Associations in preventive sexual health service utilization and pre-exposure prophylaxis (PrEP) interest among young Black women in the United States, 2018

Abstract

Despite declines in HIV prevalence among all U.S. women, HIV remains a serious concern for Black women. PrEP is an effective biomedical intervention and has high acceptability among Black women. Therefore, offering PrEP, in addition to screening and testing for STI/HIV consistently, can reduce HIV risk among this population. We examine the associations of preventive sexual health service utilization (PSHSU) and PrEP interest among young Black women (YBW) (N = 209) in the United States in 2018. YBW, ages 18–25, completed a self-administered questionnaire, assessing sexual risk and prevention behaviors, HIV/STI testing, and PrEP interest. More than half of YBW were aware of PrEP and its benefits. YBW, who received an HIV test within the past three to six months, had higher odds of PrEP interest. The proportion of YBW who reported being interested in PrEP did not differ by PSHSU. Active contraceptive use was associated with PrEP interest. The results suggest YBW engage in preventive sexual health services, including HIV/STI testing, reproductive health, and sexual health behavioral counseling. Additional efforts should be made to normalize PrEP education for heterosexual, cisgender women at student health centers on college and university campuses, and other venues outside of traditional HIV/STI testing facilities.

Black women are disproportionally impacted by HIV compared to other racial/ethnic U.S. women. Although Black women only make up 13% of U.S. women population (U.S. Census, 2020), Black women account for 57% of all HIV cases/infections among U.S. women (Centers for Disease Control and Prevention [CDC], 2020a). Testing positive for sexually transmitted infections (STIs) has been identified as a risk factor for HIV (Workowski & Bolan, 2015). Approximately half of all new STIs cases occur among people aged 15–24 years, particularly among young Black women (YBW; CDC, 2018). According to the CDC, in 2017, Black women ages 15–19 had 4.5 times the rates of chlamydia and 9.3 times the rates of gonorrhea than White women of the same age group; and Black women ages 20–24 had 3.6 times the rates of chlamydia and 7.4 times the rates of gonorrhea than White women in the same age group. Furthermore, Black women aged 20–24 had the highest primary and secondary syphilis rates out of all women (CDC, 2018).

Early detection of STIs is a critical contributing factor of sexual and reproductive health disparities among Black women (CDC, 2018). Research has shown untreated gonorrhea and chlamydia infections can adversely impact fertility among women and even cause pelvic inflammatory disease (Tsevat et al., 2017). The United States Preventive Services Task Force (USPSTF) recommends sexual health care providers deliver sexual health behavioral counseling (e.g., assessing the sexual behaviors that may place women at risk for infection) and screening (e.g., Testing for STIs and HIV) to all sexually active youth and adults (USPSTF, 2017). Sexual health care providers are well-positioned to offer HIV prevention options, such as pre-exposure prophylaxis (PrEP), to Black women (Pollock & Levison, 2018).

Recent reports indicate that Black women are more likely to report a willingness to adopt PrEP if recommended by a healthcare provider (Auerbach et al., 2015), and would prefer to start PrEP in their usual source of medical care (Hirschhorn et al., 2020). However, few studies have examined preventative sexual health service utilization (PSHSU) and PrEP interest among Black women. PSHSU includes STI/HIV screening, testing and treatment, reproductive healthcare service delivery, and annual preventive gynecological wellness exams. This study examines the associations of PSHSU and PrEP interest among a sample of sexually active, HIV-negative young Black women (YBW) (N = 209) in the United States in 2018. We hypothesize that (a) PSHSU is associated with PrEP interest among YBW and that (b) YBW who have a history of STI/ HIV testing, recent contraception use, or routine care are more likely to be interested in PrEP.

Methods

Study population

Data for this study come from The Sex, Relationship and Health Study, of 209 YBW ages 18–25 in the United States (Craddock, 2019). Participants were recruited in the parent study using a combination of text-enhanced respondent-driven sampling (RDS) (Craddock, 2018; Craddock, 2020) and computer-based referrals (Craddock, 2019).

Individual-level data and social network-level data were collected from participants via a computer-assisted self-interview (CASI) survey. The individual-level data captured responses within six main topic areas: demographics, HIV/STI risk behaviors, contraception use; PrEP knowledge, attitudes, and use; relationship dynamics; and social media use (Craddock, 2019). A full description of the methods for the original study is outlined in Craddock (2019). This study utilizes the individual-level data.

