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Published in final edited form as: AIDS Care. 2024 Dec 30;37(3):445–454. doi: 10.1080/09540121.2024.2445792

Urban, Formerly Incarcerated, Black, Heterosexual Men with Substance Use Disorders: Eligible for Pre-Exposure Prophylaxis (PrEP) But Unaware of Their Vulnerability to HIV Acquisition

Rogério M Pinto 1, Isabella Bonnewit 2, Evan Hall BS 3, Carol A Lee 4, Liliane Windsor 5
PMCID: PMC11922643  NIHMSID: NIHMS2045482  PMID: 39878750

Abstract

Research on incarcerated men indicates low PrEP access, even though HIV disproportionately affects them. Research shows that intersecting attributes—urban, incarcerated, Black, heterosexual men with substance use diagnoses (SUDs) —improves the odds of HIV transmission/acquisition. It is crucial to determine, among “key populations,” those individuals who might be eligible to take PrEP to prevent transmission/acquisition. However, the extant literature has used PrEP-eligibility criteria inconsistently. For this exploratory quantitative study, we used the CDC’s criteria to determine PrEP eligibility—HIV-negative test and sexually active plus a sexual partner living with HIV, and/or diagnosed with an STI, and/or inconsistent or no condom use for intercourse. We identified a considerable percentage (n=61; 32.8%) of PrEP-eligible individuals in a sample (n=186) of urban, formerly incarcerated, Black, heterosexual men diagnosed with SUDs. Most PrEP-eligible participants (78.7%) had not received PrEP information from service providers. Most PrEP-eligible participants (85.2%) reported that they were “not likely” to contract HIV. Accurate determination of PrEP-eligibility allowed us to advance research on the incongruence of an individual’s PrEP-eligibility status and unawareness of one’s vulnerability to HIV acquisition, while lacking information about PrEP—the first step toward PrEP access. The relevance of future interventions to improve PrEP access hinges on the accurate determination of PrEP-eligibility and on innovative ways to enhance PrEP-eligible individuals’ awareness of their vulnerability to HIV acquisition and how/when they receive information about PrEP.

Keywords: PrEP eligibility and access, Black heterosexual men, incarceration, substance use, reduced inequality

Introduction

“PrEP-Eligibility” refers to a person that could be prescribed Pre-Exposure Prophylaxis (PrEP) by a healthcare provider based on a set of criteria recommended by the United States (U.S.) Centers for Disease Control and Prevention (HIV Surveillance Report, 2021). To be PrEP-eligible, a person needs to meet two primary criteria: they need to be (1) sexually active and (2) not have the Human Immunodeficiency Virus (HIV). In addition, they need to meet one or more secondary criteria: (3) having a sexual partner living with HIV; and/or (4) being diagnosed with a bacterial Sexually Transmitted Infection (STI) in the past six months; and/or (5) history of inconsistent or no use of condoms for intercourse. These criteria call for research on the accurate and consistent application of PrEP-eligibility criteria in HIV research and potential incongruences between PrEP-eligibility (“being at-risk”) awareness of one’s HIV vulnerability and lack of information about PrEP.

The extant literature has used PrEP-eligibility criteria inconsistently. Participants are often asked about PrEP knowledge and vulnerability to HIV acquisition without assessing PrEP eligibility. Studies using community samples involving participants (e.g., incarcerated men) with a high chance of acquiring HIV (“key populations”) are needed to explore the congruence between PrEP-eligible behaviors and PrEP knowledge and HIV vulnerability. The current study aimed (1) to identify the proportion of PrEP-eligible individuals in a sample of participants with intersecting attributes—urban, formerly incarcerated, Black, heterosexual men diagnosed with substance use disorders (SUDs)— related to HIV acquisition; (2) to explore their perceived vulnerability to HIV acquisition; and (3) to assess if they were informed about PrEP—the first step toward accessing PrEP (CDC, 2021).

