Perspectives of Black Women in the United States on Salon-based intervention to promote the uptake of pre-exposure prophylaxis (PrEP) for HIV

Abstract

Aims and objectives:

To understand Black women’s perspectives on a pre-exposure prophylaxis (PrEP) education intervention in a salon setting.

Background:

Black women have a significant lifetime risk of acquiring HIV. Pre-exposure prophylaxis (PrEP) is an effective prevention approach in reducing that risk. Despite this, Black women are least likely to use PrEP.

Design:

This was a qualitative study to identify Black women’s perspectives on acceptability of a PrEP education intervention in a salon setting using hair stylists. The paper adhered to the COREQ checklist in reporting.

Methods:

Seven focus groups among Black women (n=44) living in north-central North Carolina were conducted. Ethical approval was obtained. The interview guide included questions on knowledge of PrEP and barriers and facilitators to a PrEP promotion program in a salon setting.

Results:

Conventional content analysis considered content in relation to themes of facilitators, barriers, and women’s preferences for intervention delivery. Facilitators included the salon characteristics, social culture, and relationship with the stylist. Women noted concerns of accuracy of content from stylists and privacy as barriers.

Conclusions:

Participants’ trust with their stylists make a PrEP education salon-based intervention feasible. Salon based interventions are not one-size-fits-all and researchers interested in this setting should tailor interventions to the individual salon. Interventions for PrEP in a salon setting should be culturally appropriate, confidential, and consider the potential reach to the social networks of Black women in the salon.

Relevance to clinical practice:

The insights shared by Black women can contribute to developing a PrEP uptake intervention as a way of reducing new cases of HIV.

INTRODUCTION

Overall, individuals in the United States (US) have a 1 in 99 chance of being diagnosed with Human Immunodeficiency Virus (HIV) at some point in their life (Centers for Disease Control and Prevention (CDC), 2016). However, there are significant racial and geographic disparities underlying this overall statistic. Black women have nearly 20 times the risk of White women of contracting HIV, and lifetime HIV risk is greatest for people living in the South (CDC, 2016; Garfinkel, Alexander, McDonald-Mosley, Willie, & Decker, 2016; Hess, Hu, Lansky, Mermin, & Hall, 2017). Reducing HIV incidence among Black women is a public health priority. Pre-exposure prophylaxis (PrEP) is an effective, HIV prevention strategy that is not optimally utilized among women at risk for HIV (Goparaju et al., 2017, Sales et al., 2018), especially Black women who have elevated risk. The literature reports overall barriers to the uptake of PrEP among Black women. Some of these barriers include lack of awareness and knowledge (Collier, Colarossi & Sanders, 2017; Patel et al., 2019), mistrust of medical professionals (Flash et al., 2014; Goparaju et al., 2017), and social stigma associated with PrEP use (Auerbach, Kinsky, Brown & Charles, 2015; Aaron et al, 2018). Interventions that facilitate the use of PrEP through awareness and knowledge and improve barriers to PrEP uptake are precursors to improving the use of PrEP for Black women and are urgently needed. However, few interventions take into consideration how best to facilitate the uptake of PrEP and decrease barriers among Black women.

BACKGROUND

Lack of Awareness and Knowledge

Prior research has shown that individuals aware of PrEP will seek the knowledge needed to better understand PrEP, which may lead to increased willingness to use it (Auerbach et al., 2015). In a national survey of Black Americans, knowledge of PrEP was found to be a key facilitator of willingness to use it (Ojikutu et al., 2018). Thus, increasing research efforts to improve awareness of PrEP may help increase efforts to improve PrEP uptake. While prior studies have considered the awareness and willingness of at-risk groups, such as men who have sex with men, to use PrEP as an HIV prevention method, few studies have examined the specific approaches that could be used to effectively increase PrEP awareness and uptake among Black women. Approaches to increase awareness have included the use of technology and educational interventions (Biello et al, 2018; Bond & Ramos, 2019). Although the use of technology-based approaches (e.g., iPads, text messaging) has the potential to effectively target a larger number of individuals at a relatively low cost (Bond & Ramos, 2019), future research is needed to examine whether these approaches are feasible for Black women and lead to increased awareness, accurate knowledge about, and actual uptake of PrEP (Bond & Ramos, 2019).

