Intention to Initiate and Uptake of PrEP among Women Who Injects Drugs in a Demonstration Project: An Application of the Theory of Planned Behavior

Abstract

Some women who inject drugs (WWID) would benefit from pre-exposure prophylaxis (PrEP), yet there are few studies of issues related to uptake in real-world settings. In this study, participants (n=95) were offered PrEP and responded to items measuring PrEP-related attitudes, norms, and perceived behavioral control based on the Theory of Planned Behavior. We tested associations with intention to initiate PrEP and uptake. Most WWID (88%) intended to initiate PrEP and 80% accepted a prescription. Compared to WWID who did not express PrEP intentions, those who did were less concerned about attitudinal and perceived behavioral control constructs such as temporary (75% vs. 36%, p=0.01) and long-term (63% vs. 27%, p=0.05) side effects, negative interactions with their birth control (93% vs. 38%, p<0.01), their ability to take a daily pill (80% vs. 36%, p<0.01), and the cost of PrEP (87% vs. 36%, p<0.01). WWID who went on to take PrEP had fewer concerns with subjective norms constructs such as talking to health care providers about sex (91% vs. 65%, p<0.01) and drug use (88% vs. 55%, p<0.01) compared to those who did not. Attitudes and perceived behavioral control influenced intention while subjective norms had a greater impact on actual uptake.

INTRODUCTION

Women who inject drugs (WWID) are at elevated risk for HIV infection in the United States. A recent study using pooled data from nationally representative samples estimated that WWID were 40% more likely than men who inject drugs (MWID) to have a new HIV diagnosis in 2011 (Lansky et al., 2014) despite the higher absolute numbers of new infections among MWID (Center for Disease Control and Prevention, 2018). Research has demonstrated that gender is an important factor for understanding the differences in HIV acquisition among persons who inject drugs (PWID) (Bogart et al., 2005; Davey-Rothwell & Latkin, 2007). WWID often report more frequent syringe sharing and inconsistent condom use which introduces greater opportunities for HIV exposure compared to male counterparts (Bogart et al., 2005; Davey-Rothwell & Latkin, 2007). In part, WWID’s vulnerability is shaped by having to negotiate prevention methods (e.g., condoms or new syringes) with male partners, which has been shown to impede their use (Davey-Rothwell & Latkin, 2007; El-Bassel et al., 2014b; Worth, 1989). Thus, innovative, WWID-controlled strategies are needed to reduce the likelihood of HIV acquisition in this population.

Pre-exposure prophylaxis (PrEP) is a biomedical tool that had been shown to decrease HIV incidence by up to 74% among PWID (Choopanya et al., 2013) but remains underprescribed among PWID compared to other vulnerable populations (e.g., men who have sex with men (MSM) and serodiscordant heterosexual couples) (Edelman et al., 2017). For these reasons, a growing body of literature has focused on potential barriers to PrEP use among PWID. Low PrEP awareness (Walters et al., 2017), perceptions that the process for obtaining PrEP is burdensome (Bazzi et al., 2018), unstable housing (Allen et al., 2019), and concerns with having to take a daily pill (Allen et al., 2019) have been noted. While informative, the literature to date around PrEP and PWID has three major limitations. First, the bulk of this research lacks gender-specific perspectives on barriers to initiating PrEP, and as a result, gender-specific information necessary for tailoring interventions are largely unknown. Second, there are no PrEP implementation studies published among PWID, so little is known about barriers and facilitators to PrEP initiation experienced by PWID in real-world settings. Lastly, few studies have explicitly examined theoretical issues that influence PrEP initiation (Pinto et al., 2019). The integration of theory in health research can improve measurement, which ultimately produces stronger research findings to inform the development of behavioral interventions as well as programs and policy at organizational and state levels, respectively (Brazil et al., 2005).

