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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: AIDS Behav. 2023 Oct 4;28(5):1522–1530. doi: 10.1007/s10461-023-04178-x

Association of Partnership-Level Methamphetamine Use on inconsistent PrEP Care Engagement among GBMSM in Los Angeles County

Alexander Moran 1,*, Marjan Javanbakht 1, Matthew Mimiaga 1, Steven Shoptaw 2, Pamina M Gorbach 1
PMCID: PMC11041383  NIHMSID: NIHMS1973554  PMID: 37792232

Abstract

There are limited quantitative studies describing the association between meth use in the context of male-male sexual partnerships and PrEP care engagement. We assessed the longitudinal relationship between individual and partnership level meth use with inconsistent PrEP engagement among young gay, bisexual and other men who have sex with men (GBMSM) in Los Angeles. The primary exposure was meth use at the partnership level with a ternary variable (neither partner nor participant used meth, either used meth, or both used meth). Generalized estimating equations were used to assess odds of inconsistent PrEP engagement at different levels of partner-participant meth use, adjusting for age at visit, number of recent male partners and partner intimacy. Among inconsistent PrEP engagement, 61% (n=84, vs 79.5%, n=346 continuous) reported that neither they nor their partner used meth, 22% (n=31, vs 18%, n=56) reported that either partner or participant used meth and 17% (n=24, vs 8%, n=33) reported that both partner and participant used meth (P<0.01). There were increased odds of inconsistent PrEP engagement when both partner and participant reported meth use (aOR: 3.82; 95%CI: 1.83–7.99) and when either partner or participant reported meth use (aOR: 2.46; 95%CI: 1.28–4.75). Meth use plays an important role in consistent PrEP engagement among GBMSM in mSTUDY. PrEP users who use meth with partners may benefit from integrated interventions addressing both meth use and PrEP engagement.

Keywords: Pre-exposure Prophylaxis, men who have sex with men, methamphetamine, PrEP discontinuation, PrEP care

Introduction

Gay, bisexual and other men who have sex with men (GBMSM) remain the population most at risk of HIV acquisition in the US. In 2020, 68% (n=20,758) of new diagnoses were among GBMSM, and an additional 4% (n=1,109) of new diagnoses were attributable to male-to-male sexual contact and injection drug use.(1) Despite an absolute decrease in new diagnoses in 2020 – which is documented as being at least partially attributable to sub-optimal HIV surveillance during the ongoing COVID-19 pandemic (2) – trends are similar to those observed from 2014 to 2019, representing an ongoing challenge in curtailing the HIV epidemic in the US.(1,3,4) Over the same period, access to PrEP has improved as evidenced by a nearly 600% increase in HIV pre-exposure prophylaxis (PrEP) providers from n=9,621 providers writing PrEP prescriptions in 2014 to n=65,822 in 2019.(5)

Despite this increase in PrEP providers, the distribution of providers nationally remains unequal and there are ongoing challenges with initiation in PrEP care and PrEP persistence, even in urban areas where most PrEP providers practice.(5,6) In one community clinic in Los Angeles, for example, despite 70% of the patient population reporting PrEP eligibility, only 10% were using PrEP.(6) In another clinic in New York City, retention in PrEP care was 68% at the first follow up visit after initiation and as low as 35% by the third follow up visit, highlighting ongoing challenges in PrEP persistence and retention in care despite access to PrEP prescriptions.(7)

There are several known drivers of PrEP care disengagement, including health insurance status, disclosure of sexual practices to healthcare provider, racial/ethnic disparities and perceived HIV risk.(8–14) Aside from these drivers, there is increasing evidence that methamphetamine (meth) use is an important driver of inconsistent PrEP care engagement, PrEP disengagement and other losses along the PrEP care continuum.(15,16) In addition to its prevalent use among GBMSM in the US, those who report meth use during sex (chemsex) have poorer PrEP care outcomes compared to those who do not use meth and those who do not engage in chemsex.(16) Further, stimulant use is an important driver of the HIV epidemic among GBMSM in the US and represents a high-priority population for PrEP care engagement.(17–19)

