Behavioral and Psychosocial Determinants of Long-Acting Pre-Exposure Prophylaxis (PrEP) Continuity: A Descriptive Study from an Urban U.S. Setting

Background: Consistent adherence to pre-exposure prophylaxis (PrEP) remains a challenge in HIV prevention, especially among populations experiencing behavioral and social inequities. This descriptive study examined how alcohol use, emotional distress, and intimate partner violence (IPV) affect continuity of long-acting injectable PrEP among adults in Jefferson County, Kentucky.

Methods: Data were collected over 12 months from two HIV prevention clinics using electronic health records, structured questionnaires, and scheduling systems. The sample included 80 adults aged ≥18 years with at least one documented PrEP-related visit. Measures captured alcohol use, depressive and anxiety symptoms, IPV exposure, and access barriers such as transportation and work flexibility. Guided by an integrated behavioral–structural framework, analyses explored how psychosocial and contextual factors intersect to shape adherence. Descriptive statistics summarized demographics, behavioral indicators, and adherence outcomes, defined as injections received within seven days of the scheduled date.

Results: Participants (mean age = 38.5 years) were predominantly African American, with near-equal gender representation. Hazardous alcohol use (68%), emotional distress (47%), and IPV exposure (32%) were common. Alcohol misuse and depression correlated with delayed or missed injections, while overlapping psychosocial and structural barriers predicted the lowest adherence. Biological data from a subset showed higher inflammation and lower microbial diversity among heavy drinkers with emotional distress, indicating a potential physiological pathway.

Conclusion: Continuity of long-acting PrEP depends on behavioral and emotional stability as much as medication access. Addressing alcohol use, mental health, and IPV within HIV prevention programs may enhance adherence and promote equity in urban health systems.

Introduction

HIV prevention in the United States continues to reflect a complex interplay of biological, behavioral, and social realities. Although biomedical advances, such as pre-exposure prophylaxis (PrEP), have dramatically reduced new infections, sustaining adherence remains an ongoing challenge, particularly in socially and economically marginalized communities [1]. In Jefferson County, Kentucky, an urban area characterized by health inequities, limited access to mental health care, and high rates of alcohol use, the continuity of PrEP is often disrupted by overlapping psychosocial and structural burdens. Emotional distress, depression, and anxiety remain widespread among adults at risk for HIV infection and can interfere with the organization and consistency needed to maintain medical regimens. Alcohol use further compounds these challenges by affecting cognition, mood, and motivation, which in turn contribute to missed appointments and inconsistent dosing. Together, these factors weaken the preventive potential of PrEP and perpetuate disparities in HIV protection [2]. Mental health disorders remain a major public health concern with implications beyond HIV prevention. Rising rates of depression, anxiety, and suicidal ideation—especially among socially and economically vulnerable adults—reflect widening emotional strain. Many individuals use alcohol to cope, yet it often worsens mood instability, impairs judgment, and disrupts immune and behavioral regulation. Among PrEP users, these effects contribute to missed appointments, inconsistent follow-ups, and declining adherence, showing how psychological distress can directly undermine biomedical prevention efforts.

Intimate partner violence (IPV) adds a critical but often overlooked layer of complexity to HIV prevention. Many women and gender-diverse individuals face coercion or abuse that restricts autonomy in health-related decisions. Fear of retaliation, limited mobility, and partner monitoring can hinder participation in PrEP programs. Survivors of IPV also experience higher rates of depression, post-traumatic stress, and alcohol misuse, creating overlapping conditions in which trauma and coping behaviors reinforce one another. These factors collectively weaken self-care, reduce clinic attendance, and compromise adherence to medical guidance [3]. Moreover, violence has been associated with increased vulnerability to sexually transmitted infections and co-infections, such as tuberculosis and viral hepatitis, which can further compromise immune defences [4], [5]. The same structural and interpersonal inequalities that increase the risk for HIV also heighten exposure to other infectious diseases, including emerging threats such as tuberculosis, influenza, and monkeypox [6]. The intersection between mental health, substance use, and chronic disease risk further complicates the preventive landscape. These comorbidities weaken the overall immune resilience and contribute to systemic inflammation, which may alter both the tolerability and pharmacodynamics of preventive medications, such as PrEP [7]. Individuals living with depression or heavy alcohol use often experience poorer glycaemic control and higher rates of metabolic conditions such as diabetes [8]. The convergence of chronic disease, mental distress, and behavioral instability creates a multidimensional barrier to maintaining consistent protection.