To fill these gaps in the literature, we applied the Theory of Planned Behavior (TPB) (Fishbein, 2000) to study the intention and uptake of PrEP among WWID enrolled in a PrEP community demonstration project operating out of a syringe services program (SSP) in Philadelphia, Pennsylvania (U.S.A.). TPB, one of the most well-supported theories of behavior change (Davis et al., 2015), posits that initiation of a new health behavior is most strongly predicted by one’s intention to perform that behavior. Intention is informed by three theoretical constructs: 1) attitudes about the behavior (in this case, one’s positive or negative beliefs about using PrEP); 2) subjective norms (e.g. perceptions that an important person or group of people will approve or disapprove of their PrEP use); and 3) perceived behavior control (e.g., one’s beliefs about how easy or difficult it is to access, initiate, or adhere to PrEP) (Ajzen, 1985). There is an accumulating body of PrEP research that uses TPB to explain PrEP intentions among several populations (Mimiaga et al., 2009; A. Roth et al., 2019; Wang et al., 2017, 2020), but not WWID. These studies among MSM, heterosexuals, and transgender women demonstrate that positive attitudes (e.g., no perceived negative side effects of PrEP) and greater perceived behavioral control (e.g., feeling able to take the pill every day) were associated with higher levels of intention, which in turn, may be a proximal predictor of behavior, in this case PrEP uptake.

The present analysis uses TPB as a framework for identifying how attitudes, subjective norms, and perceived behavioral control relate to WWID’s intention to initiate PrEP when offered a prescription at an SSP. As a secondary analysis, examine whether similar TPB factors are associated with actual PrEP uptake. By explicitly grounding our analysis in TPB, a theory that has not yet been applied to PrEP among WWID, we aim to contribute to the recent call for the integration of theory in PrEP research (Pinto et al., 2019) and overcome a previous limitation in the literature for WWID (i.e., the reliance of hypothetical willingness to initiate PrEP without data on real world behavior) (Glick et al., 2020). Taken together, this study seeks to inform the development of theoretically grounded interventions that increase PrEP uptake among WWID.

MATERIALS AND METHODS

Study Design and Recruitment

The current analysis examines baseline data from a PrEP demonstration project conducted at Prevention Point Philadelphia (PPP) and is part of a larger study to understand the factors that impact the PrEP care continuum among WWID. Details about the study design and measures are reported elsewhere (Roth et al., 2020). Participants were HIV-negative, cisgender women ≥ 18 years old that reported injecting drugs in the past 30 days and any one of the following behaviors considered a clinical indication for PrEP by the Center for Disease Control and Prevention (CDC) at the time of the study: sharing syringes, inconsistent condom use with PWID or MSM, serodiscordant partnerships, and diagnoses of bacterial sexually transmitted infections (STI) (Centers for Disease Control and Prevention, 2018). Participants were recruited at the SSP during a weekly evening program for women. After providing written informed consent, participants completed an anonymous, 1.5-hour interviewer-administered survey that included a brief educational video about basic PrEP facts (e.g. how it works to prevent HIV, the need to use it daily) (Rivet et al., n.d.). Participants were asked to return one week after the baseline survey to obtain their PrEP prescription. We selected this period to allow enough time to receive laboratory results in order to establish baseline creatinine levels and Hepatitis B serology as measures of safety. Participants received all PrEP care at PPP at no cost but used their own insurance to pay for PrEP. Uninsured or underinsured participants were enrolled in public insurance and/or co-pay assistance program [Gilead Pharmaceuticals, Foster City, CA]. Protocols for this study was approved by Drexel University Institutional Review Board and PPP Executive Board. Participants were compensated with $40 USD for their time.

Measures

Sociodemographic characteristics included in this analysis were age, race/ethnicity, self-identified current homelessness, and housing status (i.e., living in their own home, with family/friends, single room occupancy, shelter, treatment facility, or on the street). Based on our prior research, we also included frequency of SEP access, which was measured on a 7-point Likert scale (i.e., daily to never).

Items measuring theoretical constructs from TPB were developed through a review of the PrEP acceptability and attitudes literature (Table 1) (Auerbach et al., 2015; Eisingerich et al., 2012; Golub et al., 2013; Mimiaga et al., 2009; Whiteside et al., 2011; Young et al., 2014). We utilized 11 items to measure PrEP attitudes. These items focused on assessing perceived PrEP efficacy, concerns about PrEP side effects, feeling embarrassed for taking PrEP, and concerns about the risk of physical or sexual violence. Subjective norms were measured with seven items evaluating concerns of talking to health care providers about stigmatized behaviors and feeling judged negatively for taking PrEP (Eisingerich et al., 2012; Golub et al., 2013). Perceived behavioral control was assessed with four items, which measured perceived ability to pay for and adhere to PrEP. All items were measured on a 5-point Likert scale.

Table 1.

Survey Questions Related to Attitudes, Social Norms, and Perceived Behavioral Control Towards PrEP in a PrEP Demonstration Project of Women Who Inject Drugs

Attitudes

I am concerned that PrEP does not provide complete protection against HIV.

