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: 28 Nov 2022
Reviewer's report:
This analysis aimed to understand the relationship between inaccurate beliefs about PrEP and
perceived barriers and benefits of PrEP and how this may factor in the decision to use PrEP
among women who inject drugs. The authors found that women who had the most accurate
PrEP beliefs were more likely to report the intention to use PrEP if it was offered, and therefore
identified that improving PrEP knowledge (ie. "Correcting" inaccurate beliefs) could help
increase PrEP interest and uptake. The authors also suggest that their results highlight how
beliefs about PrEP are associated with other perceived barriers and benefits of PrEP on personal,
social and structural levels.
Overall, the aim of this analysis is pertinent but I have several concerns regarding the
construction of the survey.  The choice of items that are used to assess PrEP perceptions,
drug use stigma and barriers to accessing healthcare are somewhat problematic. In terms of
methodology, it would have been interesting to use or develop a conceptual framework to
describe the interaction between PrEP beliefs, barriers and benefits, and experience of stigma,
and access to healthcare and PrEP interest (see Turan et al 2017 (https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC5425866/) and Baral et al 2013 (https://bmcpublichealth.biomedcentral.com/
articles/10.1186/1471-2458-13-482).
The authors do not provide enough information to fully understand healthcare access for the
participants outside of the recruitment site or information regarding gender based violence which
are two major factors to understand access to health information and the ability to make their
own decisions on their health.
Background
1) Please specify what is meant by "priority accessible population" in the sentence "WWID are
not considered a priority accessible population for HIV prevention efforts." (Page 3, line 58).
2) I would have liked to see the authors develop the subject of gender based violence more in
the introduction. Also, the pertinence of this analysis is based on the fact that there are specific
barriers to HIV and risk reduction services for women who inject drugs but this is also not well
developed.
Methods
3) Please clarify if eligibility criteria "did not have HIV" is based on self report.
4) Please clarify if all participants have recent injection drug use.
5) Concerning the statistical analysis, I would suggest the (non-parametric) Kruskal-Wallis test
and report the medians + IQR, which is much better than the means + SD on 30 people.
6) It is not clear to me why two true statements about PrEP are mixed with other beliefs. The
inclusion of "I am more likely to take PrEP if I am being paid to take it " is also problematic in
this section as I would not consider this a "belief".
7) "PrEP is affordable" is considered in the "Benefits of using PrEP" however this is not a benefit.
8) Likewise certain statements in the "Barriers to using PrEP" are formulated as
"beliefs" ("taking PrEP would dull my high," "Taking PrEP would cause too many side
effects","Even if I take PrEP I might get HIV anyway"). To identify a barrier it would be more
appropriate to state "I am afraid of experiencing side effects" and "I don't believe [PrEP] works."
9) And again, in the section "Feelings about getting healthcare", are a mix of experience ("I
have had positive interactions with the staff") and feelings ("I feel doctors listen to me and do
not rush me").
10) In the Confidence about PrEP knowledge, it is again a mix (personal knowledge of PrEP,
knowledge about where to access to PrEP, and then where they would like more information).
Results
11) Table 2: there are no values # 0.01 so no need to put "**p # 0.01" in the legend.
12) Table 2: clarify if "condom use" is a yes/no response
13) Please clarify if you have any data on marriage/couple status, violence, experience of stigma
and discrimination, use of other risk reduction strategies (besides condom use, sharing needles).
Discussion
14) Authors should provide more evidence to support the claim "our results agree with other
contradicting studies that state relationship power imbalances, male partners' reaction , and
reliance on partner for survival outweigh this benefit" as there is little evidence presented in the
article to support this.
15) "Pertinent," "targeted" or "adapted" should be used instead of "persuasive" page 11 line 301.
16) The authors do not address the fact that all the participants were recruited at a center that
provides PrEP. More information is needed regarding the services provided, and how PrEP is
promoted at the center. It is surprising that the authors do not mention how the results could
improve the PrEP services at this center.