A recent New York Times article highlighted that of the more than 39 million people living with HIV worldwide, 9 million are not receiving treatment. Without medicine to suppress the virus, HIV can spread. While strides in HIV care are essential at reducing transmission, Pre-Exposure Prophylaxis, more commonly known as PrEP, protects against HIV acquisition and can proactively bridge the gap left by insufficient HIV treatment. It’s about 99% effective in preventing HIV when taken as prescribed and yet, care providers are not talking to their patients about PrEP.
The Centers for Disease Control and Prevention estimates that approximately 1.2 million Americans could benefit from PrEP, yet only about 400,000 people have received prescriptions. New research just published in the Lancet shows PrEP use among Americans increased between 2012 and 2021, but PrEP equity for Black Americans decreased. Central to this failure is the lingering stigma surrounding PrEP for Black people—a stigma perpetuated by healthcare providers themselves.
Despite urgency around ending the HIV epidemic, there exists a glaring gap in PrEP access and education, particularly among Black women. Why hasn’t their sexual health been prioritized? Black girls and women make up 13% of the female population but account for 55% of HIV infections among females. Despite its proven efficacy, PrEP remains a promising option unmentioned by care providers, reflecting a systemic failure to prioritize the sexual health needs of Black women.
These statistics also bear out in personal experience. Two Black women, who are also HIV prevention researchers and public health nurses of childbearing age, discuss how public health strategies to end the HIV epidemic are in stark contrast to their personal experiences with care providers.
In Willis’s recent encounter with a medical provider during a routine annual exam, she was struck by a glaring omission: the absence of a sexual history assessment and discussion of HIV/STI screening. As a Black woman and a medical professional, she couldn’t help but feel dismayed by this oversight. Willis, who regularly prescribes PrEP, acknowledges this as a missed opportunity to address a critical health concern within a demographic disproportionately affected by HIV. Reflecting on this encounter highlights a pressing need to call for healthcare providers to shift their own PrEP narrative to align with sex positivity. Black women, in particular, face significant medical mistrust, which can hinder open discussions about preventive measures like PrEP. Despite this, studies have shown that Black women express a strong interest in learning about and using PrEP.
Recognizing the implicit bias against prescribing PrEP to women and the lack of awareness among women about PrEP, it’s crucial for healthcare providers to actively educate patients, regardless of perceived risk, at every opportunity. To do so, clinicians must not only understand but believe that PrEP benefits patients other than men who have sex with men. As clinicians, we understand the challenges providers encounter (i.e., time constraints, burnout, and discomfort conversing about sex). Guidelines, however, are updated for a reason, and if we want all women to be healthy and safe, we need to get with the ever-evolving program of HIV prevention.
When care providers are not prepared to engage in conversations about PrEP, patients suffer. For example, Crooks, a Black female nurse researcher and expert in Black female sexual health saw a new provider for her well-woman exam. To understand the experience of usual care, Crooks did not disclose her professional background. She did, however, share that she was starting a new sexual relationship, highlighting that she is unlikely to use condoms.
Crooks asked the provider her thoughts about PrEP and if it would be a good fit, to which the provider then responded, “Why would you want to go on PrEP?” The provider stated that she typically doesn’t prescribe PrEP for her patients unless one of their sexual partners is HIV positive. Crooks was discouraged from using PrEP because of one provider’s bias and perception of who “needs PrEP” and by her individual but not unique experience of being disregarded as a Black woman. It’s time to reframe the narrative surrounding PrEP, replacing risk and shame with preventive empowerment akin to birth control.
PrEP advertisements, as seen on TV, have changed over time, inspiring women, specifically Black women, to ask their care providers about PrEP. Public health studies and firsthand accounts expose the stark contrast between public health messaging and the gritty truth within clinical settings. Furthermore, patients shouldn’t have to ask about PrEP. Care providers should be taking the lead.
But first, care providers must believe that PrEP is for everyone. Providers should prioritize PrEP education and reflect on their clinical understanding of implicit or unconscious bias.
PrEP works, so providers must work the PrEP conversation to fit in with sexual health promotion. Crooks and Willis, like all Black women, deserved better. This serves as a call to action for the medical community to unwaveringly commit to equitable sexual health care by including PrEP in the conversation.
To learn more about PrEP inclusive care, providers can access training through The Choice Agenda, PrEP guidelines from the CDC, and direct guidance on all aspects of PrEP care from the National Clinician Consultation Center for PrEP or call PrEP Warmline at (855) 448-7737 or (855) HIV-PrEP.
