Association between homelessness and PrEP uptake among men who have sex with men: Results from the American Men's Internet Survey, 2017-2021.

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by housing insecurity across the US. This study examined the association between homelessness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among GBMSM in the United States and investigated the modifying effect of injection drug use.

METHODS

47,750 cisgender GBMSM who participated in the American Men's Internet Survey from 2017 to 2021 and who self-reported not living with HIV were included in this secondary, cross-sectional analysis. Homelessness was defined as living on the street, a shelter, a Single Room Occupancy hotel, or a car in the past 12 months. Associations between sociodemographic characteristics and homelessness were tested using chi-squared tests. Weighted univariable and multivariable Poisson regression models with robust variance estimation assessed associations between homelessness and PrEP uptake; weights were constructed based on race/ethnicity and region.

RESULTS

8304(17.4%) participants reported PrEP uptake in the last 12 months. Those experiencing homelessness were more likely to be younger, Black, uninsured, living in the US South, and report lifetime injection drug use. Homelessness was independently negatively associated with PrEP uptake (aPR = 0.85; 95%CI: 0.75, 0.95). Homelessness was negatively associated with PrEP uptake in those not reporting injection drug use (aPR = 0.77; 95%CI: 0.67, 0.90). However, homelessness was not associated with PrEP uptake in those reporting injection drug use.

CONCLUSIONS

Homelessness was associated with lower PrEP uptake among GBMSM. Outreach and peer-based interventions tailored specifically to homeless GBMSM are needed given the disproportionate need. Future research on the impact of macro-level systems of inequality and individuals with marginalized identities are needed to unpack intersectional vulnerabilities.