I am concerned that PrEP may have a negative interaction with my birth control.

I am concerned that PrEP may have a bad interaction with other medications that I am taking.

I am concerned that if I do become HIV+, certain medicines won’t work because I was taking PrEP.

I am concerned that PrEP might negatively affect my Hepatitis C.

I am concerned that PrEP may be unsafe if I use injection drugs.

I am concerned that PrEP may be unsafe to take on days that I drink alcohol.

I am concerned about the temporary side effects of PrEP.

I am concerned about the long-term effects of PrEP on my health.

I would feel embarrassed about taking PrEP.

I think I am at greater risk for physical violence or rape if I am taking PrEP.

Subjective Norms

I am concerned about having to talk to a health care provider about my sex life.

I am concerned about having to talk to my health care provider about my drug use.

I am concerned that people will see me taking medication and think I have HIV.

I am concerned that people will see me taking medication and will want to know why I am taking it.

I think people would judge me if I am taking PrEP.

I think I am not following the “rules” of my community if I take PrEP to prevent HIV.

I think people will give me a hard time if I tell them I am taking PrEP.

Perceived Behavioral Control

I am concerned about how I will pay for PrEP.

I am concerned about having to take a pill every day.

I am concerned that taking PrEP means I am putting myself at risk for HIV.

I am concerned that taking PrEP might make me more likely to have sex without a condom.

In addition to TPB constructs, we assessed prior PrEP awareness with a yes/no item: “Before today, had you heard of PrEP, or when people who do not have HIV taking AIDS medicines (also known as antiretrovirals) to keep them from getting HIV?” Intention to initiate PrEP was measured with a yes/no item: “We are going to offer you prescription for PrEP today. Do you plan to take the prescription?” (Whiteside et al., 2011). PrEP uptake was defined as leaving the study visit with a bottle of Truvada® or with a prescription for Truvada® one week after baseline (yes/no).

Statistical Analysis

We used descriptive statistics including percentages, means, and standard deviations (SD) to describe the sample and the range of PrEP-related attitudes, subjective norms, and perceived behavioral control. After reviewing the response distribution of each TPB item, we dichotomized responses to somewhat/strongly disagree vs. neither or somewhat/strongly agree. Chi-square or Fisher’s Exact tests were performed to assess the relationship between each TPB-related item and intention to initiate PrEP. For each item, participants who reported “Not relevant to me” or “Refuse to answer” were excluded from bivariable comparisons given the uncertainty in which these participants would have reported their concerns regarding PrEP uptake. In secondary analyses, we assess whether TPB factors and behavioral intention were associated with actual PrEP uptake to better understand how these constructs influence behavior. An alpha level ≤ 0.05 was used to determine statistical significance for all tests. Analyses were conducted in R version 3.5.2.

RESULTS

Ninety-five women were included in this analysis and have been previously described in greater detail by Roth et al. (Roth et al., 2020). Most were white, non-Hispanic (68%; n = 65), reported current homelessness (62%; n = 59), and had a mean age of 37.8 (SD = 8.5). Of those reporting homelessness, 61% (n = 36) were living on the streets, 19% (n = 11) were living in a shelter or treatment facility, 15% (n = 9) were living in the homes of family or friends, and 5% (n = 3) were living in a single occupancy room. About three-quarters (n = 75) accessed the SEP at least once per week.

Intention to initiate PrEP was 88% (n = 84) and similar for women who knew about PrEP prior to the study compared to those who did not (54% vs. 46%, p=0.85; Table 2). Overall, most WWID held positive attitudes and subjective norms, and perceived high behavioral control about PrEP. Most participants (≥ 70%) did not have concerns about PrEP’s efficacy or the potential for a negative interaction between birth control, other medications, Hepatitis C, or drug/alcohol use. Most also reported little/no concern about side effects and did not anticipate PrEP-related social stigma and issues related to cost, adherence, or risk compensation (e.g., having more sexual partners after initiating PrEP).

Table 2.

