Social Networks and Its Impact on Women's Awareness, Interest, and Uptake of HIV Pre-Exposure Prophylaxis (PrEP)

Implications for Women Experiencing Intimate Partner Violence

Tiara C. Willie, MA; Jamila K. Stockman, PhD, MPH; Danya E. Keene, PhD; Sarah K. Calabrese, PhD; Kamila A. Alexander, PhD, MPH, RN; Trace S. Kershaw, PhD


J Acquir Immune Defic Syndr. 2019;80(4):386-393. 

In This Article

Abstract and Introduction


Background: In the United States, women represent less than 5% of all pre-exposure prophylaxis (PrEP) users. Social networks may promote and/or inhibit women's PrEP awareness, which could influence PrEP intentions. Furthermore, women experiencing intimate partner violence (IPV) may have smaller, less supportive networks, which could deter or have no impact on PrEP care engagement. This study examined associations between network characteristics and women's PrEP awareness, interest, uptake, and perceived candidacy and analyzed IPV as an effect modifier.

Setting/Methods: From 2017 to 2018, data were collected from a prospective cohort study of 218 PrEP-eligible women with (n = 94) and without (n = 124) IPV experiences in Connecticut. Women completed surveys on demographics, IPV, social networks, and PrEP care continuum outcomes.

Results: Adjusted analyses showed that PrEP awareness related to having more PrEP-aware alters. PrEP intentions related to having more alters with favorable opinions of women's potential PrEP use and a smaller network size. Viewing oneself as an appropriate PrEP candidate related to having more PrEP-aware alters and more alters with favorable opinions of women's potential PrEP use. IPV modified associations between network characteristics and PrEP care. Having members who were aware of and/or used PrEP was positively associated with PrEP care engagement for women without IPV experiences but had either no effect or the opposite effect for women experiencing IPV.

Conclusion: Improving PrEP attitudes might improve its utilization among women. Social network interventions might be one way to increase PrEP uptake among many US women but may not be as effective for women experiencing IPV.


In the United States, women who contract HIV through heterosexual contact are recognized as one of the most-affected subpopulations for HIV diagnoses.[1] In 2016, women represented 19% of all new HIV diagnoses in the United States, and heterosexual contact accounted for 87% of HIV diagnoses among women.[1] In 2012, the FDA approved the dissemination of pre-exposure prophylaxis (PrEP), a daily oral medication HIV-negative persons can take to reduce their risk of HIV acquisition.[2] In the United States, only 4.6% of national PrEP users are women.[3] Despite being one of the most innovative HIV prevention strategies to date, PrEP is underutilized by US women. There is a clear need for research that investigates factors influencing women's decisions and engagement surrounding PrEP to protect women's sexual health.

Although largely unexplored, women's social networks may shape their interest, awareness, and uptake of PrEP. Research literature suggests that an individual's beliefs and behaviors can be shaped by the social norms, behaviors, and reward system of their social network members.[4] In the context of HIV prevention, existing research among men indicates that characteristics of one's social network can impact whether an individual engages in the PrEP care continuum (ie, awareness, uptake, adherence, and retention).[5,6] For example, Kuhns et al[5] found that having a large network size was associated with PrEP uptake among young men who have sex with men. Similarly, Schneider et al[6] found that, among Indian truck drivers, having at least one close friend was associated with high PrEP acceptability compared with having no close friends. Together, these studies show preliminary evidence that structural characteristics (eg, network size—number of network members) and ego attributes (eg, closeness—how close a participant is to all other individuals in their network) impact men's PrEP acceptability and uptake. Although previous research suggests that networks can shape PrEP engagement among men, very little research has examined this relationship among heterosexual women is sparse. This sparse research is problematic because the same social network characteristics that are associated with women's HIV-risk behaviors[7] could also affect women's PrEP engagement. Social network analysis may be a key strategy for understanding women's underutilization of PrEP because this method affords an in-depth investigation of how social networks influence women's PrEP awareness, interest, and uptake.

Further understanding of how intimate partner violence (IPV) can impact the relationship between social networks and women's PrEP engagement behaviors is pivotal. IPV is an important predictor of women's HIV susceptibility. Women with IPV experiences may have been sexually assaulted by a risky male partner.[8,9] IPV can also interfere with women's ability to negotiate safe sex practices with abusive partners.[8,9] Optimizing women-controlled HIV prevention methods is key for this vulnerable population. Women with IPV experiences have a higher odds of reporting interest in PrEP but are also concerned about their partner controlling their PrEP.[10] Given women's concerns about controlling partners, it is possible that abusive partners might discourage women from engaging in HIV prevention such as PrEP. A recent study found that the social networks of women experiencing IPV were smaller and offered less social support than the social networks of women not experiencing IPV.[11] Therefore, if abusive partners are discouraging women's engagement in the PrEP care continuum, it is possible that women have limited access to supportive social network members. In addition to abusive partners, some PrEP research found that family and friends could have positive and/or negative influences on PrEP adherence.[12,13] Women experiencing IPV may face additional difficulties accessing PrEP and less support from their social network; however, no study has examined IPV as an effect modifier on the association between women's social networks and the PrEP care continuum. A growing number of PrEP engagement interventions are leveraging social networks among men who have sex with men,[14,15] but this intervention delivery format may only enhance PrEP engagement among those with supportive social networks. Empirically investigating IPV as an effect modifier may reveal some important insights for the development and implementation of social network-based interventions aimed at promoting PrEP awareness, interest, and uptake among US women and those who experience IPV in particular.

The current study aimed to (1) examine the association between social network characteristics and multiple outcomes along the PrEP care continuum (ie, awareness, interest, intentions, and perceived candidacy) and (2) examine how IPV experiences modify the association between social network characteristics (characteristics of social network members; composition of the overall social network) and multiple outcomes along the PrEP care continuum. We hypothesize that having more social network members who are aware of PrEP are using PrEP and think favorably of women's potential PrEP use will be positively associated with PrEP awareness, interest, intentions, and perceived candidacy. We also hypothesize that higher closeness and density will be positively associated with PrEP awareness, interest, intentions, and perceived candidacy. Finally, we hypothesize that these associations will be modified by IPV, such that they would be attenuated for women experiencing IPV than those without these experiences.