Psychosocial Correlates of HIV Pre-Exposure Prophylaxis (PrEP) Linkage Among Persons Who Inject Drugs In Rural Appalachian Kentucky

Background: People who inject drugs (PWIDs) are highly susceptible to HIV, yet there is a significant gap in the uptake of Pre-Exposure Prophylaxis (PrEP) among this vulnerable population. To address barriers to PrEP care engagement among PWIDs, community public health settings (e.g., syringe service programs/SSPs) have established supportive programs, such as integrating PrEP providers directly within SSPs, offering transportation and housing assistance, and promoting positive, non-stigmatizing relationships between providers and PWIDs. Despite these efforts, there remains a significant need for strength-based approaches to enhance PWIDs’ engagement in the PrEP care continuum. Evidence suggests that a strength-based resilience-oriented approach is effective in alleviating the negative experiences encountered by PWIDs (intersecting stigmas related to HIV, PrEP, and substance use), which hinder their PrEP uptake. Research also indicates that fostering resilience enhances the coping strategies of PWIDs, thereby promoting their health-seeking behaviors, including PrEP uptake, despite facing multiple overlapping stigmas and other socio-structural challenges. However, research on factors that facilitate or hinder PrEP uptake among PWIDs has mostly focused on socio-structural barriers (e.g., poverty, unstable housing, transportation availability, and access to medical coverage), rather than on psychosocial factors (e.g., social support and resilience). As a result, the impact of psychosocial correlates on PrEP uptake among PWIDs remains underexplored. This study examined the psychological correlates of PrEP care linkage, specifically social support (SS) and resilience (RES), among PWIDs at risk for HIV in rural Appalachian Kentucky.

Methods: Data were obtained from a NIDA-funded pilot study (November 2022-October 2023) that evaluated brief interventions to enhance PrEP uptake among 80 PWIDs in rural Appalachian Kentucky. We conducted bivariate Chi-square analysis to assess correlates of linkage to a PrEP care provider (0=no; 1=yes) among PWIDs, including socio-demographics (age, gender, and SSP site), structural (educational attainment, health coverage, cellphone, transportation, and income access), and psychosocial (SS and RES) factors. SS was measured using the Medical Outcomes Study Social Support (MOS SS) short-form scale (α=0.92) and RES using the 10-item Connor-Davidson Resilience Scale (α=0.714). Based on prior studies, we categorized SS scores around the mean [low SS=0-73 vs. high SS >73] and RES scores around the 66th percentile [low RES <66th percentile vs. high RES ≥66th percentile] for bivariate analysis.

Results: Our sample of PWIDs was predominantly female (52.5%), with a mean age of 39.7 years (SD=9.2). Most of the PWIDs had health coverage (97.5%) and access to a personal cellphone (83.8%). However, fewer reported educational attainment of ≥12 years (46.3%), access to transportation (35.0%), and access to income (23.8%). Additionally, most PWIDs reported high SS (65.0%) but low RES (62.5%) scores. Our assessment of facilitators of PrEP linkage revealed that those with higher SS (Chi-square=4.597[df1], p=0.032) and RES scores (Chi-square=4.392[df1], p=0.036) reported successful linkage to a PrEP provider, whereas socio-demographic and structural determinants of PrEP uptake were not statistically significant predictors of PrEP linkage.

Conclusion: The findings emphasize the importance of strengthening support systems and tailored, strength-based, resilience-focused interventions to improve coping strategies among vulnerable rural PWIDs, thus promoting increased uptake of PrEP.