Medical mistrust

Medical mistrust is a major barrier to accessing quality healthcare within Black communities that is often overlooked in interventions addressing HIV in this community. In a qualitative study by Goparaju et al., 2017, 20 women (16 of the 20 of whom were Black) reported mistrust and difficulties discussing risk behaviors related to HIV with health care providers, an important step in obtaining PrEP. Women reported detailed humiliating experiences with providers and concerns about providers’ reactions to their sexual behaviors. Tekeste and colleagues (2019), in a study assessing women’s interest in PrEP among 500 Planned Parenthood clients in three cities with high HIV prevalence, found that not only did Black women have higher levels of medical mistrust than other women, but this mistrust was specifically associated with being less comfortable discussing PrEP with a medical provider.

Social stigma associated with PrEP

HIV continues to be viewed as a stigmatizing condition among Black women. There remains social stigma associated with PrEP in Black women’s own attitudes towards PrEP when they talk to their social networks and in their interactions with providers (Goparaju et al., 2017). Several studies have reported that women may not take PrEP because of fears that family or friends might assume that they were taking medications because they were living with HIV (Goparaju et al., 2017; Smith, Toledo, Smith, Adams, & Rothenburg, 2012). This perspective of the women provides evidence that social support from one’s social networks plays a critical role in determining a woman’s decision to take and maintain adherence of PrEP. Young and McDaid (2014) argued that how individuals “view, chose and maintain the use of particular HIV prevention methods are significantly influenced by social, cultural and structural factors” (p. 213). To this end, leveraging the social networks of Black women in trusted environments, such as the beauty salon, are warranted and have the potential to facilitate PrEP uptake and improve barriers to PrEP uptake among women.

Beauty salons are promising venues where Black women socialize and have historically been a trusted place for health promotion activities (Linnan, D’Angelo, & Harrington, 2014, Luque, Ross & Gwede, 2014). Salons provide opportunities for networking, social support, companionship and social influence. Therefore, salons provide a unique opportunity for women to increase awareness of PrEP, not only for themselves, but for the networks of women with which they associate and/or influence, in and outside of the salon setting. Engaging women in these trusted environments also has the potential to improve barriers to PrEP, such as stigma, by normalizing conversations around the use of PrEP for Black women (Basset et al., 2019). Therefore, a salon-based intervention to improve PrEP awareness and uptake among Black women holds great promise. In this article, we present perspectives from Black women on the acceptability of a salon-based intervention to increase awareness and promote uptake of PrEP.

AIMS AND OBJECTIVES

To explore the perspectives of Black women regarding the barriers and facilitators to a salon-based intervention promoting the uptake of PrEP for HIV prevention.

METHODS

Design

In this formative study, we conducted seven focus groups among Black women (n=44) living in north-central North Carolina. Data were collected between February and August 2019; the Duke University Institutional Review Board approved the study. This study adhered to the Consolidated criteria on reporting qualitative research (COREQ, Supplementary File 1) (Tong, Sainsbury, & Craig, 2007).

Sample and recruitment

Eligible participants for the focus groups self-identified as African American/Black women 18 years of age or older who frequented a beauty salon serving primarily Black women at least every two weeks (common frequency for Black women customers, Bassett et al., 2019). Two consultants who were salon owners and hair stylists along with study staff invited women to participate in the study through flyers and word of mouth.

Data Collection

Forty-four women participated in six focus groups, each held in private spaces in the beauty salon or other private community meeting places. There were 6–8 women participants in each group. Sessions averaged 1.5 hours in length and were audio-recorded. The focus groups intended to elicit women’s perspectives of facilitators and barriers to a salon-based PrEP educational intervention.

