Persistent disparities in HIV diagnoses in the United States, driven by racism, stigma, discrimination, poverty, and other social determinants of health, must be addressed. Cisgender women account for 19% of all new HIV infections; however, racial disparities continue to affect Black cisgender women, who account for 57% of the new HIV diagnoses among cisgender women in the United States (Centers for Disease Control and Prevention [CDC], 2022). These disparities are pronounced in the South, a region where more than half (55%) of new HIV diagnoses occur among Black Americans (CDC, 2019). Efforts to address these disparities within the context of the lived experience of Black cisgender women are limited.

Pre-exposure prophylaxis (PrEP) is a pill that, when taken daily, has proven to be 99% effective at preventing HIV infection. Pre-exposure prophylaxis has been approved by the Federal Drug Administration (FDA). The FDA has approved PrEP for over a decade, and it has been highly marketed and used by men who have sex with men. However, PrEP uptake since the FDA approval has been low among cisgender women, more specifically, Black cisgender women (Bradley et al., 2019; Mayer et al., 2020). Efforts to improve PrEP messaging, decrease stigma, promote trust, and increase PrEP uptake for this population are urgently needed.

In 2019, only 10% of US women who could benefit from PrEP were prescribed PrEP (CDC, 2021). Black women represent just 26% of female PrEP users while constituting 57% of new infections among women (Huang et al., 2018). Black women vulnerable to heterosexual HIV acquisition have not significantly benefited from PrEP, which may have been partially responsible for recent reductions in new HIV infections among gay, bisexual, and other men who have sex with men. Barriers to PrEP uptake (i.e., low perceived risk of needing PrEP, no or limited awareness and knowledge of PrEP, PrEP trust, and PrEP stigma) have been widely documented with limited strategies to overcome these barriers for Black cisgender women (Hirschhorn et al., 2020; Johnson, Myers, et al., 2021; Kurek et al., 2022; Lambert et al., 2018). As a result, Black cisgender women remain underrepresented in PrEP research and uptake intervention in real-world settings, despite having disproportionately higher risks for HIV acquisition.

Effective interventions to facilitate PrEP uptake are needed. Various modes of education, such as eHealth and motivational interviewing, have successfully increased knowledge and interest in taking PrEP (Bond & Ramos, 2019; Dale, 2020; Teitelman et al., 2020,2021). However, in a recent scoping review, most studies assessed knowledge, attitudes, and intention but did not implement interventions to change knowledge, attitudes, or practices (Conley et al., 2022). Experimental and observational studies introducing culturally responsive innovative interventions are needed. Gender and culturally relevant interventions are needed to improve knowledge, awareness, and uptake of PrEP among Black women who are informed by Black women and their communities and implemented within a trusted environment.

Social support from one's social networks plays a crucial role in determining to take and maintain adherence to PrEP (Randolph et al., 2021). To this end, leveraging the social networks of Black women within trusted environments, such as beauty salons, have been reported by Black cisgender women as an acceptable implementation strategy to improve PrEP stigma, trust, and uptake. Salons and stylists provide a unique opportunity for women to increase awareness to PrEP, not only for themselves, but for networks of women that they associate with and influence (Johnson, Green, et al., 2021; Randolph et al., 2021). In a qualitative study with Black cisgender women customers who frequent the beauty salon, salon owners' and hair stylists' results indicated that, across all subgroups, a salon-based intervention to promote awareness and uptake of PrEP was feasible and acceptable. Social networks and trusted spaces have a critical role in determining women's decisions to start PrEP. Integrating evidence-based implementation strategies, such as engagement of beauty salons, opinion leaders training, educational videos, and nonclinical health care delivery mechanisms, offer culturally and socially relevant options to improve PrEP uptake among Black cisgender women (Johnson, Myers, et al., 2021).

Evidence-based intervention “d-up: Defend Yourself!” by the Centers for Disease Control (CDC) enlists trusted community members whose advice is respected to serve as opinion leaders. D-up! is aimed at Black, same-sex loving men and uses opinion leaders to change social norms regarding condom use to prevent HIV (Jones et al., 2008). Adapting this evidence-based intervention for training of beauty salon stylists as opinion leaders about women's health and PrEP has been found promising. There is evidence that stylist and customer confidence increase when stylists undertake training to share information. However, only a single study conducted in Brazil has evaluated such a training program for beauty salon professionals (Bassett et al., 2019). Edutainment videos, eHealth, and mHealth are preferred evidence-based intervention strategies for health promotion and HIV prevention among Black women in delivering of HIV prevention messaging (James et al., 2016; Johnson, Myers, et al., 2021).

