Closing the PrEP Gap in Gynecology

2021 was a big year for me. It was the year of my first pregnancy, and meeting with an Obstetrician (OB) and a Gynecologist (GYN) came with mixed feelings. There were so many changes happening in my body, and I needed a professional who could explain it all in plain, simple terms. I went in ready to discuss anything about my reproductive health and pregnancy, but when I finally sat down with the doctor, I found myself holding back the questions I wanted to ask.

The truth was that I didn’t feel comfortable discussing certain things with a male doctor. A 2017 study in the National Library of Medicine found that 53.2% of patients preferred a female OB-GYN, and 38.5% admitted no gender preference. I wanted someone I was comfortable with, someone who understood my experience, and someone I could trust.  

For me, the barrier was gender. For many Black women in the US, the barrier is race, because Black OB-GYNs understand our cultural experiences in ways others may not. In 2024, NBC News reported that Black women prefer Black OB-GYNs because of the fear of discrimination. The American College of Obstetricians & Gynecologists (ACOG) said Black women don’t get the same quality of care as White women, with racism being a significant reason. Because so many Black women have experienced a lack of trust with their OB-GYNs, even outside of pregnancy, we often feel uncomfortable asking questions for fear of being judged. This includes essential questions about HIV and other STIs—and the education and prevention strategies we deserve but may hesitate to request.

Even though Black women are disproportionately affected by HIV—Georgetown University reports that Black women account for 10% of new HIV cases in the US despite making just 7% of the entire population—the conversation of PrEP (pre-exposure prophylaxis) has hindered our routine reproductive and maternal care because of mistrust, stigma, preference, and negative experience with healthcare providers.

Why Lack of Counseling is Dangerous

PrEP is a once-daily pill or shot that significantly reduces HIV risk if taken as prescribed. The Centers for Disease Control and Prevention reports that PrEP is ideal for people who have repeated STIs,  partner with HIV, or engage in transactional sex. Since many women are very mindful of their bodies, counseling during routine reproduction and maternal care can only happen if they are comfortable with the doctor; otherwise, it will hamper how they communicate. Here is why this is a big deal:

• Missed Access Point:

Many Black women see their OB-GYN more often than a primary care provider, especially for contraception and prenatal care. These visits are ideal to assess HIV risk and offer prevention services. Still, OB-GYNs rarely initiate conversations about PrEP. When they do, patients shove it up because they don’t feel comfortable discussing such with the doctor, hence missing a vital opportunity for discussing PrEP and HIV. This missed opportunity is alarming because, as the Office of Minority Health reveals, Black women are >3.5 times more likely to be diagnosed with HIV and >4 times more likely to have an AIDS prevalence rate when compared to other races in the US.

• Structural and Knowledge Barriers in Clinics:

Many OB-GYNs are not explicitly trained in PrEP. This insufficient knowledge and training are a significant barrier to PrEP access for women, according to Mary Ann Liebert. Many OB-GYNs are uncertain about prescriptions, monitoring, billing, and insurance for PrEP, which has led to fewer conversations that would have benefited many women. AIDSVu disclosed that only 8% of women use PrEP in the US, while men make up 92%.

If these issues are not addressed, millions of women in our community, who would benefit from a highly effective prevention tool, would miss out.

Making PrEP Counseling in Reproductive and Maternal Care Effective

Integrating PrEP counseling into routine OB-GYN helps prevent maternal HIV acquisition and eliminate mother-to-child HIV transmission. Here are practical steps and policy actions that can make PrEP a routine part of reproductive and maternal health effectively:

1. Women’s Comfort and Preference Should Come First:

Texas Children’s suggests that representation is essential; and Black women benefit from Black physicians. Additionally, if a woman prefers a specific gender, as in my own case, let that be an option. As a woman, you must become your own advocate. If you are not comfortable with your doctor at any stage, it is your responsibility to ask for and research another. When a woman is comfortable with a doctor, she will be more open and receptive to the doctor’s advice.

