The THRIVE demonstration project was supported by the U.S. Department of Health and Human Services Minority HIV/AIDS Fund (CDC RFA-PS15–1509). This project was determined by the CDC to be exempt from IRB approval. Data from THRIVE were collected from 2015 to 2020 in seven funded jurisdictions: Birmingham, Alabama; Baltimore City, Maryland; Washington, DC; New Orleans, Louisiana; Brooklyn, New York; Philadelphia, Pennsylvania; and Hampton Roads, Virginia. For all THRIVE jurisdictions, the key PrEP implementation activities were the formation of a community collaborative of multi-disciplinary health care professionals, laboratory-based HIV antigen–antibody testing, establishment of PrEP-navigation programs, and linkage to and provision of PrEP.¹⁰

A THRIVE client was any person aged 18 years or older who received at least one THRIVE-funded service. A unique study identification for each THRIVE client was used to mark enrollment and all subsequent follow-up encounters. For STI testing, each test was recorded with a client identification, the test date, test name and time, and test result. Longitudinal client-level data were deidentified and reported to the CDC. Data related to demographic characteristics such as age, sex, gender, race and ethnicity, and health insurance status were collected during their initial assessment and enrollment in THRIVE. Age categories were 18–29, 30–39, 40–49, 50–59, 60–64, and 65 years or older. Race and ethnicity categories were Black, White, Hispanic or Latino (any race), and other race (including individuals who identified as American Indian or Alaska Native, Asian, Hawaiian or Pacific Islander, multi-racial, another race, or unspecified race or ethnicity). Human immunodeficiency virus status for THRIVE clients at enrollment was categorized as having either a known positive or negative HIV test result, including tests conducted at the initial visit, or an unknown HIV status. Positive STI test results included as a positive test result for syphilis, gonorrhea, or chlamydia at any time during THRIVE. Pre-exposure prophylaxis services were identified as an individual’s having been screened and deemed eligible for PrEP and receipt of subsequent steps along the continuum, that is, referred to a PrEP clinician, linked to a PrEP clinician, and being prescribed PrEP medication. The screening and eligibility criteria for PrEP were locally defined by THRIVE jurisdictions. Referral to PrEP was defined as the process by which clients received information about PrEP and how to access PrEP services from a clinician. Linkage to PrEP was defined as the outcome of the referral to a PrEP clinician, as indicated by attending an appointment at which PrEP services were offered. Prescription of PrEP was defined by evidence of a PrEP prescription by a health care clinician.

Although the programmatic services of this project focused on men who have sex with men and transgender women, the current analysis is restricted to THRIVE clients who reported sex assigned at birth as female and self-identified their current gender as female. We used the Fisher exact test to compare proportions of Black women and Hispanic or Latina, White, or women of additional races and ethnicities stratified by age group, STI testing and infections, HIV status during initial assessment, and the five steps of the PrEP service continuum (screening, eligibility, referral, linkage, and prescription).¹¹ We summarized the number of Black women who were screened and eligible for PrEP among those with a negative HIV test result or assumed negative HIV status at the time of THRIVE enrollment; among Black women who were eligible for PrEP, we summarized the number referred, linked, and prescribed PrEP. Missing continuum data were categorized as service not received, except when services received later in the continuum were imputed into earlier steps (eg, PrEP screening must have occurred if PrEP prescription occurred).

Among Black women, we used multiple logistic regression to estimate adjusted odds ratios and 95% CIs for associations of age, syphilis infection, and gonorrhea infection with receipt of four PrEP services: screening, referral, linkage, and prescription. We did not include PrEP eligibility as a service step in our series of logistic models because eligibility depends on participant characteristics rather than receipt of a PrEP service.⁵

From 2015 to 2020, THRIVE served a total of 12,647 women: 8,758 (69.2%) Black women, 1,691 (13.4%) Hispanic or Latina women, 1,413 (11.2%) White women, and 785 (6.2%) women from additional racial and ethnic groups (Table 1). Among all women served in THRIVE, nearly half (n=6,215, 49.1%) were aged 18–29 years; Black women were more likely than others to be younger than age 30 years or 50 years or older. During the THRIVE project, 9,866 women (78.0%) received STI test results, with 291 (2.9%) positive for syphilis only, 438 (4.4%) positive for gonorrhea only, 407 (4.1%) positive for chlamydia only, and 105 (1.0%) positive for two or all three of these infections. Black women were more likely to test positive for each infection (Table 1).

