Pre-Exposure Prophylaxis Cascade Outcomes Among Black Cisgender Women in the Southern United States

Black cisgender women in the Southern United States experience disproportionate human immunodeficiency virus (HIV) rates. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool but is underutilized in this population. We assessed PrEP cascade outcomes and correlates among Black women in the Southern United States. Between March and June 2022, we administered a cross-sectional online survey to Black cisgender women residing in the Southern United States who reported unprotected sex in the past 6 months and were negative for HIV by self-report. Participants provided information on sociodemographic characteristics, HIV knowledge, PrEP awareness and use, psychosocial factors, and health care access. We used descriptive statistics and multivariate logistic regression models to describe the sample and assess the correlates of PrEP outcomes, respectively. Participants included 491 Black women, with a mean age of 40.1 years (SD: 17.5); 53% had a college degree or lower, and 79% were single. PrEP awareness was 39.5%, willingness 25.7%, and current use only 5.5%. The factors associated with PrEP awareness included younger age (aOR = 1.02, 95% CI: 1.01-1.03), higher education (aOR = 1.68, 95% CI: 1.09-2.60), medical trust (aOR = 1.09, 95% CI: 1.03-1.15), binge drinking (aOR = 1.77, 95% CI: 1.06-2.94), and HIV testing in the past year (aOR = 1.55, 95% CI: 0.98-2.45). The PrEP willingness predictors included HIV testing in the past year (aOR = 1.80, 95% CI: 1.11-2.90) and HIV worry (aOR = 1.84, 95% CI: 1.09-3.09). HIV testing emerged as a key facilitator for both PrEP awareness and willingness, suggesting that testing encounters represent critical opportunities for PrEP integration. PrEP strategies should address both individual-level factors and structural barriers, particularly medical trust within health care systems.