Despite these research advances in understanding drivers of PrEP care disengagement, there is limited research on partnership level associations between meth use and PrEP care engagement patterns (20). Xavier Hall et al. note that changes in relationship status (e.g., establishing partnership or ending partnerships) are associated with re-initiation of PrEP and may be a factor in perceived HIV acquisition risk among GBMSM.(10) Understanding the extent to which meth use influences this risk perception determination and the general PrEP usage pattern among GBMSM remains a priority for investigation.

To date there has been little investigation into drivers of inconsistent PrEP care engagement over time, and in particular the role of partnership level methamphetamine use in PrEP care interruption. While Xavier Hall et al. (10) describe certain drivers of PrEP re-initiation in the context of number of partners, partnership type and partner HIV status, substance use considerations are not assessed. This paper seeks to describe the role of methamphetamine use at the individual and partnership level on inconsistent PrEP care engagement, with the goal of understanding additional areas of HIV risk which can be addressed through emerging PrEP delivery options (21) like event-driven PrEP and long-acting injectable PrEP.

Methods

Study population and design

This study is a secondary analysis of data collected by the Men Who Have Sex with Men and Substance Use Cohort at UCLA Linking Infections, Noting Effects (mSTUDY). The mSTUDY is an ongoing NIH-funded prospective cohort study which enrolls HIV-positive and HIV-negative Black and Latinx MSM in Los Angeles ages 18 to 45 years.(22) Recruitment and sampling procedures are described in detail elsewhere.(23) Participants were recruited from two different study sites in Los Angeles, CA, including a community-based organization providing services for the lesbian, gay, bisexual, and transgender community, and a community-based university research clinic. By design, about half of study participants are living with HIV and the remaining half do not have HIV. Substance use, including use of amphetamines, cannabis and other substances is high.(23) After an initial baseline visit, participants return for follow up visits every six months. In cases where there were restrictions on in-person visits due to the COVID-19 pandemic, follow up visits were offered through remote, smartphone-compatible web browser surveys. At the time of analysis there have been n=558 total participants enrolled and n=4,094 total visits available.

Inclusion and Exclusion Criteria

The mSTUDY inclusion criteria are defined by age between 18 and 45 years at enrollment, male sex assignment at birth, condomless anal sex with a male partner within six months (if HIV-negative status), ability to provide informed consent and willingness and ability to return to the study every six months for questionnaires, clinical assessments and biological specimen collection.(23) This specific analysis further limits eligibility to participants who have reported recent PrEP use (in the six months preceding the study visit) at least once and who have at least 18 months (three study visits, including the baseline visit) of follow up time, starting at initial PrEP use report. The baseline visit for this study is the first mSTUDY visit at which a participant reported recent PrEP use, after which all subsequent valid mSTUDY visits were included for analysis.

Measures and Data Collection

Using a self-administered computer assisted interview The mSTUDY measures factors linked to substance use and HIV transmission dynamics and collects information on demographics, physical and mental health status, substance use (self-report and through specimen collection), sexual history, STIs, PrEP use, stigma and discrimination. After an initial baseline visit, participants return for follow up visits every six months where in addition to completing a questionnaire participants provide specimens for laboratory testing for HIV viral load, STIs, toxicology screening, and a basic metabolic panel. In cases where there were restrictions on in-person visits due to the COVID-19 pandemic, follow up visits (excluding clinical testing) were offered through remote, smartphone-compatible web browser. STI testing under analysis included laboratory (PCR) testing for gonorrhea, chlamydia and syphilis (with pharyngeal and rectal swabs and urine as applicable). Participants are offered an incentive for completing remote and in-person visits, the amount of which varies by visit type and has been approved by the UCLA Institutional Review Board (IRB). This secondary analysis has been approved by the UCLA IRB (IRB#21–001686).