Measures

This study’s variables of interest included those known or suspected to be associated with HIV risk or preventive sexual health-seeking behaviors. The measures that expressed these variables are described below.

Demographics

Age was assessed categorically, “How old are you now [18, 19, 20, 21, 22, 23, 24, 25, or 26 or older]?”. Education level was assessed categorically,

What is the highest grade in school or year of college that you have completed and got credit for (a GED would be 12 years)

[less than high school, high school graduate, some college, 2-year degree, 4-year degrees, professional degree, or doctorate]?

Employment status was assessed categorically,

Which one of the following best describes your employment situation most of the time during the past 6 months

[Full-time paid job (>35 h per week), part-time paid job, unemployed, not looking for work, unemployed, looking for work, or student/vocational training]?

The demographic screening question for health insurance was captured with: “Have you had health insurance in the past year [yes = 1 or no = 0]?”.

Main predictors-preventive sexual health services utilization

PSHSU was assessed with four questions: last HIV/AIDS test, last STI test, last routine checkup, and active use of birth contraceptive. The last HIV/AIDS test was assessed with a set of categorical questions starting with the stem “Have you ever been tested for HIV/AIDS? [yes = 1or no = 0]?”. If the respondent answered yes, they progressed to the following question “When was the last time you were tested for HIV/AIDS [within the past 3 months, 3–6 months ago, 6 or more months ago]?”. Last STI test was assessed with a set of categorical questions starting with the stem “Have you ever been tested for a sexually transmitted infection or STI or STD, for example, Chlamydia, gonorrhea, syphilis, genital warts [yes = 1or no = 0]?”. If the respondent answered yes, they progressed to the following question “When was the last time you were tested for a sexually transmitted infection, or STI or STD, for example, Chlamydia, gonorrhea, syphilis, genital warts?” The responses were within the past 3 months, 3–6 months ago, 6 or more months ago. Last routine checkup was dichotomized to less than 1 year or greater than 1 year. Finally, birth contraceptive was assessed as either current use (yes = 1) or not currently using (no = 0).

Covariates

PrEP knowledge

PrEP knowledge was assessed using a single item “Have you ever heard of the HIV prevention pill called PrEP [yes = 1or no = 0]?”. For analysis, respondents who had never heard of PrEP were coded no = 0, and those who had heard of PrEP were coded as yes = 1. Responses were dichotomized.

Perceived HIV risk

Perceived HIV risk was captured categorically: It would be easy for me to get infected with HIV or AIDS [strongly agree, somewhat agree, somewhat disagree, strongly disagree]. For analysis, responses were recoded into three ordinal-level risk categories, low, medium, and high risk. Respondents who strongly disagreed were coded as low risk = 0. Respondents who somewhat agreed and somewhat disagreed were coded as medium risk = 1, and respondents who strongly agreed were coded as high risk = 2.

Comfort level accessing HIV/STI services

Comfort level accessing HIV/STI, and reproductive health services was assessed categorically with the following question: I would/do feel confident and comfortable visiting a sexual health clinic [strongly agree, somewhat agree, neither agree nor disagree somewhat disagree, strongly disagree]. For analysis, responses were recoded into three ordinal-level comfortability categories, low, medium, and high. Respondents who strongly disagreed and somewhat disagreed were coded as low comfort = 0. Respondents who neither agreed nor disagreed were coded as medium comfort = 1, and respondents who strongly agreed were coded as high comfort = 2.

Recent positive STI

Recent positive STI was assessed with a set of categorical questions starting with the stem “Have you ever been tested for a sexually transmitted infection or STI or STD, for example, Chlamydia, gonorrhea, syphilis, genital warts?” The responses were yes or no. If the respondent answered yes, they progressed to the following question “When was the last time you were tested for a sexually transmitted infection … ?” The responses were within the past 3 months, 3–6 months ago, 6 or more months ago. The last sequence question asked, “Did you test positive for any STDs?”. The responses were yes, no, or didn’t get my results. For the analysis, respondents who tested positive were coded as yes = 1, respondents who were tested negative were coded as no = 0. Respondents who did not get their results were coded as other = 2 and were not included in the analysis.

