Bond 2021

Review Article
Applying a Nursing Perspective to Address the

Challenges Experienced by Cisgender Women in the
HIV Status Neutral Care Continuum: A Review of
the Literature
Keosha T. Bond, EdD, MPH, CHES • Rasheeta Chandler, PhD, RN, FNP-BC, FAANP, FAAN •
Crystal Chapman-Lambert, PhD, CRNP • Lorretta Sweet Jemmott, PhD, RN • Yzette Lanier, PhD •
Jiepin Cao, MS, RN • Jacqueline Nikpour, BSN, RN • Schenita D. Randolph, PhD, MPH, RN, CNE*
Abstract
The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender
women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black
women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social
ecological framework to provide a detailed review of the risk factors that drive the women’s HIV epidemic. By presenting examples of
effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical,
and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing
viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention
programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that
women receive effective services that are evidence-based and which they perceive as important to their lives.
Key words: care continuum, HIV, nursing research, prevention, sexual and reproductive health, women
n a national and global level, women have been af- et al., 2018; Schilt & Westbrook, 2009). Gender and racial
O fected by HIV since the onset of the epidemic in the
early 1980s and experience distinct barriers that limit their
disparities related to HIV prevention and treatment persist
as contributing factors to women’s vulnerability to HIV in
sustained access to resources for HIV prevention, care, and the United States and globally (CDC, 2020a; Newsome
treatment (Higgins et al., 2010; Centers for Disease Con- et al., 2015; United Nations Programme on HIV/AIDS,
trol and Prevention [CDC], 2019a; Kaiser Family Foun- 2014, 2018, 2019). Unfortunately, on both a domestic and
dation, 2020). Although HIV research that targets women a global level, women are still disproportionately affected
has led to treatment advances, proven prevention methods by HIV across the lifespan, especially among adolescent
may not be reaching the most vulnerable women (Brown girls and young women (Brown et al., 2018; United Na-
tions Programme on HIV/AIDS, 2018, 2019). Globally,
women account for more than half the people living with
Sponsorships or competing interests that may be relevant to content are disclosed at
the end of this article. HIV (PLWH), and HIV-related illnesses remain the leading
Keosha T. Bond, EdD, MPH, CHES, is an Assistant Medical Professor, Department cause of death among women of reproductive age (United
of Community Health and Social Medicine, City University of New York School of Nations Programme on HIV/AIDS, 2018).
Medicine, New York, New York, USA. Rasheeta Chandler, PhD, RN, FNP-BC,
FAANP, FAAN, is an Assistant Professor, School of Nursing, Emory University, Using a social ecological perspective (Bronfenbrenner,
Atlanta, Georgia, USA. Crystal Chapman-Lambert, PhD, CRNP, is an Associate 1979; McLeroy et al., 1988), we review factors that con-
Professor, School of Nursing, University of Alabama at Birmingham, Birmingham,
Alabama, USA. Loretta Sweet Jemmott, PhD, RN, is Vice President, Health and
tribute to HIV transmission among women in the United
Health Equity, and Professor, College of Nursing and Health Professions, Drexel States. The objectives of this article are to describe how the
University, Philadelphia, Pennsylvania, USA. Yzette Lanier, PhD, is an Assistant
Professor, School of Nursing, New York University, New York, New York, USA. Jiepin
different factors in each system interact to create an addi-
Cao, MS, RN, is a Graduate Student, School of Nursing, Duke University, Durham, tive impact on women’s sexual behaviors; discuss clinical
North Carolina, USA. Jacqueline Nikpour, BSN, RN, is a Graduate Student, School of care and research on preventative interventions (including
Nursing, Duke University, Durham, North Carolina, USA. Schenita D. Randolph,
PhD, MPH, RN, CNE, is an Assistant Professor, School of Nursing, and Co-director, behavioral, biomedical, and structural); and examine the
Community Engagement Core, Duke Center for Research to Advance Healthcare continuum of care (including treatment, adherence, and
Equity (REACH Equity), Duke University, Durham, North Carolina, USA.
retention in care), advocacy, and policy that present op-
*Corresponding author: Schenita D. Randolph, e-mail: schenita.randolph@
duke.edu portunities for promising interventions and strategies to
Copyright © 2021 Association of Nurses in AIDS Care prevent HIV. We identify existing knowledge gaps and
http://dx.doi.org/10.1097/JNC.0000000000000243 priority areas for future research among nursing scientists.
Journal of the Association of Nurses in AIDS Care May-June 2021 • Volume 32 • Number 3 283
Copyright © 2021 Association of Nurses in AIDS Care. Unauthorized reproduction of this article is prohibited.
284 May-June 2021 • Volume 32 • Number 3 Bond et al.
Although there are various forms of gender identification, with a diagnosed HIV infection were also less likely to be
it is limiting to assume that all individuals who identify as linked to care and, if they did access care, it was often delayed
women were assigned female at birth (Schilt & Westbrook, (CDC, 2020c). Finally, American Indian and Alaska Native
2009). For the purposes of this article, the epidemiology, women were three times more likely to be diagnosed with
interventions, and policies discussed will focus on the his- HIV infection compared with White women, despite repre-
torical and current perspective of the HIV care continuum senting less than 1% of the total cases (CDC, 2020b, 2020c).
among cisgender women, individuals who were assigned These data showcase the need to support efforts to reduce
as female at birth and self-identified as women, and will be HIV-related health disparities among women of color by
referred to as women throughout the article (Schilt & expanding HIV linkages to care and treatment capacity at
Westbrook, 2009). the community and organizational level.
Epidemiology of HIV Infection Among Women Disparities by Age Group

in the United States Although there has been significant progress, women of
In the United States, the proportion of women among different age groups are affected very differently. In
new HIV cases rose from 8% in 1985 to 19% in 2018 2018, women in the age groups of 25–34 years and
(CDC, 2018), reaching its highest percentage at 27% in 35–44 years accounted for more than half (27% and
2007 (CDC, 2009). Although new HIV diagnoses 24%, respectively) of new HIV diagnoses in the United
among women continued to decline between 2010 and States among women, highlighting the need to promote
2017, dropping by 6% among women overall and by and support the integration of HIV prevention strategies
18% among young women aged 13 to 24 years, as of for women at reproductive age into sexual and re-
2018, women still accounted for nearly 1 in 5 new HIV productive health (SRH) practices (CDC, 2020b,
diagnoses (CDC, 2019a). Among the estimated 7,000 2020c). The high percentage of new infections among
women diagnosed with HIV in the United States, 85% of women at reproductive age has an influence on the rate
cases were attributed to heterosexual transmission, of mother-to-child HIV transmission (CDC, 2020d;
whereas the remaining 15% were attributed to injection Kaiser Family Foundation, 2020). In the United States,
drug use (15%; CDC, 2018). In 2018, women repre- perinatal infections disproportionately affected Black
sented 24% (4,106) of all AIDS diagnoses, the most children (65%) due to missed opportunities for pre-
advanced form of HIV disease (Kaiser Family Founda- vention, such as HIV testing and use of antiretroviral
tion, 2020). New HIV infections and AIDS diagnoses therapy (ART), during the early stages of pregnancy
among women are decreasing, probably because women (CDC, 2020d; Kaiser Family Foundation, 2020).
are diagnosed earlier and engage in care at improved Women are diagnosed with HIV at marginally older
rates (Kaiser Family Foundation, 2020). Among all ages than men (CDC, 2020b). In 2018, men ages 13 to 34
women living with HIV (WLWH) in 2018, eight in nine years accounted for the majority of HIV diagnoses
were aware of their HIV diagnosis, 66% received HIV among men (60%), whereas women ages 13 to 34 years
medical care, 51% were retained in HIV care, and 53% accounted for 40% of HIV diagnoses among women
had a suppressed viral load (CDC, 2020c). (CDC, 2020b). In 2018, new HIV diagnoses among
women ages 45 to 54 years and those older than 55 years
was 20 and 16%, respectively. (CDC, 2019b). Accord-
Racial and Ethnic Disparities ing to the CDC, 35% of people ages 50 years and older
Among women, Blacks and Latinas (92% and 87%, re- already had late-stage infection (AIDS) when they re-
spectively) accounted for a greater proportion of new HIV ceived a diagnosis (CDC, 2020c). Adolescent girls and
diagnoses due to heterosexual transmission compared with young women in the United States are also highly af-
White women (65%); conversely, injection drug use fected by HIV (14%), reflecting similar global trends
accounted for a greater proportion of new HIV diagnoses among reproductive-age women (Brown et al., 2018).
among White women (34%; CDC, 2019b). The rate of
new HIV infections among Black and Latina women was 14
and 3 times higher, respectively, as compared with White Geographic Disparities
women in 2018 (Figure 1; CDC, 2020b; Kaiser Family The impact of HIV varies across the United States, af-
Foundation, 2020). WLWH followed a similar pattern, with fecting women differently across states. In 2017, 10
a greater proportion of WLWH being Black and Latina states accounted for the majority of WLWH (67%), with
(Kaiser Family Foundation, 2020). Black and Latina women New York, Florida, Texas, California, and Georgia
Journal of the Association of Nurses in AIDS Care Ending the HIV Epidemic Among Cisgender Women 285
factors contribute to women’s vulnerability to HIV across