Prior PrEP Awareness and Related Attitudes and Beliefs by PrEP Initiation Intention Among Women Who Inject Drugs (n = 95)

	Total n (%)	Intention n (%)	No Intention n (%)	p
	95 (100)	84 (88.4)	11 (11.6)
Prior PrEP Awareness	50/95 (52.6)	45/84 (53.6)	5/11 (45.5)	.85
Attitudes: Not concerned about/that…
Incomplete protection against HIV	65/93 (69.9)	59/82 (72.0)	6/11 (54.5)	.29
Negative interaction with birth control	57/66 (86.4)	54/58 (93.1)	3/8 (37.5)	<.01
Bad interaction with other medications	63/83 (75.9)	57/73 (78.1)	6/10 (60.0)	.24
Certain medicines won’t work if HIV+ because of PrEP	69/93 (74.2)	61/82 (74.4)	8/11 (72.7)	1
Negative effect on Hepatitis Ca	29/40 (72.5)	29/38 (76.3)	0/2 (0)	**
PrEP is unsafe with injection drugs	72/93 (77.4)	65/82 (79.3)	7/11 (63.6)	.26
PrEP is unsafe with alcohol	58/77 (75.3)	53/68 (77.9)	5/11 (55.6)	.21
Temporary side effects	64/91 (70.3)	60/80 (75.0)	4/11 (36.4)	.01
Long-term side effects	55/94 (58.5)	52/83 (62.7)	3/11 (27.3)	.05
Feeling embarrassed about taking PrEP	81/92 (88.0)	73/82 (89.0)	8/10 (80.0)	.34
Risk of physical/sexual violence if taking PrEP	84/94 (89.4)	75/83 (90.4)	9/11 (81.8)	.33
Subjective Norms: Not concerned about/that…
Talking to health care provider about sex life	79/93 (84.9)	71/83 (85.5)	8/10 (80.0)	.64
Talking to health care provider about drug use	73/92 (79.3)	67/82 (81.7)	6/10 (60.0)	.21
People will think I have HIV if I take PrEP	76/90 (84.4)	68/80 (75.6)	8/10 (80.0)	.65
People will want to know why I take PrEP	73/91 (80.2)	65/81 (80.2)	8/10 (80.0)	1
Judgement for taking PrEP	80/90 (88.9)	73/81 (90.1)	7/9 (77.8)	.26
Following the community’s rules if taking PrEP	88/92 (95.7)	79/82 (96.3)	9/10 (90.0)	.37
Someone giving me a hard time if I tell them I am taking PrEP	80/93 (86.0)	72/83 (86.7)	8/10 (80.0)	.63
Perceived Behavioral Control: Not concerned about/that…
Cost of PrEP	76/94 (80.9)	72/83 (86.7)	4/11 (36.4)	<.01
Taking a pill every day	70/94 (74.5)	66/83 (79.5)	4/11 (36.4)	<.01
Taking PrEP will increase HIV risk	84/94 (89.4)	75/83 (79.8)	9/11 (81.8)	.33
Decreased condom use due to PrEP	71/88 (80.7)	63/77 (81.8)	8/11 (72.7)	.43

^aStudy sample was restricted to WWID that reported a Hepatitis C infection

^**p-value were not reported given the cell’s zero value

In bivariate analyses, only attitudes and perceived behavioral control were significantly associated with PrEP intention. Compared to participants who did not intend to initiate PrEP, a greater proportion of WWID expressing intention to start PrEP had fewer concerns about temporary (75%, vs 36%. p=0.01) or long-term (63% vs. 27%, p=0.05) side effects, and the potential for negative interaction between PrEP and birth control (93% vs. 38%, p<0.01). With regards to perceived behavioral control, participants who intended to initiate PrEP expressed fewer concerns about their ability to take a daily pill (80% vs. 36%, p<0.01) or be able to cover the cost of PrEP (87% vs. 36%, p<0.01) compared to those without intention. None of the subjective norms measured as part of this study were associated with PrEP intention.

Most of the participants returned for their one-week follow-up appointment (94%; n = 89; Table 3). Among them, 89% (n = 79) intended to initiate PrEP. However, there was no difference in PrEP intention between WWID who accepted PrEP and those who did not (91% vs. 80%, p=0.22). The only TPB construct associated with uptake was subjective norms. Specifically, compared to WWID who did not take PrEP, those who did felt less concerned with talking to a health care provider about their sex life (91% vs. 65%, p<0.01) and drug use (88% vs. 55%, p<0.01).

Table 3.