Outcome variable-PrEP interest

PrEP interest was assessed using a single item “Does PrEP sound like something you would be interested in taking to help prevent you from getting HIV?”. Response options were “yes or no”. For the analysis, respondents who indicated they were not interested in taking PrEP were coded as no = 0. Respondents who indicated they were interested in taking PrEP were coded as yes = 1.

Data analysis

Before analyses, a missingness analysis was conducted for variables of interest. The analysis did not uncover missingness in the data. Univariate analyses were conducted on the demographic, HIV risk, and preventive sexual health-seeking variables. Then we assessed bivariate associations between our variables of interest and PrEP interest with Chi square test of independence. Next, we examined the associations of PrEP interest using binomial logistic regression models, controlling for last time tested for STI, last time tested for HIV/AIDS, recent positive STI, perceived HIV risk, awareness of PrEP, last routine checkup, and active contraception use. We conducted all analyses using Stata 16 software (StataCorp College Station, 2019). The current study was approved by the Institutional Review Board at the University of Pittsburgh.

Results

Demographic characteristics

Demographics and PSHSU characteristics of the sample are described in Table 1. On average, YBW were 21.15 (SD = 1.73) years old. Close to half of YBW (44%) had some college education and over one-third (34.5%) had a four-year college degree. Twenty percent of YBW reported full-time employment, while 46% reported part-time employment. Most YBW (97%) had health insurance in the past year. More than one-third of YBW (43%) reported being single, while a quarter (25%) reported being in a committed relationship (Table 1).

Table 1.

Demographics and Preventive Sexual Health Service Utilization Characteristics of Young Black Women (N = 209).

Characteristics	N (%)	M (S.D.)
Age		21.14 (1.7)
Education Level
High School Graduate	28 (13.4)
Some College	92 (44.0)
Associates Degree	7 (3.3)
Bachelor’s Degree	73 (34.9)
Professional Degree	9 (4.3)
Employment Status
Full-time	41 (19.4)
Part-time	97 (45.9)
Unemployed	16 (7.5)
Student/Vocational	57 (27.0)
Relationship Status
Single	90 (42.8)
Dating	20 (9.5)
Committed Relationship	53 (25.2)
Casual Sex Partner	9 (4.2)
Sexually Experienced
Yes	186 (88.1)
No	23 (11.9)
Last vaginal sex experience
Less than three months	132 (75.8)
More than three months	42 (24.2)
Partner Status of Last Sexual Encounter
Life partner, husband, wife, spouse	11 (5.98)
Boyfriend or girlfriend	82 (44.6)
Hookup or casual sex partner	53 (28.8)
Friends with benefits	38 (20.7)
Health Care Use
Seen by a health provider within the past year	181 (89.6)
Routine or preventive care within the past year	99 (49.0)
Health Care Setting of Last Visit
Hospital	35 (17.4)
Community Health Clinic	34 (16.9)
Private Doctor’s Office	95 (47.3)
Student Health Center	19 (9.5)
Recent Birth Control Method within the past year
No	92 (44.0)
Yes	117 (55.9)
Knowledge of PrEP
No	101 (48.3)
Yes	108 (51.6)
Health Insurance in the Past Year
No	5 (2.4)
Yes	197 (97.5)
Last STI Testing
Less than six months	86 (63.2)
More than six months	50 (36.8)
Last HIV/AIDS Testing
Less than six months	78 (57.8)
More than six months	57 (42.2)
Interest in PrEP
No	133 (63.6)
Yes	76 (36.3)

Preventive sexual health services utilization

Most YBW (90%) reported being seen by a health provider within the past year, and of those, 49% reported being seen for preventive or routine care (Table 1). Sixty-one percent of YBW reported feeling confident and comfortable visiting a sexual health clinic. Over half (65%) of YBW reported ever being tested for STIs, and 66% of YBW reported ever being tested for HIV/AIDS. More than half of YBW (58%) reported being tested for HIV within the past six months. YBW who had been tested for HIV/AIDS were more likely to have been tested for STIs (x² (1,209) = 93.97, p < .00). Most YBW (82%) reported testing negative for a sexually transmitted infection the last time they were tested. Fifty-five percent of YBW reported contraceptive use within the past year. Overall, close to one-half of the YBW (47%) perceived their HIV risk as low or moderate.

