"without Doing This, I Would Never Have Had the Tools to Self-Reflect": Qualitatively Exploring the Change Mechanisms of SBIRT on PrEP Users' Risky Alcohol Use

Background and Purpose: While the efficacy of PrEP in preventing HIV transmission is well-established, the intersection of PrEP use and alcohol consumption poses challenges that warrant a nuanced understanding. This research seeks to illuminate the intricate dynamics of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in this specific healthcare context, contributing valuable insights to the integration of harm reduction strategies and furthering our ability to reduce barriers to PrEP uptake and adherence, essential to efforts to expand care and prevention strategically to those who need it most. This study qualitatively explores and describes the mechanisms underlying SBIRT for individuals using Pre-Exposure Prophylaxis (PrEP) engaged in moderate to high-risk alcohol consumption.

Methods: Our interdisciplinary study (medicine, public health, and social work), employed a qualitative research design, utilizing findings from in-depth interviews with ten oral-PrEP users engaged in moderate to high-risk alcohol use, as identified by the Alcohol Use Disorders Identification Test (AUDIT). Thematic analysis was applied to delve into their experiences, perceptions, and behavioral patterns related to PrEP adherence and alcohol use within the context of the SBIRT intervention. We recruited a diverse sample of participants from three healthcare settings (infectious disease, internal medicine, and behavioral health) in a southeastern U.S. state, emphasizing demographic characteristics, including age, gender identity, sexual orientation, and socio-economic status.

Findings: Findings highlighted emergent themes related to the impact of SBIRT on PrEP users engaged in moderate to high-risk alcohol use. Key elements were the effectiveness of screening tools, the appropriateness of brief interventions, and the referral process. Specific mechanisms that produced change responses in participants were weighing the pros and cons of behaviors, engaging in a decisional balance, connecting behaviors to personal motivation to change, and goal setting. The participants reflected that the Brief Intervention (BI) phase of SBIRT was particularly helpful, as attention was given to participant change talk, which was conducted in a spirit of collaboration, compassion, curiosity, and goal orientation.

Conclusion and Implications: This research contributes to the growing body of knowledge surrounding the integration of harm reduction strategies, specifically SBIRT, for PrEP users navigating moderate to high-risk alcohol use. By uncovering the behavior change mechanisms of SBIRT, our findings inform healthcare practitioners, policymakers, and researchers, guiding the development of interventions that enhance the overall well-being of individuals at disproportionate risk of HIV acquisition using a harm reduction approach. Ultimately, this work aligns with the broader goal of optimizing social work and public health strategies to address the complex intersectionality of HIV prevention and substance use.