This exploratory quantitative study represents a step toward population-level research to accurately determine the proportion of PrEP-eligible urban, formerly incarcerated, Black, heterosexual men with SUDs in the general population. It contributes to a better understanding of PrEP-eligible behaviors vis-à-vis PrEP knowledge and perceived HIV vulnerability as we use an intersectional approach to HIV prevention research highlighting myriad social attributes (Bauer, 2014). From this point forward, for conciseness, we will refer to urban, formerly incarcerated, Black, heterosexual men with SUDs as “this study’s population.” “Black” refers to individuals who identify themselves as Black African-American or Black Caribbean-American.

PrEP as a tool to help end the HIV epidemic

During 2011–2012, the Centers for Disease Control and Prevention (CDC) responded to recently developed research demonstrating that antiretroviral therapy (ART) could reduce HIV transmission by lowering the viral load in the bloodstream of people living with HIV (PLWH) (Thompson et al., 2012). Around the same time, ART emerged as the key strategy for HIV treatment and prevention based on research showing a reduction (by more than 96%) of sexual transmission in HIV-serodiscordant couples (Cohen et al., 2012; Dodd et al., 2010). Since then, ART has been prescribed to key populations. Specifically, the Food and Drug Administration (FDA) approved Truvada™ [Emtricitabine/Tenofovir Disoproxil Fumarate (TDF/FTC)] in 2012 as Pre-exposure Prophylaxis (PrEP); it reduced HIV acquisition by 73% among adult men who have sex with men (MSM) and transgender women in clinical trials (Anderson et al., 2012; Donnell et al., 2014; Grant et al., 2010). Emtricitabine Tenofovir Alafenamide or Descovy® is also approved for daily use as PrEP. The CDC asserts that PrEP medications, when taken as prescribed by a health provider, can reduce the risk of acquiring HIV through sexual activity by approximately 99%. PrEP reduces the risk of acquiring HIV by at least 74% among individuals who inject drugs (CDC, 2021). Research for the past decade (2012–2023) has shown that PrEP should be easily accessed by key populations—marginalized groups most vulnerable to HIV, including currently and formerly incarcerated men. However, access to HIV services and resources was severely disrupted by the COVID-19 pandemic, including pre-existing (e.g., transportation to sites offering HIV services) and newly-developed (e.g., fear of contagion) barriers to care and prevention (Pinto et al., 2018). These disruptions further complicated access to PrEP in the U.S. and globally, markedly in carceral settings where people are six times more likely to live with HIV than adults in the general population (UNAIDS, 2021).

Intersectional attributes and HIV transmission

Carceral settings host people with multiple intersecting attributes and health needs that exacerbate their vulnerability to acquiring HIV (Grant et al., 2010; Alistar et al., 2014; Shieh et al., 2019). PrEP is not available in most carceral settings nor is it accessible to most formerly incarcerated people. Surveillance categories have shifted over time following the politics of inclusion and exclusion. Therefore, this study does not privilege one single attribute (e.g., gender, race, mental disorder, and others), nor do we embrace a singular theory of “risk” for each separate attribute. Instead, we apply an intersectionality lens to understand current research trends. PrEP research on previously incarcerated men is needed to reveal barriers to PrEP access and to develop individual and systems-level interventions to address intersecting vulnerabilities concerning HIV transmission.