Indicators of PrEP awareness and interest

Half of YBW (52%) had heard of PrEP before participating in this study. A chi-square test of independence examining the relationship between active contraceptive use and PrEP awareness revealed YBW who reported active contraceptive use within the past year were more likely to have heard of PrEP (x² (1, 209) = 4.42, p < .03). The proportion of YBW who reported being interested in PrEP did not differ by PSHSU (x² (1, 209) = 0.71, p = .39) (Table 2). Additionally, recency of last HIV/AIDS testing was marginally associated with PrEP interest (x² (1,135) = 4.56, p = .10). YBW who were tested for HIV/AIDS within the past six months were less likely to be interested in PrEP. Furthermore, self-perceived HIV risk was marginally associated with PrEP interest (x² (1,158) = 4.56, p = .10).

Table 2.

Prevalence of PrEP Interest by Preventive Sexual Health Services Utilization.

	Preventive Sexual Health Services Use
PrEP Interest	Yes	No
Yes	67 (35.5%)	9 (45%)
No	122 (64.5%)	11 (55%)

Note: χ² (1) = 0.71, p = .398. Numbers in parentheses indicate column percentages.

Predictors of PrEP interest

Contraceptive use (odds ratios [OR] = 3.24, p = 0.03), HIV testing in the past six months ([OR] = 6.53, p = 0.02), and HIV testing more than six months ago ([OR] = 8.04, p = 0.01) were significantly associated with PrEP interest (Table 3). YBW with contraceptive use within the past year had increased odds of PrEP interest than those YBW without contraceptive use within the past year. YBW who received an HIV test within the past three to six months and YBW who were tested for HIV more than six months ago had increased odds of PrEP interest than those YBW tested for HIV less than three months ago. There was marginal significance of YBW who were tested for STIs within the past three to six months ([OR] = 0.26, p = 0.08) and more than six months ([OR] = 0.25, p = 0.08) and PrEP interest, with reduced odds amongst those participants.

Table 3.

Predictors of PrEP Interest among Young Black Women in the United States, 2018 (n = 209).

	PrEP Interest
	Unadjusted OR (95%CI)	P value
Demographic Characteristics
Health Insurance (yes vs. no)	.40 (.01–10.58)	0.58
Education Level
High School	Ref
Some College	.44 (.06–3.12)	0.41
Associates	.30 (.01 −6.39)	0.44
Bachelors	.47 (.06–3.55)	0.47
Professional	.69 (.04–10.65)	0.79
Employment Status
Full-time	Ref
Part-time	.93 (.28–3.14)	0.91
Unemployed	2.14 (.30–15.24)	0.45
Student/Vocational Training	.50 (.10–2.26)	0.37
Last Time HIV/AIDS Tested
Within the past Three Months	Ref
Last Three to Six Months	6.53 (1.25–34.13)	0.02
More Than Six Months	8.04 (1.52–42.53)	0.01
Last Time STI Tested
Within the past Three Months	Ref
Last Three to Six Months	.26 (.05–1.23)	0.08
More Than Six Months	.25 (.05–1.21)	0.08
Comfort Level Accessing HIV/STI Services
Low Comfort	Ref
Medium Comfort	2.06 (.36–11.63)	0.41
High Comfort	1.70 (.46–6.28)	0.42
Last Time Check-up/Routine Care
Less Than a Year	Ref
More Than a Year	2.21 (.61 −8.05)	0.22
PrEP awareness (yes vs. no)	.72 (.26–2.02)	0.53
Perceived HIV Risk
Low Risk	Ref
Medium Risk	1.66 (.73–5.21)	0.32
High Risk	2.29 (.33–15.75)	0.39
Recent Positive STI (yes vs. no)	1.96 (.56–6.77)	0.29
Active Contraceptive Use (yes vs. no)	3.24 (1.06–9.91)	0.03

Discussion

In our study, 89.6% of YBW engaged in PSHSU. These findings were higher than previous studies that found 58% of YBW used preventive sexual health services (Hall et al., 2012). Our sample was mostly college educated, insured women with accessible medical care. We may have had different results if the sample were community drawn and not based on ego-centric social network methodology. There may be commonalities among the two groups, but further research is needed. One potential explanation for the high level of PSHSU in our sample may be due to the expanded access to care because of expanded healthcare coverage through the Patient Protection and Affordable Care Act (Obamacare), whereas women in the comparative study were low-income, uninsured, and reliant on publicly funded clinics for sexual health care. One study found the number of young women who were uninsured and without access to preventive health services decreased from 18.9% in 2012–11.5% in 2015 (Jones & Sonfield, 2016). Furthermore, Murray Horwitz et al. (2018), revealed a trend of increased use of reproductive health services among YBW from 2002 to 2015.

