High Motivation but Low Access to PrEP: Social Determinants Undermine HIV Prevention Among Sexual and Gender Minority People Who Use Methamphetamine.

Methamphetamine (meth) use is endemic among sexual and gender minority (SGM) populations and a well-established correlate of HIV acquisition. Less understood are the behavioral, psychosocial, and structural vulnerabilities associated with meth use that may complicate HIV prevention. We examined differences in HIV-related vulnerabilities, perceptions of pre-exposure prophylaxis (PrEP) need, and access to PrEP care among SGM people who use meth compared with those who do not. Cross-sectional data were drawn from the baseline assessment (2022-2023) of a U.S. national cohort of SGM individuals aged 16-49 (n = 2,847 who used meth; n = 2,518 who did not). Participants completed an online survey assessing demographics, vulnerabilities associated with HIV acquisition and barriers to PrEP access, and PrEP use and interest. Multivariable logistic regression compared participants who recently used meth with those who did not. Compared with non-users, participants who used meth reported greater HIV-related vulnerability across multiple domains, including higher behavioral risk, greater socioeconomic disadvantage, lower engagement in HIV testing, and poorer psychosocial and mental health outcomes. They were also more likely to perceive themselves as appropriate candidates for PrEP and express interest in initiating PrEP, yet less likely to report access to resources and infrastructure that facilitate engagement in PrEP care. These findings may reflect a phenomenon we term the "Meth-PrEP Paradox," whereby individuals who use meth recognize their heightened vulnerability to HIV and express interest in PrEP while simultaneously encountering barriers to PrEP care. Longitudinal research is needed to evaluate this framework and identify strategies to improve HIV prevention among SGM people who use meth.