While heterosexual sex accounts for 23% of new HIV diagnoses in the U.S., heterosexual men have been grossly under-represented in PrEP research, notably incarcerated men (HIV Surveillance Report, 2021; Bailey et al., 2017). Current and formerly incarcerated, Black, heterosexual men with SUDs face a severe lack of access to health and social services that could help abate multiple health needs (Denning & Dinenno, 2010; Mukku et al., 2012). Globally, incarcerated people are six times more likely to be living with HIV than adults in the general population (UNAIDS, 2021). A systematic review and meta-regression analysis (24 studies; 18,388 incarcerated individuals; 10 countries) indicated that the prevalence estimate of drug use disorders for incarcerated men was 30% (Fazel et al., 2017). In the U.S., men are more likely to have SUDs than women (Falker et al., 2022). Compared to their White counterparts, Black men admitted for substance use treatment are, on average, less likely to complete treatment and more likely to be discharged from treatment facilities (Grooms & Ortega, 2022). The prevalence of HIV among carceral populations in the U.S. (1,144 per 100,000) is three times greater than the general population (380 per 100,000) (Widra, 2023). Using data from the 2013 National HIV Behavioral Surveillance system (n=5,321 formerly incarcerated heterosexual men), Wise et al. showed that incarceration was associated with several factors that increase vulnerability to HIV acquisition, including condomless sex with multiple female sexual partners, injection drug use, and having sexual partners who were more likely to have ever injected drugs (Wise et al., 2019). Other factors, such as poverty and mental health disorders, including substance misuse, are also associated with the acquisition of STIs among incarcerated Black men (Khan et al., 2015).

PrEP-eligibility, lack of information about PrEP, and unawareness of HIV vulnerability

PrEP eligibility has been measured inconsistently in HIV prevention research, making it challenging to assess the proportion of key populations eligible to use PrEP. For example, in a study including 9,359 participants in 23 urban areas with high HIV prevalence, only 32.3% of heterosexual adults had information about PrEP, and less than 1% used PrEP (Baugher et al., 2021). This study was limited to participants with a negative HIV test result who reported “low income.” Instead of using a comprehensive set of eligibility criteria, low-income status was used as a proxy for increased vulnerability to acquiring HIV through heterosexual sex. Another study regarding incarcerated heterosexual men showed that 92% of the sample had received an HIV test. Even though people are supposed to be informed about PrEP during an HIV test, in this study, only 4% of participants had heard of PrEP, while 3% had heard of Post-Exposure Prophylaxis (Valera et al., 2022). Contrastingly, one cross-sectional observational study in Zambia, primarily including men (11,794; 95.4%), used the HIV-negative test plus the national HIV prevention criteria to determine PrEP eligibility. The study identified 1,276 people as PrEP-eligible, about 10% of the sample (Lindsay et al., 2023).

The literature suggests that groups with minoritized identities and multiple health and social needs live under high exposure to HIV while facing myriad barriers to accessing PrEP. Sub-standard or lack of individual health insurance is a major barrier to PrEP access (Pinto et al., 2020). Current research shows a lack of health education in general and in carceral settings in particular (Parsons & Cox, 2019). The intersection between PrEP and HIV stigma and disparities across racial and ethnic groups also constitute significant barriers. The literature shows that healthcare providers (who can prescribe PrEP) and social service providers (who can refer patients to PrEP prescribers) share concerns about cost, adherence, stigma, and behavioral/health outcomes; but most importantly, they lack knowledge about PrEP (Pinto et al., 2018; Pleuhs et al., 2020). Therefore, people with minoritized intersecting attributes are not consistently receiving information about PrEP—the first step toward accessing it.

Clear and consistent use of PrEP eligibility is essential because research for the past decade has revealed incongruences between perceived HIV vulnerability and behaviors that facilitate transmission—a contributing factor for high HIV prevalence among Black heterosexual men (Baidoobonso et al., 2013; Gao et al., 2021; Khawcharoenporn et al., 2012; Tan et al., 2021). Men who might be PrEP-eligible are often unaware of their HIV vulnerabilities based on their sexual behaviors. Lack of knowledge and unawareness of risk are substantial barriers to PrEP-seeking behaviors.

