV offered less social support. In general, social support protects women experiencing IPV from a host of negative outcomes.29–31 However, some women do not seek social support because of stigmatization, fear or partner retaliation from disclosing abuse, and/or they feel that violence in the home is a private matter.31 It is also likely that when women experiencing IPV do seek social support, they might not receive the type of support they need or may be blamed for the experience.31 In the context of PrEP, women experiencing IPV may have previously sought social support from their network and did not receive the type of reaction and/or support that they needed. These interpersonal experiences may leave women experiencing IPV feeling as though their social network would exhibit the same lack of support if they were to use PrEP.

The effect modification results consistently showed a pattern where alter attributes had a positive effect on women’s PrEP care continuum outcomes, but not for women experiencing IPV. Specifically, having more PrEP-aware network members tended to relate to reduced interest and intentions to use PrEP among women experiencing IPV. These findings have implications for PrEP-focused interventions and strategies for women experiencing IPV. First, social network approaches to increase PrEP engagement may not be an effective intervention strategy for women experiencing IPV. Women experiencing IPV may feel that the sexual risk and other relevant experiences within their social network are not comparable to their individual experiences, which is leading to a reduction in PrEP engagement. However, women experiencing IPV may also be socially isolated from network members and thus the diffusion of social norms and behaviors may be weaker when compared to women not experiencing IPV. Further, the social networks of women experiencing IPV may offer less support for PrEP use; thus, having more PrEP-experienced network members may not translate into engagement. Moreover, women experiencing IPV are concerned about their partner’s reactions to their potential PrEP use.10 Expanding this research, it is possible that having a PrEP-experienced network does not translate into increased PrEP engagement for women experiencing IPV because the women’s network may be unable to alleviate their concerns surrounding her partner’s reaction to PrEP.

Our findings offer promise for PrEP engagement interventions for at-risk Hispanic women. Our findings suggest lower PrEP awareness but greater PrEP intentions among Hispanic women than non-Hispanic White women. There might be insufficient PrEP marketing to Hispanic women among the few women-focused PrEP advertisements, resulting in lower awareness among this population. PrEP marketing should depict a diversity of women to thwart stereotypes of female PrEP candidates.

These findings should be interpreted considering the study limitations. The cross-sectional data do not allow causal inferences to be made. All the study variables were self-reported. Since IPV reporting can be influenced by social desirability bias, the prevalence of IPV could be under-reported. It is important to note that self-report measures for IPV are the most common methods.32articipants reported whether alters had expressed their involvement and knowledge of PrEP. We cannot definitively state whether such conversations occurred and the alters’ specific perspective. Further, in order to reduce respondent burden, participants were only able to list 7 individuals within the social networks. Although very few participants listed 7 individuals within their social networks, this limit on the name generator could have impacted the structure of participants’ networks. Less than 10% of the total sample did not complete the social network assessment and thus were excluded from the analyses. We are unable to assess the potential bias causes by attrition. The inclusion criteria for the study were limited to the northeastern region of the U.S., thus potentially limiting generalizability to women living in other geographical locations.

CONCLUSIONS

Leveraging social networks might be a potential strategy to address the under-utilization of PrEP for women, but our data suggest these interventions may be less effective for women experiencing IPV. For women who are not experiencing IPV, social network interventions designed to stimulate PrEP awareness and positive PrEP attitudes among network members might facilitate women’s engagement in PrEP. For example, it may be useful for future research to adapt PrEP Chicago,14 an intervention that trained PrEP/peer change agents, for women and examine its efficacy. However, women experiencing IPV may respond better to a non-network based engagement strategy. Future research is needed to develop and implement potentially successful PrEP engagement strategies for women experiencing IPV. For example, it may be useful to engage women experiencing IPV and key stakeholders such as domestic violence agencies to learn the best practices to inform, educate, and empower women experiencing IPV to use PrEP.10 Future research could identify women experiencing IPV who are currently using PrEP in order to inform the development of PrEP engagement strategies.

Supplementary Material

Supplemental Digital Content

Acknowledgements

The authors would like to thank the women who participated in this study. The authors would also like to thank Dr. Peter Aronow, who generously contributed time, effort, and support. The authors would also like to thank the following sources of funding and resources for this project: the Center for Interdisciplinary Research on AIDS (CIRA) Pilot Projects in HIV Program at Yale University; the National Institute on Mental Health via F31-MH113508 (TCW); and the Surgeon General C. Everett Koop HIV/AIDS Research Grant from the Rural Center for AIDS/STD Prevention, Indiana University School of Public Health-Bloomington. Additional support for TCW was provided through Brown Initiative in HIV and AIDS Clinical Research for Minority Communities (R25-MH083620). Support for SKC was provided by the National Institutes of Mental Health via Award Number K01-MH103080.

Conflicts of Interest and Sources of support: Authors declare no conflicts of interest. Funding for this research was provided by the Yale University Center for Interdisciplinary Research on AIDS and the National Institute of Mental Health (NIMH) via P30-MH062294. TCW was supported by the NIMH via F31-MH113508 and R25-MH083620. Support for SKC was provided by the National Institutes of Mental Health via Award Number K01-MH103080. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH).

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