Medical Distrust and the Intention to Initiate Pre-Exposure Prophylaxis in Black Cisgender Women

Black women bear a disproportionate burden of the US HIV epidemic, compared with women of other racial groups. Pre-exposure prophylaxis (PrEP) is a highly effective prevention tool. Evidence indicates that Black women are interested in initiating PrEP, but low utilization persists in this population. Historical mistreatment of women of color and the resulting distrust erect barriers to communication and shared decision-making with health care providers. Using an institutional review board-approved questionnaire, we surveyed 186 adults (83% Black; 9% White; 3% American Indian/Alaskan Native; 4% Other) who were PrEP eligible, HIV seronegative, cisgender women in Washington, DC. We tested the interaction of patient racial identification and group-based medical mistrust on intentions to use PrEP, as mediated by intentions to discuss PrEP with a health care provider during the imminent clinical interaction. Results indicate significant moderated mediation of the interaction between race and distrust on intention to initiate PrEP at 3 months [index = -0.3093, standard error (SE) = 0.1886, 95% confidence interval (CI; -0.7455, -0.0122)] and 12 months [index = -0.3248, SE = 0.1987, 95% CI: (-0.7827, -0.0040)] through an anticipated discussion with a provider. When distrust is low, Black women had stronger intentions to utilize PrEP (relative to women of other racial groups). This was explained by stronger intentions to discuss PrEP with the provider during the clinical visit. These results underscore the critical importance of provider-initiated discussion of PrEP with women to improve health equity. This study was limited by the low number of non-Black participants (17%) as well as the requirement that subjects be English-speaking only.