Alcohol-Related Disruptions in PrEP Continuity and Associated HIV and STI Vulnerabilities: An Umbrella Review
DOI:
https://doi.org/10.47672/ejhs.2805Keywords:
HIV Prevention, Pre-exposure Prophylaxis (PrEP), Alcohol Use, Adherence, Sexually Transmitted Infections (STIs), Umbrella ReviewAbstract
Purpose: Sustained adherence to pre-exposure prophylaxis (PrEP) is central to preventing HIV acquisition, yet real-world outcomes show persistent gaps, particularly among individuals who consume alcohol or experience overlapping psychosocial or structural vulnerabilities. This umbrella review synthesizes the current evidence on how alcohol use influences PrEP adherence, treatment continuity, and downstream HIV and sexually transmitted infection (STI) outcomes, with attention to population-specific patterns and indicators of clinical severity.
Materials and Methods: A comprehensive search of MEDLINE, Embase, Cochrane Library, PsycINFO, Scopus, and Web of Science identified systematic reviews and meta-analyses published from January 2006 through June 2025. Twenty-two reviews met eligibility criteria. Screening and extraction procedures were conducted in duplicate using Covidence and REDCap. Primary-study overlap was quantified through the Corrected Covered Area, and evidence strength was evaluated using heterogeneity indices, risk-of-bias assessments, and established umbrella review credibility metrics.
Findings: Across pooled analyses, high adherence consistently produced strong protection: maintaining dosing above approximately 70 percent reduced HIV acquisition by nearly 75 percent (RR ≈ 0.25–0.30). When adherence fell below 60 percent, protection diminished substantially (RR ≈ 0.95). Hazardous alcohol consumption was linked to a 25–35 percent reduction in adherence and nearly doubled the odds of discontinuation. Background STI burden remained high among PrEP users, with a mean baseline prevalence of 24 percent and incidence approaching 72 per 100 person-years. Structural barriers were pronounced: about 60 percent of providers lacked adequate PrEP knowledge, fewer than 35 percent had prescribing experience, and PrEP uptake among transgender and gender-diverse individuals remained under 10 percent.
Unique Contribution to Theory, Practice and Policy: Future research should use longitudinal and implementation-focused studies to clarify how alcohol use affects prevention outcomes, test integrated interventions combining counseling, mental-health care, and flexible PrEP delivery, and ensure inclusion of marginalized groups. Programs should also adopt digital tools, routine alcohol screening, and rapid-restart pathways to improve equitable, durable HIV prevention.
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