Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

“Yes, I’m interested in taking PrEP!”: PrEP interest among women respondents to the European community-based survey “Flash! PrEP in Europe”

  • Rosemary M. Delabre ,

    Roles Project administration, Validation, Writing – original draft, Writing – review & editing

    rdelabre@coalitionplus.org

    Affiliation Coalition PLUS, Community-Based Research Laboratory, Pantin, France

  • Adeline Bernier,

    Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

    Affiliation Coalition PLUS, Community-Based Research Laboratory, Pantin, France

  • Flor Sánchez,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation Department of Social Psychology, Universidad Autónoma de Madrid, Madrid, Spain

  • Antoine Vilotitch,

    Roles Data curation, Formal analysis, Writing – review & editing

    Affiliations Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France, ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d’Azur, Marseille, France

  • Sophocles Chanos,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation Ath & Thess Checkpoints, Athens, Greece

  • Maria Luisa Cosmaro,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation Fondazione LILA Milano, Milan, Italy

  • Harriet Langanke,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation GSSG–Gemeinnützige Stiftung Sexualität und Gesundheit, Cologne, Germany

  • Coline Mey,

    Roles Writing – review & editing

    Affiliation AIDES, Pantin, France

  • Cary James,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation Terrence Higgins Trust, London, United Kingdom

  • Sascha B. Duken,

    Roles Conceptualization, Data curation, Formal analysis, Writing – review & editing

    Affiliation University of Amsterdam, Amsterdam, The Netherlands

  • Vincent Schlegel,

    Roles Conceptualization, Investigation, Methodology, Project administration, Writing – review & editing

    Affiliation AIDES, Pantin, France

  • Richard Stranz,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation AIDES, Pantin, France

  • Kai J. Jonas,

    Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

    Affiliation Maastricht University, Maastricht, The Netherlands

  • Bruno Spire,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliations Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France, AIDES, Pantin, France

  • Daniela Rojas Castro

    Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

    Affiliations Coalition PLUS, Community-Based Research Laboratory, Pantin, France, Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France

“Yes, I’m interested in taking PrEP!”: PrEP interest among women respondents to the European community-based survey “Flash! PrEP in Europe”

  • Rosemary M. Delabre, 
  • Adeline Bernier, 
  • Flor Sánchez, 
  • Antoine Vilotitch, 
  • Sophocles Chanos, 
  • Maria Luisa Cosmaro, 
  • Harriet Langanke, 
  • Coline Mey, 
  • Cary James, 
  • Sascha B. Duken
PLOS
x

Abstract

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. “High objective risk” (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18–29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), “rather high”/ “high” self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

Introduction

Promotion of available and development of new HIV prevention tools adapted to the needs of women and young adolescent girls are crucial to lowering the burden of HIV among this group. In Europe, the rate of new HIV diagnoses among women is lower compared to men; however, heterosexual contact is the main mode of HIV transmission in certain countries [1]. Due to various biological, social and cultural factors, women and adolescent girls are particularly at risk for HIV infection [24]. Furthermore, HIV prevalence may be higher in specific groups of women, such as sex workers [5] and women who have experienced intimate partner violence [68]. Gender inequality has largely been considered a major driving force of the HIV epidemic in the context of heterosexual transmission [4, 9, 10].

Recognition of the gender-related specificities of the HIV epidemic has led to a call for the development of comprehensive HIV prevention programs which strengthen women’s capacities on sexual and HIV risk, and empower them to protect themselves; community involvement and support are essential elements of these programs [3, 9]. Oral pre-exposure prophylaxis (PrEP), which is the use of antiretroviral drugs by HIV-negative individuals to reduce the risk of HIV infection, may be an important self-controlled prevention method for women. Efficacy of daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as PrEP has been shown in randomized controlled trials among different populations (heterosexual men and women) [11, 12]. However, other studies evaluating PrEP efficacy and involving only women have found no associated reduction in risk [13, 14]. The lower efficacy observed in these studies has been attributed, in part, to adherence issues linked to various factors such as an underestimation of personal risk of HIV infection, PrEP or HIV-related stigma from the community and fear of side effects [1518]. Despite a variance in levels of efficacy among women, PrEP is still considered a viable tool for self-controlled HIV prevention for women.

The World Health Organization (WHO) recommended PrEP for HIV prevention among men who have sex with men (MSM) in 2014 [19] and expanded their recommendation to “all population groups at substantial risk of HIV infection” in 2015 [20]. European guidelines on PrEP offer more detailed recommendations for MSM and transgender people but add that PrEP “may be considered” for HIV-negative heterosexual men and women who do not consistently use condoms or who have potentially untreated HIV-positive partners [21]. Although these broader recommendations theoretically allow more women to access and benefit from PrEP, uptake of PrEP among women remains largely dependent on knowledge, personal HIV risk assessment and interest [22].

