Substance Use and Healthcare Utilization Across the Pre-Exposure Prophylaxis (PrEP) Care Cascade among Black and Latino Men Who Have Sex with Men

Alcohol Use Disorder Diagnoses Among Individuals Who Take HIV Preexposure Prophylaxis

Importance

Alcohol use disorder (AUD) may negatively affect preexposure prophylaxis (PrEP) adherence and continuation, reducing PrEP effectiveness.

Objective

To estimate the prevalence of and and factors associated with AUD diagnoses among commercially insured individuals who take PrEP.

Design, Setting, and Participants

This retrospective cohort study used US health care claims data to identify individuals aged 16 to 64 years who received at least 1 new PrEP prescription between January 1, 2014, to December 31, 2021. Data were analyzed from June 2024 to February 2025.

Exposure

Sociodemographic characteristics included patient age, sex, geographic location, employment status, and type of health insurance. Clinical characteristics included sexually transmitted infection (STI) diagnosis and testing, use of psychotherapy services, and diagnosis of other mental health conditions.

Main Outcomes and Measures

The main outcome was an AUD diagnosis within 6 months before or after the date of PrEP initiation. Among individuals with an AUD diagnosis, receipt of medications for AUD (MAUDs), including Food and Drug Administration (FDA)-approved MAUDs (acamprosate, disulfiram, and oral and injectable naltrexone) and non-FDA-approved MAUDs (baclofen, gabapentin, and topiramate) was determined.

Results

The study cohort included 43 913 individuals receiving PrEP (mean [SD] age, 35.8 [10.94] years; 35 027 [90.1%] male assigned at birth). There were 6274 individuals (14.29%) who had an AUD diagnosis, with 1245 (2.84%) and 5029 (11.45%) receiving their diagnosis before and after PrEP initiation, respectively. The sociodemographic and clinical factors that were associated with an AUD diagnosis were similar whether AUD was diagnosed before or after PrEP initiation, including male sex assigned at birth (before: adjusted odds ratio [aOR], aOR, 0.62; 95% CI, 0.52-0.73; after: aOR, 0.81; 95% CI, 0.73-0.90) and the presence of other mental health diagnoses such as depression (before: aOR, 3.26; 95% CI, 2.78-3.84; after: aOR, 3.17; 95% CI, 2.88-3.49), anxiety (before: aOR, 2.16; 95% CI, 1.83-2.55; after: aOR, 2.24; 95% CI, 2.04-2.46), and any substance use disorder (before: aOR, 14.54; 95% CI, 12.46-16.96; after: aOR, 13.09; 95% CI, 11.82-14.49). There were 531 individuals with AUD diagnosis (8.46%) who received an FDA-approved MAUD and 883 (14.07%) who had a claim for a non-FDA-approved MAUD.

Conclusions and Relevance

This population-based cohort study found that nearly 15% of individuals who took PrEP had an AUD diagnosis within 6 months of PrEP initiation; individuals with an AUD diagnosis were more likely to have co-occurring mental health conditions, and less than 9% received any FDA-approved MAUD. These findings suggest that interventions are needed to improve AUD services among individuals who take PrEP.

Willingness to Use Long-Acting Injectable PrEP Among PrEP Naïve Black and Hispanic Sexual Gender Minority Persons

In December 2021, long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was approved for the prevention of HIV in at-risk adults and adolescents. LAI-PrEP may address adherence issues of daily oral daily PrEP and PrEP stigma. However, studies assessing LAI-PrEP willingness among PrEP naive Black and Hispanic sexual and gender minority (SGM) persons- a group disproportionately impacted by the HIV epidemic in the United States - is rare. To assess the extent of and characteristics of willingness to use LAI-PrEP in a national sample of Black and Hispanic SGM who are self-reported that they have never used PrEP. We analyzed data from a national sample of Black and Hispanic SGM collected between March and August 2020. We used log-binomial regression models to assess characteristics associated with willingness to use LAI-PrEP. Of the overall sample (N = 380), the mean age was 24 (SD = 2.8) and the majority of the sample (54%, n = 205) reported willingness to use LAI-PrEP. In multivariable log-binomial regression models, PrEP stigma was independently associated with less [prevalence ratio (PR) = 0.7, 95% confidence interval (CI) = 0.6, 0.9], while number of sexual partners in the past 12 months was associated with a more willingness to use LAI-PrEP (PR = 1.1, 95% CI = 1.0, 1.2). Our findings highlight the persistence of PrEP stigma as a potential barrier to willingness to use LAI-PrEP in this sample of Black and Hispanic SGM who have never used PrEP. Additional work needs to be done to reduce PrEP stigma more broadly.

