Introduction

HIV disproportionately affects African immigrants in the United States (US). Sobering analyses suggest that African immigrants are six times more likely to be living with HIV than other minority groups and the general US population [1, 2]. Accurate data on the odds of infections for African immigrants are lacking, in part, because African immigrants are often overlooked or misclassified as “Black” or “African American” in National HIV surveillance data [3, 4]. Given the ever-growing size of African immigrants in the US (approximately 2 million as of 2019 [5]) and the persistently high rates of HIV infections [1, 6, 7], new approaches to HIV prevention are needed among this population. One such approach is preexposure prophylaxis (PrEP), where antiretroviral medications are used to prevent HIV among HIV-uninfected individuals [8].

Oral PrEP has been demonstrated to minimize the sexual transmission of HIV significantly. Models predict that oral PrEP reduces the incidence of HIV by 99.9% for men who have sex with men (MSM) and by 90% for women, assuming daily adherence [9, 10]. Currently, three Food and Drugs Administration (FDA) approved PrEP medicines exist. Two are daily oral single-tablet combinations F/TDF (Truvada® or generic) The third is a 2-monthly injection, Apretude® (cabotegravir 600 mg), which was recently approved in December 2021. [11]. Oral PrEP has mostly been well received, yet overall uptake continues to fall short of what was projected [12]. As an alternative to oral PrEP, long-acting injectable (LAI) PrEP may improve adherence because it needs to be administered less frequently and may increase uptake. Given PrEP’s (both oral and injectable) proven efficacy, it could help reduce the incidence of HIV among African immigrants.

A growing but limited body of literature on African immigrants’ awareness and knowledge of PrEP indicates a low awareness and knowledge of PrEP as an HIV prevention option [13,14,15]. These studies were mostly focused on oral PrEP; thus, the option of injectable PrEP remains unexplored. While not much is known about the willingness to use both existing and new PrEP modalities among African immigrants, long-acting injectable PrEP may help lessen difficulties reported in oral PrEP research (e.g., around privacy and pill fatigue [16]). In addition, the studies on PrEP among this population remain primarily qualitative with limited sample sizes, thus limiting generalizability [13, 14]. To date, no known quantitative study has investigated awareness and willingness to use oral and injectable PrEP among African immigrants in the US. In this article, we aim to describe the proportion of PrEP awareness and knowledge, the willingness to use oral and injectable PrEP among African immigrants, and identify the associated sociodemographic factors. This study represents an initial effort to characterize awareness, knowledge, and willingness to use oral or injectable PrEP among African immigrants in the US.

Methods

Study Population

Participants were drawn from a cross-sectional study conducted among African immigrants in the United States. Eligibility criteria were: [1] being 18 years and above; [2] identifying as an African immigrant; [3] reading and writing in English, and [4] not currently using PrEP.

Recruitment and Procedures

Enrollment occurred in April and May 2022. Participants were recruited using WhatsApp, a social media and communication platform [17]. A recruitment message with a REDCap link was posted on WhatsApp status of the first and second author, including the research assistant, and groups (about 30 different groups) that were made up of other African immigrants and asked to share with their networks. African immigrant WhatsApp groups usually have at least 50 people, with some groups having close to 700 people. Such groups are organized across shared interests such as ethnicity, education, religious or social interests. WhatsApp has been demonstrated to be highly effective in recruitment among this population [18], and remains the preferred research recruitment method of choice beyond word of mouth or through community-based organizations [19]. Studies highlight WhatsApp as an innovative, flexible, low-cost strategy to recruit African immigrants [18, 19]. The recruitment messages sent out to groups and individuals on WhatsApp asked that the link not be shared outside of WhatsApp. This was to ensure the validity of the responses. Eligible participants completed a web-based survey assessing demographic characteristics, PrEP awareness and knowledge, and willingness to use oral or injectable PrEP using their phones or computers in English. We documented informed consent by having participants check the “agree” box after being provided with details of the study. The survey was programmed to prevent participants from retaking the survey more than once. Participants received a $10 gift card as compensation. The IRB approved all study procedures at the University At Buffalo.

Measures

We collected sociodemographic data to aid our understanding of the composition of our sample. These items assessed year of birth, gender, marital status, education, annual income, healthcare provider status, and country of origin.

PrEP Awareness

We provided a brief description of PrEP and assessed PrEP awareness using a single item “Prior to reading the description above, were you familiar with PrEP?” [ Response options: Not at all familiar = 1, familiar = 2].

PrEP Knowledge

For those who indicated they were familiar with PrEP, we assessed their PrEP knowledge using an 18-item PrEP knowledge questionnaire [Response options: True = 1, False = 2, I don’t know = 3].

PrEP Modalities

We used two stand-alone items to assess willingness to use a different modality of PrEP. Participants were asked, “If there was a pill you had to take once daily every day, would you be willing to use it to help prevent you from getting HIV?” and “If there was an injectable, where you will need a dose every 12 weeks, would you be willing to use it to help prevent you from getting HIV?” [Response options: Very unwilling, Unwilling, Neutral, Willing, very willing]. This variable was collapsed as unwilling to use/neutral (Very unwilling, Unwilling, or Neutral) and willing to use (Willing or very willing) to achieve our study’s objectives. While injectable cabotegravir is administered every two months (8 weeks), we chose to inquire about PrEP usage every 12 weeks (3 months) [20].