Our study demonstrated a low proportion of YBW (37%) were interested in PrEP. These findings are contradictory to previous research that illustrate YBW report strong interest in using PrEP (Sales et al., 2018), with one study finding almost 60% of YBW reporting interest in PrEP (Sales & Sheth, 2018). We did not find this, but our sample had different characteristics. Lower PrEP interest may be due to the limited targeted PrEP messaging to Black women. Because this sample is college educated, a proportion reported utilizing the student health centers for their sexual health needs. Comparing our findings with a study of similar sample characteristics, YBW were more likely to initiate PrEP in the future after participating in a PrEP educational intervention (Chandler et al., 2020). To increase interest of YBW, greater targeted marketing to YBW needs to occur.

YBW may also perceive themselves at lower risk for HIV but at greater risk for STIs and pregnancy which may account for lower interests among women who engage in preventative health services. Lower perceived risk for HIV among Black women contributed to both lower interest and uptake of PrEP in both clinical trials and non-clinical studies of PrEP interest and use (Bond & Gunn, 2016; Lambert et al., 2018; Van Damme et al., 2012).

Although we hypothesized PSHSU would be associated with PrEP interest, only two of the indicators of preventive sexual health services were associated with PrEP interest among YBW, recent HIV testing and active contraceptive use. These two indicators of PrEP interest suggest YBW who are currently receiving sexual health services are more likely to have knowledge about PrEP and, therefore, may have more interest.

To increase access to PrEP for YBW, there must be greater engagement of these women in healthcare service settings outside of reproductive health services (Goparaju et al., 2017; Patel et al., 2019; Smith et al., 2012). A substantial amount of our sample self-identified as college students. Recent research on PrEP awareness among Black men and women at a Historically Black College/University revealed PrEP awareness is low among this group (Marshall et al., 2020).

We understand that partner status is an indicator for PrEP use among this group, however that variable was unable to be analyzed in this study, which is a limitation of the study. Because women were able to report multiple types of sex partners simultaneously, we are unable to parse out specific factors relating to partner status (e.g., a woman might report having both, main and casual partners). Future studies should explore relationship dynamics of cisgender heterosexual Black women and partner characteristics. Furthermore, research and outreach are needed among YBW who do not currently receive sexual health services to reach YBW who are at greater risk for HIV infection.

This study has limitations. Since this is a secondary data analysis, there was sole reliance on already collected data to explore the study questions. The original study’s sampling method utilized respondent-driven sampling, a non-probability sampling methodology, which is ideal for this population, but limits our ability to generalize the findings to the larger population due to the non-randomness of the sample (Goel & Salganik, 2010). A staple of this sampling method is nominating peers within one’s social network. An additional limitation of this study is social desirability. It is possible that respondents did not answer questions honestly because of the social stigma associated with STI and HIV testing, perceived HIV risk, and engaging in risky sexual behaviors. Moreover, because women were able to report multiple types of sex partners simultaneously, we were unable to parse out specific factors relating to partner status e.g., a woman might report having both, main and casual partners. In addition, generalizability of the sample is limited due to the uniqueness of the sample characteristics being highly educated, insured, and having greater access to PSHSU.

Conclusion

Our study findings suggest YBW throughout the United States engage in sexual health behavioral counseling, STI/HIV screening and testing, and reproductive health services. Given the disproportionate HIV acquisition rate, additional efforts should be made to normalize PrEP education for heterosexual, cisgender women at student health centers on college and university campuses, and other venues outside of traditional HIV/STI testing facilities. YBW are diverse and require nuanced HIV prevention planning strategies to ultimately reduce HIV incidence among this population.