Exposures of interest

Primary exposures of interest include demographic factors, recent (past six months) sexual history, last sexual partner, recent sexually transmitted infection (STI) laboratory results, recent substance use, recent mental health status and recent partner intimacy. Demographic factors were limited to age at visit, housing, employment and insurance status. Recent sexual history included gender of sexual partners (men only vs. men and/or women, transgender partners), number of male partners, number of new male partners, acting as the receptive partner, reporting condomless anal intercourse, reporting group sex, reporting chemsex (use of cocaine, meth, heroin or fentanyl during anal intercourse) and reporting transactional sex. Last partner information, which elucidates context of partnership and partnership dynamics, included type of partner (main, regular, friend or acquaintance or one-time, unknown or trade partner), days since most recent anal sex with last partner and days since first anal sex with last partner. Partner intimacy was summarized using a modified version of Gorbach’s Partnership Assessment Scale (PAS), in which participants were asked if they knew six pieces of information about their partner in a binary yes/no fashion (first name, last name, cell phone number, email or social media, home address and name of workplace, school or place where they hang out) and whether participants engaged in a selected set of 12 activities.(24) The sum of responses to these 18 yes (1) or no (0) questions is the modified PAS, where low scores indicate less knowledge about a partner. The 18-element modified PAS had high internal consistency in this sample (Cronbach’s alpha = 0.922) and was deemed appropriate for use in this population. Recent STI history was measured based on a positive STI test (including chlamydia (any site), gonorrhea (any site) or syphilis) and individual variables for a positive chlamydia (any site), gonorrhea (any site) or syphilis test (positive rapid plasma regain, confirmatory Treponema palladium particle agglutination test). Days since latest HIV test was also captured. Recent substance use was limited to meth and cocaine use. For both substances, index participant use was summarized in a ternary fashion (never, less than weekly, or weekly/daily use) and partner use was summarized in a dichotomous fashion (use or no use, where no use included those who did not know their partner’s meth use history). Index and partner meth use were also summarized together in four levels (neither index participant nor partner uses meth, only index participant uses meth, only partner uses meth and both index participant and partner use meth). This variable was further summarized to a ternary (neither, either or both index participant and/or partner use meth) for analysis due to small cell sizes for partner-only meth use. Psychosocial factors were summarized using the Center for Epidemiological Studies Depression Scale (CES-D 20)(25) to measure depression, the Multidimensional Scale of Perceived Social Support (MSPSS)(26) and the Generalized Anxiety Disorder (GAD-7)(27) scales.

Primary outcome

The primary outcome for this analysis is PrEP care engagement pattern, measured over 18 months of follow up (three study visits) and has two levels: consistent PrEP care engagement and inconsistent PrEP care engagement. Consistent PrEP care was defined as a series of exactly three consecutive visits in which a participant reports recent (past six months) PrEP use at the study visit. inconsistent PrEP care was defined as a single visit in a series of three visits during which a participant stopped using PrEP either temporarily (one visit – a “lapse” in PrEP use, the visits directly before and after which the participant reported using PrEP) or permanently (no PrEP use in the subsequent two visits after PrEP use was reported). Visits occur on a semi-annual basis, with three visits resulting in one 18-month time frame. To standardize follow up time comparing the two different outcome levels, all participants had at least 18 months of follow up time for inclusion in the analysis, and all outcomes required multiples of 18 months of follow up time to be recorded. That is, a participant with 5 visits could only contribute one 18-month outcome (either consistent PrEP engagement or inconsistent PrEP engagement) and a participant with 6 visits could contribute two 18-month outcomes. For the purposes of this analysis, all three consistent PrEP engagement visits were retained for analysis, and only the interruption visit (either the “lapse” visit or the first of two “discontinuation” visits) was retained in the analysis (for inconsistent PrEP engagement events) to maintain comparability between different trajectories after initial PrEP discontinuation.