Grounded in transportation theory, the educational videos were created by the researchers as “edutainment” videos, which are designed to entertain while communicating prosocial norms and behaviors. Transportation theory provides a lens for understanding the concept of media enjoyment. The theory suggests that enjoyment can benefit from the experience of being immersed in a narrative world and from the consequences of that immersion. Consequences implied by transportation theory include connections with characters and self-transformations. Videos have been used effectively to communicate HIV risk reduction and promote sexual health among Black women using smartphone-delivered culturally relevant content, such as a dramatic play to increase awareness and knowledge of HIV produced for a Black community (Bond & Ramos, 2019).

In partnership with Black cisgender women, stylists, and an established community advisory council, we co-developed Using PrEP and Doing it for Ourselves (UPDOs) Protective Styles: Using PrEP and Doing It for Ourselves, a salon and web-based intervention designed to increase PrEP uptake among Black cisgender women. In a pilot test, we engaged Black cisgender women in the web-based intervention accessible in the beauty salon setting. This article aims to report the preliminary results of the intervention in improving PrEP knowledge and awareness, PrEP stigma, PrEP trust, and PrEP intentions and uptake among women engaged in the study.

Methods Sample and Setting

This project was funded in October 2020 by Gilead Sciences, Inc. and approved by the institutional review board in April 2021. This multicomponent, mixed-methods study used a community-engagement approach to develop and pilot test a salon-based intervention, UPDOs. Study procedures were previously reported (Randolph et al., 2022). Eligibility criteria included (a) age 18 years or older, (b) frequency of visiting the salon at least every 2 weeks, (c) self-identification as Black or African American, (d) self-identification as a woman, and (e) ability to speak and read English.

Procedures

Using PrEP and Doing it for Ourselves consists of three components: (a) stylist training, (b) women-focused edutainment videos and modules, and (c) engagement of PrEP Navigator. Virtual or face-to-face stylist trainings were provided to beauty salon stylists in the community who saw primarily Black women as their clientele. A pretest–posttest design was used to examine knowledge and awareness improvement of PrEP among stylists. Upon full completion of training, stylists received a certificate of completion and “Ask Me about PrEP” signage for their beauty salons to facilitate conversations with women. Second, together with the community, an edutainment series (The Wright Place) was co-developed with Black women and an established community advisory council (Randolph et al., 2022). The series uses culturally and socially relevant stories to highlight key messages about (a) HIV, (b) PrEP, and (c) Black women's social contributors to health. UPDOs Protective Styles considers the complex interplay between individual, relationship, and community factors that can influence decision making for women to start PrEP. Quantitative measures were used in a pretest–posttest design to examine PrEP knowledge, awareness, risk, stigma, trust, and intentions.

Ethical Considerations

The Duke University School of Nursing Institutional Review Board provided study approval in April 2021 (Pro00106307). All study participants read the electronic consent form, were allowed to reach out to the study team to have any questions addressed, and advised that participation was voluntary. Informed consent was obtained from all study participants when accessing the intervention site. This study used unique identification numbers to help protect the confidentiality of study participants; participant names were not used on any study-related forms.

Measures

Measures were administered online through REDCap electronic data capture tools hosted by the Duke University School of Nursing (Harris et al., 2009,2019). Demographic characteristic questions were collected at Pretest and included gender, race, ethnicity, state, transgender, age, highest level of education completed, expected annual household income for the past year, marital status, and sexual orientation questions. Communication preferences were also collected to coordinate intervention access and data collection. Pretest and posttest measures included PrEP knowledge, stigma, trust, intentions, and risk.

Pre-exposure prophylaxis knowledge and awareness

Pre-exposure prophylaxis knowledge and awareness were measured with an adapted 2 items (Chandler et al., 2020). Awareness was measured with the item, “Before this study, had you ever heard of PrEP?” (yes or no) and extent of knowledge with the item, “What is your knowledge of PrEP?” with a knowledge score ranging from 1 (no knowledge) to 10 (expert). Both items were measured at baseline with the second item used to assess knowledge gained postintervention.