Currently, much of the research on PrEP knowledge and potential uptake among (primarily at risk) women has taken place in the United States (US) and in some African countries [2227]. Information regarding PrEP knowledge and interest among women is severely lacking within Europe, where PrEP access is still limited. With more European countries authorizing the prescription and reimbursement of PrEP, it is crucial to collect standardized data regarding PrEP, to ensure public health policies are engaging, responding and supportive of the needs of women. The objective of this analysis was to identify factors associated with interest in using PrEP among women respondents to a large, European community-based survey.

Materials and methods

Study organization and study population

The Flash! PrEP in Europe (FPIE) survey was a community-based cross-sectional study aiming to assess knowledge of, attitudes towards, interest to use and current use of PrEP. FPIE was conducted with the University of Amsterdam and the Universidad Autónoma de Madrid, as well as 15 non-governmental organizations (NGOs) based in 12 European countries (Denmark, France, Germany, Greece, Ireland, Italy, the Netherlands, Portugal, Romania, Spain, Switzerland, and the United Kingdom). People living with, exposed to HIV and/or involved in the fight against HIV actively participated throughout the entire project. This research was conducted as a part of “Flash PrEP in Europe,” a joint European research project, coordinated by the community-based NGOs AIDES and Coalition PLUS, in partnership with the University of Amsterdam. Participating NGOs (see acknowledgements) were identified through an informal network or word of mouth and dedicated their own resources to the survey. NGOs were actively involved in the questionnaire conception, validation, and translation. NGOs also promoted the survey, in addition to participating alongside experts and academics in the steering and scientific committees during which results and analyses were discussed.

The 82-item, self-completed, anonymous and voluntary online questionnaire was available from 15 June to 15 July 2016 in ten languages and diffused in the participating countries. At the time the survey was conducted, PrEP was only officially available and reimbursed in France. The Ethics Review Board of the Faculty of Social and Behavioral Sciences, University of Amsterdam, the Netherlands, granted approval for the study (2016-SP-7030). Eligible respondents were at least 18 years old and declared being HIV negative or unaware of their serological status. Respondents who were HIV positive or who did not wish to report their HIV status were excluded. All respondents provided written informed consent before starting the questionnaire.

Survey promotion/recruitment

A convenience sampling method was used with a specific focus on all populations highly exposed to HIV. Study promotion aimed to target all key populations on the European and country level, including: migrants (especially those from endemic African countries), people who use drugs, HIV-negative members within serodifferent relationships, trans people, and people who engage(d) in transactional sex. Women were therefore not specifically targeted as a group in itself, but rather would be concerned based on whether they identified with one of the groups above.

All participating organizations were encouraged to communicate about the survey on their social media pages, during regular activities, and to work with other organizations that would be willing to promote the survey. Promotion methods used by NGOs included internal mail listings, websites, social media, organization website, as well as dating apps/websites. European organization such as the European AIDS Treatment Group (EATG)), the International Lesbian, Gay, Trans and Intersex association (ILGA) diffused the link for the survey. Informative websites including Aidsmap/NAM, PrEPster and PrEP Watch also diffused messages about the survey on their websites. Banner ads were also displayed on dating applications and websites Hornet® and PlanetRomeo®. See S1 File for more information.

Survey instrument

PrEP was briefly described at the start of the survey as a new prevention tool against HIV and the respondents were informed of the countries where it was currently authorized. Respondents were then asked if they knew of PrEP before the survey, and were subsequently given a more complete, but brief, explanation of PrEP. The questionnaire is found in the S2 File.

Prior knowledge of PrEP, interest in using PrEP and current use of PrEP were assessed. Data related to socio-demographic characteristics (including sex at birth, current gender, age, country of birth, current country of residence, education level, and perceived financial situation) were collected in addition to information on sexual activity in the last 6 months, number and gender of sexual partners, condom use, history of sexual abuse, history of transactional sex, drug taking behaviors, frequency of HIV and other sexually transmitted infections (STI) testing, number of STI diagnoses, and perceived HIV and STI risk.

Data and analysis

Respondents included in this analysis declared female sex at birth and at the time of the survey. Respondents with a migrant background were defined as those who were born in a country different from where they currently lived; region of birth and current residence (North or South) was determined based upon the Brandt line as defined in the Brandt report [28]. Respondents who reported using condoms “never”, “rarely”, “from time to time” or “nearly always” in the past 6 months with their occasional sex partners (excluding main sex partner if they had one) were considered to have inconsistent condom use compared to those that declared having “always” used condoms. Sexual abuse was defined as “sex against [one’s] will because of verbal, physical or any other form of pressure”. Transactional sex was defined as “money, goods or drugs in exchange for sex”. Respondents indicated their HIV risk perception using a 5-point Likert scale, ranging from 1 for low to 5 for high; this variable was recategorized as “low/rather low”, “average”, or “rather high/high”.