Cannabis Use Frequency is Associated with PrEP Cessation and Self-reported HIV Diagnosis

To achieve stated targets in the United States of Ending the HIV Epidemic by 2030, it is necessary to decrease rates of pre-exposure prophylaxis use (PrEP) cessation. In particular, it is key to assess PrEP use and cannabis use frequency given the recent wave of cannabis decriminalization across the U.S., particularly among sexual minority men and gender diverse (SMMGD) individuals. We used data from the baseline visit of a national study of Black and Hispanic/Latino SMMGD. Among participants reporting any lifetime cannabis use, we further assessed the association between frequency of cannabis use in the past 3 months and: (1) self-reported PrEP use, (2) recency of last PrEP dose, and (3) HIV status using adjusted regression models. Compared to those who never used cannabis, odds of PrEP cessation were higher among those who used it once or twice (aOR 3.27; 95% CI 1.38, 7.78), those who used it monthly (aOR 3.41; 95% CI 1.06, 11.01), and those who used it weekly or more frequently (aOR 2.34; 95% CI 1.06, 5.16). Similarly, those reporting cannabis use 1-2 times in the past 3 months (aOR 0.11; 95% CI 0.02, 0.58) and those reporting weekly or more frequent use (aOR 0.14; 95% CI 0.03, 0.68) were each more likely to report more recent PrEP cessation. These results suggest that cannabis users in general may be a population at elevated risk of HIV diagnosis although more research regarding these findings is needed with nationally representative populations.

Characterizing Drug use Typologies and Their Association with Sexual Risk Behaviors: A Latent Class Analysis Among Men who have Sex with Men in Mexico

Introduction

Drug use behaviors are closely associated with increased risk for HIV and other STIs among men who have sex with men (MSM) globally. Less is known about the drug use characteristics and their association with HIV/STI risk among MSM in Mexico, who have 13 times higher risk of acquiring HIV than the general population. We characterized distinct classes of drug use behaviors among a nationwide sample of MSM in Mexico and tested their associations with HIV risk behaviors.

Methods

We used latent class analysis (LCA) to analyze injection/non-injection drug use data collected by the online Encuesta de Sexo Entre Hombres self-administered survey among 15,875 MSM living in Mexico between May-June 2017. MSM were recruited on general social media sites (e.g. Facebook and Twitter), popular LGBT + focused web pages (e.g. Soy Homosensual and Desastre), and dating apps (e.g. Grindr and Hornet). We used robust Poisson regression to examine associations between drug use classes and recent sexual risk behaviors while adjusting for sociodemographic characteristics.

Results

Most participants were under 30 years of age (65.5%), received a Bachelor's degree or higher (65.2%), gay-identified (82.5%), HIV negative (58.1%), and lived in the Mexico City/State of Mexico region (34.5%). We identified five distinct drug use classes: Limited Drug Use (75.4%), Marijuana Only (15.1%), Sex Event Popper + Marijuana (4.3%), Club Drug + Marijuana (4.2%), and Elevated Polydrug Use (1.0%). Compared to the Limited Drug Use class, participants in all other drug use classes were significantly more likely to engage in condomless anal intercourse (aPR = 1.14-1.39; p < 0.001), sex exchange (aPR = 1.37-4.99; p < 0.001), anonymous sex (aPR = 1.22-2.01; p < 0.001), group sex (aPR = 1.50-3.28; p < 0.001), and report an STI diagnosis in the past 12 months (aPR = 1.24-2.20; p < 0.002). Estimates were largest among the Elevated Polydrug Use class.

Conclusions

This study is the first to characterize drug use behaviors and HIV/STI risk among a national sample of MSM in Mexico. Understanding how distinct combinations of drug use behaviors impact sexual risk and prevention behaviors among MSM can inform how best to target and tailor future interventions to reduce HIV/STI incidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13178-023-00861-9.