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"Everybody thinks that it won't happen to them": A mixed-methods study of HIV prevention strategies among people experiencing homelessness who use drugs.

Danielle R Fine·Carlos Sevilla·Angela Ma·Bailey Little·Nora Sporn·Travis P Baggett·Alysse Wurcel
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Abstract

BACKGROUND: HIV disproportionately affects people experiencing homelessness, particularly those who use drugs. Although effective prevention strategies exist, uptake remains suboptimal in high-risk populations. Limited research has examined how this population engages with HIV prevention strategies and the contextual factors shaping behaviors. METHODS: We conducted a mixed-methods study of adults (≥18 years) experiencing homelessness with recent drug use, recruited from three Boston sites (Feb 2024-Jan 2025). Participants completed a survey assessing HIV prevention strategy uptake. A subsample completed in-depth interviews on factors influencing behavior. Guided by the Theoretical Domains Framework, we coded qualitative data and identified themes to help contextualize uptake. RESULTS: Among 196 participants, mean age was 48; 61% identified as male and 44% as non-Hispanic White. Forty-two percent reported condomless sex, and among those who had ever injected drugs (n = 123), 24% reported syringe sharing in the prior three months. Only 9% reported current PrEP use, and 12% had ever used HIV self-tests. Qualitative findings highlighted perceived control as a key facilitator, while low perceived HIV risk hindered uptake across strategies. Additional barriers varied by strategy and included partner dynamics and substance use affecting condom use, structural constraints affecting syringe use, and knowledge, stigma, and cost concerns affecting PrEP and self-testing. CONCLUSION: In this cohort of people experiencing homelessness who use drugs, HIV prevention strategy uptake was suboptimal, with particularly low PrEP and HIV self-testing use. Qualitative findings suggest that interventions to promote HIV prevention strategy uptake in this population should leverage perceived control, address perceived risk, and target strategy-specific interpersonal and structural barriers.

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HumansIll-Housed PersonsHIV InfectionsMaleFemaleAdultMiddle AgedBostonPre-Exposure ProphylaxisNeedle SharingSubstance Abuse, IntravenousSexual BehaviorUnsafe SexSurveys and QuestionnairesCondom useDrug useHIV preventionHIV self-testingHomelessPre-exposure prophylaxisSyringe sharingJournal Article

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Danielle R Fine, Carlos Sevilla, Angela Ma, Bailey Little, Nora Sporn, Travis P Baggett, Alysse Wurcel. 2026-07-16. "Everybody thinks that it won't happen to them": A mixed-methods study of HIV prevention strategies among people experiencing homelessness who use drugs.. https://doi.org/10.1016/j.drugpo.2026.105429

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Journal Article resourceAdult subjectFemale subjectHIV Infections subjectHumans subjectJournal Article subjectMale subjectMiddle Aged subjectPre-Exposure Prophylaxis subject

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