Co-authored by Anna Forbes & the U.S. Women and PrEP Working Group
image credit: HIVEonline.org
While stuck in Washington DC traffic, a highly respected HIV researcher and a cab driver have time to chat. Both are Black women. Both are painfully aware of HIV. The researcher knows that although Black women make up half of the adult female population in DC, they comprise 92% of women living with HIV. The driver tells the researcher about burying three women in her family because of HIV.
Then the researcher brings up PrEP (short for pre-exposure prophylaxis), an antiretroviral pill that HIV-negative people can take to reduce their risk of getting the virus if exposed. The FDA approved PrEP for public use in 2012. When taken daily, PrEP reduces a woman's risk of acquiring HIV by over 90%.
The cab driver is stunned and immediately starts asking questions. Then she becomes angry. "How come I don't know about this already? Why aren't they telling people about it? I need to be talking to my kids about this!!" She urgently wants her family and friends to be able to get PrEP if they need it. But knowledge is the first step to access. People can't demand something they've never heard of.
This is a very common reaction when women hear about PrEP. The vast majority of women are completely unaware that it exists. Those who have heard of it often assume it is only for men who have sex with men (MSM), not for women.
The CDC estimates 468,00 women in the U.S. might benefit from using PrEP, about as many as the number of MSM likely to benefit. Gilead, the company manufacturing PrEP, released data this week on the number of PrEP prescriptions filled by U.S. retail pharmacies between 2012 and 2015.The number filled for women remains consistently low - too low to effectively reduce the overall number of women getting HIV. But the number for men increased substantially and men are now 89% of all new PrEP users. Unfortunately, transgender women and men were not counted as discreet categories, so we don't know about actual PrEP usage among these populations.
Gilead reported that only 10% of the people starting PrEP were Black despite the fact that 44% of all new HIV infections are occurring among Black Americans. While the total number of people taking PrEP had climbed to nearly 50,000, 75% of PrEP users are White. White women are six times more likely to initiate PrEP use than Black women, despite the fact that their lifetime risk of acquiring HIV is massively lower (one woman in 880) than Black women's risk, which is one in 48. Black women living in Southern states are even more heavily impacted by HIV and simultaneously lower access to preventative health care in states where the Affordable Care Act has not been implemented.
Knowledge is the first step to access. PrEP awareness and promotion has escalated rapidly among gay men, especially in some urban areas. Awareness among MSM has climbed from 45% to 68% in the last three years. Gay men's actual PrEP use also rose but uptake varied widely by location. Only 2% of men in rural areas reported using PrEP compared to 17% in San Francisco, 12% in New York and 8% in Chicago.
To date very little has been done to promote PrEP directly to women. This omission is not due to lack of expertise in doing such health promotion. In 1994, the US Public Health Service recommended the use of nevirapine, an antiretroviral drug, to prevent perinatal or vertical HIV transmission. Healthcare providers and pregnant women were rapidly educated about this new prevention option and the number of babies born with HIV declined by more than 90%. We do know how to get vital new HIV prevention information to women and their health care providers rapidly and effectively.
PrEP is the first female-controlled HIV prevention method that can be taken with or without a partners' knowledge. The success of oral contraception proves that many women can and will take a daily pill if it is important to them. Women can and will choose PrEP if they understand their HIV vulnerability, know about PrEP as a prevention option, and have access to PrEP. With 50,000 people in the US acquiring HIV every year, and at least one in five them women, how can we NOT invest in educating women and their health care providers about a pill that can stop HIV?