Focus groups can reduce participants’ anxiety by providing a comfortable setting for discussion. Participants become familiar with the environment and feel a connection to the other focus group members (Krueger, 2000). The focus group interview guide (Table 1), developed by the principal investigator with input from a community advisory council which included two salon owners and other Black women who frequent the beauty salon, was based on social network constructs. Social network constructs aim to explore social support linkages between a group of people in terms of the network as a whole and/or the relationship characteristics of the network. This construct was chosen to explore the social networks of Black women and how these could facilitate salon-based interventions and improve barriers to PrEP uptake among women. For example, we assume that a salon-based intervention to promote PrEP uptake would be heavily influenced by the community of women who frequent the salon and the relationships among women and with the stylists. Example questions included: Describe the relationship women who visit this salon have with the stylist and other women in the salon; what are your suggestions for delivering PrEP information in the salon setting, and share your feelings about your level of trust with your doctor and taking PrEP. Experienced qualitative researcher and moderator (first and last author), a co-moderator, and note-taker alternately conducted each focus group. All research personnel were Black women to encourage comfort of participants. Researchers explained their interest in the topic, purpose of the research, and nature of participation to all participants.

Table 1.

Focus Group Sample Questions

HIV knowledge and salon settings

• What does hair salons, women’s health, and HIV mean to you?

Relationships in and outside of salons

• Describe how women customers in the salon know one another inside and outside of the beauty salon.  • Do you interact with either the customers or the stylists inside and outside of the salon?  • Describe the relationship women who visit the salon have with their stylists.

Acceptability of a salon based HIV prevention educational intervention

• Describe how women feel about receiving health information from their stylist.  • Would women in the salon limit their interactions with their stylists to beauty tips alone?  • Does the relationship with your stylist influence decisions that you make about your health?

Medical mistrust

• How would women compare the relationship they have with their stylist to the relationship they have with their physician?  • Can you tell us your experience with the healthcare system and your level of trust?  • Some Black women have reported that they do not use PrEP because of a lack of trust in the medical system. Can you share your feelings about this?  • What are some things your health care organizations can do to make you feel more comfortable about PrEP?

Preferences of intervention

• What are your suggestions for methods of receiving health information?  • How would women want to learn about PrEP in the salon?  • What would hinder women from receiving PrEP information in the salon?

To encourage truthfulness, participants were assured that their identities would not be revealed, conversations would be confidential, they could speak without risk of judgment, and non-participants were not allowed. Throughout the focus group sessions, the moderators probed for examples of salon-customer relationships, summarized initial interpretations, and confirmed with participants to allow for clarification of their responses. The co-moderator took notes during the session. Following the focus group session, participants received a $50 gift card as an incentive. Facilitators debriefed and discussed what went well or not, reactions to participant responses, and potential improvements for future focus groups.

Data Analysis

The present study was conducted through conventional content analysis method (Hash & Shannon, 2005) in which concepts are directly derived from data. Using this method, all focus groups were audio-recorded and transcribed verbatim, with identifying information redacted. A team of three qualitative researchers analyzed the data collaboratively (first two and the last authors). The team reviewed the transcripts and created a preliminary codebook of topical and interpretive codes derived from common words, statements, and themes in the transcripts. Topical codes were applied to specific words and phrases related to specific topics queried in the guide. Interpretive codes were applied to ideas that were expressed but not explicitly queried or stated (e.g., trust). The team applied topical and interpretive codes to significant utterances exemplifying each code and compared results to assess consistency between coders and to ensure saturation. Where there was disagreement among coders, topics were discussed further to achieve consensus to develop a final codebook. Researchers used the final codebook to code the transcripts and examined codes and quotations for clusters of meaning related to women’s perceptions of facilitators and barriers to a salon-based intervention, with attention to points of overlap and contrast within and among each discussion.

Validation of findings included 4 primary strategies: (a) bracketing or temporarily setting aside of the researchers assumptions (by having detailed, reflective discussions about data) and creating an audit trail of analyzed data; (b) providing rich descriptions to convey the findings; (c) external auditing by asking a person outside the project to conduct a thorough review of the study results; and (d) member checking by soliciting feedback from the community advisory panel and one follow up group interview of women participants on the accuracy of the identified categories and themes.