Conceptual approach

The current study is supported by a socioecological perspective suggesting that incongruences—between PrEP eligibility, lack of PrEP information, and being unaware of risk—exist within four domains. The Individual Domain and Relationships Domain, represented by community members and their prevention/care providers, comprise variables that may hamper and/or facilitate navigation of the HIV continuum of care—e.g., PrEP-knowledge and lack of awareness of HIV vulnerability. The Community Domain and Policy Domain, represented by guidelines that regulate HIV prevention efforts, include variables that may hamper and/or facilitate the distribution of HIV resources and implementation of best practices across systems of prevention and care [34]. This study also leans on the concept of intersectionality to acknowledge concurrent (non-additive) attributes affecting individual behaviors and social interactions (e.g., between clients/patients and providers) and to stress how people with intersecting attributes have been under-served by health and policymaking systems (Mugavero et al., 2013).

Founded in this conceptual approach, the current study focuses on how to accurately determine PrEP eligibility (Policy Domain) among key populations (Community Domain) whose members have myriad intersecting attributes (Individual Domain). It also examines whether health providers are fulfilling their role of providing information about PrEP (Relationships Domain) to key populations. Understanding incongruences between PrEP eligibility, lack of PrEP information, and perception of HIV vulnerability has the potential to inform prevention programming for populations with intersecting attributes, for example, in areas with high incarceration rates in geographic areas with predominantly Black populations.

Methods

Parent study

For the current study, we used data collected for “Community Wise” (“parent study”), an NIH-funded behavioral intervention to reduce substance misuse among formerly incarcerated men with SUDs (Windsor et al., 2022). The study took place in Newark, an urban city in the state of New Jersey. The study was conceived and conducted in partnership with the Newark Community Collaborative Board (NCCB). The study used a multi-phase optimization strategy (MOST) with a 24 factorial design. Participants were randomly assigned to one of 16 conditions, each of which contained a different combination of the following components: (1) peer or licensed facilitator, (2) group dialogue, (3) personal goal development, and (4) community organizing. Eligibility was determined by a 40-minute clinical/recruitment survey, for which participants were compensated $10. Participants completed a baseline survey and five monthly follow-ups. We recruited participants by distributing flyers to community-based organizations and clinics providing SUD treatment, HIV prevention, and re-entry services. Men who were interested in participating called the study’s assigned mobile phone or visited our partner agency drop-in center. Eligibility criteria for the parent study included: over 18 years of age; living in Newark; diagnosed SUD; agreeing to be audio-recorded during group sessions; released from incarceration in the prior four years; English-speaking; and willing to provide informed consent. We collected data using tablets and managed data using REDCap electronic data capture tools hosted at University of Michigan. This study was granted exemption by the University of Michigan IRB because the secondary analysis was performed with de-identified data.

Current study’s sample selection

The analyses for the current study focus on data obtained from the parent study’s follow up survey to which we added PrEP-related questions. We selected heterosexual Black participants for whom we had PrEP-related data to determine their PrEP eligibility according to the CDC’s criteria. Among the 418 participants who completed the follow-up survey, 107 were excluded because they did not identify as Black and heterosexual, and 125 were excluded because they did not provide sufficient data to identify PrEP eligibility using the CDC criteria. No participants were eligible to be prescribed PrEP based on the CDC’s Injection drug user criteria. Figure 1 summarizes the steps we took to arrive at the current study’s sample (N=186).

Figure 1:

Figure 1:

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PrEP Eligibility Determination for Urban, Formerly Incarcerated, Black, Heterosexual Men with SUDs (N=61)

Measures

The parent study included 415 questions, to which we added 18 PrEP-related questions. For the current study, we used questions about (1) demographic characteristics, (2) PrEP eligibility, (3) HIV testing, (4) perception of HIV vulnerability, and (5) access to PrEP Information.

Demographic Characteristics

Age was measured in years, calculated by the difference between a participant’s birthday and the date of survey completion. Race included Black/Caribbean, African American, White, Asian, Alaskan/Native American, Hispanic/Latino/Latina, and “Other.” Only those who self-identified as Black Caribbean or African American (“Black”) were included in this study. Income was measured by self-reported estimated annual income. Ever had a full time job was measured by the question, “Have you ever held a full-time job?” (Yes/No). Current Employment was measured by the question “Are you currently employed.” Choices included “Employed” (full time, part time) and “Unemployed” (looking for work, disabled, volunteer work, retired, not looking for work, other). The mean length of incarceration (in months) was measured by asking, “How long have you been incarcerated when you were last incarcerated?” The mean length since being released was calculated by the difference between the date of the last release and the date of recruitment survey completion.