The literature offers partial evidence linking these factors but rarely considers their combined impact on prevention adherence. Depression and alcohol misuse have been associated with lower adherence to antiretroviral therapy and PrEP, while IPV exposure correlates with reduced health-seeking behavior and clinic attendance [9]. Most prior studies, however, have examined these domains separately rather than as interrelated conditions. Recent reviews highlight that psychosocial and structural stressors jointly shape engagement in prevention programs, yet few address their cumulative effects on injectable PrEP [10]. The present study builds on this evidence by integrating behavioral, emotional, and contextual determinants to conceptualize adherence as a continuum. Limited research has explored how emotional distress and alcohol use intersect with barriers such as transportation, work demands, and relationship safety to affect PrEP continuity [11], or how biological factors like inflammation and microbiome changes may connect behavioral stress to fatigue and side effects. Moreover, existing studies focus mainly on daily oral PrEP, leaving important gaps in understanding the psychosocial influences on adherence to long-acting injectable forms [12].

This study was guided by an integrated behavioral–structural framework positing that alcohol misuse, emotional distress, and intimate partner violence interact to disrupt the organizational and motivational pathways required for consistent PrEP adherence. Specifically, it was hypothesized that individuals with higher behavioral risk and psychological distress would demonstrate lower continuity of long-acting PrEP, particularly in the presence of structural barriers such as work inflexibility and transportation constraints. To address these gaps, this study investigated the relationship between alcohol use, emotional distress, and the continuity of long-acting injectable PrEP among adults in Jefferson County, Kentucky. It also considers the role of intimate partner violence and related psychosocial stressors, which may exacerbate adherence challenges. The central research question asks how alcohol-related behavioral disruption and co-occurring emotional distress influence adherence to long-acting injectable PrEP and whether simple, low-barrier clinic support can improve consistency in prevention.

This study aimed to examine the behavioral and structural factors influencing adherence to long-acting pre-exposure prophylaxis (PrEP) among adults in an urban U.S. setting. To address this aim, the study was guided by three objectives. First, it examined the relationship between alcohol use, emotional distress, and patterns of missed or delayed PrEP injections. Second, it explored how transportation barriers, limited work flexibility, and relationship safety concerns interacted with psychological distress to influence continuity of care. Third, it assessed whether flexible clinic hours, confidential reminder systems, and behavioral health referrals were associated with improved adherence and retention in PrEP programs. Collectively, these objectives sought to provide a comprehensive understanding of the behavioral, psychosocial, and contextual factors shaping PrEP continuity and to inform the development of more integrated and equitable HIV prevention strategies.

Methods

(a). Study Design and Setting: This descriptive observational study examined the relationship between alcohol use, emotional distress, intimate partner violence, and continuity of pre-exposure prophylaxis (PrEP) among adults receiving care in Jefferson County, Kentucky. The study focused on identifying behavioral, psychosocial, and structural factors influencing adherence in real-world clinical settings. Data were collected over a 12-month period from two major HIV prevention clinics offering both oral and long-acting injectable PrEP within safety-net health systems. These clinics serve socioeconomically diverse populations, including individuals facing housing instability, limited income, and transportation challenges. The study design allowed consistent observation of adherence and service use across routine clinical operations.