the continuum (Chapman Lambert et al., 2017; El-Bassel
et al., 2009; Flash et al., 2014; Frew et al., 2016; Figure 2).
At the individual level, personal factors such as con-
domless sex, irregular or outdated HIV testing, concur-
rent partnering, and low risk perception increase
women’s risk for HIV infection (Crosby et al., 2013;
Dyson et al., 2018; Evans et al., 2018; Hall et al., 2014;
McLaurin-Jones et al., 2015; Noar et al., 2012; Seth et al.,
2015; Siegel et al., 2010; Teitelman et al., 2015). Research
has focused on addressing these individual factors, such as
interventions designed to increase condom use (Crosby
et al., 2013). Interpersonal level factors that influence
HIV risk transmission refer to relationship contexts, such
as domestic and sexual abuse and intimate partner vio-
lence (El-Bassel et al., 2009). For example, it has been
shown that women who have not been in abusive rela-
Figure 1. New HIV diagnoses among women by race/ethnicity in the tionships are less likely than women who have been in
United States and dependent areas, 2018. *Black refers to people having
origins in any of the Black racial groups of Africa. African American is a term abusive relationships to engage in high-risk behaviors,
often used for Americans of African descent with ancestry in North such as having sex for drugs, having sex with multiple
America. †Hispanics/Latinas can be of any race. Source: CDC. Diagnoses partners, not using condoms, or not adhering to ART
of HIV infection in the United States and dependent areas, 2018
(Preliminary). HIV Surveillance Report 2019; 30. This figure is available in
(Champion & Collins, 2012; Hess et al., 2012; Senn et al.,
color online www.janacnet.org. 2006; Seth et al., 2015; Teitelman et al., 2015).
Community factors include broad cultural values and
belief systems that influence HIV risk transmission and
accounting for nearly half (47%; CDC, 2019b; Kaiser treatment (Corneli et al., 2016). Multiple studies suggest
Family Foundation, 2020). At a more local level, 25 that community factors related to gender roles and dis-
counties represented 44% of WLWH in the United closing HIV status to partners and health care providers
States, with the largest number (9,960) and highest in- (HCPs) influence engagement in medical care (Corneli
cidence (1,576.5 per 100,000) of WLWH diagnoses et al., 2016; Darlington & Hutson, 2017; Earnshaw
found in Bronx County in New York City (CDC, 2019b; et al., 2013; Relf et al., 2019; Relf, Silva, et al., 2015).
Kaiser Family Foundation, 2020) Finally, societal level factors are those that influence
one’s environment and increase the likelihood of en-
gaging in high-risk HIV transmission behaviors. There is
Contributing Factors to HIV Vulnerability a growing body of literature that reports that structural
Among Women level factors, such as racism and racial discrimination,
Using a social ecological framework, we will discuss the and patient–provider communication in the clinical en-
contributing factors to HIV diagnoses among women counter pose significant health risks to individuals and
across the areas of HIV prevention, treatment, adherence, communities of color, specifically Black and Latinx
and retention. The ecological framework considers the populations (Dale et al., 2018; Ford et al., 2009; Logie
complex interplay between individual (i.e., sex without a et al., 2011; Prather et al., 2018; Randolph, Golin, et al.,
condom, HIV testing, multiple sex partners, low percep- 2020). For example, several studies have shown that
tion of risk, childhood sexual abuse, substance abuse, and racial discrimination is associated with high-risk sexual
sexually transmitted infections [STIs]), interpersonal behaviors among Black communities (Braksmajer et al.,
(i.e., relationship power dynamics, domestic and sexual 2018; Lewis et al., 2017; Rosenthal & Lobel, 2020).
abuse, intimate partner violence, patient provider relation- There is extensive literature that supports that poor
ship, and social networks), community (i.e., HIV-related patient–provider communication in the clinical en-
stigma, broad cultural values and belief systems about counter has a direct impact on the quality of care and
gender roles, social norms, and attitudes toward safer sex health outcomes of Blacks (Agénor et al., 2015; Beach
practices), and societal factors (i.e., racial discrimination, et al., 2011; Dolezsar et al., 2014; Earl et al., 2013; Eli-
poverty, incarceration, and lack of access to health care; El- acin et al., 2020; Hagiwara et al., 2016; Sutton et al.,
Bassel et al., 2009). Research suggests that several multilevel 2020). Although patients in HIV care settings report
Figure 2. Social ecological framework applied to contributing factors of HIV among women in the United States. This figure is available in color online
www.janacnet.org.
greater patient–provider communication, there remain strategies (Prevention Research Synthesis [PRS], 2020;
differences for Black women compared with White Rotheram-Borus et al., 2009). The CDC maintains an
women (Beach et al., 2011). For example, in a study of active compendium of EBIs and evidence-informed in-
354 patient–provider encounters to explore the role of terventions that have been proven effective and are
the patient–provider relationship in explaining racial identified through ongoing systematic reviews (PRS,
and ethnic disparities in HIV care, providers were more 2020). Even with successful behavioral interventions,
controlling in conversations with Black patients as women continue to be affected disproportionately by
compared with White patients, and Black patients were HIV (Brown et al., 2018; CDC, 2020b). Most HIV-
provided with less information (Beach et al., 2011). This related interventions for women that have been recog-
supports the need for improved communication between nized by the CDC’s Evidence-Based Interventions data-
HIV providers and their Black patients. base are led by medicine, social work, or public health,
Based on the social ecological framework, contribut- and two include nurses as intervention facilitators.
ing factors at one level influence factors at another level, Among the 18 CDC EBIs that address HIV care across
thus interventions that consider these complexities are the spectrum for women (Table 1), two are led by
more likely to sustain prevention intervention efforts nursing: (a) Centering Pregnancy and (b) Sisters Saving
over time, favorably modulate behaviors, and influence Sisters (Jemmott et al., 2005; Kershaw et al., 2009). The
social norms (El-Bassel et al., 2009). Taking into account compendium defines EBIs as those interventions sup-
the multiple contributing factors to HIV across the ported by well-designed randomized controlled trials
continuum among women in the United States, we will that showed significant outcomes relative to a compar-
examine the CDC’s evidence-based intervention (EBI) ison group. EBIs are defined as interventions with sig-
compendium and other examples of EBIs under the nificant HIV-related outcomes; however, they may
categories of behavioral, biomedical, and structural. include fewer participants or a weaker design and,
therefore, need further testing (PRS, 2020). Currently,
197 EBIs are included in the compendium, with 33 being
Overview of Evidence-Based HIV Risk- directed specifically at women (PRS, 2020). Of these, 29
Reduction Interventions are categorized as risk reduction, with the remaining
Effective HIV risk-reduction interventions require a four addressing structural interventions. Notably, three
combination of behavioral, biomedical, and structural of the four structural interventions involve women
Journal of the Association of Nurses in AIDS Care