PrEP-Eligibility Criteria

We used the CDC criteria to determine PrEP-eligibility—(1) sexually active and (2) HIV-negative test plus (3) sexual partner living with HIV and/or (4) diagnosed with STI and/or (5) inconsistent or no use of condoms for intercourse (Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2021 Update: A Clinical Practice Guideline., 2021). HIV Status was measured by the question: “When was the last time, if ever, you were told by a health provider that you have HIV?” Sexual Activity was determined by asking: “Are you sexually active?” Participants were considered PrEP-eligible if they had a negative HIV test and were sexually active, in addition to one or more of the following criteria. Recent STD Diagnosis was assessed by the question, “When was the last time, if ever, you were told by a health provider that you had sexually transmitted diseases or infections, such as syphilis, gonorrhea, or chlamydia?” Sex Without Condom was measured by the following question: “During the past month, did you have sex without using any kind of condom, dental dam, or other barrier to protect you and your partner from diseases?” Sexual Partner HIV Status was evaluated by the question, “During the past month, did you have sex with someone who you thought might have HIV or AIDS?”

HIV Testing

HIV test taken in the past year was measured by the question: “What was the last time you took an HIV test?” The variable was dichotomized into “yes” (within the last six months or year) and “no” (one to three years ago, three to five years ago, five to ten years ago, never taken HIV test).

Perception of HIV Vulnerability

Perception of Vulnerability was evaluated by asking participants, “How likely do you feel you might be at risk for contracting HIV?” (Very likely, Likely, Somewhat likely, Not likely, Not likely at all). This variable was dichotomized into “Likely to Contract HIV” (Very likely, Likely, Somewhat likely) and “Not Likely to Contract HIV” (not likely, not likely at all).

Access to PrEP Information

PrEP Information was assessed by asking, “Have you ever received information about PrEP (Pre-Exposure Prophylaxis) from a social service and/or a health care provider?” (“Yes” or “No”).

Data Analysis

We used SPSS software to calculate descriptive statistics (frequency and proportions). In order to assess whether there were differences between PrEP-eligible and non-eligible participants, we used Chi-square tests for categorical data and independent t-tests for numerical data concerning demographics, awareness of HIV vulnerability, and PrEP Information. Missing data were excluded from tests for significance.

Results

We found no significant differences concerning age, race, partner status, income, ever having a job, employment status, mean length of incarceration, or mean length since release (Table 1). Table 2 shows 61 PrEP-eligible participants, 32.8% of the parent study’s sample. Sexual Activity, HIV Status, and Sex Without Condom were used for PrEP eligibility criteria. All PrEP-eligible individuals self-reported sexual activity at a significantly higher proportion than PrEP-ineligible group, X2(1, N=186) = 85.095. All PrEP-eligible individuals were not living with HIV, X2(1, N=185) = 6.31. Among PrEP Ineligible individuals, 9.7% (n=12) were living with HIV. The PrEP eligible group was more likely to report condomless sex, X2(1, N=185) = 90.582. Table 3 shows measures specific to HIV prevention, including data on both the PrEP eligible and PrEP ineligible group in order to be as complete as possible. Since these questions are focused on prevention, participants living with HIV are excluded from this analysis. There was no significant difference between PrEP eligible and ineligible groups concerning whether they had taken an HIV test in the past year, yet the overall percentage of those who were tested for HIV in our sample was 92.5%. The majority of participants within the eligible (78.7%) and ineligible (89.2%) groups had not received PrEP information from providers. The majority of participants within the eligible (85.2%) and ineligible (80.0%) groups reported that they were “not likely” to contract HIV (unaware of vulnerability).