RESULTS

Demographic Data

Forty-four Black women (mean age range = 34–49) participated in six focus groups. All women identified as heterosexual. The majority of women had never been married (38%). All participants reported an education level of high school graduate or higher. Table 2 describes additional demographic data of the sample.

Table 2.

Demographics of Women Salon Customers who participated in the Focus Groups (N=44)

Age
18–33	18% (8)
34–49	43% (19)
50–65	34% (15)
66 AND OLDER	5% (2)
Sexual Orientation
Heterosexual	100% (44)
Homosexual	0% (0)
Bisexual	0% (0)
Transgender	0% (0)
Marital Status
Married	36% (16)
Divorced	16% (7)
Widowed	5% (2)
Separated	5% (2)
Never been married	38% (17)
Member of an unmarried couple	0% (0)
Employment Status
Employed for wages	75% (33)
Self-employed	9% (4)
Out of work > 1 Year	5% (2)
Out of work < 1 year	5% (2)
Homemaker	0% (0)
Retired	5% (2)
Unable to work	2% (1)
Educational Status
Some High School	0% (0)
High school graduate or GED	9% (4)
Some college of technical school	38% (17)
College graduate (4 years or more)	25% (11)
Graduate school (advanced degree)	27% (12)
Household Income
Less than U.S. 14,999	9% (4)
15,000–24,999	20% (9)
25,000–49,999	27% (12)
50,000–74,999	36% (16)
More than 75,000	7% (3)

Themes

There was high acceptability of a salon-based intervention to improve PrEP awareness and uptake among Black women customers. The results from focus group discussions with women are described as subthemes of facilitators and barriers.

Facilitators

Salon characteristics matter for a PrEP focused intervention

Women customers found salon characteristics influence the extent of sensitive conversations, such as HIV prevention and PrEP, in the salon. Variations in the physical layout of salons (e.g. one stylist in a private room verses multiple stylists in a large, open room setting), the unique culture of individual salons, and individual relationships with stylists determine the acceptability of health promotion and prevention activities, including PrEP, within this setting. Depending on the salon’s physical layout, conversations may be one on one with the stylist or involve everyone present in the salon at the time. One participant gave a description of how beauty salons have evolved over the years.

Cause salons are moving towards the more closed in areas. They are having more bays. Salons used to be an open area, almost like a barber shop where everyone had chairs and when you got in discussions, I mean everybody talked whether you knew people or not. But now, everyone’s going to their own private bays or their private units and so now you just really interact with the stylists.”

Black women consistently noted that the salon setting provides opportunities to interact with their stylist and one another about a number of topics, including PrEP. Individual salon cultures influenced the types of conversations discussed. Black women felt that discussing sexual health and PrEP is not discordant with conversations taking place in salons, but several participants stated they only engaged in the conversations in which they were comfortable. One woman stated, “If it is something I don’t want to talk about, I start playing with my phone”. However, this did not necessarily equate to a lack of information sharing. Another woman stated, “so sometimes somebody will bring up a subject you didn’t know about or you hadn’t thought about, you may not say nothing, but you take that information with you.”

Social networks among women in salons exist

Women often have predetermined social connections with other women attending the same salon as many are co-workers, friends, family members, or sorority members. However, the significance of these social connections and networks varied among women as some women viewed the salon as a place to build relationships and others only as a place to receive a service. One woman explained that finding a salon often happens through “word of mouth” from pre-established social networks. Other women reported that relationships initially formed in the salon also exist outside of the salon. For example, women attending church together was common. Additionally, women use social media as a way of keeping up with other women from the salon as well as commonly attended social events in the area. One participant stated she engages other women from the salon through “social media and church”. These relationships often lead to genuine friendships and social networks. Another participant stated:

“I have made a lot of friends, close friends from the salon.”