A variable was created to identify women who would be considered at high objective risk (HOR) for HIV infection following a selection of EACS and CDC guidelines [21, 29, 30]. The following criteria were used: (i) two or more occasional male sex partners in the previous 6 months and inconsistent condom use during vaginal or anal sex in the previous 6 months; or (ii) two or more STI diagnoses in the previous twelve months; or (iii) drug injection in a sexual context in the previous twelve months; or (iv) seropositive main sex partner with a detectable or unknown viral load.

Interest in using PrEP was the primary outcome studied. Interest in using PrEP was assessed with the question: “Are you interested in using PrEP?”; respondents who replied “No, definitely not”, “No, probably not” or “Maybe” were compared to those who replied “Yes, probably” or “Yes, definitely”. Differences between women who were interested in PrEP compared to those who were maybe/not interested were examined using the chi-square or Fisher test for categorical variables. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Variables for which p<0.20 in univariable analysis were included in the multivariable analysis. The multivariable model was built using a complete case approach. A backward procedure based on the Likelihood Ratio Chi-2 test was used to select significant variables for the final model (p-value <0.05).

Qualtrics® software [31] was used in the development of the survey and data collection. Statistical analyses were conducted using STATA (12.1) and SPSS (version 20.0.0).

Results and discussion

A total of 15 880 individuals responded to the FPIE survey, of whom 907 (5.7%) were women. Romanian women respondents (n = 217) were excluded from the analysis due to a translation error. PrEP interest information was missing for 6 women and another 6 were using PrEP at the time of the survey; these 12 women were, thus, excluded from the current analysis.

The 678 women included in this analysis resided in 11 different European countries participating in the survey; the majority came from Germany (n = 111, 16.4%), France (n = 96, 14.2%), Portugal (n = 90, 13.3%) and Switzerland (n = 85, 12.5%). Thirty-eight women (5.6%) resided in other countries: 26 resided in other European countries and 12 were residing in countries outside of Europe. Almost half 46.8% (n = 317) knew of PrEP prior to the survey. Regarding PrEP interest, 122 women (18.0%) declared that they “probably” or “definitely” would be interested in using PrEP. PrEP interest varied by country (Fig 1) ranging from 0.0% (in the Netherlands) to 40.0% (in Denmark), however these percentages should be interpreted with caution due to small sample sizes in both countries.

thumbnail
Fig 1. PrEP interest among women respondents to the Flash! PrEP in Europe survey by participating country.

https://doi.org/10.1371/journal.pone.0246037.g001

Characteristics of the study sample according to PrEP interest are presented in Table 1. Almost half of the women included in the analysis (48.9%, n = 331) were between 18 and 29 years old and 50.9% (n = 345) lived in a city (population of more than 500 000). A large majority (77.8%, n = 523) had a bachelor’s degree or higher and 83.8% (n = 568) reported fair/good perceived financial situation. Close to one fifth of the women (17.5%, n = 118) were migrants, primarily coming from other northern countries. Sixty-one percent (n = 415) were in a relationship and 25.8% (n = 175) had at least one child. Almost three-quarters 72.5%, (n = 490) were satisfied with their life in general. Regarding sexual activity, 77.1% (n = 523) had sex within the last 6 months, 70.8% (n = 478) had sex with men and 73.0% (n = 420) had a main sexual partner. One quarter of women 24.8%, (n = 161) reported history of sexual abuse, 4.8% (n = 31) reported history of transactional sex, and 8.0% (n = 53) have used non-injection drugs in a sexual context. Thirty percent (n = 203) had during the past 12 months at least one HIV recent test and 4.3% (n = 28) were diagnosed with an STI. A small proportion 4.0% (n = 27) evaluated their risk of becoming infected with HIV as “rather high” or “high”, however, eighty-five women (12.5%) were considered at HOR for HIV according to the defined criteria. A large majority of women at HOR (90.6%, n = 77) met the criteria regarding two or more occasional male sex partners in the previous 6 months and inconsistent condom use during vaginal or anal sex in the previous 6 months. Among women identified at HOR, 40.0% (n = 34) were interested in PrEP.

thumbnail
Table 1. Main characteristics of women respondents to the FPIE survey according to interest in PrEP (n = 678).