Table 1.

Sample Characteristics

PrEP Eligible (n=61)
mean (sd) / n (%)		 PrEP Ineligible (n=125)
mean (sd) / n (%)		 Chi-Square Value or Test Statistic
Age 44.78 (13.38) 45.49 (11.74) 0.365
Race
 Black/Caribbean 9 (14.8) 26 (20.8) 0.981
 African American 52 (85.2) 99 (79.2)
Income (before taxes) $16,668.66 ($26,269.01) $15,136.01 ($53,736.84) −0.207
Partner Status
 Unmarried 49 (80.3) 111 (88.8) 2.447
Ever held a full-time job 53 (86.9) 97 (78.2) 0.026
Current Employment
 Unemployed 33 (54.1) 65 (52.8) 2.375
Last Incarceration Duration (months) 11.64 (30.86) 12.15 (36.06) 0.093
Time since last release (months) 14.66 (12.49) 11.60 (12.45) −1.572
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Table 2.

PrEP Eligibility Factors: Urban, Formerly Incarcerated, Black, Heterosexual Men with SUDs

Characteristic PrEP Eligible (n=61)
n (%) 		PrEP Ineligible (n=125)
n (%) 		Chi Square Value
Eligibility Criteria
Sexual activity
 Yes 61 (100.0) 35 (28.0) 85.095
 No 0 90 (72.0)
HIV Status (told by a provider)
 Living with HIV 0 12 (9.7) 6.313
 Not Living with HIV 61 (100) 112 (90.3)
Sex Without Condom (past month)
 Yes 55 (90.2) 21 (16.9) 90.582
 No 6 (9.8) 103 (83.1)
Diagnosed with STI (past year)
 Yes 11 (18.0) 11 (8.8) 3.351
 No 50 (82.0) 114 (91.2)
Sex with Partner with HIV (past month)
 Yes 58 (100) 120 (97.6) 1.438
 No 0 (0) 3 (2.4)
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Table 3.

Awareness of HIV Vulnerability, & PrEP Information: Urban, Formerly Incarcerated, Black, Heterosexual Men with SUDs

PrEP Eligible (n=61) PrEP Ineligible and Not Living with HIV (n=112) Chi Square value or test statistic p-value
Contextual Variables
HIV test taken in the past year
 Yes 55 (90.2) 105 (93.8) 0.731 p=0.393
 No 6 (9.8) 7 (6.3)
Received Information on PrEP from Provider
 Yes 13 (21.3) 12 (10.8) 3.494 p=0.062
 No 48 (78.7) 99 (89.2)
♦ Awareness of Vulnerability
 Likely to contract HIV 9 (14.8) 6 (20.0 0.402 p=0.526
 Not likely to contract HIV 52 (85.2) 24 (80.0)
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♦

This question was only asked for participants who identified as being sexually active

Discussion

In order to end the HIV epidemic in the U.S. by 2030, agencies across the U.S. Department of Health and Human Services (HHS) will need to prioritize PrEP access among key populations, notably formerly and currently incarcerated men (Ending the HIV Epidemic, 2023). We set out to explore insights on PrEP-eligibility criteria in HIV research and on incongruences between PrEP-eligibility, PrEP information, and HIV vulnerability. To do so, we applied the CDC’s criteria to determine PrEP eligibility among a community sample characterized by multiple intersecting attributes—urban, formerly incarcerated, Black, heterosexual men with SUDS. Our findings are supported by a socioecological perspective suggesting that this study’s sample needs to be understood within four domains of reference—Individual, Relationships, Community, and Policy—affecting their HIV vulnerability, whether they are informed about PrEP, and whether they meet PrEP-eligibility criteria (Mugavero et al., 2013). For example, the COVID-19 pandemic disrupted the HIV continuum of care and prevention and hampered the capacity of health systems and community settings to implement PrEP fully (Pinto & Park, 2020; Sanchez et al., 2020). Our findings add crucial information to this literature as they reveal that 32.8% of this study’s sample is PrEP-eligible. However, the study sample is largely uninformed about PrEP and unaware of their vulnerability to HIV acquisition through sexual behavior.