Yet another participant, when asked about developing friendships in the salon, did not have any interest in developing friends at the salon. She felt that networking in the salon may be a geographical cultural practice, commenting that this was: “a southern thing, ‘cause I’m from Michigan and we don’t do that.”

However, these variances in significance of relationships did not hinder women from being open to sharing and receiving information on PrEP with other women while in the salon. The majority of Black women were not aware of PrEP, and were concerned about this lack of knowledge in their community. One woman said,

“And we have kids and family members, so you want to know these things because if I don’t know these things, I’m pretty sure they don’t know these things are out there. The protection. We don’t hear it on TV, we don’t hear it anywhere because I didn’t hear it until you started talking about it and I’m like, what pill? So, we don’t know. And so, if we do have information out there, we could start asking questions, but we don’t know it’s out there.”

To that end, women recognized knowledge as a critical step in health and thought that gaining PrEP information in the salon would improve their health and that of their networks. Therefore, sharing information about PrEP in the salon may be empowering. One woman said,

“Knowledge is power and when you know more, when you know better you do better. You feel better. You, it’s just better. You, you take the precautions whether it’s your sex life, your health, just little things like drinking water.”

Relationship with Stylists matter

Women reported variations in their bond and sharing of personal information with their stylist. Most viewed their stylists as a friend, counselor, social worker, and nurse, while others viewed their stylist as someone delivering a service while they relax in the salon environment. These variations contributed to trust between the women and their stylist. Some women reported having been serviced by their stylist for greater than 10 years. Thus, longevity of the relationship with their stylists was an indicator of trust. One woman shared that her stylist has “been doing my hair since I was 14, she’s my cousin.” Several women also described a tendency for stylists to provide services to family members as well:

“My hair stylist has been doing my daughter’s hair since she was six, so you know, we call her, she calls her momma…Cause we got a nice connection.”

Another woman stated that this may present a challenge to instituting PrEP interventions in the salon. The woman expressed concern that:

“I can see certain people thinking, depending on the age, the different ages that might come in there that some parents, if you haven’t already exposing your children to that kind of information, then they might not want it to come from a stranger.”

While most women saw their stylists as confidantes, some women viewed the salon as a place of relaxation and rejuvenation only. Although they enjoyed their salon experience, they did not engage with their stylist or other women within the salon setting during their services. One participant stated:

“Some women have a very personal relationship with their stylists and some women have just a casual, hey, how you doing? Now, let me sit here for an hour and a half and then I’m out.”

While some women did not want to share their personal information with the stylist, women were not opposed to accepting information about PrEP from the stylist. As one woman stated “It’s about that relationship because if she was giving me information say[ing], I read this or they sent this to us to share with our clients, I’m okay with her giving it to me…”

Barriers

Acceptance of stylists as health educators varied among women

Many women felt comfortable discussing health topics with their stylists and often discuss specific health issues with them. Women also trust their stylist have certain aspects of health knowledge specific to issues affecting the hair and scalp. Trust in stylists compared to health care providers varied. One woman explained: “I know there are things that I’ve told my hair dresser that I don’t think I would ever tell a doctor.” Another woman stated: “I have a more open, more trusting relationship with the stylist than with the physician and you have more time to discuss whatever’s on your mind.”

However, another participant shared a different perspective, stating:

“I’m a little bit different cause I’m more open and honest with my physician than I am with my stylist, so I feel like I would probably tell my physician a whole lot more than I would tell my stylist just because they have more of a detailed history, and they can actually prescribe me something if I need it.”

Acceptability of a PrEP intervention increased with the idea of trained or certified stylists. Women consistently agreed that if their stylist was well informed about PrEP or certified in an area of health, their level of trust increased. For example, one participant stated: “I would feel fine receiving health information from my stylists as long as she knows what she’s talking about.” Another participant explained:

“I have psoriasis on my scalp, and she’s dealt with a lot of clients who have the same issues and she will say, you know, you’re not getting enough water. I can tell it ‘cause I can see it in your scalp.”

