One of the issues that cisgender women HIV advocates have long discussed is the concept of "risk." In most cases, public health epidemiologists use the term to characterize the likelihood of something happening -- such as risk of heart attack, diabetes, or HIV. The term is used even for heterosexual cisgender women, who may not present any of the common risk factors associated with contracting HIV (high number of sexual partners, drug use, sex work, etc.).
It's true that black women in the United States often don't present any traditional HIV risk factors, yet they are still nine times as likely to contract HIV as their white counterparts. The question is: Why?
A research study presented at the IDWeek conference on Oct. 5 in Washington, D.C., showed some of the factors associated with black women contracting HIV in Atlanta, Georgia, in order to better identify which women are most likely candidates for PrEP.
Determining Which Women Are Most Likely to Seroconvert
Researchers looked at data from one of the Fulton County sexual health clinics in downtown Atlanta (the city of Atlanta does not have its own health department). Forty percent of their clients are cisgender women, 91% are black, and the vast majority are uninsured. Researchers looked at the medical charts of all cisgender women who came to the clinic from 2011 through 2016, a total of nearly 19,000 women. They then divided the women into two groups.
The first group were women (18,171 in total) who visited the clinic one or more times, were HIV negative upon entry, and remained HIV negative as of December 2018. The second group were women (110 in total) who entered care HIV negative but seroconverted by December 2018. They used data from 80 women who seroconverted in the final analysis (30 women who seroconverted had no prior clinician-assisted visit in the study window).
Of the women who seroconverted, 93% were black, the median age was 32 years (although they were as young as 18 and as old as 55), and nearly half had seroconverted within two years of their initial visit. Nearly 21% contracted HIV in 2015, and more than half seroconverted from 2015 to 2018. The researchers' analysis found that women who had a history of syphilis, reported receptive anal sex, had injected drugs, or used crack were six times more likely to be diagnosed with HIV than women of similar race and age who didn't have those risk factors.
"The focus of our study was, how can we more effectively identify women who seek care at our sexual health clinic who may benefit from PrEP?" said Udodirim Onwubiko, M.B.B.S., M.P.H., an epidemiologist with the Fulton County Board of Health, who presented this study on behalf of her colleagues.
In 2017, Atlanta ranked number three in new HIV diagnoses among all U.S. metropolitan areas. Fulton County is also among the top three counties for people living with HIV in the state of Georgia. While 77% of all HIV diagnoses were among "males" in Atlanta, black women are 15 times more likely to contract HIV than white women. And reductions in the rates of HIV diagnoses among women in Atlanta have stalled in the last few years. With the Atlanta metro area being one of the areas chosen for federal action under the Ending the HIV Epidemic by 2030 plan, many women advocates are demanding more attention be paid to PrEP knowledge and access for cisgender women. A 2018 study showed that two-thirds of college-age black women had never heard of PrEP.
Fighting for Better PrEP Access for Black Women in Atlanta
Leisha McKinley Beach is an Atlanta-based activist who's been working to change that. In 2017, she helped launch the Atlanta Black Women Leaders on PrEP coalition, a group of women who work in HIV as providers and advocates to mobilize black women toward getting more information and tools to black women -- including better access to PrEP. Many black women feel as though the've been left without access to this prevention tool due to the heavy focus of resources and information on gay men.
"Nearly 40 years in this epidemic, women have consistently been in the background as an 'after-thought' and that has to stop!" wrote Beach in a long Facebook post on Oct. 6 about the disparities in PrEP access for women. "We don't get to the end of the HIV epidemic without including strategies and resources to prevent new diagnoses among women. Decisions that are made to include some groups and not others send a message that our lives as women don't matter."
Beach was responding to news a few days prior that the Food and Drug Administration (FDA) had approved the HIV drug Descovy (emtricitabine/tenofovir alafenamide) for PrEP -- but only for cisgender men and transgender women. Drug developer Gilead Sciences did not conduct research to determine how Descovy functions vaginally and whether it would be protective for vaginal intercourse. Instead, white men were the vast majority of the group in the DISCOVER trial for Descovy as PrEP that led to the FDA approval.
The FDA issued a notice after the approval that Gilead had committed to doing studies to determine safety and efficacy for women. Although Truvada (FTC/tenofovir disoproxil fumarate) as PrEP is currently approved for women, the fact that it takes longer to work in the vagina than the rectum has been an issue, and many advocates have been demanding more prevention products that work equally well in the vagina.
In the same Oct 6. Facebook post, Beach listed a series of action steps from Atlanta Black Women Leaders on PrEP to address these issues. These include:
- Developing a risk-assessment tool for providers.
- Requesting that Gilead conduct a Descovy study prioritizing recruitment of black women and create marketing campaigns to reach black women.
- Continuing to educate local OB-GYNs about PrEP and how to discuss it with their patients.
- Supporting black transgender women advocates on their specific needs as they pertain to PrEP education and access.
Though Atlanta Black Women Leaders on PrEP's action items were posted separately from the presentation of this research study at IDWeek, it seems that the Fulton County Board of Health plans to use these findings to support scaling up PrEP in its downtown clinic and beyond.
"It's important for us to look at if a woman has a history at all of syphilis, if the woman has any history or mention of injection drugs, or crack cocaine or anal sex at all at any time -- [it] is important to look at this question to see if this person is a candidate for PrEP," said Onwubiko. "We also want to use this as a baseline study to do a more robust HIV prevention study amongst women in similar practices like ours in the U.S. South."