https://doi.org/10.1371/journal.pone.0246037.t001

Results of the univariable and multivariable analyses are presented in Table 2. The univariable analyses identified several factors that were significantly associated with interest in using PrEP: age, education level, perceived financial status, migrant status, (having) children, relationship status, history of sexual abuse, number of HIV tests in the past year, STI diagnosis in the past year, perceived HIV risk, and HOR status. In the final multivariable model, seven variables were associated with higher interest in using PrEP: younger age (18–29 years old) (aOR: 1.91, 95% CI: 1.07–3.41), “bad” self-perceived financial status (1.84[1.09–3.11)], migrant status (South to North) (2.87[1.05–7.89]), not being in a relationship (single or dating) (1.93[1.23–3.03]), sexual abuse history (1.86[1.17–2.97]), having “rather high”/ “high” self-perceived risk of becoming infected with HIV (3.21[1.32–7.81]), and high objective HIV risk status (2.49[1.42–4.35]).

thumbnail
Table 2. Factors associated with PrEP interest–univariable (n = 678) and multivariable (n = 649) logistic regression models.

https://doi.org/10.1371/journal.pone.0246037.t002

This analysis of women respondents of a large European survey brings valuable information regarding self-perceived HIV risk assessment, PrEP knowledge and interest that is crucial to informing effective public health prevention programs for women in the context of increasing availability of PrEP in Europe. Close to half of the women respondents had prior PrEP knowledge but interest in using PrEP was lower. Importantly, women who had high subjective and objective HIV risk showed a vested interest in PrEP. Additionally, results show an association between social determinants of health (age, socio-economic status, migrant status) and PrEP interest which further highlight the need to address structural factors that have an impact on HIV risk and adherence to PrEP.

Women identified at HOR and who are interested in using PrEP are ideal targets for PrEP implementation programs and identification of these women is vital. A total of 85 (12.5%) women in this analysis would be considered at HOR for HIV, and according to the results of the multivariable model, the odds of being interested in PrEP among this group of women were 2.49 times that of women who were not identified at HOR. HIV risk assessment tools have been developed [32] in specific subgroups of women such as African women [33], serodifferent couples [34, 35], and pregnant and postpartum women [36], and are increasingly important to help women understand their (and their partner’s) HIV risk. For medical providers, these and other tools such as algorithms that can identify a patient’s risk based on their medical data [37], may be helpful to identify those who may underestimate their risk [22] and who may benefit from PrEP.

In this analysis, women with rather high/high HIV risk perception also reported higher interest in PrEP, supporting previous findings among women [32, 38, 39] and other key populations, that perception of HIV risk is an important factor of PrEP interest [4043]. Additionally, high risk perception may play an important role in PrEP adherence [17, 39, 44], a key lesson from the PrEP implementation process in the US [40]. It is important to underline, however, that a majority of women in this sample who were considered at HOR for HIV were not interested in using PrEP (51 of 85 or 60%). Furthermore, 63% (n = 32) evaluated their HIV risk to be “low” or “rather low”. These results suggest that more work needs to be done to empower women to better evaluate their risk of HIV and to identify and implement pertinent risk reduction strategies.

In this study, younger age and a financial situation perceived to be bad were associated with higher interest in using PrEP. The association between low socio-economic status and increased likelihood of reporting potential PrEP uptake has been previously been reported [45]. Several studies have identified the need to integrate structural interventions in prevention programs to address social determinants which contribute to HIV risk among women [4649] and other at-risk groups [50]. The association between history of sexual or physical gender-based violence and engagement in HIV-related risk behavior has been well established in various settings and particularly among female sex workers [5154]. PrEP could be an important method for empowering at-risk women [38, 55], particularly those who are affected by synergistic epidemics of substance abuse, violence, and HIV/AIDS and who are otherwise at a disadvantage with regard to condom negotiation [49, 56]. Increasing knowledge and interest in using PrEP, while facilitating its authorization and access, is critical for expanding PrEP uptake among women. However, effective prevention strategies should not rely on this biomedical intervention alone and should address structural factors that are beyond the scope of individual choice and behavior for a maximal effect at the population level [50, 57].

Study results regarding PrEP knowledge and interest differ from other studies among women and other at risk groups which generally show low prior PrEP knowledge, but rather high interest in PrEP after receiving information on it [24, 58, 59]. In contrast to a majority of studies investigating PrEP, which focused on female at risk populations such as sex workers, African-Americans (US studies), and areas of high HIV prevalence [23, 45, 6062], the FPIE survey reached a broader population of women in an understudied region (Europe). Women in this study had a higher level of knowledge compared to other studies based on at risk women in the US in which PrEP knowledge ranged from almost 0 to 33% [23, 61, 63]. This result may be a consequence of the population sampled here, who may be more connected to HIV prevention services and organizations [64]. Regarding PrEP interest, women in this study expressed relatively low (18.0%) interest, which is comparable to another US study citing only 20% willingness to use PrEP among Caribbean immigrant women, but contrasts with other reports of high (60–65%) interest among at risk women in the US and internationally [23, 60, 61, 65].