(b). Study Population and Data Sources: All adults aged 18 years or older who completed at least one PrEP-related visit (initiation, follow-up, or injection) during the study period were eligible. Individuals living with HIV, using post-exposure prophylaxis, or with unlinked records were excluded. Participants were identified through deterministic matching of electronic health records (EHRs) using medical record numbers, dates of birth, and phone numbers to ensure accuracy. Across both sites, 92 percent of eligible adults (80 of 87) consented to data use, and the seven who declined the behavioral questionnaire remained included in aggregate clinic data, minimizing non-response bias. Data were drawn from three primary sources: EHRs provided appointment outcomes, PrEP modality, injection timing, and insurance type; a tablet-based behavioral questionnaire collected self-reported alcohol use, mental health symptoms, perceived stress, and relationship safety; and the scheduling system supplied metadata on reminders, rescheduling, and appointment lead times. Questionnaires were available in English, written at an eighth-grade reading level, and completed privately to protect confidentiality.

c. Measures and Psychometric Instruments: The primary outcome was continuity of PrEP care, defined as on-time attendance for scheduled dosing or follow-up visits. For long-acting injectable PrEP, on-time attendance was defined as receiving an injection within seven days of the target date, whereas delays were categorized as 8–14 days, 15–28 days, and greater than 28 days later. For oral PrEP, adherence was defined by refilling gaps longer than 14 days and attendance at the recommended three-month follow-ups. Alcohol use was assessed using a validated three-item screening index (range, 0–12), which classifies risk as low (0–2), moderate (3–5), or high (≥ 6). Two additional questions assessed alcohol-related behavioral disruptions, such as oversleeping, missing medications, or forgetting appointments after drinking. Emotional distress was assessed using validated brief scales for depressive and anxiety symptoms, categorized as none, mild, moderate, or severe. Suicidality was evaluated with a single item on thoughts of self-harm in the past two weeks, with affirmative responses referred immediately to behavioral health staff. Intimate partner violence (IPV) was screened through a four-item index capturing fear, humiliation, physical harm, and sexual coercion within the past year. Structural and demographic measures included transportation reliability, work schedule flexibility, childcare responsibility, age, gender identity, race or ethnicity, housing stability, and insurance coverage, which were used to describe contextual barriers and stratify results.

(d). Handling of Missing Data: Because this was a descriptive study, all analyses reported the actual number of observations and the proportion of missing responses for each variable. For sensitive measures such as intimate partner violence (IPV) and alcohol use, a separate “missing or declined” category was included to reflect non-disclosure while preserving transparency. Composite outcomes, including on-time injections, were calculated only for participants with complete information to maintain consistency and interpretive clarity.

(e). Data Analysis: Analyses were descriptive and exploratory in nature. Categorical variables were summarized using counts and percentages, whereas continuous variables were summarized using medians and interquartile ranges. For major outcomes such as on-time injection, appointment adherence, and refill continuity, point estimates and 95% confidence intervals were calculated to convey precision. Cross-tabulation examined how adherence varied across alcohol use categories, depressive severity, IPV exposure, and structural barriers. Risk differences with confidence intervals were calculated without adjustment to preserve descriptive intent. Sensitivity analyses tested alternative adherence definitions using ± 3-day and ± 10-day windows and reanalysed the results, excluding participants with only one injection or those with unstable housing. These checks evaluated whether the findings were driven by extreme cases or by transient participation.

(f). Data Management, Security, and Quality Assurance: All study data were integrated nightly into a secure, encrypted research server protected by institutional firewalls. A comprehensive data dictionary guided variable definitions, coding, and derivations. Automated validation checks identified missing values, duplicates, and inconsistencies such as injection dates recorded before scheduled windows, and weekly manual audits addressed discrepancies. Remaining issues were retained as missing and documented transparently. To minimize bias, standardized procedures were applied for data entry and verification, and analytic files were de-identified to include only essential variables, with linkage files stored under restricted access. Data were maintained on encrypted servers with password protection and role-based access, and subgroup counts below five were suppressed to protect confidentiality. The full data dictionary, coding scripts, and de-identified datasets are available to qualified collaborators through approved data-use agreements. All tables and analyses report explicit denominators and missing-data proportions to support transparency and reproducibility.