Table 1. Centers for Disease Control Evidence-Based and Informed Interventions
Intervention Method of Intervention
Name of Intervention Location Type Target Population Delivery Outcomes Reference
Behavioral interventions
AMIGAS USA Risk reduction Latina women Education sessions by Reduce HIV risk behaviors Wingood et al. (2011)
Latina health educators.
Topics are culturally tailored
and include videos of Latina
women living with HIV, risk-
reduction strategies,
cultural norms and issues
that may affect sexual health
Centering Pregnancy USA Risk reduction Young pregnant women Sessions on self-care, Reduce STI incidence Ickovics et al. (2003);
Plus receiving prenatal care childbirth prep, prenatal and Reduce sexual risk behavior Kershaw et al. (2009)
postpartum care, HIV Reduce repeat pregnancy
prevention skills, and sexual Reduce psychosocial risk
communication skills factors
CHAT USA Risk reduction High-risk heterosexual Group and individual Davey-Rothwell et al. (2011)
women and their social counseling sessions to
network discuss HIV and STI risk
reduction
Connect: Couples USA Risk reduction Minority, inner-city Orientation and Increase safer sex practices El-Bassel et al. (2001, 2003)
Connect: Woman- heterosexual couples relationship-based sessions among couples (i.e.,
Alone that can be delivered to increasing condom use,
Ending the HIV Epidemic Among Cisgender Women

couple or to woman alone; decreasing STD
goal to enhance relationship transmission, and reducing
communication, safer sex number of sex partners)
negotiation, and problem- Increase relationship
solving skills communication
Connect 2 USA Risk reduction Drug-involved, uninfected, Sexual and drug risk Reduce unprotected sex El-Bassel et al. (2011)
concordant, high-risk reduction via weekly 2-hr Reduce STI incidence
heterosexual sessions; can be delivered Reduce dyadic drug risk
to couple together or just the behaviors
partner who is drug-
involved
Couples HIV Intervention USA Risk reduction Transgender women and Three counseling sessions Reduce HIV risk behavior Operario et al. (2017)
Program (CHIP) their primary cisgender male on sexual transmission, Improve relationship
partner condom use, HIV testing, communication
HIV risk in relationships,
287
(continued on next page)
288
Table 1. (continued)
May-June 2021
stigma on gender identity Improve partner
(for trans women) and interpersonal dynamics
sexuality (for cis male
•
partners); final session
Volume 32
included role-playing
communication skills
Eban USA Risk reduction African American HIV Eight weekly sessions on Increase overall condom El-Bassel et al. (2010)
•
Number 3
serodiscordant interpersonal factors use
heterosexual couple associated with sexual risk Increase consistent
reduction (condom usage, condom use
problem solving, Reduce unprotected sex
communication, monogamy) Reduce STD incidence
Female Condom Skills USA Risk reduction Uninfected, heterosexual Increase knowledge about Increase use of female Choi et al. (2008)
Training women attending family safe sex, condom use, and condoms
planning ability to negotiate condom Increase protected sex
use, as well as barriers and
facilitators for female
condom usage
Healthy Love USA Risk reduction Black women Single session for Diallo et al. (2010)
preexisting group of black
women; delivers HIV
prevention info and teaches
condom skills in interactive
manner; eroticizes safer sex
and creates a safe space
where women can connect
with sexuality in ways that
are positive and self-loving
Motivational USA Risk reduction Recently incarcerated, HIV- One-on-one intervention Weir et al. (2009)
Interviewing-Based negative women at risk for sessions in motivation
HIV Risk Reduction HIV enhancement; four
components: recent
substance use, self-
assessed risk for HIV and
other STIs, assessment of
readiness to address her risk,
Bond et al.
stage-based discussions on
behavior change; can also
identify life concerns

Journal of the Association of Nurses in AIDS Care

Project LifeSkills USA Risk reduction Young transgender women HIV risk and transmission Reduce sexual risk Garofalo et al. (2018)
information, sexual partner
communication, and
negotiation; info on trans
pride and skill building, as
well as access to other
services
Safer Sex Skills Building USA Risk reduction Heterosexually active HIV risk awareness, Increase condom use Tross et al. (2008)
(SSSB) women in drug treatment condom use, partner Decrease unsafe sexual
negotiation skills; problem behaviors
solving, behavioral Increase safer sex
modeling, role-play negotiation skills
rehearsal, peer feedback, Increase HIV/STD risk
and support; emphasis on awareness
women’s safer sex
negotiation skills and
safeguard against the risk of
partner abuse
Sisters Saving Sisters USA Risk reduction Inner-city African American Culturally sensitive single Eliminate or reduce sex risk Jemmott et al. (2005)
female clinic patients sessions by African behaviors
American nurses Prevent new STD infections
demonstrating condom
Ending the HIV Epidemic Among Cisgender Women

use, practice with an
anatomical model, and role-
playing skills to negotiate
condom use
WiLLOW—Women USA Risk reduction Sexually active, female clinic Skills for women living with Reduce HIV transmission Wingood et al. (2004)
Involved in Life patients living with HIV HIV to identify and maintain risk behaviors
Learning supportive social networks, Reduce STDs
discredits myths regarding Enhance HIV-preventative
HIV prevention, negotiating psychosocial and structural
safer sex factors
289
290
May-June 2021
Women on the Road to USA Risk reduction Drug-involved, high-risk Group sessions for drug- Increase proportion of El-Bassel et al. (2014)
Health (WORTH) female offenders under involved women on HIV condom protected sex
community supervision knowledge, risk reduction, Increase consistent
•
and problem solving, as well condom use
Volume 32
as negotiation, access to Reduce unprotected
services, and partner abuse vaginal and anal sex
risk assessment Reduce HIV and STD
•
incidence
Number 3
Biomedical interventions
No CDC EBIs for women
Structural interventions
County-Township- China Structural Female sex workers and Local CDC provides Increase HIV testing Yu et al. (2017)
Village Allied intervention persons who use drugs resources to township Increase linkage to care
Intervention hospitals to support training Increase ART initiation
clinics. Village clinics
organize HIV awareness
campaigns, services for
those at risk, education;
FSWs as peer educators
Provision of Coupons for Uganda Structural Female sex workers FSWs trained as peer Increase HIV testing Ortblad et al. (2017)
Free HIV Self-tests intervention educators to give out Increase linkage to care
among Female Sex coupons to participants for Increase ART initiation
Workers in Uganda free oral HIV self-tests; FSW
educators teach participants
how to perform and interpret
test and help them get linked
to care if positive
Direct Provision of Free Uganda Structural Female sex workers FSWs trained as peer Increase HIV testing Ortblad et al. (2017)
HIV Self-tests among intervention educators and provide on- Increase linkage to care
Female Sex Workers in site free oral HIV tests; Increase ART initiation
Uganda continue to meet with
participants individually over
the following three sessions
to provide condoms,
educate, and screen for
Bond et al.
adverse events; last study
session, free test is repeated

outside of the United States, with two in Uganda and one
Note. ART 5 antiretroviral therapy; CDC 5 Centers for Disease Control and Prevention; FSW 5 female sex worker; STD 5 sexually transmitted disease; STI 5 sexually transmitted
in China (Ortblad et al., 2017).
Ortblad et al. (2017) Behavioral Interventions