Limitations

Due to the methodology used for this survey (promotion of the survey by NGOs, on social network and/or dating applications/websites, online questionnaire) respondents were not representative of European women and therefore results may not be generalizable; yet, this is one of the first data sets on this population. No information was collected for the individuals who refused study participation and therefore we are unable to assess if they are significantly different from respondents. The possibility of social desirability bias regarding sensitive items cannot be excluded. While the survey was conducted in 2016, current data shows PrEP is only fully reimbursed and available in 16 of 49 reporting European and Central Asian countries [66]. PrEP interest was assessed based on hypothetical use at the time of assessment however, according to recent data [66], PrEP uptake is overwhelmingly concentrated among MSM. Finally, as PrEP availability increases in Europe, future studies will be able to evaluate the determinants of actual PrEP uptake.

Conclusion

While overall interest in using PrEP was low, women in Europe who are at high objective HIV risk and those who perceive themselves to be at high HIV risk are interested in using PrEP. In addition to increasing knowledge on PrEP among women, it is critical that efforts are made on the national level to explicitly include women in the national guidelines and to develop PrEP services that meet their specific needs. Community-based approaches and interventions may be particularly relevant to reach at risk women and help improve prevention package access. Finally, there is a need for structural approaches in HIV prevention, to tackle underlying mechanisms of gender-based inequalities.

Supporting information

S1 File. Flash! PrEP in Europe survey promotion.

https://doi.org/10.1371/journal.pone.0246037.s001

(DOCX)

S2 File. Flash! PrEP in Europe survey, English version.

https://doi.org/10.1371/journal.pone.0246037.s002

(DOCX)

S1 Dataset. Flash! PrEP in Europe dataset for analysis.

https://doi.org/10.1371/journal.pone.0246037.s003

(DTA)

Acknowledgments

This study was endorsed by UNAIDS and the EATG and supported by Hornet®. The authors thank the respondents and the following NGOs and Universities: Aids Fondet, Deutsche AIDS Hilfe, GSSG, ATH Checkpoint, HIV Ireland, Plus Onlus, Fondazione LILA Milano, Soa aids Nederland, University of Amsterdam, GAT, ARAS, Check Point Barcelona, Apoyo positivo, Adhara Sevilla, Universidad Autónoma de Madrid, Groupe Sida Genève, and Terrence Higgins Trust. This study would not have been possible without their active participation. Preliminary results of this study analysis were presented at AIDS Impact Conference which was held November 13–15 2017 in Cape Town, South Africa.