Data Analysis

The analysis was conducted in STATA Version 16.1 (StataCorp, 2019) among a sample of African immigrants. We described the prevalence of PrEP awareness and willingness to use PrEP modalities by the participants’ sociodemographic characteristics (i.e., year of birth, gender, marital status, education, annual income, healthcare provider status, and country of origin), respectively. We used Pearson’s chi-squared or Fisher’s exact test to determine the statistically significant differences in the prevalence rates by sociodemographic characteristics. A statistically significant test was set at < 0.05 based on a 2-sided test. We also computed the prevalence of PrEP knowledge among the participants who reported being aware or familiar with PrEP to describe those who reported correctly, incorrectly, or didn’t know the use of PrEP.

Results

Sociodemographic Characteristics

A full summary of selected demographic variables is presented in Table 1. There was a total of 92 participants in the study. Majority of participants were female (70.7%), from West Africa (44.6%), college-educated (69.6%), married or cohabiting (63.0%), born between 1990 and 1999 (46.7%) and earning between $30,000-$59,999 (31.5%).

Table 1 Descriptive and bivariate analyses of PrEP awareness based on sociodemographic characteristics of African immigrants (N = 92)
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PrEP Awareness

Associations between sociodemographic variables and PrEP awareness are also presented in Table 1. More than half of the participants (52.2%) were unaware of PrEP. PrEP awareness was associated with educational status (p = 0.026) and healthcare provider status (p = 0.005). Among those who were unaware of PrEP, majority had high school or less education (90.00%) and based on the healthcare provider status (i.e., the type of healthcare receive regularly), had not received healthcare services regularly (90.0%). Those aware of PrEP mostly had college or higher education (54.7%) and received healthcare service regularly from primary care providers (60.3%).

PrEP Knowledge

Participants who indicated they were aware of PrEP were asked questions to test their PrEP knowledge. Table 2 shows the prevalence of PrEP knowledge among the participants. Overall, the participants reported a high prevalence of correct knowledge about PrEP use. More than 50% of the participants correctly reported that (i) PrEP/Truvada protects against HIV, (ii) PrEP/Truvada should be used with a condom during sex, (iii) PrEP/Truvada is effective when taken correctly, (iv) must be HIV negative to use PrEP/Truvada, (v) people on PrEP/Truvada still need HIV testing, (vi) there are side effects associated with PrEP/Truvada, but most people don’t experience them after the 1st month, (vii) PrEP should be taken every day for it to be effective at preventing HIV, (viii) people on PrEP must be tested for HIV every three months. More than 50% of them also correctly reported that (x) PrEP is not a vaccine against HIV, (xi) PrEP also does not protect against other sexually transmitted diseases (STDs), like gonorrhea and syphilis, and (xii) PrEP is not a cure for HIV.

Table 2 PrEP knowledge among PrEP-aware African immigrants (n = 44)
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Willingness to Use a PrEP Modality

We examined the prevalence of willingness to use a PrEP modality (whether pill or injectable) and the association between willingness to use a PrEP modality and sociodemographic variables (Table 3). There was a high willingness to use a PrEP modality for HIV prevention among the participants (65.6%)0.70.4% of men were willing to use PrEP, compared to 63.5% of women who were willing to use PrEP. Additional analysis was run to examine willingness to use PrEP by the modality (whether Pill or Injectable), though the results are not presented in Table 3. 51.1% of participants were willing to use an oral pill for prevention and 47.8% were willing to use injectable PrEP. These findings indicate a high unwillingness to use injectable PrEP (52.2%). Also not presented in Table 33.3% of the 90 participants were willing to use both oral and injectable PrEP. In Table 3, willingness to use a PrEP modality was associated with healthcare provider status (p = 0.03). Those who received dental and other healthcare services regularly were the majority of the participants willing to use PrEP modality (80.0%). Most of those unwilling or were neutral to use PrEP modality were those who had not received healthcare services regularly (77.8%).

Table 3 Prevalence of willingness to use a PrEP modality based on sociodemographic characteristics of African immigrants (n = 90)
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Discussion