At the time of enrollment in THRIVE, 447 women (3.5%) were known to be HIV-positive, with a proportion twice as high among Black women (4.2%) compared with non-Black women (2.1%). Seven women were newly diagnosed with HIV infection in THRIVE: six Black women, and one White woman (not shown in Table 1). Among 12,200 women not known to have HIV, 9,886 (81.0%) were screened for PrEP, of whom 3,876 (39.2%) were deemed to be eligible for PrEP. Black women were more likely than non-Black women to be screened (88.4% vs 64.9%) but less likely to be found eligible (37.8% vs 43.3%). Among women who were eligible for PrEP, 3,525 (90.9%) were referred to a PrEP clinician, but of these, only 390 (11.1%) were linked to a PrEP clinician. Among women who were referred, 282 (8.0%) were reported to have received a PrEP prescription. Further breakdown of non-Black race and ethnicities is presented in Appendix 1, available online at http://links.lww.com/AOG/D497.

Among the 8,392 Black women not known to have HIV infection before enrolling in THRIVE, 7,415 (88.4%) were screened for PrEP eligibility, and 2,805 (33.4%) were found to be eligible (Fig. 1). Among Black women who were eligible for PrEP, 2,538 (90.5%) were reported to be referred to PrEP services, but only 270 (9.6%) were reported as being linked to a PrEP clinician, and 190 (6.8%) were reported to be prescribed PrEP. Corresponding data for the PrEP service continuum for non-Black women are presented in Table 1 and Appendix 1 (http://links.lww.com/AOG/D497).

In multiple logistic regression among Black women, those with a syphilis diagnosis were more likely to be screened for PrEP eligibility (adjusted odds ratio [aOR] 5.2, 95% CI, 2.3–11.7), and all women with a gonorrhea diagnosis were screened (Table 2). Black women aged 30 years or older were significantly less likely to be screened for PrEP eligibility than those aged 18–29 years. Among those found to be eligible, only 53.3% of women with syphilis were referred compared with 92.1% of those without (aOR 0.09, 95% CI, 0.06–0.13) and 77.2% of those with gonorrhea compared with 91.4% among those without (aOR 0.27, 95% CI, 0.19–0.40). No differences were observed in PrEP referrals by age group.

Among Black women who were referred, those with syphilis (aOR 2.02, 95% CI, 1.06–3.86) or gonorrhea (aOR 1.64, 95% CI, 1.01–2.68) were more likely to be linked to PrEP services, as were women in their 30s and 40s. Among Black women who were linked to a PrEP clinician, there were no statistically significant differences in prescription of PrEP by syphilis or gonorrhea infection or by age group. Ultimately, among the 219 Black women diagnosed with syphilis, only 10 (4.6%) were prescribed PrEP, and among 407 with gonorrhea, only 11 (2.7%) were prescribed PrEP. Unadjusted odds ratios are presented in the Appendix 2 (available online at http://links.lww.com/AOG/D497).

Our goal with this article was to describe the PrEP continuum among Black women within the context of a large, national program and, in doing so, to identify gaps that can inform clinicians and public health practitioners where multiple strategies are needed to improve uptake of PrEP services. The THRIVE demonstration project provided PrEP and other services, including STI testing, to more than 12,000 women. THRIVE enrolled almost 9,000 Black women, a population prioritized for HIV prevention because of the high rates of HIV diagnoses in the group. In our study, we found that Black women were more likely to be diagnosed with an STI, including HIV. Our findings are consistent with national surveillance data indicating that Black women are disproportionately affected by HIV and STDs.^1,2

Among THRIVE participants, although 90% of Black women were screened and referred to PrEP services, fewer than 10% who were eligible were reported to be linked to a PrEP clinician, and only 7% were reported to be prescribed PrEP. The number of individuals with PrEP indications is higher among those in racial and ethnic minority groups, yet PrEP uptake has been low in these populations.^12,13 The small proportion of Black women who were prescribed PrEP in THRIVE has important public health implications for HIV prevention among Black women.¹³

As expected, Black women diagnosed with syphilis or gonorrhea were more likely than those without these STIs to be identified as eligible for PrEP. Unfortunately, these women with syphilis or gonorrhea who were eligible for PrEP were less likely to be referred to PrEP services. In THRIVE, the proportion of Black women who were eligible for PrEP and prescribed PrEP (7.0%) was much smaller compared with the proportion of Black and Hispanic men who have sex with men (37.0%) and transgender women (45.0%) who were eligible for PrEP and prescribed PrEP.¹¹ This may have been a result of the focus in THRIVE to support PrEP use by Black and Hispanic men who have sex with men and transgender women. Although THRIVE was very successful in reaching Black women to provide HIV and STI testing, our finding suggests that opportunities were missed to increase PrEP use by Black women. Interventions and activities that are developed specifically for women would likely increase their use of PrEP.

