Methamphetamine use and HIV prevention: a qualitative study on challenges and opportunities for PrEP utilization.

Methamphetamine use often co-occurs with sexual behaviors that may increase HIV acquisition risk and disrupt adherence to HIV pre-exposure prophylaxis (PrEP). To explore barriers and opportunities for PrEP among people who use methamphetamine, we conducted semi-structured interviews with 28 self-reported HIV-negative adults (ages 18-55) with current moderate-to-high risk methamphetamine use in the New York City metropolitan area. Transcripts were thematically analyzed with double coding and iterative consensus. Participants described sexualized methamphetamine use, polysubstance use, and sexual behaviors associated with increased HIV exposure risk (condomless intercourse, group sex, transactional sex, encounters with unfamiliar partners). Awareness of PrEP was high (86%), whereas 46% reported current use. Adherence frequently decreased during periods of heavy methamphetamine and polysubstance use, despite self-management strategies (e.g., phone/calendar reminders). Reported obstacles included insurance coverage interruptions, concerns about side effects, and reluctance to discuss sexual health with clinicians. Interest in long-acting PrEP was considerable (71% would try injections; 57% would try implants), though some expressed concerns about comparative efficacy, visit adherence, and access. Findings suggest that long-acting formulations may mitigate daily dosing burdens, particularly if delivered in settings already accessed by this population. Prospective clinical studies, ideally randomized trials, are needed to determine whether long-acting PrEP improves adherence and reduces HIV incidence in methamphetamine-using populations.