Shaping Movement through the PrEP Care Continuum: A Grounded Theory of High-Risk Alcohol Use and PrEP Engagement

Background and Purpose: Pre-exposure prophylaxis (PrEP) is recognized as an effective biomedical strategy for HIV prevention among populations at risk. However, the effectiveness of PrEP depends on engagement across the PrEP care continuum, including identifying individuals at risk, access to PrEP-related care, and optimal adherence following initiation. Among individuals engaging in high-risk alcohol use, PrEP adherence is frequently jeopardized, and disengagement from PrEP is common, which contributes to increased HIV risk. Despite this, limited evidence exists regarding mechanisms through which high-risk alcohol use shapes disruption, disengagement, and re-engagement across the PrEP care continuum. The purpose of this study was to explore processes through which high-risk alcohol use shapes movement through the PrEP care continuum. Methods: Using a grounded theory approach, data were drawn from 55 in-depth interviews with 16 PrEP users who reported hazardous alcohol use, defined as an Alcohol Use Disorders Identification Test (AUDIT score >= 8), recruited from clinical sites in Louisville, Kentucky, between December 2023 and June 2025. Analysis proceeded iteratively through repeated engagement with transcripts, analytic notes, and memo writing, using constant comparative techniques to identify phase-based patterns of PrEP engagement. Of the 16 participants, 100% were assigned male at birth and identified as male (n = 16). Regarding sexual orientation, 11 participants identified as gay (68.8%), three identified as bisexual (18.8%), one identified as queer (6.3%), and one identified as heterosexual/straight (6.3%). With respect to age, 11 participants were between 18–39 years (68.8%), three were between 40–59 years (18.8%), and two were aged 60 years or older (12.5%). Results: Analysis revealed four phases through which alcohol use influenced movement across the PrEP care continuum: (a) positioning alcohol use as a context for HIV risk, (b) integrating PrEP within daily routines to maintain protection, (c) encountering alcohol-related disruptions to adherence and care, and (d) re-stabilizing PrEP engagement following lapses. Alcohol use acted as a contextual factor shaping dynamic and non-linear patterns of PrEP engagement, with implications for understanding patient experiences and care-related barriers in the context of PrEP care and engagement. Conclusion and Implications: Understanding how alcohol use shapes movement through the PrEP care continuum may inform PrEP care approaches that better support engagement, disruption management, and re-engagement over time.