Behavioral interventions focus on eliminating or re-
Reference
ducing HIV transmission behaviors, reducing rates of

new HIV or STI transmissions, or increasing HIV-
protective behaviors. Many behavioral interventions
include both males and females or males alone (PRS,
2020). Women-focused interventions are far less com-
Increase linkage to care
coupons to participants for Increase ART initiation
mon. We highlight individual, couple-level, and group-

Increase HIV testing
level interventions that target women and are included

in CDC evidence-based studies (Table 1). Across in-
Outcomes
dividual and small group interventions, major out-

comes included increased safer sex practices, such as
condom usage, reduced STI and HIV occurrence, and
reduced number of sexual partners. Most often, these
free oral HIV self-tests; FSW
participants how to perform

and interpret test and help
interventions were delivered through individual or

Method of Intervention
them get linked to care if
group counseling sessions, health education, and skills

FSWs trained as peer
educators to give out
training (Choi et al., 2008; Davey-Rothwell et al.,

educators teach
2011; Diallo et al., 2010). Few interventions were solely

one-to-one individual interactions developed specifi-
cally for women; however, several interventions had an
Delivery
positive
individual component (Jemmott et al., 2005; Wenzel

et al., 2016).
The majority of couple-level interventions for
women and their male sexual partners focus on high-
risk heterosexual couples. A few CDC EBIs used a
Female sex workers
Target Population
couple-based approach to address risk reduction

among heterosexual couples (El-Bassel et al., 2011,
2019; Operario et al., 2017). These couple-level inter-
ventions focused on relationship communication, ne-
gotiation, problem-solving skills, and goal setting. The
majority of couple-based interventions for women fo-
cused on high-risk women, drug-using women, and
Intervention
their male partners (El-Bassel et al., 2011; McMahon

intervention
Structural
et al., 2013, 2015).

Location Type
Biomedical Interventions
Provision of Coupons for Uganda
Many HIV prevention strategies have been biomedical

interventions that target both men and women, such as
ART for prevention (Rotheram-Borus et al., 2009), or
those that target women only, such as vaginal micro-
among Female Sex

Name of Intervention
Workers in Uganda
Free HIV Self-tests
bicides (Abdool Karim et al., 2010). Both treatments as

prevention (ART taken by PLWH to reduce HIV trans-
mission) and pre-exposure and postexposure pro-
phylaxis (PrEP and PEP; ART taken by HIV-negative
infection.
individuals to prevent HIV acquisition) demonstrate

effectiveness in preventing HIV acquisition or trans-
mission (Baeten et al., 2012; Cohen et al., 2011).
Table 2. HIV Prevention Research Gaps for Women Table 2. (continued)