Pre-exposure prophylaxis stigma

Pre-exposure prophylaxis stigma was measured with an adapted 8-items scale (Calabrese et al., 2018) consisting of two subscales to assess PrEP user stereotypes (five-items, Cronbach α = 0.87) and disapproval by others (three-items, Cronbach α = 0.91), where stereotypes are perceived as what “people” in general think or assume about the participant as a potential user, and disapproval focuses on participant's personal relationships (i.e., “my sexual partners,” “my family,” and “my friends”). Response options were 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), and 5 (strongly agree) with reverse scoring on the three-items of the disapproval by others subscale. Scores are an average with a range of 1–5. Higher scores represent higher perceived negative user stereotypes and disapproval by others. The stigma scale was measured at baseline and postintervention.

Pre-exposure prophylaxis trust

Pre-exposure prophylaxis trust was measured with an adapted 12-items scale (D'Avanzo et al., 2019) with items addressing themes of participant beliefs, communication channels, and health care experiences (D'Avanzo et al., 2021). Items align on two subsets that assess medication trust (four-items) and health care provider trust (eight-item). Response options range from 1 (strongly disagree) to 10 (strongly agree), with a summative score between 12 and 120 and reverse scoring on items 2, 6, 7, 8, 9, and 12. Higher scores represent higher levels of trust. The trust scale was measured at baseline and postintervention.

Pre-exposure prophylaxis intentions

Intention to use PrEP was measured using an adapted one item (Walsh, 2019) asking, “How likely are you to use PrEP in the future?” with participants selecting one of the following responses: “I am not currently considering taking PrEP” (precontemplation), “I am not considering taking PrEP in the next month” (contemplation), “I am planning to take PrEP in the next month” (preparation), “I have started taking PrEP in the past 3-6 months” (action), “I have been on PrEP for more than 6 months” (maintenance), and “I was on PrEP but decided to stop using it” (relapse). The intention to use PrEP was measured at baseline and postintervention.

Pre-exposure prophylaxis risk

Pre-exposure prophylaxis risk was measured using six-items based on (CDC) PrEP guidelines (CDC, 2018). The items are categorical and assessed individually. The items include the following: (a) “What do you think about the chances you might get infected with HIV in the future?” with response options of “none”, “low”, “medium”, and “high”, (b) “Have you had sex with more than one partner in the past 30 days?” with response options of “yes”, “no”, and “don't know”, (c) “Have you had sex with more than one partner in the past 30 days, regardless of the partner's gender?” with response options “yes” and “no”, (d) “Have you been treated for a bacterial sexually transmitted infection (STI) in past 12 months?” with options “yes” and “no”, (e) “Have you injected drugs with needle sharing in the past 6 months?” with options “yes” and “no”, (f) “Do you use, or plan on, using any of the following risk reduction methods?” with check all that apply between condom use, reducing number of sexual partners, partner STI/HIV testing, using PrEP for HIV prevention, and other followed by a text box to write other methods used. Risk was measured at baseline and postintervention.

Data Analysis

All statistical analyses were completed in RStudio version 2022.12.0.353 (Boston, MA; Posit Team, 2022) using R version 4.4.2 (Vienna, Austria; R Core Team, 2022). Baseline (pretest) and postintervention (posttest) surveys were used to assess change for each measure. Participants were excluded for missing data in either the preset or posttest survey. Descriptive statistics were computed to describe the study sample and summarize measures. A two-sided alpha level of 0.05 was used to determine statistical significance. Dependent sample t-tests were used to analyze the knowledge and awareness, stigma, and trust measures. An independent sample t-test was performed using the knowledge and awareness measure's two-items to compare knowledge change based on PrEP awareness before the study. Equality of variance was calculated using Brown–Forsythe, whereas Shapiro–Wilk was used to test normality before t-test analysis. Dependent sample, corrected McNemar tests (2×2), and Bhapkar tests (two-way, k×k) were used to analyze change for the intention and risk measures with an ordinal item on the risk measure requiring the Wilcoxon signed-ranks test with a log transformation. Effect sizes were calculated using Cohen d for each t-test with statistically significant differences.

Results

Of the 105 participants recruited, 72 women (69%) completed the pretest survey, and 44 (42%) completed the posttest survey. Women who completed all pretest and posttest measures (n = 44) were included in this analysis. Demographic characteristics reported at baseline were similar for state of residence, sexual orientation, race, ethnicity, and gender. Most participants identified as heterosexual (39, 89%), African American (40, 91%), cisgender women (44, 100%), and living in North Carolina (39, 89%). The mean age was 42.3 (SD 9.5, range 19–61) years. Differences arose in marital status, education level, and annual household income with marital status including married or cohabitating (20, 46%), single never married (16, 36%), and divorced (8, 18%), as well as education and income levels skewing higher (Table 1).