Given the absence of research on US-based African immigrants’ awareness and knowledge about PrEP, the primary purpose of this study was to assess and describe their awareness and knowledge of PrEP and the willingness to use oral or injectable PrEP modality for HIV prevention. Results from this study demonstrate that African immigrants have low awareness of PrEP and a high willingness to use a PrEP modality for HIV prevention. Notably, the finding that women and individuals with lower levels of education exhibit lower awareness of PrEP, despite not being statistically significant, holds clinical significance. The significance lies in the fact that these subgroups may face increased barriers to accessing an effective HIV prevention method. PrEP has demonstrated substantial efficacy in reducing HIV acquisition rates, and its effectiveness is directly linked to awareness and uptake. Consequently, low awareness of PrEP among these subgroups may translate into greater susceptibility to HIV infection. This finding may also reflect broader health disparities and inadequate access to healthcare resources and information. Given the potential implications for HIV prevention efforts, the study underscores the importance of targeted interventions and education efforts to promote PrEP awareness and uptake among all individuals at risk of HIV acquisition, irrespective of their demographic background. The findings on low awareness of PrEP among women are consistent with previous studies on PrEP awareness among women in the US [21] and African immigrant women [14, 22]. African immigrant women are disproportionately affected by HIV, with an estimated 12-fold risk compared to women in the US population [1]. PrEP is a promising, female-controlled HIV prevention strategy that has so far been underutilized in women. In order to optimize the usage of PrEP among African immigrant women, it is critical to increasing awareness about PrEP. Evidence suggests that PrEP is a valuable HIV prevention option for women [21].

For those who indicated that there were aware of PrEP, this awareness did not translate to correct responses on the knowledge items. Almost half of the participants incorrectly answered that PrEP is antiretroviral therapy for HIV patients. More than half also incorrectly answered that PrEP prevents HIV-positive persons from making enough virus to transmit to a partner. In addition, slightly more than half indicated that they did not know if a woman taking hormonal contraceptives (birth control) would make PrEP less effective at preventing HIV. These results suggest that health education and awareness-raising efforts are needed to increase PrEP awareness and improve knowledge, which can positively impact broad HIV prevention services and PrEP uptake among this population.

Consistent with studies on willingness to use PrEP among different African immigrant groups [14, 15], participants were willing to use PrEP for HIV prevention. Having a healthcare provider was significantly associated with the willingness to use PrEP, as people may have heard about PrEP from their provider or be willing to access it from their regular provider. This finding is consistent with existing literature highlighting healthcare providers’ critical role in promoting and prescribing PrEP for African immigrants [13,14,15]. However, studies among healthcare providers in the US reveal low awareness and discomfort with prescribing PrEP [23, 24], as well as a lack of cultural competency to engage with African immigrants in a culturally responsive way [13]. Further research is among healthcare providers providing care for this population to understand their training needs to recommend and prescribe PrEP for African immigrant groups.

Limitations

There are important limitations to this study. First, this was a cross-sectional study, limiting our ability to make causal inferences from the finding. Second, the study materials were in English, which excluded non-English speaking participants from taking the survey. It must be noted the most sub-Saharan African countries have over 50 major languages, thus attempting to translate this survey into the many languages may not have been possible at this current time, however, the countries with the most survey responses (Nigeria and Ghana) have English as their official language thus making us more comfortable having an English survey. Additionally, this study did not ask questions about sexual orientation, sexual behaviors, HIV risk behaviors and testing. The cultural norms and values that undergird discussions related to sex, sexuality, and sexual health make it challenging to ask questions about these topics using surveys. Anecdotal evidence suggests that for African immigrants, sensitive topics such as HIV and sexual health topics are usually best asked using qualitative methods such as interviews with a culturally competent and sensitive interviewer. While sexual behaviors such as number of sexual partners within the last months, frequency of condom use, unprotected sexual intercourse, and HIV testing may have been critical and provided information to better situate the PrEP conversation among this population, the absence thereof does not negate the finding of low awareness generally among this population, and their willingness to use PrEP regardless of their sexual behavior. Furthermore, the small number of participants in the survey limits our ability to provide specific recommendations for PrEP and generalize the findings. Nonetheless, given the significance of the subject matter and the limited existing literature on PrEP uptake among African immigrants, these preliminary findings offer valuable data and insights. We initially aimed to recruit 150 participants; however, we fell short of our goal and could only enroll 90 participants. We acknowledge this recruitment shortfall as a study limitation. To address this limitation and improve the robustness of future research, we plan to conduct expanded studies that include a larger and more inclusive sample of African immigrants. By increasing the sample size, these future studies seek to enhance statistical power and strengthen the generalizability of the findings, enabling more definitive recommendations regarding PrEP utilization within this populationIt is important to acknowledge that the available research on HIV in the African immigrant community in the US is limited, out of date, and largely consists of grey literature. This limitation is beyond our control, but it underscores the need for the current research we are conducting. Finally, African immigrants are a heterogeneous group; thus, a one-size fits all recommendation may not be effective. Despite this limitation, this study adds to the limited literature on PrEP awareness and uptake among African immigrants in the US.

New Contribution to Literature

This study makes several contributions to the literature. This study represents a first attempt to characterize awareness, knowledge, and willingness to use oral or injectable PrEP among African immigrants in the US. It provides baseline data on awareness, and willingness to use PrEP. Secondly, with the advent of injectable PrEP, it is critical to understand if this method would be an option for HIV prevention among this population. Thus, our study contributes to the literature on PrEP uptake and preferred modalities. Our study provides a foundation for understanding PrEP needs and how to effectively roll-out PrEP among this population. This may be instrumental in developing effective interventions and achieving positive outcomes such as the reduction of HIV infections.