PrEP as a “Hidden Message”: The Impact of Partner Dynamics on Oral PrEP Adherence Among Cisgender Women in Serodiscordant Relationships

BACKGROUND: Heterosexual sex accounts for 87% of new HIV diagnoses among cisgender women. We sought to explore the intersection of partner dynamics and oral preexposure prophylaxis (PrEP) adherence among cisgender women in heterosexual serodiscordant relationships. METHODS: From June 2017-August 2018, we conducted semi-structured in-depth interviews using a social ecological model framework. Twenty cisgender women in serodiscordant relationships, who participated in a PrEP demonstration project to evaluate adherence and retention in San Diego and Los Angeles, participated in in-depth interviews. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis. RESULTS: Among the 20 participants, the median age was 37.5 years (IQR 32, 48), with n = 6 (30%) identifying as Black and n = 5 (25%) as Hispanic. Sixty-five percent of women had protective drug levels based on real-time tenofovir-diphosphate drug level assays at the study visit prior to their interviews. Some partners played a significant role in PrEP adherence, often showing support by vocalizing encouragement and appreciation, offering reminders to take PrEP, and sometimes administering PrEP. Other partners were unsupportive and discouraged PrEP use, which may have hindered adherence. HIV and PrEP stigma were identified as potential barriers for women to take PrEP and disclose their PrEP use to others. CONCLUSIONS: Within the context of this PrEP demonstration project, partner dynamics impacted PrEP adherence for HIV-negative cisgender women in serodiscordant relationships. We urge further investigation of relationship dynamics and PrEP adherence and persistence specifically among US-based cisgender women.