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

Despite the effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV, many individuals engaged in unhealthy alcohol use (UAU) or Alcohol Use Disorder (AUD) struggle to maintain adherence and engagement in care. This study situates individual PrEP care within a broader social and healthcare ecosystem, viewing PrEP disengagement for those at disproportionate risk of HIV acquisition as a shared systems-level responsibility. Guided by the Multilevel Intervention Framework as a starting point, we examined: (1) barriers to consistent PrEP care among individuals who engage in UAU, and (2) how individual, relational, social, and policy factors shape PrEP adherence and disengagement among this population.

The study team conducted 46 in-depth qualitative interviews with 15 participants who used PrEP and scored eight or above on the Alcohol Use Disorders Identification Test (AUDIT). Each participant completed multiple interviews between December 2023 and June 2025 and was recruited from four clinical sites in Louisville, Kentucky. Thematic analysis explored multilevel barriers to PrEP adherence and retention among individuals who use PrEP while also engaging in UAU. We used a hybrid analytic approach that paired deductive attention to the Multilevel Intervention Framework with inductive openness to concepts emerging from participants' narratives. Our stance focused on how participants understood their experiences and the pathways connecting alcohol use and PrEP adherence.

Qualitative findings identified UAU as a central, multilevel driver of PrEP disruption, directly impairing decision making, increasing sexual risk taking, disrupting daily routines, reducing motivation, and risk perception, which operated at the individual level, but permeated experiences at the community, relational, and policy levels as well, affecting engagement in care. Alcohol use also shaped relational and community contexts by contributing to conditional risk management, missed clinical opportunities to address substance use, and reliance on self-directed strategies rather than provider-supported care. At the policy level, structural barriers such as insurance instability, medication cost, and pharmacy delays were amplified by alcohol-related vulnerability, resulting in compounded disruptions to adherence and sustained engagement in PrEP care.

The study highlights the importance of multifaceted, equity-driven interventions that incorporate harm-reduction strategies, adaptable care-delivery models, and structural reforms to promote sustained PrEP engagement alongside alcohol reduction. These insights call for a shift from individualized approaches to systemic solutions that reflect the lived realities of diverse PrEP users and aim to reduce disparities in HIV prevention outcomes.