in the United States: Exemplars
Area Exemplars
Area Exemplars dialogue and empower Black
Behavioral • Engage women who are at risk for or women to address specific topics
living with HIV as community health with their providers to improve
workers in the community in communication and satisfaction
interventions from conception to with HIV care services.
evaluation.
• Target interventions to expand
outcomes from individual-level
outcomes (increase condom use) to Research has demonstrated the effectiveness of ART for
community-level outcomes (improve PLWH for improving health outcomes and reducing
HIV-related stigma). HIV transmission (Abdool Karim et al., 2010; Baeten
• Create interventions that mobilize
et al., 2012; Cohen et al., 2011); however, many persons
assets in the community and social
networks of women. Use technology- remain unaware of ART for HIV prevention. This lack
based (i.e., mobile applications) of awareness is especially relevant for women because
interventions that have proven efficacy they are more susceptible to vaginal–penile transmission
through randomized control trials for of HIV than men (Krakower et al., 2015).
women of color (Black and Latinx). There are limited data regarding the awareness of
Biomedical • Increase the inclusion of women of and utilization of PEP for sexual exposure among
color into clinical trials for pre- women outside the emergency department (Donnell
exposure prophylaxis (PrEP). et al., 2010; Draughon & Sheridan, 2012), but more
• Fund needed research to determine
attention is being given to PEP usage since the in-
the efficacy of ART adherence to
improve health outcomes in already troduction of PrEP (Krakower et al., 2015). PrEP rep-
developed evidence-based resented an historic breakthrough in HIV prevention
interventions. for women because it can be used without dependency
• Initiate clinical and community on their male sex partners (Bond & Gunn, 2016). When
interventions that focus on Black
taken daily, it is more than 90% effective in preventing
women to improve the uptake of
PrEP, especially in the U.S. south. the sexual transmission of HIV to women (Donnell
• Fund research that examines the et al., 2014). In 2014, both the CDC and the American
awareness of and utilization of College of Obstetricians and Gynecologists issued
postexposure prophylaxis for sexual clinical practice guidelines for women’s PrEP eligibility
exposure among women beyond the (American College of Obstetricians and Gynecologists,
emergency department, in primary
2014; CDC, 2014). Despite the benefits of PrEP in
care and community settings.
preventing sexual transmission of HIV, less than 4% of
Structural • Design exploratory studies using the eligible women in the United States had used it by
models that account for racism and
the end of 2016 (Mera-Giler et al., 2017; Smith et al.,
its effects on health, such as Critical
Race Theory, Black Feminist 2015). Moreover, although Black and Latina women
Thought, and intersectionality. accounted for 60% and 17%, respectively, of new adult
• Initiate interventions that examine female HIV diagnoses in 2016, they accounted for only
how structural racism influences 20% and 10% of female PrEP users (Bush et al., 2016).
efforts to develop and implement The extent to which these findings generalize to U.S.
viable strategies to protect women of
color, specifically Black women from
women at risk of HIV is unknown. Also unknown are
HIV infection and to maximize care for women’s rates of retention and adherence to PrEP
women living with HIV. (Sheth et al., 2016).
• Initiate interventions that address There is an urgency for more women-focused inter-
implicit bias and improve ventions aimed at increasing their uptake and adherence
patient–provider communication in
to PrEP (Blackstock et al., 2017; Bond & Gunn, 2016;
the clinical encounter.
• Train physicians to more effectively Bond & Ramos, 2019). Currently, there are few studies
engage patients in nonstigmatizing published on the PrEP care continuum for women (Dale,
2020) and no CDC EBI focused on PrEP uptake among Limitations of CDC Evidence-Based Intervention
women. Compendium for Women
The CDC’s EBI Compendium includes a wide range of
Structural Interventions interventions across the spectrum of HIV care, from
addressing structural factors to individual prevention and
Central to the success of HIV interventions among women is linkage to continuation of treatment (Table 1). Yet, inter-
recognition of the systematic factors that contribute to the ventions targeted at women primarily focus on risk re-
elevated risk of infection, particularly among women of duction; therefore, they only address one area of the HIV
color. Studies over the past 20 years have shown that spectrum and create a gap in knowledge, particularly re-
structural racism and oppression influence the SRH of Black lated to the unique needs of WLWH. As technology has
women (Ford et al., 2009; Newsome et al., 2015; Prather become widely used for health education and maintenance,
et al., 2018; Randolph, Golin, et al., 2020). Three structural interventions that use mobile applications, for example, are
interventions in the CDC compendium focused on women warranted (Noar et al., 2009). Current technology-based
outside of the United States, with two in Uganda and one in interventions for women across the continuum have the
China (Table 1). No structural interventions were found potential to be included in the CDC’s compendium in the
specific to U.S. women. Given the contributing factors that future (Bond & Ramos, 2019; Chandler, Hernandez, et al.,
have been repeatedly documented for women in the United 2020; Njie-Carr et al., 2018; Relf, William, et al., 2015;
States, CDC EBI structural interventions are urgently Sun et al., 2020). Similarly, there is a lack of interventions
needed that address societal factors such as racism, dis- across the HIV care spectrum that focus on minority
crimination, and access to care (Prather et al., 2018; Ran- women, specifically Black and Latinx women. Of the 33
dolph, Golin, et al., 2020). women-focused interventions identified, only 8 were di-
To date, there have been few studies outside of the EBIs rectly targeted toward Black women and 6 toward
that have specifically measured the impact of racism or Hispanic/Latinx women, with none directed at Indigenous
racial discrimination on the lives of women at risk of HIV or First Nations women (Table 1). As such, there is a need
infection or WLWH (Adimora & Schoenbach, 2005; for more interventions in the biomedical aspect of HIV
Kalichman et al., 2016). Several researchers have begun to care, particularly focused on the needs of minority women.
emphasize the importance of examining how racism and Further, among the one PrEP CDC EBI (Liu et al., 2019)
discrimination influence the HIV epidemic among and the two evidence-informed interventions in the com-
women in terms of prevention, treatment, and retention pendium (Desrosiers et al., 2019; Mayer et al., 2017), none
(Adimora & Schoenbach, 2005; Dale et al., 2019; Ran- had a focus on women; all focused on men who have sex
dolph, Golin, et al., 2020; Relf et al., 2019; Turan et al., with men (Liu et al., 2019).
2017). For example, a study of Black WLWH in the Additionally, researchers have reported a multitude of
southeastern United States examined the cross-sectional reasons for the limited effectiveness of EBIs in real-world
association between racial discrimination, HIV-related settings that included the fact that they are not designed
discrimination, gendered racial microaggressions, and for providers or consumers, required training of practi-
barriers to care (Dale et al., 2019). Findings of this study tioners, and lacked adoption fidelity by practitioners and
showed that discrimination related to race significantly community-based organizations (Rotheram-Borus et al.,
predicted a higher total of barriers to care (Dale et al., 2009). “Development and dissemination of EBIs is a
2019). In another study that explored how perceived resource-intensive process that has not progressed as
structural racism and discrimination experienced by quickly as has our understanding of the epidemiology of
Black women contribute to their participation in health HIV” (Rotheram-Borus et al., 2009, p. 3). Multilevel in-
services, results indicated that barriers to utilization of terventions that take into consideration contributing
health services were grounded in personal experiences factors of HIV among women are critical, and nurses are
and historical medical mistrust of the health care system in a unique position to lead such efforts.
(Randolph, Golin, et al., 2020). Women perceived a lack
of communication by providers in the clinical encounter,
and some women believed that false medical information
was given to patients who were Black (Randolph, Golin, Nursing’s Role in HIV Prevention, Advocacy,
et al., 2020). Frameworks such as Critical Race Theory and Policy for Women
(West et al., 1995) and Black feminism (Collins, 2000) Nurses have a unique role in developing and carrying out
may be valuable to future researchers seeking to address HIV interventions. Situated at the intersection of society and
gaps in HIV interventions for minority women. medicine, nurses have a key perspective on HIV care,
particularly the recognition that root causes of HIV include geographic hotspots (Department of Health and Human
both social and biomedical factors (Pittman, 2019). The Services [HHS], 2020). As such, an opportunity exists
holistic practice of nursing is, therefore, well-aligned with for nursing to become increasingly engaged with HIV
the needs of HIV care, including related interventions. In- policy, particularly through the profession’s revamped
deed, only 2 of the 33 EBIs were nurse-led or nurse-involved, social justice lens. Nurses have a critical understanding
potentially limiting the extent for interdisciplinary ap- of the ways in which medical and social factors, such as
proaches to HIV interventions (Jemmott et al., 2005; Ker- PrEP utilization, risk reduction, stigma and health in-
shaw et al., 2009). Furthermore, the historic lack of equities, combine in caring for marginalized pop-
investment in HIV research targeting women may be a key ulations, such as PLWH (Pittman, 2019). Advocacy and
factor in the current lack of women-centered interventions, policy involvement informed by this framework are key
disproportionately affecting Black women who are often at to advancing evidence-based practice and policy in the
high risk due to structural factors (Durvasala, 2018; Ran- care of PLWH and those at risk for HIV.
dolph, Johnson, et al., 2020; Relf et al., 2019). Nursing is
currently engaged in advocacy and policy; however, there is
an opportunity to expand the presence of nursing repre- Future Areas for Future Research/
sentation on health care boards and other decision-making Recommendations
platforms at the local, state, national, and international Addressing the challenges in HIV among women in the
levels to influence policy across the HIV care continuum. United States, especially women of color, will require a
response beyond the traditional medical model. Con-
tributing factors for HIV among U.S. women operate at
Advocacy and Policy multiple levels, including individual, interpersonal,
Advocacy and policies arekey strategies to improve pre- community, and societal levels. Identifying determinants
vention and the continuum of care, including treatment, of risk and protective behaviors among women is sig-
adherence, and retention aiming to enhance the lives of nificantly important to ensure interventions are appro-
WLWH. A resurgence of social justice advocacy in nursing, priate and socially relevant. The need for a combination
beginning in the early 21st century and expanding over the of HIV intervention strategies across the HIV care con-
last decade, is valuable for reshaping practice and policies tinuum, incorporating strategies that address biological,
surrounding the care of PLWH (Boutain, 2005; Watson, behavioral, and structural factors, is critical to affecting
2018). A focus on the social influencers of health and un- the epidemic among women in the United States. Re-
derstanding that racial, ethnic, and socioeconomic dispar- search is urgently needed on identifying and selecting
ities play a role in care (Association of Nurses in AIDS Care, these combinations for greatest effect as significant gaps
2009) have been critical for the adoption of policies and in HIV interventions across the continuum for women
models of care that align with the goals of HIV prevention remain. Recommendations for future research should
and management. For example, the Medicaid Health use a combination prevention approach for women. The
Home State Plan Option, authorized through the Afford- recommendations for future research highlight studies
able Care Act, presents a model of care including care co- that expand across behavioral, biomedical, and struc-
ordination, individual and family support, and community- tural interventions. Exemplars are provided in Table 2.
based referrals for the management of complex chronic
diseases such as HIV. Advocacy for sustained funding to
develop evidence-based treatment allowed for the in- Recommendations for HIV-Related Research
troduction of PrEP in 2012 and the first clinical practice for Women