Prior PrEP Awareness, Attitudes and Beliefs, and PrEP Intention by PrEP Uptake Among Women Who Inject Drugs Returning for Their One-Week Visit (n = 89)

	Total n (%)	Uptake n (%)	No Uptake n (%)	p
	89 (100)	69 (77.5)	20 (22.5)
Prior PrEP Awareness	49/89 (55.1)	38/69 (55.1)	11/20 (55.0)	1
Attitudes: Not concerned about/that…
Incomplete protection against HIV	61/87 (70.1)	49/67 (73.1)	12/20 (60.0)	.29
Negative interaction with birth control	55/63 (87.3)	47/51 (92.2)	8/12 (66.7)	.06
Bad interaction with other medications	59/68 (86.8)	49/52 (94.2)	10/16 (62.5)	.19
Certain medicines won’t work if HIV+ because of PrEP	64/87 (73.6)	51/68 (75.0)	13/19 (68.4)	.77
Negative effect on Hepatitis Ca	29/39 (74.4)	24/30 (80.0)	5/9 (55.6)	.21
PrEP is unsafe with injection drugs	68/88 (77.3)	55/68 (80.9)	13/20 (65.0)	.22
PrEP is unsafe with alcohol	54/62 (87.1)	42/57 (73.7)	12/15 (60.0)	.77
Temporary side effects	62/86 (72.1)	50/66 (75.8)	12/20 (60.0)	.26
Long-term side effects	57/88 (64.8)	44/68 (64.7)	13/20 (65.0)	.25
Feeling embarrassed about taking PrEP	76/86 (88.4)	60/66 (90.9)	16/20 (80.0)	.21
Risk of physical/sexual violence if taking PrEP	78/88 (88.6)	60/68 (88.2)	18/20 (90.0)	1
Subjective Norms: Not concerned about/that…
Talking to health care provider about sex life	75/88 (85.2)	62/68 (91.2)	13/20 (65.0)	<.01
Talking to health care provider about drug use	69/86 (80.2)	58/66 (87.9)	11/20 (55.0)	<.01
People will think I have HIV if I take PrEP	71/84 (84.5)	53/64 (82.8)	18/20 (90.0)	.49
People will want to know why I take PrEP	68/85 (80.0)	52/65 (80.0)	16/20 (80.0)	1
Judgement for taking PrEP	75/84 (89.3)	59/64 (92.2)	16/20 (80.0)	.20
Following the community’s rules if taking PrEP	82/86 (95.3)	63/66 (95.5)	19/20 (95.0)	1
Someone giving me a hard time if I tell them I am taking PrEP	75/87 (86.2)	60/67 (89.6)	15/20 (75.0)	.14
Perceived Behavioral Control: Not concerned about/that…
Cost of PrEP	72/88 (81.8)	56/69 (81.2)	16/19 (84.2)	1
Taking a pill every day	75/88 (85.2)	50/68 (73.5)	15/20 (75.0)	1
Taking PrEP will increase HIV risk	79/88 (89.8)	62/68 (91.2)	17/20 (85.0)	.67
Decreased condom use due to PrEP	66/82 (80.5)	50/62 (80.6)	16/20 (80.0)	1
PrEP Intentions	79/89 (88.8)	63/69 (91.3)	16/20 (80.0)	.22

^aStudy sample was restricted to WWID that reported a Hepatitis C infection

DISCUSSION

In this community demonstration project, 88% of WWID intended to initiate PrEP, and most (63/79) went on to take a PrEP prescription one week later. In the context of our data, this is likely explained by participants’ positive attitudes towards PrEP, perceived normative support from their health care providers, and fewer anticipated barriers related to behavioral control. However, TPB constructs related differently to PrEP intention than the health behavior of taking PrEP one week later. This difference may explain why, for some health behaviors, there is intention-behavior discordance since the actual factors influencing these outcomes vary. Given these underlying differences, a strength of this analysis is the use of theory to understand PrEP intention, as well as its relationship to actual behavior.

Intention to initiate PrEP was much higher in our study compared to those of other PWID populations, which range from 47% to 71% of samples (Kuo et al., 2016; Sherman et al., 2019; Stein et al., 2014). It is possible that recruiting and delivering care within a setting already utilized and trusted by participants influenced their willingness to try a new HIV prevention tool. Despite high overall intention, there were importance differences in attitudes and perceived behavioral control between those who intended to initiate PrEP and those who did not. Namely, concerns related to side effects, taking a daily pill, and paying for PrEP were associated with a lower intention to initiate PrEP. These findings corroborate previous PrEP research grounded in TPB among other vulnerable populations that also found attitudes and perceived behavior control to be important predictors of PrEP intention (Mimiaga et al., 2009; A. Roth et al., 2019; Wang et al., 2017) and support work by Shrestha et al. (2018) which reported that PWID would prefer a PrEP program that was low cost and highly efficacious with no side effects. However, our study uniquely contributes to the literature by identifying beliefs specific to ciswomen such as the impact of PrEP on birth control. This is an important finding for intervention development of gender-informed PrEP programs. Incorporating messages on the limited long-term side effects and the influences of PrEP on birth control, such as highlighting that one does not negatively impact the other, may be important for increasing intention in this population.