2. Routine Risk Screening at Visit:

Evidence from ScienceDirect shows that clinic-based interventions can increase counseling. Inclusion of brief standardized questions about STI history, injection drug exposure, sexual partners and their HIV status, and interest in HIV prevention during the doctor visit can lay the ground for discussing PrEP and HIV counseling.

3. Train and Empower Clinicians:

A deliberate effort should be made in training and educating physicians, residents, and nursing staff on:

• Who is eligible for PrEP
  • How to counsel about the benefits and side effects of PrEP
  • How to get baseline labs and follow-up testing
  • Billing and documentation practice

This training equips healthcare workers with the necessary tools to address questions and other issues that may arise during counseling.

4. Use Patient-Facing Education and Normalize Discussions:

Displaying concise, culturally sensitive materials in waiting rooms and exam rooms can be highly effective. And I don’t mean materials that display only pictures of white doctors and patients or doctors of a specific gender. This material can explain what PrEP is, who it benefits, and how to take it. OB-GYNs can encourage Black women to review the materials. 

It is important to note that as long as OB-GYNs miss opportunities to discuss PrEP and HIV with their patients, the rate of HIV transmission will continue to increase in our community. At Elevate Black Health, we emphasize that Black women have specific preferences regarding whom they feel comfortable discussing their health challenges and concerns with. These preferences should not be overlooked, as honoring them may be key to increasing PrEP uptake and reducing the spread of HIV within our community.

You’ll find these resources useful:

1. Ob-Gyn Gender Preferences of Gynecology Ambulatory Patients and Students’ Choice of the Specialty. https://pmc.ncbi.nlm.nih.gov/articles/PMC10309398/
2. ‘I was terrified’: Black women may prefer Black OB-GYNs due to fear of discrimination, dying during pregnancy. https://www.nbcnews.com/health/health-news/black-woman-may-prefer-black-obs-due-fear-discrimination-dying-pregnan-rcna138456
3. What I’d Like Everyone to Know About Racism in Pregnancy Care. https://www.acog.org/womens-health/experts-and-stories/the-latest/what-id-like-everyone-to-know-about-racism-in-pregnancy-care
4. Discrimination, resilience, and HIV testing frequency among black women seeking services from STD clinics. https://www.sciencedirect.com/science/article/abs/pii/S0277953622006505
5. The Forgotten Community: Black Women Weathering the Waves of HIV. https://oneill.law.georgetown.edu/the-forgotten-community-black-women-weathering-the-waves-of-hiv/
6. Clinical Guidance for PrEP. https://www.cdc.gov/hivnexus/hcp/prep/index.html
7. Impact of Trump’s HIV Medication Ban. https://www.elevateblackhealth.com/impact-of-trumps-hiv-medication-ban/
8. HIV/AIDS and Black/African Americans. https://minorityhealth.hhs.gov/hivaids-and-blackafrican-americans
9. Finding a Support Network After an HIV Diagnosis. https://www.elevateblackhealth.com/finding-a-support-network-after-an-hiv-diagnosis/
10. Assessing Barriers in Obstetrics and Gynecology Trainee Knowledge and Prescribing of HIV Pre-Exposure Prophylaxis in a High-Risk Community. https://www.liebertpub.com/doi/10.1089/whr.2024.0123
11.  AIDSVu Releases New Data Showing Significant Inequities in PrEP Use Among Black and Hispanic Americans. https://aidsvu.org/news-updates/prep-use-race-ethnicity-launch-22/
12. Revisiting HIV/AIDS Prevention in Black Community. https://www.elevateblackhealth.com/revisiting-hiv-aids-prevention-in-black-community/
13. Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland. https://www.sciencedirect.com/science/article/abs/pii/S0002937823005185
14. Representation Matters: Why Black Women Benefit from a Black Physician. https://www.texaschildrens.org/content/wellness/representation-matters-why-black-women-benefit-from-black-physician