guidelines for PrEP usage in 2014. Finally, the reintro- Recommendation 1: Develop, implement, and
duction of social justice principles into nursing education evaluate tailored women’s interventions using
over the past decade, specifically in the care of PLWH, may technology-based platforms, such as mobile phone
be valuable for driving forward equitable policies and apps, interactive games, or socially and culturally
practices for PLWH (Groh et al., 2011; Phillips et al., 2016). relevant videos. Developing technology-based inter-
Currently, the federal proposal to invest in HIV ventions that focus on women is imperative, given that
treatment and prevention to end the HIV epidemic in the past research has demonstrated technology-delivered
next decade has brought increased attention to HIV HIV prevention interventions were more effective when
policy. The proposal, announced in February 2019, in- they focused on either men or women but not both; in-
vests approximately $117 million to increase capacity terventions that focus specifically on women showed
for testing and PrEP distribution, as well as to target large effect sizes (Blackstock et al., 2015; Noar et al.,
2009). Despite the potential of technological HIV pre- (Barrett et al., 2020). Community organizations and
vention interventions, the vast majority have not tar- partners can collaborate with patients to provide support
geted women and are not tailored to women’s needs when developing and implementing programs and
(Blackstock et al., 2015). Future interventions using engaging communities in research (Barrett et al., 2020).
these platforms have the potential to increase knowledge Gaining insight from women as partners in in-
regarding underused HIV prevention methodologies tervention development from planning to evaluation
among women, such as PrEP (Blackstock et al., 2015). (Randolph, Johnson, et al., 2020) allows for the de-
Future studies should also assess the effects of velopment of culturally and socially relevant interven-
technology-based interventions over longer time periods tions. For example, engaging social networks of women
and evaluate user engagement. through beauty salons for improved uptake of PrEP has
Technology has the potential to provide a non- been found acceptable (Randolph, Johnson, et al.,
traditional method for health education delivery and can 2020). Future research should consider Black women’s
potentially affect the uptake of HIV prevention and participation as consultants, advisory council members,
treatment options through the dissemination of electronic and members of research teams in the development of
health (eHealth) strategies that are customized for women interventions to improve the potential for sustainability.
(Bond & Ramos, 2019). In an eHealth intervention using Also, the utilization of women as community health
an avatar-led video to increase knowledge of PEP and workers (CHWs) in interdisciplinary approaches is critical
PrEP for Black women, the avatar video product was for promoting high-quality care for PLWH (Busza et al.,
found to be informative and engaging (Bond & Ramos, 2018). CHWs are specially trained laypersons who pro-
2019). In addition, participants were willing to adopt the vide basic medical services, advocate for their community’s
innovation and share it more broadly within their social population health needs, and bridge the gap between the
networks, including social media networking sites (Bond medical care system and communities themselves (Na-
& Ramos, 2019). There is evidence to support that the use tional Heart Lung and Blood Institute, 2014). As CHWs
of diffusion of innovation theory into HIV prevention hail from the communities they serve, they are often more
programs can be useful for changing risk behaviors and reflective of a community’s diversity than a medical pro-
increasing HIV risk reduction knowledge (Bertrand, fessional and can therefore help to build trust between
2004). A qualitative study exploring Black women’s clinicians and community members. The literature shows
preferences regarding usability, acceptability, and design an increasing number of interventions using CHWs across
of a mobile HIV prevention app found that participants the spectrum of HIV prevention and management that
had a preference for an app that included HIV prevention have had positive effects on psychosocial domains, such as
into the topic of optimal sexual health promotion quality of life, self-efficacy, social support, and stigma
(Chandler, Hernandez, et al., 2020). These studies reflect (Busza et al., 2018; Han et al., 2018). Although a few
the need to reach more diverse samples of subpopulations interventions exist, understanding the impact of CHW-led
affected by the HIV epidemic using web-based technolo- programs on outcomes, such as HIV testing and manage-
gies (Bond & Ramos, 2019). ment, remains largely unaddressed (Ortblad et al., 2017).
Recommendation 2: Engage women throughout As care for PLWH continues to move toward a team-based
the research process to identify and prioritize approach in community settings, the role of CHWs may
outcomes that matter to them, from development continue to grow in importance for HIV prevention and
of concept through evaluation and dissemination. management.
Nurse scientists should continue their work to design, Recommendation 3: Use the RE-AIM framework to
implement, and evaluate interventions to improve care on improve the scalability and sustainability of inter-
the HIV continuum with a focus on hot spots. By en- ventions to prevent, treat, and manage vulnerability
gaging the local communities of women, nurse scientists to HIV among women. The RE-AIM framework was
can identify their needs and develop or implement tailored “developed to address the issue that the translation of
interventions to address the unique needs of communities. scientific advances into practice, and especially into public
The use of community engagement approaches can ad- health impact and policy, have been slow and inequitable”
dress health disparities in ways that traditional ap- (Glasgow et al., 2019, p. 1). The RE-AIM dimensions in-
proaches cannot (Barrett et al., 2020). For example, clude reach (R), effectiveness (E), adoption (A), imple-
engaging Black women with diverse perspectives and mentation (I), and maintenance (M). Despite the successful
experiences in intervention development provides op- history of coordinated national strategy, EBIs are still not
portunities for sharing real-world examples that will help widely integrated into clinical practices (Grimshaw et al.,
to better understand contributing factors to HIV risk 2012). To move women forward in the HIV care
continuum, we need to translate EBIs into policy and engage in intervention activities. There is a need for more
practice. In other words, our aim for intervention research couple-based research to better understand the effects
should be implementation of these strategies in a real- and research that includes the perspectives of both
world setting beyond a clinical trial environment; however, members of the couple. Couple-based interventions have
implementation in real-world settings can be challenging been found to be effective in increasing safe sexual
for women. One of the major challenges with imple- practices, including increased condom use and HIV
mentation science in the United States is that most of the testing (El-Bassel et al., 2019; Jiwatram-Negrón & El-
studies focus on men who have sex with men, in contrast to Bassel, 2014).
other countries where greater attention is given to women For women, intimate or romantic relationships are a
regarding implementation of interventions (Alonge et al., highly important context for HIV prevention and in-
2019). To achieve the 90-90-90 goal in the United States, tervention (Higgins et al., 2014). The majority of women
strategies and interventions that address barriers to HIV acquire HIV from their male partners within romantic
testing, linkage to ART, and HIV care adherence among relationships. This has led to the emergence of a body of
vulnerable subpopulations of women are needed (Hall research that explores the role of partner and relation-
et al., 2019). “Gender-focused, behavioral interventions ship characteristics on HIV risk. For example, consid-
that address multiple risk-taking behaviors can facilitate erable research has explored the role of partner age
PrEP and ART initiation and retention” (Wechsberg et al., discordance on women’s HIV risk (Akullian et al., 2017;
2017, p. 2). Garnett & Anderson, 1993; Ritchwood et al., 2016).
For implementation science to become an established There is also evidence that relationship-level factors,
field in HIV research, there needs to be better co- such as length of relationship, satisfaction, commitment,
ordination between funders of research and funders of and trust, are influential in sexual decision making
service delivery, and greater consensus on scientific re- (Ewing & Bryan, 2015; Harvey & Bird, 2004; Norris
search approaches and standards of evidence (Schack- et al., 2004). Within romantic relationships, however,
man, 2010). With improved funding support, better there are often gender power differentials that increase
coordination, and greater scientific clarity, researchers women’s vulnerability to HIV (Altschuler & Rhee,
will be able to deliver interventions grounded in imple- 2015; Worth, 1989). For example, women who may be
mentation science (Lambdin et al., 2015; Schackman, financially dependent on their male partners may be less
2010). Contextual understanding encourages the con- likely to refuse unwanted or undesired sex and to ne-
sideration of the real-life social, political, and technical gotiate safe sexual practices such as the use of male and/
environments that may influence how well an in- or female condoms (Altschuler & Rhee, 2015).
tervention or policy performs (Logan et al., 2002). For
example, key populations, such as Black women, are of-
ten stigmatized and historically have been denied access to Biomedical Interventions for Women
quality health services (Prather et al., 2018). Therefore, if Recommendation 5: Increase the number of clinical
an intervention study aims to increase women’s partici- trials tailored for women with the goal of improving
pation, especially those from racial and ethnic minority PrEP uptake to prevent new infections and ART ad-
groups, it would likely need to move beyond the tradi- herence to sustain viral suppression. Although there
tional clinical setting to a more innovative community- have been monumental developments surrounding PrEP
centered approach (Levison et al., 2018). use, cisgender women have been substantially over-
looked as high-priority participants in clinical trials of
PrEP, antiretrovirals, and HIV vaccines (Falcon et al.,
Behavioral Intervention for Women 2011; Curno et al., 2016), including recent clinical trials
Recommendation 4: Explore the efficacy and long- of Descovy (TDF/FTC) and long-term injectable cabo-
term impact of couple-based HIV interventions that tegravir/rilpivirine efficacy. Barriers to PrEP uptake
focus on the value of the romantic relationship to among Black women have been well-documented in the
enact couples’ decisions and behaviors that will literature (e.g., financial barriers, lack of awareness, low
promote the SRH of women. Couple-based approaches risk perception, and structural barriers); however, the
are advantageous for HIV prevention because they rec- exclusion of Black women within such seminal studies is
ognize the importance of the relationship and partners in a considerable barrier to PrEP uptake (Ojikutu et al.,
HIV acquisition and place mutual responsibility for HIV 2018). With the advent of new PrEP medications (Flash
prevention on both members of the couple. Couple- et al., 2017), there is a need for studies to assess the ac-
based interventions also allow both members to jointly ceptability and efficacy of these medications among Black
women, as well as testing ways to educate them and provide such as Critical Race Theory, Black Feminist Thought,
resources about PrEP. and intersectionality, to understand how structural
Optimal ART regimens to achieve durable viral load racism influences efforts to develop and implement vi-
suppression are essential for the survival of PLWH. Yet, able strategies to protect women of color, specifically
most clinical trials have enrolled majority male samples Black women, from HIV infection and to maximize care
(Lambert et al., 2018), despite ample evidence that for WLWH. Research suggests that social determinants of
women have unique needs requiring tailored in- health (e.g., poverty, unemployment, limited education) are
tervention. Because clinical trials are the gold standard contributors to HIV disparities, with racism being a prob-
for determining the safety, efficacy, and effectiveness of able underlying determinant of all these social conditions
medical and behavioral interventions, greater inclusion (Bailey et al., 2017). Yet, despite racism’s distressing impact
of women participants is needed to determine their ef- on health and the abundance of scholarship that outlines its
fects on women’s health outcomes. ill effects, research addressing disparities often fails to in-
Recommendation 6: Increase the number of PrEP tegrate racism as a critical driver of racial health inequities.