Increasing PrEP uptake is a pillar of the EHE (Ending the HIV Epidemic in the U.S.) initiative.^13,14 Focused efforts are needed to address the low use of PrEP among Black women.^12,13,15 Data from our study highlight a large gap in service delivery between Black women who were referred to a PrEP clinician and who were ultimately prescribed PrEP. Qualitative research has identified barriers that may be contributing to this PrEP service gap.¹⁶ One barrier may be the lack of awareness among Black women that PrEP is an effective prevention tool available to them.^17,18 Awareness of PrEP increases interest in PrEP use.^16–19 Increased PrEP promotion and its benefits and PrEP navigation services designed specifically for women are needed to help increase PrEP uptake among Black women along the continuum, ie, referred to a PrEP clinician, linked to a PrEP clinician, and being prescribed PrEP medication.¹⁹

Perceived HIV risk is another barrier that limits Black women’s uptake of PrEP.²⁰ Studies show that Black women with a diagnosed STI^16,20 who are aware of their risk for HIV infection were more likely to be interested in PrEP.²¹ In THRIVE, Black women with a diagnosed STI (syphilis or gonorrhea) were substantially more likely to be screened for PrEP and, among those referred to PrEP, were more likely to have evidence of being linked to PrEP services, ie, attending an appointment at which PrEP services were offered. This finding in our study is encouraging because it suggests that women who are made knowledgeable about PrEP and understand its role in promoting their sexual health can have increased intention to use PrEP.^15–22 However, in our study, Black women with a diagnosed STI were less likely than Black women without an STI to be referred for PrEP services, indicating a missed opportunity for PrEP promotion and population-specific strategies to increase awareness of the effectiveness of PrEP for HIV prevention.

Although there may be interest in and intent to use PrEP, other barriers to PrEP initiation could account for the low percentage of Black women prescribed PrEP in THRIVE. Issues related to the health care experience—medical mistrust and stigma, lack of support by family and social networks for PrEP use, and concerns about PrEP side effects and the need for adherence—may be barriers.^{16,18,19,23–27} In THRIVE, community collaboratives were established to ensure clinical, behavioral health, and essential support service practitioners to provide comprehensive services for Black and Hispanic men who have sex with men and transgender women. Although these services were available to all THRIVE clients, they were designed specifically for the needs of men who have sex with men and transgender women. To increase PrEP use by Black women, strategies are needed to decrease the effects of stigma, gender discrimination, and structural racism on the provision and uptake of PrEP at both the structural and interpersonal levels.²⁴

In 2019, the CDC initiated services in STI clinics to scale up HIV-prevention services, a venue that provides sexual health services for women in diverse racial and ethnic communities. In 2020, the Minority HIV/AIDS Fund committed to invest in under-resourced STI clinics,²⁸ and these resources can bolster PrEP programs for women in this setting. Pre-exposure prophylaxis services are easily provided not only by infectious disease specialists but also by a woman’s own preferred and trusted obstetrician, gynecologist, or primary care physician. Many resources are available to support clinicians to prescribe PrEP, including CDC PrEP guidelines⁵ and the National Clinical Consultation Center PrEP warmline.²⁹

Additional efforts are needed to support the use of STI diagnoses reported to health departments to identify and link individuals to PrEP services, similar to the model used by disease intervention specialists to identify and link individuals with syphilis or HIV infection to treatment and care. Furthermore, the use of community-to-clinic models with women-serving community-based organizations providing education and referral to PrEP services and co-location of HIV testing and PrEP clinical services could support increasing PrEP use among Black women.³⁰

The THRIVE project and the data we used in this analysis are subject to limitations. We may have underestimated the proportion of Black women prescribed PrEP if they received PrEP services from a clinician not included in the THRIVE collaborative. The availability of resources, partnerships, and service capacity within each collaborative varied by jurisdiction. Jurisdictions were not required to provide outreach or dedicated resources to assist Black women to navigate PrEP care. Furthermore, jurisdictions conducted screenings and determined eligibility for PrEP on their own. We were unable to assess whether sites adhered to the same eligibility criteria for PrEP for each THRIVE client. However, results from our study are likely similar to PrEP services available for women in other U.S. jurisdictions, given the low proportion of women with indications who were prescribed PrEP.¹² Our results may not be generalizable to other jurisdictions with lower HIV diagnosis rates compares with THRIVE jurisdictions. Finally, the COVID-19 public health emergency was in effect for the last 6 months of THRIVE data collection. Health care venue closures and stay-at-home orders likely disrupted THRIVE services.

Although THRIVE activities were focused on increasing HIV-prevention services for Black and Hispanic men who have sex with men and transgender women, THRIVE also served Black women. THRIVE provided a robust sample of Black women who sought services in the THRIVE collaboratives. Only a small proportion of Black women who were eligible for PrEP in THRIVE were ultimately linked and prescribed it. In the THRIVE project, many opportunities to prescribe PrEP for women with STI diagnoses were missed. Multiple strategies are needed to improve uptake of PrEP. Our findings underscore the need to prioritize HIV prevention among Black women and to implement strategies to improve their knowledge of and access to PrEP. To achieve the goals of the EHE initiative, it is essential to focus tailored interventions and strategies to reduce barriers to PrEP uptake and adherence among Black women in the United States.