Analytic strategy

Univariate analyses described the racial/ethnic composition of the sample at baseline. Bivariate analyses were used to describe the primary exposures of interest (demographic factors, recent (past six months) sexual history, last sexual partner, recent sexually transmitted infection (STI) history, recent substance use, recent mental health status and recent partner intimacy), comparing consistent PrEP care engagement to inconsistent PrEP care engagement. Differences between outcome levels were assessed using Type III p-values, which account for within-subject correlation, given that participants could contribute more than one outcome to the sample. Based on the results of the bivariate analyses, we conducted multivariable analysis using generalized estimating equations (GEE) to describe the odds of inconsistent PrEP care engagement versus consistent PrEP care engagement after controlling for potential confounders. Descriptive analyses were conducted in R version 4.0.5 (R foundation, Vienna, Austria)(28) and GEE modeling was conducted in SAS version 9.4 (SAS Institute, Cary, NC).

Results

Characteristics of Study Population

There were 149 participants (n=602 visits) eligible for inclusion in this study, which represents 53.4% of all HIV-negative participants in the full mSTUDY cohort. At the index PrEP use visit (i.e., the baseline visit for this analysis), 48% (n=72) identified as Black/African American, 36% (n=54) as Hispanic/Latinx, 8.7% (n=13) as white and the remaining 6.7% (n=10) as other race. Median age among consistent PrEP users was 32 years (IQR: 27,37) and 31 years among inconsistent PrEP users (IQR: 27,37, P=0.5). Inconsistent PrEP care engagement was reported in 26% (155/602) of visits with no significant differences in race/ethnicity comparing consistent PrEP care engagement visits to inconsistent PrEP care engagement visits (P=0.8). Unemployment was reported more frequently in inconsistent PrEP care engagement visits than consistent PrEP care engagement visits (37.4% vs 21.7%, p<.01). Median duration between visits was 185 days overall and did not differ significantly between groups (184 days among inconsistent PrEP visits and 185 days among consistent PrEP visits).

Both number of male partners and number of new male partners were lower in inconsistent PrEP care engagement visits compared to consistent PrEP care engagement visits (1 [IQR: 0, 4] vs 4 [IQR: 2, 10], p=0.04 and 1 [IQR: 0, 2] vs 2 [IQR: 0, 5], p=0.01, respectively). There were no significant differences in sexual positioning (receptive vs. insertive partner), condomless anal intercourse, group sex, chemsex, transactional sex or partner type (main, regular, friend or acquaintance vs. one-time, unknown or trade partner). Most recent anal sex in days was more recent among consistent PrEP care events (7, IQR: 2,30) than inconsistent PrEP care engagement events (20, IQR: 4,90) (p = 0.02). There were 79 positive STI tests in the analytical sample, among which 55 were during consistent PrEP care visits (15.7% of visits) and 24 were during inconsistent PrEP care engagement visits (22.9% of visits). Positive gonorrhea test was more frequently reported among inconsistent PrEP care engagement visits than consistent PrEP care engagement visits (13.2% vs 5.4%, p = 0.04). Latest HIV test was significantly more recent among consistent PrEP care engagement visits than inconsistent PrEP care engagement visits (60 days vs 134 days, p <0.01).

There were no significant differences in mental health measures, including CES-D 20 score, MSPSS and GAD-7 between inconsistent and consistent PrEP users. Modified PAS scores were significantly lower in inconsistent PrEP care engagement visits compared to consistent PrEP care engagement visits (5 [IQR: 0, 13] vs 7 [IQR: 2, 15], p=0.04), in which a lower score indicates knowing less information about one’s most recent sexual partner.