Privacy and confidentiality

When asked about delivery of PrEP information in the salon, women were concerned about privacy and being stigmatized about using PrEP. Despite open conversations about sexual topics, women did not want to be individually targeted for PrEP information. Participants noted barriers to a salon-based PrEP intervention were concerns of potential privacy breaches during guided conversations related to PrEP in the salon. Many explained that they would be fearful of others gossiping about them or learning private information during an open conversation if customers they did not trust were in the salon. One woman shared: “Cause people have a stereotype, you know, will judge you, just even by a conversation”.

While many participants felt comfortable with one on one conversations about PrEP with the stylist, others preferred alternative messaging. One participant stated that instead of her stylist approaching her with information, she would prefer stylists have written materials available in the salon:

“I would rather have something I could touch and take with me. I don’t have to listen to you now.”

Participants also suggested signage on the wall or in the restroom, an information table, a television monitor with health information looping on the screen similar to physician offices, or other forms of technology as preferred methods for intervention delivery.

DISCUSSION

Similar to other studies (Linnan et al., 2014; Floyd, DuHamel, Raio, Shuk, & Jandorf, 2017), our study confirms that salons continue to be a safe place for health promotion among Black women. The use of salons in sexual health promotion interventions (Luque et al., 2014; Roberts-Dobie & Losch, 2018), including PrEP specific interventions (Bond & Ramos, 2019; Bassett et al., 2019) has also been explored. While relationships between Black women and their stylists may vary, overall, the relationships are those of trusted confidantes and friends. Despite the consistent trust Black women have with their stylists, the need for formal education of the stylists on PrEP was requested. Stylists receiving training about PrEP may need to have signage in the salon showing they have completed a continuing education course on the topic to ensure customers are confident in the knowledge being shared. This is also consistent with Bassett and colleagues (2019) findings suggesting certificates and uniforms for stylists participating in salon-based PrEP interventions may increase participants’ confidence.

Black women also consider salons to be a trusted, safe environment for information sharing, including PrEP. Salon characteristics and relationships vary from one salon to another; therefore, interventions should be customized. Understanding salon demographics, characteristics, and geographical location is critical for intervention development and implementation. For example, the potential for familial and inter-generational Black women attending the same salon may be unique and could result in a barrier to discussing PrEP and other sexual health topics in the salon. This needs further exploration. Including Black women customers who represent the population into intervention development is critical to applying best practices for implementation tailored to the culture of the particular salon.

Although intervention purpose remains consistent, the delivery may differ from salon to salon. One size does not fit all. Linnan and Ferguson (2007), discussed variations in salon size as a contributor to this phenomenon. However, our work adds that these factors have evolved over time from variations in size to additional variations in salon layout, design, and culture. The economic impact of having a large space with multiple salons or suites is becoming popular. Thus, salon settings continue to evolve, from open areas where conversations take place among women to private areas where conversations are limited to customer and stylist only. Private salon settings offer opportunities for more one-on-one conversations between the stylist and customer. Given the continued stigma related to HIV prevention and PrEP, this could increase women’s comfort level in discussing sensitive topics with their stylists while also providing privacy and confidentiality. Open area salons may benefit from culturally tailored interventions using technology and/or printed educational materials to address potential privacy and confidentiality concerns.

Black women may develop or have pre-developed social networks within the salon. Although individual level interventions have been found to influence knowledge and awareness of HIV prevention, interventions that have a community widespread influence are needed to improve the knowledge and uptake of PrEP. While the setting of the salon dictates the degree of social networking that takes place among women customers, targeting women in the salon setting provides the opportunity for women to share HIV prevention information with other women in all of their social networks. Although a woman herself may not be at risk for HIV, having the knowledge allows her to share the information with other family or friends who may be at risk. This sharing of evidence-based information also has the potential to influence community and social norms, thus improving medical trust and stigma because the knowledge is coming from a trusted individual. In addition to information that increases knowledge and awareness of PrEP, dissemination of information about PrEP resources, such as PrEP navigators, where to access PrEP, and how to locate resources to alleviate the cost of PrEP in a salon-based PrEP intervention may also be promising. Linking Black women, salons and stylists to trusted resources such as PrEP navigators is warranted and should be further explored. Additionally, Tekeste et al., (2018) found that it is critical to the uptake of PrEP to increase Black women’s comfort in discussing PrEP with health care providers. A salon-based PrEP intervention may be well positioned to increase Black women’s comfort resulting in individual agency for self-advocacy in the healthcare environment. These efforts have the potential of improving issues of medical mistrust.