We could not thoroughly compare our findings with other studies conducted in the U.S. or abroad, as they used different criteria to determine PrEP eligibility. Moreover, we have not found another study that, like the current one, focuses comprehensively on the same intersectional attributes—urban, formerly incarcerated, Black, heterosexual men with SUDs. This study’s sample was pre-determined by the inclusion criteria of the parent study. We never intended to dissect how each attribute may be associated with PrEP-eligibility and/or PrEP-information and/or HIV vulnerability. We are indebted to theories of intersectionality advancing contextual understanding of HIV vulnerability vis-à-vis PrEP information and PrEP eligibility among populations with intersecting attributes that influence myriad HIV-related behaviors (Dworkin, 2005).

Though our study is focused on a small sample, we are able to contrast our findings concerning PrEP eligibility with those of a large cross-sectional study in Zambia that included a majority of heterosexual men (11,794; 95.4%) (Lindsay et al., 2023). The Zambia study used an HIV-negative test plus the national HIV prevention criteria to determine PrEP eligibility. In contrast to the nearly 33% we found in our sample in the U.S., the Zambia study shows that 10% of its sample was PrEP-eligible. Based on these findings, we strongly recommend that more comparative research be conducted in different geographic areas of the U.S. to know what proportions of key populations are actually PrEP-eligible. This knowledge is needed to allocate funds to facilitate PrEP access in specific target areas and populations. We recommend that PrEP-eligibility criteria be consistently adopted in the U.S. and across the globe. This will help healthcare administrators, researchers, and policymakers determine PrEP eligibility accurately, establish cross-group comparisons, and allocate resources accordingly. More specifically, accurate data are needed to develop a broader case for PrEP in U.S. carceral settings, where we attempt to characterize a population not discussed previously in the literature. This case has been made for Zambia based on the study above, which showed PrEP implementation in 16 facilities (Chimoyi & Charalambous, 2023). In that study, over 90% of PrEP-eligible individuals initiated PrEP use (Lindsay et al., 2023).

We found no meaningful demographic differences nor differences concerning HIV vulnerability or PrEP-information when comparing PrEP-eligible and ineligible participants. This innovative descriptive evidence suggests that some participants who were ineligible when they provided data for the study might become PrEP-eligible at a later date. One limitation of the data is that a sexual partner’s HIV status is measured by the participant’s perception of their partner’s status. In addition, our study is limited by its cross-sectional design, by its small sample, and by its descriptive analyses. Therefore, longitudinal research is needed to reveal if/when and under what circumstances ineligible participants might become PrEP-eligible at different times. This information is needed for targeted interventions for key populations that are most likely to acquire HIV.

We found that most participants (over 90%) in both PrEP-eligible and ineligible groups had received an HIV test in the prior year. The state of New Jersey requires all inmates be tested for HIV at intake, unless an individual chooses to “opt out” of the testing (New Jersey Administrative Code, 2014). While providing information about PrEP can be done during an HIV, most participants reported not receiving PrEP information from a service provider. HIV testing in carceral settings differs greatly across the country with states offering mandatory (16 states), opt-out (23 states), opt-in (7 states), or upon assessment (1 state) (Maruschak, 2023). More research is needed to investigate the role of HIV testing in carceral settings, and routine testing should be encouraged beyond intake and outside of carceral settings. Here, we should point to a measurement limitation. When we asked participants about receiving PrEP information, we did not specify the circumstances under which they may have received such information. Therefore, we cannot confirm that those participants who received information about PrEP did so during an HIV test. Future research may benefit from more precise measures to reveal under which conditions key populations are learning about PrEP and then build on learning opportunities actively present in their communities.