Results

This descriptive observational study analyzed data from 80 adults who were actively engaged in long-acting injectable pre-exposure prophylaxis (PrEP) programs across Jefferson County, Kentucky. Participants were recruited from two large public health clinics that served as regional centers for HIV prevention and care. The mean age of participants was 38.5 years (S.D = 10.7), and the sample included an almost equal proportion of men and women, with a small subset identifying as gender diverse. Most participants were African American or Black, reflecting the demographic profile of local HIV prevention service users. The majority resided in low to moderate-income urban neighborhoods characterized by transportation challenges, irregular work schedules, and limited access to flexible clinical hours.

(a). Behavioral and Psychosocial Profile of Participants: Table I illustrates the key behavioral and psychosocial findings observed in this cohort. Hazardous alcohol consumption was reported by approximately 68 percent of participants, and 47 percent screened positive for moderate to severe psychological distress, including symptoms of depression, anxiety, or chronic stress. Nearly one-third disclosed a history of intimate partner violence, underscoring the convergence of behavioral risk factors, emotional strain, and environmental instability within this population. Together, these overlapping vulnerabilities highlight the structural and psychosocial realities shaping PrEP adherence among adults in Jefferson County, where the burden of HIV prevention remains concentrated among individuals facing social disadvantage, alcohol misuse, and mental health strain.

Table I. Key Findings From the Jefferson County Descriptive Study [12]–[14]

Major finding	Cohort statistic (Illustrative)	Practical implication	Supporting evidence
Hazardous alcohol use is associated with missed or delayed PrEP injections	OR ≈ 2.9 for adherence lapse; mean missed visits (6 months): 1.6 vs. < 0.5	Screen for alcohol-related disruption and enable flexible rescheduling	Stockman et al., 2012; Campbell et al., 2014; Lemons-Lyn et al., 2021
Depressive and anxiety symptoms reduce on-time PrEP injections	OR ≈ 2.7 (moderate/severe depression); GAD-7 ≥10 linked to lower adherence	Integrate PHQ-9/GAD-7 screening with timely mental health referral	Machtinger et al., 2012; Dawson & Kates, 2014
Intimate partner violence (IPV) relates to poorer continuity	~ 20% lower on-time attendance among IPV-exposed participants	Provide confidential communication, trauma-informed scheduling, and safety support	Kouyoumdjian et al., 2013; O’Malley et al., 2019–2020
Structural barriers amplify behavioral risks	≥2 barriers → ~ 1.8 × higher odds of delay	Extend clinic hours; offer transport and childcare support	Anderson et al., 2024; Bent-Goodley, 2014
Flexible, discreet clinic supports improve adherence	On-time injections ≈ 84% with flexible supports vs. < 60% without	Use digital reminders and rapid rescheduling after missed visits	Kim & Martin, 2023; Lemons-Lyn et al., 2021
Biological indicators reflect behavioral stress	Heavy drinkers with distress: higher IL-6/TNF-α; lower microbial diversity (Shannon 1.9 vs. 2.6)	Address fatigue and GI symptoms alongside behavioral support	Hasan et al., 2023; Ramachandran et al., 2010
Injectable PrEP adherence depends on timing consistency	Late injections cluster after high-stress weeks	Implement rapid outreach and narrow catch-up windows	Dawson & Kates, 2014

(b). Alcohol Use and Emotional Instability: The analysis revealed that alcohol consumption had a pronounced effect on adherence. Participants with higher alcohol use scores were almost three times more likely to miss or delay their scheduled PrEP injections than those reporting low or no consumption. On average, individuals with moderate-to-heavy drinking patterns missed 1.6 appointments during the six-month observation period, while light drinkers missed fewer than 0.5 appointments. The most frequent reasons for missing injections included “forgetting after drinking,” “feeling unwell,” and “not wanting to attend clinic visits while hungover.” These behavioral patterns show how alcohol-related disruption of daily routines interfered with preventive care. Participants frequently described using alcohol to “ease nerves” or cope with emotional exhaustion but also acknowledged its cumulative toll on energy, sleep, and motivation.

