Ethics of HIV Pre-exposure Prophylaxis (PrEP) Implementation Research in Inpatient Psychiatry: A Qualitative Study of Patient Perspectives

People living with serious mental illness (PLSMI) experience disproportionately high HIV incidence, yet remain underrepresented in HIV prevention research. PLSMI are often excluded from pre-exposure prophylaxis (PrEP) interventions in acute care settings. Inpatient psychiatry units (IPUs) are a promising but unexplored venue for PrEP intervention. However, such research requires designs sensitive to privacy, autonomy, therapeutic misconception, and inflicted insight unique to this population. We conducted semi-structured, qualitative interviews with PLSMI recruited from an academic medical center IPU. Eligible participants were ≥ 18 years old, HIV-negative, met ≥ 1 CDC PrEP-eligibility criterion, and were within 72 h of discharge. Interviews explored five domains: acceptability of IPU-based PrEP research, autonomy and undue influence, dignity and privacy, potential for inflicted insight, and fairness of randomized designs. Transcripts were analyzed thematically. Participants (n = 30; mean age 30.4 years; 80% Black; 72% male) expressed acceptability of PrEP-related research on the IPU, describing participation as informative, engaging, and aligned with their recovery goals. Privacy emerged as a central concern due to the communal IPU environment. Autonomy was consistently emphasized; participants felt more empowered to refuse research than clinical activities, and very few feared consequences for refusal. Views on randomization were mixed: some endorsed its fairness, while others preferred need-based allocation. These findings offer foundational guidance for ethically grounded PrEP research in inpatient psychiatry. PLSMI viewed IPU-based PrEP research as acceptable and potentially beneficial, and identified clear ethical priorities. Future studies should prioritize privacy, reinforce voluntariness, and transparently explain randomization.