Index participant meth use (daily, weekly or less than weekly) was higher among inconsistent PrEP care engagement visits than consistent PrEP care engagement visits (35.6% vs 19.4%, p<.01). Similarly, partner meth use was higher in inconsistent PrEP care engagement visits than consistent PrEP care engagement visits (20.5% vs 8.5%, p<0.01). Examining both index participant and partner meth use together, a higher proportion of inconsistent PrEP care engagement visits compared to consistent PrEP care engagement visits reported both “index or partner meth use” (22.3% vs 12.9%) and “both index and partner meth use” (17.3% vs 7.6%) (p<0.01). All descriptive results are presented in Table 1.

Table 1.

Demographic, sexual and mental health characteristics of a sample of n=149 PrEP users (n=602 visits) in Los Angeles County, CA, 2014–2022.

Characteristic Consistent PrEP, N = 447 Inconsistent PrEP, N = 155 p-value2
Demographics
Age in years1 32 (27, 37) 31 (27, 37) 0.5
Unstable Housing 75 (16.8%) 36 (23.2%) 0.32
Employment <0.01
 Employed 343 (76.7%) 89 (57.4%)
 Unemployed 97 (21.7%) 58 (37.4%)
 Refuse to answer 7 (1.6%) 8 (5.2%)
Insurance 0.41
 Private insurance 152 (34.0%) 44 (28.4%)
 Public insurance 231 (51.7%) 88 (56.8%)
 None or other 64 (14.3%) 23 (14.8%)
Sexual history, past six months
Partner genders 0.07
 Men only 345 (88.2%) 82 (78.8%)
 Men and women or transgender people 46 (11.8%) 22 (21.2%)
Male partners1 4 (2, 10) 1 (0, 4) 0.04
New male partners1 2 (0, 5) 1 (0, 2) <0.01
Receptive partner, ever 255 (64.7%) 78 (71.6%) 0.76
Condomless anal intercourse, any 197 (76.7%) 49 (57.6%) 0.09
Group sex, any 153 (42.6%) 32 (28.8%) 0.05
Chemsex during anal sex, any 52 (11.6%) 18 (11.6%) 0.19
Transactional sex, any 52 (14.5%) 19 (17.1%) 0.86
Last partner
Partner type 0.80
 Main partner 145 (34.0%) 53 (40.5%)
 Regular partner 77 (18.0%) 13 (9.9%)
 Friend or acquaintance 76 (17.8%) 24 (18.3%)
 One-time, unknown or trade partner 129 (30.2%) 41 (31.3%)
First anal sex (Median days ago)1 14 (3, 120) 30 (4, 278) 0.17
Most recent anal sex (Median days ago)1 7 (2, 30) 20 (4, 90) 0.02
Sexually transmitted infections, past six months
Positive test for any STI 55 (15.7%) 24 (22.9%) 0.14
 Positive chlamydia test (any site) 36 (10.2%) 6 (5.8%) 0.15
 Positive gonorrhea test (any site) 19 (5.4%) 14 (13.2%) 0.04
 Positive syphilis test 10 (2.8%) 6 (5.5%) 0.23
Latest HIV Test (Days ago)1 60 (20, 90) 134 (60, 210) <0.01
Substance use, past six months
Meth use frequency <0.01
 Never 358 (80.6%) 94 (64.4%)
 Less than Weekly 52 (11.7%) 19 (13.0%)
 Daily or Weekly 34 (7.7%) 33 (22.6%)
Characteristic Consistent PrEP, N = 447 Inconsistent PrEP, N = 155 p-value2
Partner meth use (vs. no use or unknown use) 36 (8.5%) 27 (20.5%) <0.01
Participant and partner meth use <0.01
 Neither uses meth 346 (79.5%) 84 (60.4%)
 Only participant uses meth 53 (12.2%) 28 (20.1%)
 Only partner uses meth 3 (0.7%) 3 (2.2%)
 Both participant and partner use meth 33 (7.6%) 24 (17.3%)
Cocaine Use Frequency 0.57
 Never 353 (79.5%) 113 (77.4%)
 Less than Weekly 81 (18.2%) 23 (15.8%)
 Daily or Weekly 10 (2.3%) 10 (6.8%)
Partner Cocaine Use (vs. no use or unknown use) 19 (4.4%) 11 (8.3%) 0.88
Mental health status, past six months
CES-D 201,3 score (max. score = 60) 12 (6, 21) 14 (10, 24) 0.07
MSPSS1,4 (max. score = 72) 68 (48, 74) 55 (46, 67) 0.11
GAD-71,5 score (max. score = 21) 2 (0, 7) 3 (0, 7) 0.97
Partner Intimacy, past six months
Modified PAS1,6 (max. score = 18) 7 (2, 15) 5 (0, 13) 0.04
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1

