Co-designing interventions with multiple stakeholders to address barriers and promote equitable access to HIV...

Black women are among the populations most underserved by HIV pre-exposure prophylaxis (PrEP) in England, despite higher risk of HIV acquisition. Previous research mostly focused on men who have sex with men (MSM), often neglecting Black women, and overfocused on patient-level barriers while overlooking provider and system-level factors. This study addresses these gaps by investigating barriers and facilitators to PrEP access by involving multiple stakeholders and exploring co-design strategies to tackle these barriers.

The study used a structured two-phased qualitative approach. In Phase 1, focus groups (FG) were undertaken across three stakeholder streams: Black women, healthcare professionals (HCPs), and a group combining Black women and HCPs. FG allowed for consensus-building exercises on key barriers and facilitators to PrEP access, and their transcripts were analysed via thematic framework analysis using the Capability, Opportunity, Motivation and Behaviour model of behaviour change. In Phase 2, co-design workshops were conducted with the same stakeholder groups to develop interventions targeting the barrier identified as most important using the Behaviour Change Wheel framework. Interventions were evaluated against the APEASE criteria.

Phase 1 identified six key barriers: HIV/PrEP knowledge gaps, restrictive policies, cultural stigma, healthcare system distrust, gendered relationship dynamics, and suboptimal PrEP use. Six facilitators emerged, including improved knowledge, increased accessibility, and addressing discrimination. All stakeholder groups voted for lack of awareness and knowledge as the priority barrier to address. All co-designed interventions consisted of a multimodal PrEP awareness campaign tailored to Black communities, with an emphasis on Black women's involvement to foster trust and engagement. However, the workshops produced different approaches, with Black women focusing on community-led initiatives, and HCPs advocating for government-backed, broader strategies despite known distrust of institutions.

This study highlights the importance of co-designing interventions with Black women to address multi-level barriers to PrEP access. It underscores the need for community education, healthcare system reforms, and the inclusion of Black women in decision-making processes to reduce PrEP equity gaps. The co-designed interventions provided a tailored, context-specific strategy that could improve PrEP uptake among Black women in England.