A survey conducted by Planned Parenthood in the US state of Connecticut has found that although less than a quarter of women attending their clinics were aware of pre-exposure prophylaxis (PrEP), they generally expressed positive views about it. Only about a third of respondents endorsed the view that people would assume they were promiscuous or were in fact HIV positive if they took PrEP; two-thirds said that they would expect their sexual partners or family members to approve of their taking PrEP and three-quarters said their friends would be supportive.
Only 23% of the women had heard of PrEP and only 21% regarded themselves as being at any degree of HIV risk. This is despite the fact that 29% reported sex with multiple partners, and 90% reported using condoms inconsistently or not at all.
Interestingly, the strongest negative stereotypes of PrEP were held by women who never used condoms, though this is not associated with any other respondent characteristic. The researchers do not speculate on reasons for it, such as whether women never using condoms were more likely to be monogamous, or had religious convictions.
The negative attitudes towards PrEP in women using condoms were unlikely to be fuelled by greater risk and therefore greater anxiety about HIV, because all other indicators of HIV risk were associated with positive attitudes towards PrEP. In other words, as surveys with gay men have also shown, people at higher risk of HIV tend to be more interested in PrEP.
Interest in PrEP was associated with having below degree-level education, having multiple sexual partners, not having a confirmed HIV-negative monogamous partner, not being white, and being in the lowest income band (below $10,000 a year). Intention to use PrEP was associated with all these factors, as well as younger age.
Difficulty in talking to a healthcare provider about PrEP was anticipated by 43% of the women. This was more likely to be reported by Latina and heterosexual women, maybe because non-heterosexual women already have more experience in talking to clinicians about issues of sexuality.
The study sent a brief questionnaire to 11,238 sexually active, female Planned Parenthood clients aged over 18, who attended their clinics in Bridgeport, New Haven and Hartford, the three cities in Connecticut with the highest HIV prevalence. There was a high level of interest in the survey – the researchers expected about 1000 women to answer the survey but shut it down after just four days to avoid it exceeding this number. In the event 973 women responded of whom 597 gave complete responses that could be analysed.
The average age of respondents was about 30, with 43% aged 18-25. Forty-two per cent were of white ethnicity, 39% African American and 19% mixed race or Asian. A quarter were Hispanic. Just under 60% were in a monogamous relationship.
More than three-quarters described themselves as heterosexual, 15% bisexual, 7% “other” and just over 1% lesbian. Only a quarter had had degree-level education; while 68.5% were employed, this was not a prosperous group, with 60% of women earning under $31,000 a year and a quarter earning no more than $10,000.
Two-thirds of participants expressed interest in learning more about PrEP, and a third said they would definitely or probably take it if it was freely available.
The survey asked eight questions on PrEP stigma. Respondents were asked whether they strongly agreed, agreed, disagreed or strongly disagreed with the questions.
In questions about PrEP stereotypes, respondents were asked what they thought people would think about them if they took PrEP. Thirty-seven per cent of women agreed or strongly agreed that people might assume they slept around, and 32% that they had HIV. Lower proportions (14% and 11%) agreed people might think they were 'bad' or gay.
Nearly 30% agreed or strongly agreed they would be ashamed to tell someone they were using PrEP.
The other three questions asked if sexual partners, family or friends would approve of them taking PrEP and roughly a third of women said no. Thirty-four per cent disagreed or strongly disagreed that partners would approve, and 37% that family would approve, while 25% disagreed that friends would approve.
Women who were more concerned about stereotypes of people who use PrEP were also less likely to be interested in PrEP, and women concerned about disapproval by loved ones were generally less likely to be interested in it, intend to use it, or be comfortable talking to a healthcare worker about it.
There was actually considerable heterogeneity in women’s attitudes towards PrEP, and the attitudes towards stigma only made a small difference to whether women were more or less likely to be interested in or intend to use PrEP. The strongest influence was whether women thought they’d be comfortable talking to a healthcare worker about PrEP. Anticipated discomfort made it 11% less likely that women would be interested in or intend to take PrEP.
Anticipating negative stereotypes and disapproval by others made it more likely that women also anticipated difficulty in discussing PrEP.
This survey is one of the first conducted exploring women’s attitudes toward PrEP in a high-income country setting. It finds similar attitudes towards those already expressed by gay men and by people in low-income settings.
One difference, however, was that knowledge of PrEP made no difference to whether women had negative attitudes towards it. This may indicate that other factors may be more predominantly associated with women’s attitudes towards PrEP than knowledge, such as their individual degree of risk, or it may suggest that PrEP is strongly associated with being a gay man in the US, and unexplored attitudes towards gay men may have an influence on what might be called “PrEP shame” among women.
Calabrese SK et al. HIV pre-exposure prophylaxis stigma as a multidimensional barrier to uptake among women who attend Planned Parenthood. JAIDS 79(1): 46-53. September 2018. Abstract here.
