“Why not take that pill?”: A Mixed-Methods Study of Gender, Risk Perception, and PrEP Uptake Among Drug-Involved Heterosexual Couples Under Community Supervision

People under community supervision who use drugs face elevated HIV risk. This randomized controlled trial used a mixed-methods approach to examine PrEP acceptance among community-supervised men who use drugs and their female partners. The study evaluated PrEP willingness among participants (N = 394) randomized to either PACT (5-session couples' HIV intervention) or control (1-session HIV counseling). Qualitative interviews with 20 couples (n = 40) explored PrEP attitudes. The PACT group showed significantly higher intentions to use condoms with PrEP compared to controls (64% vs. 53%, p = 0.03). Female partners in the PACT intervention demonstrated stronger PrEP use intentions than females in the control (aOR = 2.85, p = 0.02). Qualitative findings revealed five key factors affecting PrEP acceptance: (1) partner infidelity concerns, (2) substance use and decision-making, (3) HIV acquisition fears, (4) low-risk perception despite objective risk factors, and (5) medical mistrust. Gender influences PrEP acceptance among criminal legal-involved couples. Effective interventions should address gender differences, risk perception disparities, and medical mistrust. TRIAL REGISTRATION: ClinicalTrials.gov NCT01690494 registered September 19, 2012.