interventions that consider the social contributors to Examination of the impact of structural racism and dis-
health for Black and Latina women in both clinical crimination on health decision making of marginalized
and community settings. Ensure that providers groups, such as low-income Black women, is integral to
across settings have the appropriate knowledge and elimination of health disparities and promotion of health
skills to engage women effectively in the clinical equity. Structural racism refers to “the totality of ways in
encounter through interventions that focus on im- which societies foster racial discrimination through mutu-
proving patient-provider communication. Black and ally reinforcing systems of housing, education, employment,
Latina women are faced with dual health disparities earnings, benefits, credit, media, health care, and criminal
related to HIV because they have disproportionately justice; these patterns and practices in turn reinforce dis-
high rates of HIV infection and low rates of PrEP use for criminatory beliefs, values, and distribution of resources”
HIV prevention (Cohen et al., 2015; Mera-Giler et al., (Bailey et al., 2017, p. 1455).
2017). This imbalance will lead to greater health dis- There is little examination of the views of women of
parities in HIV incidence and prevalence among women color affected by the HIV epidemic regarding their expe-
if not effectively addressed (Blackstock et al., 2017; riences related to structural racism in the health care sys-
Calabrese et al., 2017). Low awareness of PrEP is be- tem. In a recent study by Randolph et al., Black women
lieved to be a critical barrier for women’s PrEP uptake, reported ways that they perceived that structural racism
but even with reported high willingness to use PrEP impeded their abilities to access health care and preventive
among women of color, other factors may impede PrEP services and to carry out certain health behaviors (Ran-
linkage, acceptance, retention, and adherence, such as dolph, Golin, et al., 2020). Listed among these were mis-
the newness of the drug, side effects, medical mistrust, trust of HCPs and institutions, perceived bias based on
and stigma (Bond & Gunn, 2016). Interventions that race, and lack of patient–provider communication in the
involve a larger range of HCPs (e.g., primary care and clinical encounter (Randolph, Golin, et al., 2020). Ex-
obstetrician-gynecologist) who are trained in the pro- ploring further effects that racism has on Black women’s
vision of PrEP are necessary to initiate utilization and participation in health practices and programs warrants
sustain engagement in care for women (Krakower & further investigation (Randolph, Golin, et al., 2020). In-
Mayer, 2016). Consistent with historical evidence, terventions that address implicit bias among providers and
Black and Latina women who are significantly affected improve patient–provider communication in the clinical
by HIV are not a population of focus for EBIs for PrEP encounter are warranted (Randolph, Golin, et al., 2020).
uptake. There is an urgent need for PrEP interventions Recommendation 8. Provide preventive HIV services
designed for Black and Latina women that will focus on to Black women and other women of color regardless
their experiences of stigma within community and of educational attainment and socioeconomic status.
health care settings and the expansion of PrEP training Current clinical and research efforts tend to focus highly on
for HCPs to support those challenges. low-income Black women who may not have high edu-
cational attainment and who may not have access to
resources (Chandler, Guillaume, et al., 2020; Newsome
et al., 2018); however, several studies have shown that
Structural Interventions for Women Black women of higher socioeconomic status are still
Recommendation 7: Design exploratory studies using vulnerable to HIV infection, and this vulnerability is
models that account for racism and its effects on health, even higher while in college due to environmental and
cultural influences (Chandler, Guillaume, et al., 2020; nurses’ leadership and involvement is critical, and the
Heath, 2016; Newsome et al., 2018). Factors such as importance of this approach will become of even
high socioeconomic status and education offer the im- greater importance to ensure the delivery of highest
pression that Black women of the middle class are less quality care. For example, nurse practitioners are
vulnerable to HIV compared with Black women of a found to provide HIV care of the same quality as
lower socioeconomic status, yet little is known about physicians with HIV expertise and better-quality care
HIV vulnerability among college-age Black women compared with physicians without HIV expertise
(Caldwell & Mathews, 2015; Chandler, Guillaume, (Wilson et al., 2005). Nurse practitioners can function
et al., 2020; Fray & Caldwell, 2017; Painter et al., as the leading clinicians in HIV care either as part of
2012). This assumption may lead to missed opportu- HIV care teams or after high-level training or expe-
nities for HIV and STI prevention and testing within rience (Wilson et al., 2005). Thus, nurse practitioners
health care settings, including access to PrEP (Chandler, or nurses with HIV expertise could significantly con-
Guillaume, et al., 2020). Black women of higher edu- tribute to maintaining access to HIV care in settings
cation levels and socioeconomic status are less likely to where access to physicians is limited because the
screen for HIV and STIs due to having a low perception greatest loss of patients in the HIV care continuum
of HIV risk among themselves, as well as HCPs having a occurs between diagnosis and care engagement. Ad-
low perception of women’s risk (Chandler, Guillaume, ditionally, nurses can also serve as the frontline HCP
et al., 2020). Ultimately, limiting HIV prevention to to integrate clinical care and public health activities,
only women from lower socioeconomic status can be of to reduce new infections by engaging communities to
great detriment to all Black women because Black increase the test rates, to reduce stigma associated
women have smaller sexual networks and there is a with HIV, and to encourage partner notifications.
higher prevalence of HIV and STIs within Black com- Given the complex medical and social needs of
munities in the United States (Chandler, Guillaume, PLWH, as well as the holistic, biopsychosocial nurs-
et al., 2020; Newsome et al., 2018). ing approach to care, nurses are well positioned to
lead multidisciplinary care teams for this population.
Nurses can fill roles such as coordination of care,
Nursing Role in the HIV Care Continuum initiating and following up on referrals to social ser-
for Women vices, and leading interventions for prevention and
Recommendation 9: Increase educational efforts to treatment adherence (Jemmott et al., 2008; Treston,
support nurses’ and nurse practitioners’ specialized 2019). Yet, effectively carrying out these tasks and
training in HIV care as part of HIV care teams’ pro- promoting better patient outcomes requires the in-
vision of treatment and management of care for volvement of a multitude of professionals including,
women at risk for and living with HIV. Eliminating the but not limited to, pharmacists, public health work-
HIV epidemic calls for the collaboration of HCPs ers, physicians, and social workers. Nurses and other
across all disciplines (e.g., nursing, medicine, public professionals must therefore work to understand ef-
health) at different levels, from national to state to fective team-based approaches to caring for PLWH
local. With a long history of working as the frontline that maximize and integrate the expertise of each
HCP combating HIV, nurses should continue to pro- discipline.
vide quality care to women across the HIV care con- Recommendation 10: Incorporate interdisciplinary,
tinuum. Guidelines for the primary care management team-based approaches in clinical practices to pro-
of PLWH indeed call for multidisciplinary, team- vide care for not only women but all PLWH. Several
based care because this approach has been shown to examples of this approach have been documented over
improve adherence to treatment, address social and the past 5 years, and primarily consist of integrated
cultural aspects of care, and identify and respond to didactic and clinical training for medical and nursing
unmet patient needs (Bares et al., 2018; Gardner et al., students, as well as other disciplines, such as pharmacy
2005; Mavronicolas et al., 2017; Pittenger et al., and social work (Bares et al., 2018; Kiguli-Malwadde
2019; Tran et al., 2019). Increasingly, the manage- et al., 2020; Rubin et al., 2018). Among other compo-
ment of PLWH is moving into primary care and other nents, these interventions have included features such
community-based settings; therefore, the nursing as participation in interprofessional rounds, team cap-
workforce is poised to have a larger presence over the stone projects, and case-based learning. Although such
coming years (Aberg et al., 2014; Pittman, 2019). As interventions have been rated by students as valuable
these settings move toward a team-based model, learning opportunities, more evidence is needed to
discern the impact of multidisciplinary approaches on oversight and supervision, conceptual development of
clinical outcomes for PLWH. the review, oversaw the writing of the original draft,
and revised and edited the final draft. R. Chandler
contributed to the conceptualization of the review, was
Conclusions responsible for drafting sections of the original draft,
HIV prevention efforts have shifted from focusing on and reviewed and edited the final draft. C. Chapman-
individual behaviors (substance use) to structural and Lambert contributed to the conceptualization of the
social contributing factors (such as racism, gender in- review, was responsible for writing sections of the
equalities, and lack of access to health care) that place original draft, and revised and edited the final version of
women at risk (Newsome et al., 2015). Combination the manuscript. L. Sweet Jemmott contributed to the
prevention approaches that expand behavioral inter- conceptualization of the review, drafted sections of the
ventions to include biomedical strategies for pre- original draft, and contributed to the editing of the final
vention, incorporate technology, and use research to draft. Y. Lanier contributed to the conceptualization of
support policy changes to combat barriers to health the review, was responsible for writing sections of the
equity surrounding HIV may be particularly beneficial original draft, and revised and edited the final version of
to addressing the challenges that women continue to the manuscript. J. Cao and J. Nikpour were responsible
experience (PRS, 2020; Rotheram-Borus et al., 2009). for writing sections of the original draft and revised and
Although the literature supports that efforts to address edited the final version of the manuscript.
HIV among women in the United States have been ef-
fective, given the rates of HIV among women, specifi-
cally Black women, more work is urgently needed. A
critical review of EBIs and other interventions in the Key Considerations
current literature shows that multilevel interventions
m Factors that contribute to women’s vulnerability to HIV
are warranted; studies that integrate contributing fac-
transmission and barriers to HIV care are complex and
tors into intervention development, implementation,
warrant complex, multilevel approaches to address
and evaluation are desperately needed. For example, it
them.
is well known that stigma, medical mistrust, and
patient–provider communication affect HIV across the m To address the HIV epidemic among women in the
continuum. Therefore, intervention studies should ex- United States, prevention and treatment strategies
pand their range of outcomes to include not only in- need to integrate behavioral, biomedical, and
creased condom use and decreased number of sexual structural approaches.
partners but also reduced HIV-related stigma, im- m Interventions to improve the uptake and adherence of
proved medical trust between providers and women, PrEP among women of color, particularly Black
improved patient–provider communication in the women, are urgently needed to reduce new
clinical encounter, and improved access to trans- infections.
portation and health care. Failure to address the con-
textual factors within interventions will very likely m Structural interventions are needed that address
hinder progress in this epidemic among women in the systemic racism and implicit bias in the
United States. patient–provider clinical experience to improve follow-
up and adherence to treatment among women in the
HIV status-neutral care continuum.
Disclosures
m Engaging women throughout the research process
The authors report no real or perceived vested interests using intersectional approaches and incorporating
related to this article that could be construed as a conflict technology as an intervention delivery mode are two
of interest. potential ways to improve sustainability of
interventions over time.
Author Contributions
All authors on this article meet the four criteria for References
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Review Article