References

  1. 1. European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2019–2018 data [Internet]. Copenhagen: WHO Regional Office for Europe; 2019. Available from: https://www.ecdc.europa.eu/en/publications-data/hivaids-surveillance-europe-2019-2018-data
  2. 2. Gómez CA. Preventing HIV in U.S. Women and Girls: A Call for Social Action. Women’s Health Issues. 2011 Nov;21(6, Supplement):S287–94.
  3. 3. Wechsberg WM, Luseno WK. The Need for Culturally Appropriate, Gender-Specific Global HIV Prevention Efforts with Vulnerable Women. J Prev Interv Community. 2010 Mar 31;38(2):85–8. pmid:20391056
  4. 4. UNAIDS. How AIDS changed everything—MDG6: 15 years, 15 lessons of hope from the AIDS response [Internet]. 2015 [cited 2020 May 24]. Available from: http://www.unaids.org/sites/default/files/media_asset/MDG6Report_en.pdf
  5. 5. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis. 2012 Jul;12(7):538–49. pmid:22424777
  6. 6. Li Y, Marshall CM, Rees HC, Nunez A, Ezeanolue EE, Ehiri JE. Intimate partner violence and HIV infection among women: a systematic review and meta-analysis. J Int AIDS Soc. 2014 Feb 13;17(1). pmid:24560342
  7. 7. Durevall D, Lindskog A. Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us? The Lancet Global Health. 2015 Jan 1;3(1):e34–43. pmid:25539967
  8. 8. Willie TC, Stockman JK, Perler R, Kershaw TS. Associations between intimate partner violence, violence-related policies, and HIV diagnosis rate among women in the United States. Annals of Epidemiology. 2018 Dec 1;28(12):881–5. pmid:30055935
  9. 9. UNAIDS. Women Out Loud. How women living with HIV will help the world end AIDS [Internet]. 2012. Available from: http://www.unaids.org/sites/default/files/media_asset/20121211_Women_Out_Loud_en_1.pdf
  10. 10. Richardson ET, Collins SE, Kung T, Jones JH, Tram KH, Boggiano VL, et al. Gender inequality and HIV transmission: a global analysis. J Int AIDS Soc. 2014 Jun 27;17(1). pmid:24976436
  11. 11. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. New England Journal of Medicine. 2012;367(5):423–434. pmid:22784038
  12. 12. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. New England Journal of Medicine. 2012;367(5):399–410. pmid:22784037
  13. 13. Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure prophylaxis for HIV infection among African women. New England Journal of Medicine. 2012;367(5):411–422. pmid:22784040
  14. 14. Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. New England Journal of Medicine. 2015;372(6):509–518. pmid:25651245
  15. 15. van der Straten A, Van Damme L, Haberer JE, Bangsberg DR. Unraveling the divergent results of pre-exposure prophylaxis trials for HIV prevention: AIDS. 2012 Apr;26(7):F13–9. pmid:22333749
  16. 16. Thomson KA, Baeten JM, Mugo NR, Bekker L-G, Celum CL, Heffron R. Tenofovir-based Oral PrEP Prevents HIV Infection among Women. Curr Opin HIV AIDS. 2016 Jan;11(1):18–26. pmid:26417954
  17. 17. Corneli A, Wang M, Agot K, Ahmed K, Lombaard J, Van Damme L. Perception of HIV Risk and Adherence to a Daily, Investigational Pill for HIV Prevention in FEM-PrEP: J Acquir Immune Defic Syndr. 2014 Dec;67(5):555–63. pmid:25393942
  18. 18. Corneli A, Perry B, McKenna K, Agot K, Ahmed K, Taylor J, et al. Participants’ Explanations for Nonadherence in the FEM-PrEP Clinical Trial. J Acquir Immune Defic Syndr. 2016 Apr 1;71(4):452–61. pmid:26536315
  19. 19. World Health Organization. Policy brief: Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations [Internet]. 2014 [cited 2020 May 24]. Available from: http://www.who.int/hiv/pub/toolkits/keypopulations/en/
  20. 20. World Health Organization. Pre-exposure prophylaxis—WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection [Internet]. 2015 [cited 2017 Jan 18]. Available from: http://apps.who.int/iris/bitstream/10665/197906/1/WHO_HIV_2015.48_eng.pdf?ua=1
  21. 21. European AIDS Clinical Society. EACS Guidelines version 10.0 [Internet]. 2019 Nov. Available from: https://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html
  22. 22. Sheth AN, Rolle CP, Gandhi M. HIV pre-exposure prophylaxis for women. J Virus Erad. 2016;2(3):149–55. pmid:27482454
  23. 23. Auerbach JD, Kinsky S, Brown G, Charles V. Knowledge, Attitudes, and Likelihood of Pre-Exposure Prophylaxis (PrEP) Use Among US Women at Risk of Acquiring HIV. AIDS Patient Care STDS. 2015 Feb 1;29(2):102–10. pmid:25513954
  24. 24. Koechlin FM, Fonner VA, Dalglish SL, O’Reilly KR, Baggaley R, Grant RM, et al. Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature. AIDS Behav. 2017;21(5):1325–35. pmid:27900502
  25. 25. Toledo L, McLellan-Lemal E, Henderson FL, Kebaabetswe PM. Knowledge, Attitudes, and Experiences of HIV Pre-Exposure Prophylaxis (PrEP) Trial Participants in Botswana. World J AIDS. 2015 Mar;5(2):10–20. pmid:26767149