Table 1. - Demographic Characteristics Characteristics N = 44a Age (years) 42 (19–61) Race  Black or African American 38 (86%)  African 4 (9.1%)  Multiracial 2 (4.5%) Ethnicity Hispanic/Latinx 1 (2.3%) Sexual orientation  Heterosexual 39 (89%)  Homosexual 2 (4.5%)  Bisexual 2 (4.5%)  Queer 1 (2.3%) Transgender 0 (0%) Marital status  Single, never married 16 (36%)  Married or cohabitating 20 (45%)  Divorced 8 (18%) State  North Carolina 39 (89%)  Florida 3 (6.8%)  Virginia 1 (2.3%)  Ohio 1 (2.3%) Highest education level completed  High school diploma or GED 1 (2.3%)  Some college 11 (25%)  Associate's degree 8 (18%)  Bachelor's degree 12 (27%)  Graduate degree 12 (27%) Annual household income  <$20,000 3 (6.8%)  $20,000–$34,999 4 (9.1%)  $35,000–$49,999 9 (20%)  $50,000–$74,999 11 (25%)  $75,000–$99,999 7 (16%)  >$100,000 10 (23%)

A statistically significant change was observed for PrEP knowledge posttest (M 2.8, SD 2.5; p < .01) with large effect size (d 1.13; Table 2). At pretest, 23 participants (52%) had not heard of PrEP before the study (PrEP unaware) compared with 21 (48%) who had (PrEP aware). Each of these groups had significant changes in knowledge with PrEP unaware participants having a mean difference of 3.78 (SD 2.33; p < .01) and PrEP aware participants having a mean difference of 1.74 (SD 2.24; p < .01). There was also a significant difference in knowledge changes between PrEP unaware and aware (M 2.07, SD 2.28; t43 3.01; p < .01). A statistically significant change was not observed postintervention for PrEP stigma score and the PrEP user stereotypes subscale. The PrEP disapproval by others subscale was observed to have a statistically significant change posttest (M −0.3, SD 0.74; p = .01) with small effect size (d .41). A statistically significant change was observed for PrEP trust posttest (M 11.6, SD 15.6; p < .01) with a medium effect size (d .74). This significant difference was also found for both subscales with medication trust having a 7.5 mean difference (SD 7.8; p < .01) and health care provider trust having a 4.1 mean difference (SD 11.9; p = .03).

Table 2. - PrEP Knowledge and Awareness, Stigma, and Trust Change Measures Mean (SD) n = 44 Mean Difference (95% CI) t-Statistic (df) p-Valuea Pre Post Knowledge and awareness 3.07 (2.2) 5.86 (2.1) 2.8 (2.04, 3.55) 7.47 (43) <.001e  Aware/unaware 1.7 (2.2)b 3.8 (2.3)c 2.3 (0.68, 3.46) 3.01 (42) .004d,e Stigma 2.84 (0.8) 2.78 (0.7) −0.06 (−0.29, 0.17) −0.5 (43) .620  User stereotype 2.88 (1.1) 2.97 (0.9) 0.09 (−0.25, 0.44) 0.53 (43) .597  Disapproval by others 2.76 (0.8) 2.46 (0.8) −0.3 (−0.53, −0.08) −2.71 (43) .01e Trust 78.3 (19) 90.0 (18) 11.6 (6.84, 16.35) 4.92 (43) <.001e  Medication 19.7 (7.2) 27.2 (8.2) 7.5 (5.12, 9.88) 6.35 (43) <.001e  Provider 58.7 (16) 62.8 (13) 4.09 (0.48, 7.70) 2.29 (43) .027e

Note. PrEP = pre-exposure prophylaxis.

aPaired t-test.

bn = 21.

cn = 23.

dIndependent t-test.

eStatistically significant.

A statistically significant change was observed for PrEP intention's one-item posttest (χ52 = 13.8; p = .02) with change directionality not indicated (Table 3). The frequency distribution offers insight with the most frequent pretest response of “I am not currently considering taking PrEP” (38, 86%) shifting to the posttest responses of “I am not currently considering taking PrEP” (28, 64%) and “I am not considering taking PrEP in the next month” (14, 32%; Table 4). No statistically significant changes were observed for the PrEP risk measure with responses maintaining low levels of perceived risk and engagement in risky behavior in pretest and posttest measures.

