Characterizing Cis and Trans Women’s HIV Risk and Access to HIV Prophylaxis in Ontario, Canada

Introduction Despite the availability of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and PEP-in-Pocket (PIP), HIV rates among women continue to increase in Canada, and comparator countries have shown lower use of PrEP among women compared to men, along with a lower PrEP-to-need ratio. This cross-sectional survey-based study aimed to characterize women’s assessment of their HIV risk, along with their awareness of, and access to medication-based HIV prophylaxis. Methods The 52-question survey was distributed at 15 community-based organizations in Southern Ontario, Canada, including shelters, addiction treatment and recovery centres, women’s drop-ins, and women’s programming from June 2023 to February 2024. Eligible participants were self-identified women who were prophylaxis-naïve and either sexually active and/or using drugs. Women who identified as HIV-positive were excluded. Results 318 participants were recruited and completed the survey. Self-reported knowledge on HIV transmission, risk, prevention, and testing was high, and women reported multiple ways to decrease risk. 56.6% reported HIV risk factors, including 51.3% who reported one or more sexual risk factors, and 31.1% who reported at least one drug use risk factor. However, of the 302 participants who provided a response regarding self-assessed HIV risk, 93.7% assessed their HIV risk as low or average. Importantly, 48.7% were not aware of PrEP or PEP; 73.3% were not aware of PIP; and 89.0% and 87.8% had never been offered PrEP or PEP, respectively, although interest in both oral and injectable medication was high. Nearly half (48.4%) believed they would not qualify for PrEP, with multiple additional barriers cited, including not being at risk (40.9%), side effects (33.6%), affordability (26.1%), and perceived adherence challenges (17.0%). Discussion This study demonstrates that women’s self-perceived HIV risk is not congruent with objective HIV risk, based on sexual activity or drug use. Most women were not aware of HIV prevention medications and believed they would not be eligible. Of those who thought they would be eligible, less than one-third had been offered HIV prevention medications, although there was a high level of interest for both oral and injectable medication. Conclusion Multiple barriers were cited that limit women's access to HIV prevention medication, and objective risk did not match subjective risk. As such, intensified efforts are required to ensure women are aware of HIV prevention medication, including eligibility, and how to access. Furthermore, additional clinical, public health, and policy efforts are required to engage women in HIV prevention care and to ensure offerings are available.