Knowledge and Attitudes about Prep and Npep among a 7-city Sample of Homeless Young Adults

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Graduate School of Social Work


Purpose: Despite evidence suggesting that they are 16 times more likely to become HIV+ than their housed peers, homeless youth have low rates of uptake and adherence to PrEP or nPEP. Notwithstanding the documented HIV risk and the potential for PrEP and nPEP as feasible prevention strategies, little research has been conducted to determine the knowledge and attitudes regarding PrEP and nPEP among homeless young adults.

Methods: We conducted a cross-sectional survey (2016–2017) among homeless youth 18–25 years old recruited from drop-in centers and shelters in 7 cities in the United States (New York, St. Louis, Denver, Phoenix, Houston, Los Angeles, and San Jose) to assess knowledge and attitudes regarding PrEP and nPEP to inform HIV prevention intervention development.

Results: Participants (n = 1427) were primarily youth of color (37% Black, 17% Hispanic, 16% mixed, 11% other), 32% LGBTQ, male (58%), female (35%), or transgender (5%), with a mean age of 20.9 years. Regarding PrEP, 4% of the sample had talked with their provider about PrEP; while 71% had low to no knowledge of PrEP. Despite no/low knowledge, 59% reported they were likely or extremely likely to take PrEP if recommended by their doctor. Significant knowledge differences were found by gender identity and location; transgender youth reported higher knowledge than cisgender males or females (f = 26.48, p < .01), and youth in Los Angeles and New York reported the highest PrEP knowledge (f = 19.45, p < .01). Transgender youth also reported significantly more interest in PrEP than cisgender males or females (f = 12.15, p < .01), though interest was high in the total sample. Access to free PrEP (55%), HIV testing (72%), healthcare (68%), one-on-one counseling on PrEP use (62%), and text messaging support (57%) were all rated as very important or extremely important for PrEP uptake and adherence among participants. Youth had low rates of post-sexual assault healthcare seeking behaviors when nPEP may be indicated for HIV prevention; 71% of youth did not seek post-assault examination despite 24% of youth being sexually assaulted since becoming homeless. Barriers to post-sexual assault examination included not wanting to involve the legal system (21%), not thinking it was important (17%), not knowing what a post-sexual assault exam was (12%), not having health insurance (11%), or being unable to safely leave the situation (9%).

Conclusions: Results of this study suggest several missed opportunities to prevent new HIV infections among homeless youth. Despite the high risk for HIV among this vulnerable population, PrEP knowledge remains low. Though, once informed, interest in PrEP uptake is high. Efforts to increase PrEP uptake and adherence among homeless youth should consider provider and systems level interventions to decrease PrEP associated healthcare costs, improve access to PrEP providers, and provide both in-person and text messaging support. Further, interventions to address the importance of and reduce system and individual-level barriers to sexual assault examinations can improve HIV prevention efforts among homeless youth. Further research is needed to design and test the efficacy of HIV prevention interventions on PrEP and nPEP uptake and adherence among homeless youth.

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