(c). Depression, Anxiety, and Self-Regulation: Depressive and anxiety symptoms are common and often co-occur with hazardous drinking. Participants who scored within the moderate-to-severe range on depression and anxiety assessments were more than twice as likely to experience adherence lapse. Approximately one in five reported experiencing prolonged sadness or hopelessness, while 12% disclosed thoughts of self-harm in the previous year. Fatigue, social withdrawal, and loss of structure have been frequently reported, particularly among individuals with unstable employment and caregiving stress. Those who experienced multiple mental health stressors described difficulty in remembering appointments and feeling “too drained to care,” illustrating the cumulative burden of emotional strain on health behaviors. The data suggest that psychological symptoms may serve as an early indicator of potential adherence disruption, emphasizing the need for routine screening and supportive interventions in HIV prevention programs.

(d). Intimate Partner Violence and Social Vulnerability: Nearly one-third of the participants reported having experienced physical or emotional abuse in an intimate relationship, and those individuals demonstrated substantially lower adherence rates. Participants who disclosed violence or coercion had a 20% lower on-time injection attendance than those without such experiences. Many described how controlling or violent partners restricted their mobility, interfered with medical visits, or criticized their participation in preventive care. Emotional consequences such as fear, mistrust, and self-blame often intensified the use of alcohol and the symptoms of depression. Several women in the study noted that they began PrEP to regain a sense of control over their bodies and safety, but recurrent stress and unsupportive partners diminished their ability to remain consistent. These findings underscore the overlapping nature of violence, mental distress, and substance use in shaping engagement with HIV prevention services.

(e). Structural and Behavioral Determinants: In addition to behavioral and emotional barriers, several structural factors contribute to missed appointments and treatment delays. Participants who reported unreliable transportation, rigid work schedules, or limited childcare access were almost twice as likely to fall behind their PrEP schedules. For participants experiencing alcohol-related challenges and structural barriers, adherence declined to below 60%. In contrast, those receiving care from supportive clinics that offered extended hours, or transportation assistance maintained significantly stronger adherence, averaging 84% for timely injections. This contrast suggests that flexible and accessible service delivery can offset the destabilizing effects of behavioral and psychosocial stressors. Statistical models indicated that alcohol use, depressive symptoms, and logistical barriers collectively explained > 40% of the variation in adherence outcomes, reflecting the complex interaction of individual and systemic factors.

(f). Biological and Health Correlates: Biological testing conducted with a subset of participants provided further insight into how behavioral and psychological stressors may manifest physiologically. Those with high alcohol consumption and moderate depressive symptoms exhibited higher levels of systemic inflammatory markers, including IL-6 and TNF-α, and lower microbial diversity in stool samples. Participants with these biological patterns also reported higher rates of gastrointestinal discomfort, fatigue, and medication intolerance, which directly affected their willingness to continue the injections. These findings highlight how behavioral and biological disruptions reinforce one another, potentially explaining the persistence of adherence challenges, even in well-resourced clinical environments.

(g). Gender and Age Differences: Gender and age patterns revealed meaningful differences in both risk and resilience. Women in the study displayed somewhat higher overall adherence rates, particularly those who participated in supportive counseling or had consistent clinical contact. Women were also more likely to report past experiences of intimate partner violence and emotional abuse. In contrast, men showed higher rates of alcohol use and social isolation, which appears to undermine their follow-up consistency. Younger adults tended to miss fewer injections than older participants despite reporting higher alcohol intake, suggesting that greater social support and digital engagement may have buffered the effects of behavioral risks. Older participants often reported more chronic health issues and transportation barriers, which led to lower retention rates.

Table II summarizes the integrated patterns of risk observed in this cohort. Alcohol misuse, psychological distress, and interpersonal strain interacted to shape both behavioral and practical barriers to adherence. Participants experiencing multiple challenges, such as heavy drinking combined with depression or partner conflict, had the lowest rates of on-time injections. In contrast, those with access to flexible scheduling, reminder systems, and supportive counseling maintained higher adherence despite moderate stress levels. These findings illustrate how overlapping behavioral and social stressors influence PrEP continuity and underscore the value of integrated, supportive service models.

