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Original research
Risk perception, safer sex practices and PrEP enthusiasm: barriers and facilitators to oral HIV pre-exposure prophylaxis in Black African and Black Caribbean women in the UK
  1. Sarah E Nakasone1,
  2. Ingrid Young2,
  3. Claudia S Estcourt3,
  4. Josina Calliste4,
  5. Paul Flowers5,
  6. Jessica Ridgway6,
  7. Maryam Shahmanesh7,8
  1. 1 University of Chicago, Chicago, Illinois, USA
  2. 2 Centre for Biomedicine, Self and Society, Usher Institute, University of Edinburgh, Edinburgh, UK
  3. 3 School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
  4. 4 PrEPster, London, UK
  5. 5 MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
  6. 6 Department of Medicine, University of Chicago, Chicago, Illinois, USA
  7. 7 Institute for Global Health, University College London, London, UK
  8. 8 Africa Health Research Institute, Durban, South Africa
  1. Correspondence to Sarah E Nakasone, University of Chicago, Chicago, IL 60637-5418, USA; sarah.e.nakasone{at}


Objectives UK Black African/Black Caribbean women remain disproportionately affected by HIV. Although oral pre-exposure prophylaxis (PrEP) could offer them an effective HIV prevention method, uptake remains limited. This study examined barriers and facilitators to PrEP awareness and candidacy perceptions for Black African/Black Caribbean women to help inform PrEP programmes and service development.

Methods Using purposive sampling through community organisations, 32 in-depth, semi-structured interviews were conducted with Black African/Black Caribbean women living in London and Glasgow between June and August 2018. Participants (aged 19–63) included women of varied HIV statuses to explore perceptions of sexual risk and safer sex, sexual health knowledge and PrEP attitudes. A thematic analysis guided by the Social Ecological Model was used to explore how PrEP perceptions intersected with wider safer sex understandings and practices.

Results Four key levels of influence shaping safer sex notions and PrEP candidacy perceptions emerged: personal, interpersonal, perceived environment and policy. PrEP-specific knowledge was low and some expressed distrust in PrEP. Many women were enthusiastic about PrEP for others but did not situate PrEP within their own safer sex understandings, sometimes due to difficulty assessing their own HIV risk. Many felt that PrEP could undermine intimacy in their relationships by disrupting the shared responsibility implicit within other HIV prevention methods. Women described extensive interpersonal networks that supported their sexual health knowledge and shaped their interactions with health services, though these networks were influenced by prevailing community stigmas.

Conclusions Difficulty situating PrEP within existing safer sex beliefs contributes to limited perceptions of personal PrEP candidacy. To increase PrEP uptake in UK Black African/Black Caribbean women, interventions will need to enable women to advance their knowledge of PrEP within the broader context of their sexual health and relationships. PrEP service models will need to include trusted ‘non-sexual health-specific’ community services such as general practice.

  • ethnicity
  • gender
  • HIV
  • HIV women
  • PREP

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  • Handling editor Tristan J Barber

  • Twitter @sarahnakasone, @ingridkyoung, @PaulFlowers1

  • Contributors SEN, IY, CSE, PF, JR and MS designed the research study. SEN, MS, IY and CSE conceived the paper and designed the analysis plan. SEN led the analysis with contributions from IY, CSE, JC and MS. SEN led the drafting of the manuscript. All authors read, critically reviewed and approved the final manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was received from the University of Chicago’s Biological Sciences Division Institutional Review Board (Ref IRB18-0622).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. De-identified manuscripts are available on reasonable request to the corresponding author.

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