  26. 26. Mugo NR, Ngure K, Kiragu M, Irungu E, Kilonzo N. PrEP for Africa: What we have learnt and what is needed to move to program implementation. Curr Opin HIV AIDS. 2016 Jan;11(1):80–6. pmid:26575147
  27. 27. Hodges-Mameletzis I, Dalal S, Msimanga-Radebe B, Rodolph M, Baggaley R. Going global: the adoption of the World Health Organization’s enabling recommendation on oral pre-exposure prophylaxis for HIV. Sex Health. 2018 Nov;15(6):489–500. pmid:30496718
  28. 28. Quilligan JB. The Brandt Equation: 21st Century Blueprint for the New Global Economy. Brandt 21 Forum; 2002.
  29. 29. USPHS-CDC. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States -2014: A Clinical Practice Guideline [Internet]. 2014 [cited 2020 May 24]. Available from: https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf
  30. 30. USPHS-CDC. Preexposure Prophylaxis For The Prevention Of HIV Infection In The United States– 2017 Update [Internet]. 2017 [cited 2020 May 24]. Available from: https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
  31. 31. The World’s Leading Research & Insights Platform [Internet]. Qualtrics. [cited 2020 May 24]. Available from: https://www.qualtrics.com/
  32. 32. Aaron E, Blum C, Seidman D, Hoyt MJ, Simone J, Sullivan M, et al. Optimizing Delivery of HIV Preexposure Prophylaxis for Women in the United States. AIDS Patient Care STDS. 2018 Jan 1;32(1):16–23. pmid:29323558
  33. 33. Balkus JE, Brown E, Palanee T, Nair G, Gafoor Z, Zhang J, et al. An Empiric HIV Risk Scoring Tool to Predict HIV-1 Acquisition in African Women: JAIDS Journal of Acquired Immune Deficiency Syndromes. 2016 Jul;72(3):333–43. pmid:26918545
  34. 34. Kahle EM, Hughes JP, Lingappa JR, John-Stewart G, Celum C, Nakku-Joloba E, et al. An empiric risk scoring tool for identifying high-risk heterosexual HIV-1 serodiscordant couples for targeted HIV-1 prevention. J Acquir Immune Defic Syndr. 2013 Mar 1;62(3):339–47. pmid:23187945
  35. 35. Irungu EM, Heffron R, Mugo N, Ngure K, Katabira E, Bulya N, et al. Use of a risk scoring tool to identify higher-risk HIV-1 serodiscordant couples for an antiretroviral-based HIV-1 prevention intervention. BMC Infect Dis. 2016 Oct 17;16(1):571. pmid:27751179
  36. 36. Pintye J, Drake AL, Kinuthia J, Unger JA, Matemo D, Heffron R, et al. A risk assessment tool for identifying pregnant and postpartum women who may benefit from pre-exposure prophylaxis (PrEP). Clin Infect Dis. 2016 Dec 28;ciw850.
  37. 37. Marcus JL, Hurley LB, Krakower DS, Alexeeff S, Silverberg MJ, Volk JE. Use of electronic health record data and machine learning to identify candidates for HIV pre-exposure prophylaxis: a modelling study. The Lancet HIV. 2019 Jul 5 pmid:31285183
  38. 38. Bailey JL, Molino ST, Vega AD, Badowski M. A Review of HIV Pre-Exposure Prophylaxis: The Female Perspective. Infect Dis Ther. 2017 Jun 9 pmid:28600755
  39. 39. Namey E, Agot K, Ahmed K, Odhiambo J, Skhosana J, Guest G, et al. When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling. Cult Health Sex. 2016 Sep 1;18(9):1081–91. pmid:27093238
  40. 40. Liu A, Cohen S, Follansbee S, Cohan D, Weber S, Sachdev D, et al. Early Experiences Implementing Pre-exposure Prophylaxis (PrEP) for HIV Prevention in San Francisco. PLoS Med. 2014 Mar 4;11(3). pmid:24595035
  41. 41. Hoagland B, Boni RBD, Moreira RI, Madruga JV, Kallas EG, Goulart SP, et al. Awareness and Willingness to Use Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men and Transgender Women in Brazil. AIDS Behav. 2016;1–10. pmid:26370101
  42. 42. Khawcharoenporn T, Kendrick S, Smith K. HIV risk perception and preexposure prophylaxis interest among a heterosexual population visiting a sexually transmitted infection clinic. AIDS Patient Care STDS. 2012 Apr;26(4):222–33. pmid:22404427
  43. 43. Amico KR, Ramirez C, Caplan MR, Montgomery BE, Stewart J, Hodder S, et al. Perspectives of US women participating in a candidate PrEP study: adherence, acceptability and future use intentions. J Int AIDS Soc. 2019 Mar 14;22(3).
  44. 44. Aaron E, Cohan D. Preexposure prophylaxis for the prevention of HIV transmission to women: AIDS. 2013 Jan;27(1):F1–5. pmid:22914582
  45. 45. Wingood GM, Dunkle K, Camp C, Patel S, Painter JE, Rubtsova A, et al. Racial Differences and Correlates of Potential Adoption of Pre-exposure Prophylaxis (PrEP): Results of a National Survey. Journal of acquired immune deficiency syndromes. 2013 Jun;63(0 1):S95.
  46. 46. Goparaju L, Praschan NC, Warren-Jeanpiere L, Experton LS, Young MA, Kassaye S. Stigma, Partners, Providers and Costs: Potential Barriers to PrEP Uptake among US Women. J AIDS Clin Res. 2017 Sep;8(9). pmid:29201531