Median (IQR)

2

P-values adjusted for within-subject correlation

3

Center for Epidemiologic Studies Depression Scale

4

Multidimensional Scale of Perceived Social Support

5

Generalized Anxiety Disorder, 7-item

6

Partnership Assessment Scale

Index participant and partner meth use and inconsistent PrEP care engagement

Adjusted analyses included combined index participant and partner meth use, age at visit, number of male partners in the past six months and the modified PAS (Table 2). After controlling for age, modified PAS and number of partners in the past six months, odds of inconsistent PrEP care engagement were higher in visits where either index participant or partner uses meth (aOR = 2.46, 95%CI: 1.28–4.75) and in visits where both index participant and partner use meth (aOR = 3.82, 95%CI: 1.83–7.99) compared to neither index participant nor partner meth use.

Table 2.

Adjusted GEE model describing the association of partner and index participant meth use on inconsistent PrEP care engagement.

Characteristic aOR 95% CI
Index and partner meth use (ref: Neither uses meth)
Either index or partner uses meth 2.46 1.28 – 4.75
Both index and partner use meth 3.82 1.83 – 7.99
Age at visit 0.98 0.94 – 1.03
Modified Partnership Assessment Scale (PAS) 0.98 0.94 – 1.01
Number of male partners 0.96 0.91 – 1.00
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Model includes index and partner meth use and controls for age at visit, modified PAS and number of male partners

Discussion

This study shows that methamphetamine use in the context of male-male sexual partnerships may have significant impact on PrEP care engagement patterns. Our results suggest that methamphetamine use is an important determinant of consistent PrEP care engagement. Compared to cases in which neither participant nor partner uses meth, odds of inconsistent PrEP care engagement were about 2.5x higher when either the participant or partner used meth, and about 3.8x higher when both partner and participant used meth. These findings remained significant even after accounting for partnership intimacy, number of partners and age. Further, it was rare for participants who did not report meth use to report that a partner used meth; meth use was most frequently reported among both partners, only the participant (and not the partner) or neither partner, indicating that participants who did not use meth were unlikely to have partners who used meth.

Taken together, these results suggest that people who use meth have an increased likelihood of inconsistent PrEP care engagement. Despite overall fewer partners, less recent sex and less recent HIV testing, people reporting meth use may have sexual encounters that increase vulnerability to HIV acquisition when compared to those who remain in PrEP care consistently, evidenced by a significantly higher proportion of gonorrhea positive tests than those who remain in PrEP care consistently. Importantly, this finding is unique to methamphetamine usage and there were no associations with other stimulants under investigation, including cocaine. Notably, the proportions of methamphetamine and cocaine use in this sample were similar (23% and 21% reporting any use in the past six months), which differs from national proportions of illicit drug use among LGB adults as reported in the 2020 NSDUH, in which 6.3% reported cocaine use and 2.4% reported methamphetamine use.(29) There were no significant differences in substance use proportions by race or ethnicity in our sample.

