Informing and promoting Shared decision making for HIV Prevention and Alcohol Reduction: Engaging Diverse Veterans to Refine and Pilot a Decision Aid (SHARE Study)

Preventing HIV transmission remains a critical public health priority, particularly among marginalized populations who experience disproportionately high rates of HIV infection. Unhealthy alcohol use is a well-established, modifiable risk factor that not only increases HIV acquisition risk but is also overrepresented among groups already facing health disparities, such as minoritized racial, ethnic, sexual orientation, and gender identity groups. Despite the availability of effective HIV prevention tools like pre-exposure prophylaxis (PrEP), few interventions address both unhealthy alcohol use and HIV prevention together, and significant gaps persist in PrEP knowledge, access, and uptake—especially among Veterans with unhealthy alcohol use. The SHARE Study aims to bridge these gaps by investigating how unhealthy alcohol use impacts PrEP initiation and persistence within the Veterans Health Administration (VA), a system recognized for its evidence-based care for alcohol use disorders but where PrEP implementation lags behind. The central research questions focus on understanding the patterns of PrEP care among Veterans with and without unhealthy alcohol use, identifying disparities across diverse subgroups, and determining how a tailored decision aid can promote shared decision-making for both HIV prevention and alcohol reduction in primary care settings. Employing a sequential mixed-methods approach, the research team will analyze data from approximately 1.9 million Veterans—capturing substantial representation from minoritized populations—using advanced natural language processing algorithms to accurately identify sexual and gender minority groups. Quantitative analyses will map variations in PrEP initiation and persistence across VA facilities and patient demographics, while qualitative work will draw on these findings to refine an existing, evidence-based decision aid. This decision aid, developed with prior support from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), will be iteratively improved and pilot-tested with input from a community advisory board to ensure its relevance and effectiveness for diverse Veterans. By integrating socioecological and implementation science frameworks, the project seeks to create a scalable, patient-centered intervention that facilitates informed, shared decision-making about both PrEP and alcohol reduction at the point of care. The significance of this work lies in its potential to address two intersecting health challenges—HIV risk and unhealthy alcohol use—within a population that stands to benefit substantially from tailored, equitable interventions. Ultimately, the SHARE Study is poised to inform clinical practice and policy by laying the groundwork for integrating multi-targeted decision aids into routine primary care, with the goal of advancing health equity and improving outcomes for Veterans at risk of HIV.