Applying a Nursing Perspective to Address the

Epidemiology of HIV Infection Among Women Disparities by Age Group

factors contribute to women’s vulnerability to HIV across

Journal of the Association of Nurses in AIDS Care

Ending the HIV Epidemic Among Cisgender Women

Intervention Method of Intervention

(continued on next page)

Journal of the Association of Nurses in AIDS Care

Ending the HIV Epidemic Among Cisgender Women

(continued on next page)

Intervention Method of Intervention

(continued on next page)

outside of the United States, with two in Uganda and one

Ortblad et al. (2017) Behavioral Interventions

ducing HIV transmission behaviors, reducing rates of

mon. We highlight individual, couple-level, and group-

level interventions that target women and are included

dividual and small group interventions, major out-

participants how to perform

interventions were delivered through individual or

them get linked to care if

group counseling sessions, health education, and skills

training (Choi et al., 2008; Davey-Rothwell et al.,

2011; Diallo et al., 2010). Few interventions were solely

individual component (Jemmott et al., 2005; Wenzel

couple-based approach to address risk reduction

their male partners (El-Bassel et al., 2011; McMahon

et al., 2013, 2015).

Many HIV prevention strategies have been biomedical

among Female Sex

bicides (Abdool Karim et al., 2010). Both treatments as

individuals to prevent HIV acquisition) demonstrate

Table 2. HIV Prevention Research Gaps for Women Table 2. (continued)

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