Faith over Protection, Faith as Foundation: A Mixed-Methods Joint Display Study of Religion, Spirituality, and PrEP Decision-Making Among Black Cisgender Women in the United States

Background: Black cisgender women in the United States bear a disproportionate burden of new HIV diagnoses, yet fewer than 1 in 10 women who could benefit from pre-exposure prophylaxis (PrEP) receive a prescription. Religion and spirituality are central to many Black women’s lives and may shape sexual health decision-making in complex ways, but their role in PrEP engagement has been undertheorized. Methods: We conducted a convergent mixed-methods study integrating cross-sectional survey data from the ReachHER study (N = 397 Black cisgender women) with qualitative, semi-structured interviews (different sample of N = 30 Black cisgender women). Three religion/spirituality items—general religiosity, religion in medical decisions, and religion in sexual decisions—were examined in exploratory bivariate analyses with prior PrEP awareness, current PrEP use, HIV testing in the past 12 months, and primary care provider access using Pearson χ2 tests. Prior PrEP awareness was assessed before participants received standardized PrEP education. Qualitative data were analysed using reflexive thematic analysis. A joint display integrated the two datasets. Results: General religious/spiritual identification and religion in medical decisions were associated with current PrEP use in bivariate analyses, and religious/spiritual identification was also associated with HIV testing in the past 12 months. Five qualitative themes emerged: (1) religion as part of a broader belief system; (2) religion as cultural and identity intersection; (3) religion as a barrier to sexual health communication; (4) faith over protection as a driver of PrEP hesitancy and stigma; and (5) religious institutions as trusted intervention spaces. Conclusions: In this mixed-methods study, religion/spirituality functioned as an ambivalent but consequential multidimensional context for PrEP decision-making among Black cisgender women, simultaneously constraining sexual discourse and providing trusted infrastructure for prevention. Faith-partnered, intersectionally tailored PrEP interventions warrant further study.