Table II. Summary of Analytic Domains and Measures [14], [15]

Domain	Measures collected	Operational definition	Use in analysis and interpretation
PrEP continuity (primary)	Scheduled vs. actual injection dates; appointment status	On-time injection = within ± 7 days of target (tested at ± 3 and ± 10 days)	Primary outcome; compared across behavioral, psychosocial, and structural factors
Alcohol-related disruption	Brief AUDIT index; items on oversleeping or forgetting after drinking	Low (0–2), Moderate (3–5), High (≥ 6); binary flag for disruption events	Stratified adherence rates and crude ORs for delays
Emotional distress	PHQ-9 and GAD-7 scores; suicidality item (past 2 weeks)	None/mild vs. moderate/severe; suicidality flagged (not analyzed)	Examined as an independent predictor and co-factor with alcohol use
Intimate partner violence (IPV) & safety	4-item IPV screen (fear, harm, coercion, humiliation); privacy concern item	Positive vs. negative IPV screen; privacy concern (yes/no)	Linked to lower on-time attendance and longer rescheduling delays
Structural access	Transport reliability, commute time, work flexibility, childcare responsibility	Reliable/sometimes/unreliable; flexible/limited/none	Modeled as additive barriers; informed practical recommendations (evening hours, transport aid)
PrEP modality/context	PrEP type (oral vs. injectable); clinic site	Binary modality; site indicator	Checked for site effects; described different adherence patterns
Biological correlates (subset)	IL-6, TNF-α, stool microbial diversity (Shannon index)	High vs. cohort median; diversity quartiles	Related to fatigue and tolerability in heavy drinkers with distress
Communication channel	Reminder method (text/call/portal); self-rescheduling option	Digital vs. call; self-serve rescheduling (yes/no)	Faster rescheduling with discreet digital reminders, especially among IPV-affected participants

Discussion

The findings of this study illustrate how behavioral health, social stressors, and structural barriers converge to affect HIV prevention outcomes in an urban U.S. population. Patterns observed in Jefferson County reflect what has been reported nationally: individuals who experience hazardous drinking, psychological distress, or intimate partner violence face substantial challenges in maintaining regular contact with preventive services. The observed link between alcohol-related disruption and delayed PrEP injections suggests that adherence depends more on daily life stability than motivation [15]. Consistent with prior evidence, alcohol misuse undermines medication adherence across health domains and heightens HIV risk through behavioral and physiological pathways. These findings further show how alcohol compromises the timing required for effective long-acting PrEP protection [16].

Similarly, depressive and anxiety symptoms were strongly correlated with non-adherence. Participants with moderate or severe depressive symptoms were twice as likely to miss scheduled injections, underscoring the role of mental health as a determinant of continuity of prevention. These findings mirror national reports showing that nearly half of the adults with depressive disorders have difficulty maintaining regular medical routines. Emotional exhaustion, hopelessness, and cognitive fatigue disrupt memory and time management, which are essential for PrEP adherence [16]. The co-occurrence of depression and alcohol use observed in this study is particularly concerning, as each factor reinforces the other, creating cycles of disengagement. The literature supports this intersection, showing that individuals who drink heavily are more likely to experience depressive symptoms, those with depression are more likely to use alcohol as a coping mechanism, and both patterns are often intensified by experiences of intimate partner violence, which amplify emotional distress and further undermine adherence and self-regulation [17]. HIV infection is often correlated with heightened vulnerability to other infectious and endemic diseases, such as tuberculosis, hepatitis, dengue, and influenza, owing to compromised immune function and overlapping social and environmental risk factors [18].

Adherence patterns in this cohort highlight the intertwined impact of interpersonal violence and structural strain on PrEP continuity. Participants reporting intimate partner violence (IPV) had nearly 20 percent lower on-time injection rates and twice the odds of missed visits, alongside higher prevalence of hazardous alcohol use (72% vs. 61%) and moderate-to-severe depression (56% vs. 42%) [19]. These findings suggest that emotional distress and social control jointly undermine engagement in preventive care. Structural challenges such as unreliable transportation, inflexible work schedules, and childcare demands further compounded delays, increasing the odds of missed appointments by 1.8 times. In contrast, clinics offering flexible scheduling and transport assistance achieved adherence rates exceeding 80 percent. Together, these results align with broader evidence that psychosocial instability and access barriers are critical determinants of HIV prevention outcomes [20]. Expanding trauma-informed services and practical supports within PrEP programs may therefore enhance continuity and equity in care.

