Title: The relationship of PrEP beliefs to perceived personal, interpersonal and structural
benefits and barriers to PrEP use in women who inject drugs
Version: 1 Date: 31 Oct 2022
Reviewer's report:
This paper evaluates the association of PrEP beliefs and perceived barriers and facilitators to
PrEP access and uptake among WWID. Overall, the manuscript is well-written, and the methods
are clear. There are, however, considerable limitations to the analyses and how that affects the
interpretation of the findings. I outline these concerns in my comments below.
Introduction
Lines 66-76: This paragraph is a bit misleading as the authors indicate that “little is known about
how specific barriers might impact PrEP uptake or how perceived barriers that drive disinterest
in PrEP use are related to the decision-making process.” Prior studies have outlined specific
factors that influence PrEP uptake, adherence, and retention among WWID including sexual
violence, economic insecurity, housing instability, and syringe service program accessibility.
Furthermore, additional work has characterized the dynamic nature of WWID’s decision-
making process for PrEP and how women choose to adhere to PrEP depending on periods of
higher (e.g., sex work) vs. lower (abstinence from drug use) perceived HIV risk. I recommend
reading works from Felsher et al (https://doi.org/10.1016/j.socscimed.2021.113809) and Roth
et al (http://doi.org/10.1097/QAI.0000000000002558) to better inform the background section.
Methods
Additional information is needed to understand how the sociodemographic characteristics,
sexual behaviors, drug use, and perceived risk, HIV/PrEP knowledge, PrEP intention is
operationalized in the study. For instance, perceived risk, knowledge, and intention were all
measures based on scales, and I’m wondering how they were calculated in the analyses.
Furthermore, did the authors develop these scales or did the abstract them from the literature.
Furthermore, it seems that the authors used ANOVA to evaluate associations between PrEP
beliefs with each item related to perceived PrEP benefits and barriers. I recommend explicitly
stating this in their analysis because I assumed that the authors may have summed/multiplied
across the items for each scale.
Lastly, how did the authors handle missing data? Were there any missing data, and if so, how
much?
Results
The results are clearly reported.
Discussion
I am concerned that the authors may have overstated the utility of their findings given the
limitations of their analysis. These limitations include the descriptive nature of the study,
arbitrary cutoffs of their PrEP belief scale, and no adjustments for potential confounders in their
analysis. Yet, the authors make the very strong conclusion that “beliefs alone might have an
impact on PrEP intent” and “correcting for inaccurate beliefs might be an easy intervention
target to encourage PrEP use.” While the study findings suggest that WWID with “inaccurate
PrEP beliefs” may have lower PrEP intentions, it does not support the conclusion that changing
PrEP beliefs will affect PrEP use. Prior research suggests that the mechanisms for increasing
intention and actual PrEP use may be different because of the contextual factors that may
influence real-life PrEP use and not hypothetical scenarios. Therefore, the authors’ extrapolation
that improving PrEP beliefs may affect PrEP use is a bit misleading.
I also think it’s quite difficult for the authors to make such strong assertions in their discussion
when they have not grounded their work within a conceptual framework. Therefore, the analytic
choices and interpretation of their findings is a bit dubious. In particular, to conclude that
WWID with inaccurate PrEP beliefs are more likely to perceive structural and psychosocial
barriers, and experience “psychological issues” implicitly suggests a specific directionality of
the association, that is WWID will experience these barriers if they have inaccurate PrEP
beliefs. This interpretation, as we have seen from the data, is not accurate. These factors
can restrict PrEP knowledge, awareness, and access among WWID, and in turn, potentially
increase inaccurate PrEP beliefs. Thus, interventions that address inaccurate beliefs will unlikely
change the individual, interpersonal, and structural barriers experienced by WWID; however,
addressing these multilevel barriers may improve PrEP beliefs among WWID.
Overall, I recommend that the authors reframe their paper as a descriptive study for generating
potential hypotheses and avoid such strong interpretation from their data.
Terminology throughout the paper
I think there are a few terms that the author might consider changing to avoid stigmatizing
language. First, consider changing “injectors” to people who inject drugs. Second, the authors
also used “female” throughout the manuscript; however, this term is specific to sex assigned
at birth and does not consider gender identity. Therefore, I recommend that the authors clarify
if gender identity was captured, and if it was, add it to the results. Finally, the authors might
consider removing jargons such as “trichotomized” and replace it with “categorized”.