The majority of participants reported feeling that they were not likely to contract HIV. Specifically, within the PrEP-eligible group, these findings reveal a lack of congruence between PrEP-eligible behaviors and one’s sense of HIV vulnerability. This could help explain descriptively why, in the extant literature, similar studies show that only a small proportion of currently and formerly incarcerated heterosexual men are aware of PrEP—even though a large proportion of participants in those studies reported having received an HIV test (Baugher et al., 2021; Valera et al., 2022).

Our findings have implications for research, practice, and policy, including recommendations for PrEP programs for incarcerated and formerly incarcerated individuals described in the related literature (Brinkley-Rubinstein et al., 2018). Research is seriously lacking regarding incongruences between PrEP eligibility and whether or not key populations are receiving PrEP-information from providers. Research shows that interprofessional collaboration among health and social service providers can improve the odds of providers educating people about PrEP and linking them to the HIV continuum of care (Pinto et al., 2020; Windsor et al., 2020). Therefore, interventions/training on interprofessional collaboration might improve access to PrEP information. Furthermore, longitudinal and qualitative research is needed to reveal if/how having information about PrEP and one’s sense of HIV vulnerability may change over time. Determining when to intervene within well-defined PrEP-eligible groups will help policymakers allocate HIV-prevention time-specific resources for key populations.

Conclusion

By describing PrEP-eligibility among urban, formerly incarcerated, Black, heterosexual men with SUDs, we explored the congruence between PrEP-eligibility, PrEP information, and perception of HIV vulnerability. The limited research on incarcerated people suggests low PrEP access (Brinkley-Rubinstein et al., 2018), even though incarcerated people are disproportionately affected by HIV. Therefore, PrEP needs to be made accessible in carceral settings. The relevance of interventions to improve PrEP access hinges on accurately determining PrEP eligibility by using national standards (and perhaps international ones). By using standardized criteria, our study shows that the majority of PrEP-eligible participants have a low perception of HIV vulnerability, and they are not being informed about PrEP by health service providers—the first crucial step toward accessing PrEP. We hope our findings will spark research using community samples and accurate PrEP-eligibility criteria as steps toward finding the accurate proportion of PrEP-eligible people in other key populations and in the general population.

Acknowledgements:

  1. We thank the research participants.

  2. We thank Professor Marie O’Neill for providing crucial feedback on advanced drafts of the manuscript.

  3. Isabella Bonnewit and Evan Hall were funded by Student Opportunities for AIDS/HIV Research (SOAR) Program, National Institute of Mental Health and the Office of Behavioral and Social Science Research, (1R25MH126703–01), University of Michigan, Ann Arbor.

  4. Carol Lee was funded by a National Institute on Alcohol Abuse and Alcoholism (NIAAA) T-32 (T32AA007477) Postdoctoral Research Training Fellowship at the Addiction Center at the University of Michigan.

Funding:

The research leading to these results received funding from National Institute on Minority Health and Health Disparities under Award Number 1U01MD010629–01.

Footnotes

Competing Interests: The authors have no relevant financial or non-financial interests to disclose.

Ethics Approval: The data was reproduced from the Community Wise study, which provided de-identified data. This study was reviewed and deemed exempt by the University of Michigan Institutional Review Board. The Community Wise protocols are in accordance with the ethical standards of our institution and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval for the parent study was obtained from the Office for the Protection of Research Subjects of the University of Illinois at Urbana-Champaign (Ethics approval number: 16574).

Consent to Participate: Informed consent was obtained from all individual participants included in the study.

Contributor Information

Rogério M. Pinto, University of Michigan, School of Social Work

Isabella Bonnewit, Biology, Health, & Society, University of Michigan.

Evan Hall B.S., Biology, Health, & Society, University of Michigan.

Carol A. Lee, University of Michigan, Department of Psychiatry

Liliane Windsor, University of Illinois at Urbana-Champaign, School of Social Work

Data Availability:

The data that support the findings of this study are available from the corresponding author, R. Pinto, upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, R. Pinto, upon reasonable request.

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