Table 3. - PrEP Intention: How Likely Are You to Use PrEP in the Future? Posttesta n χ2-Statistic (df)b p-Value Pretest No, not considering next monthc No, not currently considering Yes, considering next month Yes, taking past 3–6 months Yes, taking >6 months No, stopped taking 44 13.77 (5) .02d  No, not considering next month 2 (4.5) 1 (2.3) 0 (0) 0 (0) 0 (0) 0 (0)  No, not currently considering 10 (23) 27 (61) 1 (2.3) 0 (0) 0 (0) 0 (0)  Yes, considering next month 2 (4.5) 0 (0) 0 (0) 1 (2.3) 0 (0) 0 (0)  Yes, taking past 3–6 months 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)  Yes, taking >6 months 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)  No, stopped taking 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Note. PrEP = pre-exposure prophylaxis.

an (%).

bBhapkar Chi-squared test.

cWording shorted from original item.

dStatistically significant.

Table 4. - PrEP Intention and Risk Frequency Distribution Measures Pretesta Posttest Intention No, not considering next month No, not currently considering Yes, considering next month Yes, taking past 3–6 monthsb No, not considering next month No, not currently considering Yes, considering next month Yes, taking past 3–6 months How likely are you to use PrEP in the future? 3 (6.8) 38 (86) 3 (6.8) 0 (0) 14 (32) 28 (64) 1 (2.3) 1 (2.3) Risk None Low Medium High None Low Medium High What do you think are the chances you might get infected with HIV in the future? 20 (45) 22 (50) 2 (4.6) 0 (0) 17 (39) 27 (61) 0 (0) 0 (0) No Don't know Yes No Don't know Yes Have you had sex with an HIV-positive partner in the prior 6 months? 43 (98) 1 (2.3) 0 (0) 43 (98) 1 (2.3) 0 (0) No Yes No Yes Have you had sex with more than one partner in the past 30 days, regardless of the partner's gender? 43 (98) 1 (2.3) 42 (95) 2 (4.6) Have you been treated for a bacterial sexually transmitted infection (STI) in past 12 months? 40 (91) 4 (9.1) 41 (93) 3 (6.8) Have you injected drugs with needle sharing in the past 6 months? 44 (100) 0 (0) 44 (100) 0 (0) Do you use, or plan on using any of the following risk reduction methods?  Condom use 21 (48) 23 (52) 20 (45) 24 (55)  Reducing number of sexual partners 28 (64) 16 (36) 28 (64) 16 (36)  Partner STI/HIV testing 33 (75) 11 (25) 31 (70) 13 (30)  Using PrEP for HIV prevention 41 (93) 3 (6.8) 41 (93) 3 (6.8)  Other: 30 (68) 14 (32) 30 (68) 14 (32)   Monogamy 6 (14) 7 (16)   Abstinence 3 (6.8) 2 (4.6)   None 5 (11) 5 (11)

Note. PrEP = pre-exposure prophylaxis.

an (%).

bResponse options shorted from original “Yes, taking > 6 months” and “No, stopped taking” received 0 in pretest and posttest.

Discussion

In this article, we discussed the preliminary effects and results in change for pretest and posttest measures after experiencing the UPDOs intervention for Black cisgender women on improving barriers to PrEP uptake, including PrEP knowledge, awareness, stigma, and trust. Like prior studies, UPDOs found that Black cisgender women have insufficient knowledge and awareness of PrEP and its availability (Chandler et al., 2022). Like previous edutainment videos or mHealth research, the UPDOs intervention improved knowledge and awareness outcomes (Bond & Ramos, 2019; Jones et al., 2013). Interestingly, Black women's trust in PrEP improved. However, there was only improvement in PrEP stigma use within interpersonal relationships. This is important because others have reported that the lack of representation in PrEP marketing campaigns further decreases the uptake of PrEP in this population (Chandler et al., 2020; Hirschhorn et al., 2020; Ridgway et al., 2018). Engaging Black cisgender women throughout the research process, from clinical drug trials to behavioral interventions, can increase the likelihood of women taking PrEP in the future because the PrEP development and implementation process is better understood and trusted.

Although PrEP trust was improved, women in this study had a slight improvement in reducing PrEP stigma. Increased approval of PrEP use from close relationships—including intimate partners, family, and friends—is encouraging. These r