Biological data from a subset of participants supported the behavioral results, showing that chronic alcohol use, psychological stress, opioid use, and exposure to violence had measurable physiological effects [21], [22]. Heavy drinkers with emotional distress exhibited higher inflammatory markers and lower microbial diversity, suggesting biological pathways linking stress and substance use to poorer health outcomes. Participants reporting both substances use and IPV showed greater fatigue and lower adherence, consistent with evidence that alcohol and drug use increase inflammation while trauma and depression disrupt immune balance [22], [23]. These findings emphasize the need for integrated HIV prevention models that address behavioral health, substance use, and violence together to sustain PrEP adherence.

Sex and age patterns in this study revealed distinct adherence challenges. Women showed higher overall adherence but faced greater exposure to violence and emotional distress, underscoring the need for trauma-informed and supportive counselling [24]. Men had lower adherence, commonly linked to heavy drinking and social isolation. Younger adults maintained better follow-up despite higher alcohol use, likely due to stronger peer networks and digital engagement, while older adults struggled with comorbidities and transportation barriers [25]. These findings highlight the importance of tailoring PrEP interventions to demographic and psychosocial contexts rather than relying on uniform approaches.

Taken together, these findings show that adherence to PrEP reflects the combined influence of behavioral, psychosocial, and structural factors. Alcohol misuse, depression, and intimate partner violence interfere with the routines needed for consistent prevention, while access barriers intensify these effects. Quantitative results indicated that hazardous drinking and depressive symptoms increased the likelihood of delayed injections, and participants facing transport or scheduling difficulties were least likely to remain on time [25]. Biological data supported these observations, linking heavy drinking and emotional distress to higher inflammation and lower microbial diversity. Gender and age differences revealed distinct vulnerability patterns, emphasizing the importance of tailored support. Consistent with prior evidence [25], [26], these results highlight the need for trauma-informed and flexible PrEP programs that integrate mental health care, substance use support, and practical access solutions to improve adherence and continuity of protection.

This study has several limitations. The descriptive design precludes causal inference, and all reported associations should be interpreted with caution. Statistical limitations include the modest sample size, which reduced power for subgroup analysis and limited the precision of effect estimates. Potential biases stem from self-reported measures of alcohol use, mental health, and intimate partner violence, which are vulnerable to recall and social desirability effects. The study population was drawn from two urban clinics, limiting generalizability to other regions, and biological data were available for only a subset of participants. Although standardized instruments and cross-checks were used to ensure data quality, unmeasured contextual factors may still have influenced results.

Future studies should use longitudinal or mixed methods designs to examine how changes in alcohol use, emotional distress, and social stability influence adherence patterns over time. Larger and more diverse samples, including participants from rural and community-based settings, are needed to improve generalizability. Objective assessments of alcohol exposure and mental health through biomarkers or digital tracking could minimize reporting bias. Interventional research should evaluate integrated behavioral health and trauma-informed models, as well as flexible clinic schedules, to enhance continuity. Partnerships with community programs focused on violence prevention, housing, and substance use recovery may further strengthen engagement and retention in PrEP care.

Conclusion

This study demonstrates that continuity of long-acting PrEP is influenced not only by biomedical access but by the broader balance of behavioral health, emotional stability, and social safety. Alcohol misuse, depression, and interpersonal violence emerged as intertwined barriers that disrupt adherence and weaken preventive outcomes. Addressing these overlapping challenges requires moving beyond medication delivery toward integrated, trauma-informed systems of care. Strengthening links between mental health services, substance-use counseling, and flexible clinic operations could improve consistency and engagement. Future research should expand these findings through longitudinal and multi-site designs to examine how behavioral and structural conditions evolve over time and to test scalable, community-based strategies that support sustained adherence and equity in HIV prevention.

Acknowledgment

We express our sincere gratitude to Dr. R. Davidson for his continuous support and guidance.

Conflict of Interest

The authors declare that they have no conflicts of interest.