Navigating PrEP alongside high-risk drinking: Multilevel barriers, care disruption, and intervention pathways in...

Area of Science:

• Public Health
• Clinical Medicine
• Substance Use Research

Background:

• Pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but adherence challenges exist for individuals with unhealthy alcohol use (UAU) or Alcohol Use Disorder (AUD).
• PrEP disengagement among those at high HIV risk is viewed as a systems-level issue, requiring examination beyond individual factors.
• The Multilevel Intervention Framework guides the investigation of barriers within the social and healthcare ecosystem.

Purpose of the Study:

• To identify barriers to consistent PrEP care among individuals with UAU.
• To explore how individual, relational, social, and policy factors influence PrEP adherence and disengagement in this population.

Main Methods:

• Conducted 46 in-depth qualitative interviews with 15 participants using PrEP and scoring high on the Alcohol Use Disorders Identification Test (AUDIT).
• Recruited participants from four clinical sites in Louisville, Kentucky, between December 2023 and June 2025.
• Employed thematic analysis with a hybrid approach, combining deductive application of the Multilevel Intervention Framework and inductive exploration of participant narratives.

Main Results:

• Unhealthy alcohol use (UAU) was identified as a primary driver of PrEP disruption, impacting decision-making, risk-taking, routines, motivation, and risk perception at individual and systemic levels.
• Alcohol use influenced relational and community contexts, leading to conditional risk management and reliance on self-directed strategies over provider support.
• Structural policy-level barriers, including insurance instability, medication costs, and pharmacy delays, were exacerbated by alcohol-related vulnerabilities, causing compounded disruptions to PrEP adherence and engagement.

Conclusions:

• Multifaceted, equity-driven interventions are crucial, integrating harm-reduction, adaptable care models, and structural reforms to support sustained PrEP engagement and alcohol reduction.
• A shift towards systemic solutions is necessary to address the lived realities of diverse PrEP users and reduce HIV prevention disparities.
• Interventions should move beyond individualized approaches to encompass broader societal and healthcare system changes.