Finally, this study offers Black women’s recommendations and suggestions for how they would like to receive information in the salon setting. Researchers and interventionists should be sure to prioritize confidentiality, privacy, and legitimacy of the stylist’s knowledge. Confidentiality and privacy can be addressed with use of private areas in the salon or with technology delivered interventions. For example, information delivered via iPads, mobile apps or websites accessible on cell phones are ways for women to get the information and maintain their privacy. A culturally centered intervention using mobile technology has been piloted for feasibility and acceptability (Bond & Ramos, 2019). This study found that 116 Black women viewed an avatar-led eHealth video to increase awareness and knowledge of PrEP and Post exposure prophylaxis (PEP) as educational, entertaining, and suitable. The use of signage in the salon indicating stylists have completed specific training to PrEP and sexual health topics may offer legitimacy and increase trust in any stylist delivered information being shared. Efficacy studies are still needed to assess desired results of behavior change or PrEP uptake.

Limitations

This study is geographically limited to the Southeastern US, thereby decreasing the generalizability of the study. Although this was a small qualitative study, Black women participants overall agreed that they did not have baseline knowledge of PrEP and would be interested in learning more about PrEP in the salon setting and sharing this information among their social networks. Finally, the semi-structured focus group questions did not specifically ask about stigma associated with PrEP or perceived HIV risk. However, the fear of being stigmatized emerged from a subtheme among participants concerned about gossip or the potential of being incorrectly identified as living with HIV. Posters, pamphlets, and other technology based positive messaging could serve as destigmatizing campaigns (Bassett et al., 2019). Despite these limitations, the results of this study have important implications for tailoring salon-based interventions to each salon. In addition, leveraging social networks of salons and their customers is important in increasing an intervention’s reach and potentially reducing stigma among certain populations associated with PrEP.

CONCLUSIONS

This study explored the perceptions of Black women in receiving PrEP information in a salon setting using a qualitative approach. Despite the fact that Black women, especially in the US South, are at an increased risk of HIV exposure, PrEP usage is low among this population. Findings from this study demonstrate that 1) a salon-based intervention is acceptable based on Black women’s relationships and trust with their stylists and social networks and 2) individual salon characteristics should be considered when developing interventions. To facilitate an intervention, privacy, confidentiality, and training of stylists is essential for success. Tailored interventions such as culturally appropriate technology-based interventions (e.g. eHealth or iPad delivered videos) may show promise in salon-based interventions targeting Black women. This study can inform interventionists interested in salon-based interventions.

RELEVANCE TO CLINICAL PRACTICE

PrEP awareness and uptake is key to reducing new cases of HIV among at risk populations. Through this study, Black women were asked their perspectives of a community-based intervention. Findings can assist health care providers and clinical organizations in the need for collaborating with communities to meet the needs of marginalized populations where they are. Health care providers can partner with community organizers to provide accurate health information and facilitate access to care. Increased knowledge of at-risk populations in the community could result in a need for an increase in health care providers from all clinical settings prescribing PrEP.

What does this paper contribute to the wider global clinical community?

• Pre-exposure prophylaxis (PrEP) is effective in preventing HIV in at risk populations, including Black women who are disparately affected. However, usage is low among this population.

• Salon-based interventions have a history of acceptability. This study revealed Black women feel a salon-based intervention regarding PrEP would also be acceptable given the trusted nature of the relationship with stylists, other women in the salon, and their social networks.

• The clinical community can collaborate with community-based interventionists to provide accurate information and facilitate access to care.