Abstract
BACKGROUND: Peripregnant women who use drugs and are involved in the criminal legal system (CLS) face elevated risks of human immunodeficiency virus (HIV) acquisition due to overlapping vulnerabilities, including sexual violence, structural instability, and limited access to preventive healthcare. The unique needs of this population are routinely overlooked in both clinical practice and research. This qualitative study explores peripregnant women's perspectives on HIV risk, attitudes toward pre-exposure prophylaxis (PrEP), and opportunities for PrEP programming in jail settings and during pregnancy. METHODS: We conducted semi-structured qualitative interviews with 27 women in Miami-Dade County who met the following criteria: (1) peripregnancy experience, (2) history of drug use and CLS involvement, and (3) HIV-negative status. Participants were recruited through community-based outreach. Data collection was grounded in trauma-informed methods and community partnership. Data were transcribed and examined through a reflexive thematic analysis, employing a general inductive methodology. Coding was performed through an iterative process by an interdisciplinary team with diverse backgrounds. RESULTS: There are five major themes: (1) perceptions of HIV risk and risk reduction strategies; (2) knowledge and attitudes toward PrEP; (3) preferences for PrEP delivery modalities; (4) PrEP programming in jail; and (5) perspectives on PrEP use during pregnancy. Women generally viewed PrEP positively, especially long-acting formulations like injectables and implantable devices (in development). However, they also expressed concerns about adherence, stigma, drug interactions, and fetal safety. Jail was identified as a key site for intervention, though participants emphasized the need for confidentiality and robust education. CONCLUSIONS: Findings underscore the urgency of designing patient-informed, context-responsive PrEP interventions that center the lived realities of CLS-involved peripregnant women who use drugs. Prioritizing long-acting PrEP options and integrating services into jail and community-based settings rooted in trauma-informed care and privacy protections can enhance uptake. These strategies are essential to reducing HIV incidence and advancing the goals of the Ending the HIV Epidemic (EHE) initiative.