Our finding that meth use is associated with increased odds of inconsistent PrEP care engagement support a body of existing literature suggesting increased transmission of HIV among MSM who use meth (30–33). MSM who use meth have higher odds of condomless anal sex (30) and higher odds of STI acquisition (18,31) than those who do not use meth. Additionally, PrEP adherence and PrEP persistence are understood to be lower among MSM who use meth, especially during sex, (15,16) and may contribute to ongoing HIV transmission in this population at especially high risk. (31) A review of all mSTUDY visits for participants in this study revealed that four PrEP users discontinued PrEP and subsequently experienced HIV seroconversion. Of these participants, two used meth consistently before and after seroconversion, one began using meth after study initiation and subsequently reported seroconversion and a fourth participant did not report meth use until after seroconversion. This confirms the well-established role of meth in seroconversion to HIV.

These results offer insight into PrEP use patterns among GBMSM and into emerging research priorities. In the context of prevention-effective adherence (measuring PrEP adherence in the context of HIV risk periods, rather than exclusively over calendar time regardless of HIV risk), inconsistent PrEP use may be related to a reduction in HIV risk behaviors, leading to an emerging gap in STI prevention behaviors and STI prevention service utilization. These results also highlight the need for consistent PrEP engagement for effective HIV prevention, differentiated strategies for different risk groups and integration of other health services with PrEP care. (34–37) Behavioral activation (BA), an evidence-based, cognitive behavior therapy developed to treat depressed mood but applied to other related mental health problems, has shown promise for reducing HIV sexual risk and meth use among MSM with problematic meth use. (38–41) BA is designed to help MSM learn strategies to re-engage in life by identifying and actively participating in pleasurable, goal-directed activities that do not involve drug use (e.g., exercising) that will serve as a natural reinforcement for functional behavior, improve depressed mood when not on meth by experiencing increases in pleasure and mastery, and decrease overall distress so that MSM who use meth can better benefit from HIV risk reduction counseling. Future work should consider an essential set of factors to justify safe discontinuation of PrEP, building on research describing seasons of risk, prevention-effective adherence and patientcentered HIV prevention services.

This study has limitations that should be mentioned. The relatively low prevalence of PrEP care reported in this sample limited the analytical sample size and the extent to which we could control for additional behavioral factors in the adjusted GEE model and the granularity with which we could consider each behavioral factor and the extent to which partner or participant meth use drives the association between meth use and inconsistent PrEP care engagement. The modified PAS considered several important factors describing partner intimacy, but omits factors including partner PrEP use, partner HIV status and other possibly relevant elements. Future work should consider an HIV prevention-specific PAS to measure the applicability of these factors in the context of partner intimacy and HIV prevention. Additionally, the recency of HIV testing is captured for HIV testing done outside of the mSTUDY setting, which may limit the utility of this variable. Finally, as the outcome is defined as PrEP care engagement pattern, certain participants could be using event-driven PrEP strategies like “2–1-1” without actively engaging in PrEP follow up care. These self-report measures could also suffer from recall error. While this misclassification would only attenuate our results, the importance of PrEP delivery strategy is increasing as the landscape of PrEP options expands. However, strengths of this study include benefits from a longitudinal cohort sample of MSM with extensive HIV risk behavior and substance use behavior data. Particularly with substance use behaviors, we were uniquely able to identify individual and partnership-level substance use and combined partner and participant substance use in the context of partner intimacy and number of sexual partners. These detailed behavioral data provide unique insights into the association between substance use between partners and inconsistent PrEP care engagement.

Taken together, these findings suggest that meth use at both the individual and partnership level is significantly associated with inconsistent PrEP care engagement in this sample. Additionally, while those reporting inconsistent PrEP care engagement may report fewer sexual partners, these participants also report more positive gonorrhea tests and less frequent HIV testing, underscoring the need for consistent sexual health services for MSM at high risk of HIV acquisition. As event-driven PrEP strategies gain popularity and acceptability (42) and as longacting injectable PrEP becomes more widely available,(43,44) further research should characterize perceived barriers to continued engagement in PrEP care among MSM who use methamphetamine, and further describing the quantity and frequency of methamphetamine use in this context.

Footnotes

Declarations

The authors have no conflicts of interest to declare that are relevant to the content of this article.

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