While PrEP intention was not associated with the actual behavior, we found that there was a higher prevalence of uptake if WWID had fewer concerns discussing their sexual history and drug use with their provider. This corroborates other studies that describe how negative experiences interacting with health care providers pose as a barrier to PrEP uptake among PWID (Biello et al., 2018; Knight et al., 2016; Shrestha & Copenhaver, 2018). However, more research is needed to understand why norms were important predictors of uptake but not intention, and how this plays out in terms of patient-clinician interactions. One possible explanation for this is the belief disparity hypothesis (Ajzen & Driver, 1992) which states that people hold more positive beliefs about hypothetical behaviors compared to when the behavior is enacted in real-life. In the context of this study, this hypothesis would posit that norms of PrEP use may not be a concern when framed in the context of a hypothetical scenario (e.g., Do you plan to take PrEP?). However, when participants left the study visit and considered initiating PrEP in real life, then the reality of social norms became a concern. This may help explain why 16 participants who intended to initiate PrEP but did not during their one-week follow-up.

Our findings suggest that interventions to establish quality PrEP counseling and diminish real or perceived provider bias towards WWID will be an important component of increasing PrEP utilization. Women often experience greater stigma towards drug use than men given the stereotype of promiscuity and pressure to fulfill traditional gender roles as primary caregivers (El-Bassel et al., 2014a). These representations may deter women from accessing care due to fear of being judged negatively or having their children removed from their care (Myers et al., 2009; Washington et al., 2011). Studies among female sex workers and people of color have found that increased trust in health care providers was associated with greater willingness to use PrEP (Braksmajer et al., 2018; Jackson et al., 2013). Therefore, strategies that improve patient-provider trust by encouraging interpersonal connection, respectful communication, and professional partnering are key (Bova et al., 2012). In particular, trauma-informed approaches that are attentive to the high levels and many forms of victimization are needed. Our prior work established that past six month sexual assault is an important motivator for PrEP uptake (Felsher et al., 2020; Roth et al., 2020) and that women who experienced recent intimate partner violence are more likely to drop out of PrEP care that women who have not (unpublished data).

Findings should be interpreted considering various study limitations. We present a descriptive cross-sectional analysis to explore the association between TPB constructs and PrEP initiation intentions among WWID enrolled in a community demonstration project in an urban setting. Given our small sample, there is the potential that we had inadequate statistical power to detect a true difference in the TPB constructs by WWID’s intention to initiate PrEP and their actual behavior, especially because both intention and uptake were so high in this sample. These findings may also not translate to WWID who face more barriers to accessing health care and prevention services, or to other geographic settings. However, our sample did reflect the larger population of clientele accessing the SSP as well as the PWID population in Philadelphia. Because WWID were informed about PrEP as part of the protocol, this may have resulted in an inflation of positive responses related to TPB items, thereby introducing a form of ascertainment bias. Finally, the items we used to assess TPB constructs were based on findings from a review of the PrEP acceptability and interest literature. Therefore, our TPB items are by no means an exhaustive list of potential attitudes, subjective norms and perceive behavioral control items. Nonetheless, we feel they represent common measures of these constructs.

CONCLUSION

Our findings suggest that in this SSP-based community demonstration project in Philadelphia, WWID held positive attitudes, perceive few negative subjective norms, and felt able to control their PrEP use. Intention to initiate PrEP was high and most went on to accept it. Those intending to initiate PrEP were less concerned with side effects, negative interaction with birth control, taking PrEP daily, and financial barriers to PrEP. In contrast, participants’ comfort in discussing their sexual history and drug use with their provider was a more important motivating factor for PrEP uptake. Taken together, offering PrEP at the SSP, which may be a safe and trusting environment for WWID, could be a key factor for high PrEP uptake. Next steps for research could include implementing theoretically guided demonstration projects with larger numbers of WWID to assess the impact of gender-specific PrEP programming within the SSP to improve intention and uptake.