Sexual Health Behaviors, PrEP Use, and Household Composition: Implications for YMSM in Foster Care

Background and Purpose: Young men who have sex with men (YMSM), particularly those with experience in foster care, face disproportionately high rates of HIV infection. Foster youth and those aging out of care often encounter unstable housing, limited adult guidance, and disrupted health care access, placing them at elevated risk for poor sexual health outcomes. While pre-exposure prophylaxis (PrEP) is a proven biomedical strategy for HIV prevention, little is known about how varying living situations—especially those outside traditional parental homes—influence PrEP awareness, uptake, and sexual risk-taking among YMSM. This study aimed to: (1) identify how living situations influence PrEP awareness and use, and (2) examine how these settings shape sexual risk behaviors, with a focus on implications for foster-involved youth.

Methods: Data were drawn from the Multilevel Influences on HIV and Substance Use in a YMSM Cohort (RADAR), Chicago Metropolitan Area (RADAR) study, a longitudinal cohort of 1,026 YMSM aged 16–29 in the Chicago metropolitan area. Key variables included living situation (e.g., with caregivers, independently, unstably housed), parental monitoring, PrEP awareness/use, and sexual risk behaviors (e.g., condomless anal sex). Multivariate logistic and linear regression models were used to analyze associations, controlling for race/ethnicity, age, and personality characteristics.

Results: Living situation significantly influenced both PrEP awareness and risk behaviors. YMSM living with caregivers or in structured environments reported greater awareness of PrEP but lower rates of current use, suggesting that while knowledge may be present, barriers such as stigma or fear of disclosure limit engagement. Higher parental monitoring was associated with reduced sexual risk-taking (β = -0.18, p = .01), yet this protective factor was less available to those with foster care experience or those living independently. Notably, YMSM living independently or in unstable housing—circumstances common among youth aging out of foster care—had higher odds of using PrEP (OR = 1.45, p = .03), but also reported more frequent risk behaviors.

Additionally, impulsivity and neuroticism moderated these patterns, with higher-risk personality profiles amplifying the likelihood of condomless sex and inconsistent PrEP adherence in youth without supportive adult figures. This highlights the intersection of psychological vulnerability, housing instability, and lack of caregiving as a compounding risk structure for foster youth.

Conclusions and Implications: These findings reveal a critical need to tailor HIV prevention strategies for YMSM in foster care and those transitioning to independence. While parental monitoring may offer a buffer against risk for youth in stable homes, foster youth often lack such protective supports. Programs targeting this population must prioritize not only PrEP access but also the development of trusted adult relationships, sexual health literacy, and housing stability. Policymakers and service providers should consider integrating PrEP navigation and behavioral health interventions into foster care systems, particularly during the aging-out process for queer youth, to close gaps in HIV prevention for this group.