  47. 47. Edwards AE, Collins CB. Exploring the influence of social determinants on HIV risk behaviors and the potential application of structural interventions to prevent HIV in women. J Health Dispar Res Pract. 2014;7(SI2):141–55. pmid:27134801
  48. 48. Yun K, Xu J-J, Zhang J, Li J-M, Hu Q-H, Chu Z-X, et al. Female and younger subjects have lower adherence in PrEP trials: a meta-analysis with implications for the uptake of PrEP service to prevent HIV. Sex Transm Infect. 2018;94(3):163–8. pmid:28756409
  49. 49. Flash CA, Dale SK, Krakower DS. Pre-exposure prophylaxis for HIV prevention in women: current perspectives. Int J Womens Health. 2017 May 31 pmid:28615975
  50. 50. Roberts ET, Matthews DD. HIV and chemoprophylaxis, the importance of considering social structures alongside biomedical and behavioral intervention. Social Science & Medicine. 2012 Nov;75(9):1555–61. pmid:22495513
  51. 51. Decker MR, Lyons C, Billong SC, Njindam IM, Grosso A, Nunez GT, et al. Gender-based violence against female sex workers in Cameroon: prevalence and associations with sexual HIV risk and access to health services and justice. Sex Transm Infect. 2016 Dec;92(8):599–604. pmid:27280972
  52. 52. Decker MR, Benning L, Weber KM, Sherman SG, Adedimeji A, Wilson TE, et al. Physical and Sexual Violence Predictors: 20 Years of the Women’s Interagency HIV Study Cohort. American Journal of Preventive Medicine. 2016 Nov;51(5):731–42. pmid:27595175
  53. 53. Lang DL, Salazar LF, DiClemente RJ, Markosyan K. Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia. AIDS Behav. 2013 Feb;17(2):551–8. pmid:22760740
  54. 54. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Social Science & Medicine. 2000;50(4):459–78. pmid:10641800
  55. 55. Raifman J, Sherman SG. US Guidelines That Empower Women to Prevent HIV With Preexposure Prophylaxis. Sex Transm Dis. 2018;45(6):e38–9. pmid:29750776
  56. 56. Meyer JP, Springer SA, Altice FL. Substance Abuse, Violence, and HIV in Women: A Literature Review of the Syndemic. J Womens Health (Larchmt). 2011 Jul;20(7):991–1006.
  57. 57. Mannell J, Willan S, Shahmanesh M, Seeley J, Sherr L, Gibbs A. Why interventions to prevent intimate partner violence and HIV have failed young women in southern Africa. Journal of the International AIDS Society. 2019 Aug 1;22(8):e25380. pmid:31441229
  58. 58. Ferrer L, Folch C, Fernandez-Davila P, Garcia A, Morales A, Belda J, et al. Awareness of Pre-exposure Prophylaxis for HIV, Willingness to Use It and Potential Barriers or Facilitators to Uptake Among Men Who Have Sex with Men in Spain. AIDS Behav. 2016;20(7):1–11.
  59. 59. Mimiaga MJ, Case P, Johnson CV, Safren SA, Mayer KH. Pre-Exposure Antiretroviral Prophylaxis (PrEP) attitudes in high risk Boston area MSM: Limited knowledge and experience, but potential for increased utilization after education. J Acquir Immune Defic Syndr. 2009 Jan 1;50(1):77. pmid:19295337
  60. 60. Garfinkel DB, Alexander KA, McDonald-Mosley R, Willie TC, Decker MR. Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients. AIDS Care. 2016 Sep 29;0(0):1–8. pmid:27680304
  61. 61. Peitzmeier SM, Tomko C, Wingo E, Sawyer A, Sherman SG, Glass N, et al. Acceptability of microbicidal vaginal rings and oral pre-exposure prophylaxis for HIV prevention among female sex workers in a high-prevalence US city. AIDS Care. 2017 Mar 8;0(0):1–5.
  62. 62. Mack N, Evens EM, Tolley EE, Brelsford K, Mackenzie C, Milford C, et al. The importance of choice in the rollout of ARV-based prevention to user groups in Kenya and South Africa: a qualitative study. J Int AIDS Soc. 2014 Sep 8;17(3Suppl 2). pmid:25224616
  63. 63. Koren DE, Nichols JS, Simoncini GM. HIV Pre-Exposure Prophylaxis and Women: Survey of the Knowledge, Attitudes, and Beliefs in an Urban Obstetrics/Gynecology Clinic. AIDS Patient Care STDS. 2018 Jul 23
  64. 64. Palummieri A, De Carli G, Rosenthal É, Cacoub P, Mussini C, Puro V, et al. Awareness, discussion and non-prescribed use of HIV pre-exposure prophylaxis among persons living with HIV/AIDS in Italy: a Nationwide, cross-sectional study among patients on antiretrovirals and their treating HIV physicians. BMC Infectious Diseases. 2017 Nov 28;17(1):734. pmid:29179700
  65. 65. Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR, Piot PK. Attitudes and acceptance of oral and parenteral HIV preexposure prophylaxis among potential user groups: a multinational study. PLoS ONE. 2012;7(1):e28238. pmid:22247757
  66. 66. European Centre for Disease Prevention and Control. Pre-exposure prophylaxis for HIV prevention in Europe and Central Asia. Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia– 2018/19 progress report. [Internet]. Stockholm: ECDC; 2019. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/HIV-pre-exposure-prophylaxis-evidence-2019_0.pdf