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In addition, each can pose difficulties for antiretroviral adherence among people living with <jats:styled-content style=\"fixed-case\">HIV<\/jats:styled-content>. Scant research has examined the associations of stimulant and heavy alcohol use with adherence to daily oral pre\u2010exposure prophylaxis (Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content>) among <jats:styled-content style=\"fixed-case\">MSM<\/jats:styled-content> and transgender women. To address this gap in the literature, we evaluated the hypothesis that stimulant use and binge drinking are prospectively associated with sub\u2010optimal Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> adherence.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We analysed data from participants in a nested case\u2010cohort in the <jats:styled-content style=\"fixed-case\">iPrE<\/jats:styled-content>x open label extension. Stimulant use (i.e. powder cocaine, crack\u2010cocaine, cocaine paste, methamphetamine, cathinone) and binge drinking (i.e. \u22655 drinks in a single day) in the last 30\u00a0days were assessed. Baseline urine was tested for stimulants using immunoassays to reduce misclassification. Sub\u2010optimal adherence was defined as tenofovir drug concentrations in dried blood spots less than 700\u00a0fmol per punch, indicative of less than four doses per week. We tested the prospective association of stimulant use and binge drinking with sub\u2010optimal adherence at the 4\u2010week follow\u2010up visit.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results and Discussion<\/jats:title><jats:p>Data from 330 participants were analysed. The majority of the participants were <jats:styled-content style=\"fixed-case\">MSM<\/jats:styled-content> (89%) with a median age at baseline of 29\u00a0years (interquartile range 24 to 39). Approximately 16% (52\/330) used stimulants and 22% (72\/330) reported binge drinking in the last 30\u00a0days. Stimulant users had fivefold greater odds of sub\u2010optimal Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> adherence compared to non\u2010users in adjusted analysis (adjusted odds ratio [<jats:styled-content style=\"fixed-case\">aOR<\/jats:styled-content>] 5.04; [95% CI 1.35 to 18.78]). Self\u2010reported binge drinking was not significantly associated with sub\u2010optimal adherence after adjusting for stimulant use and baseline confounders (<jats:styled-content style=\"fixed-case\">aOR<\/jats:styled-content> 1.16 [0.49 to 2.73]). Depressive symptoms, being transgender, and number of sex partners were also not significantly associated with sub\u2010optimal Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> adherence (<jats:italic>p\u00a0<\/jats:italic>&gt;<jats:italic>\u00a0<\/jats:italic>0.05).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Stimulant use is a risk factor for sub\u2010optimal Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> adherence in the month following Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> initiation. Comprehensive prevention approaches that reduce stimulant use may optimize Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> adherence. Creating adherence plans that specifically address Pr<jats:styled-content style=\"fixed-case\">EP<\/jats:styled-content> dosing in the context of ongoing stimulant use should also be considered.<\/jats:p><\/jats:sec>","DOI":"10.1002\/jia2.25103","type":"journal-article","created":{"date-parts":[[2018,4,5]],"date-time":"2018-04-05T23:37:34Z","timestamp":1522971454000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":64,"title":["Skating on thin ice: stimulant use and sub\u2010optimal adherence to <scp>HIV<\/scp> pre\u2010exposure prophylaxis"],"prefix":"10.1002","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8654-8445","authenticated-orcid":false,"given":"J Carlo","family":"Hojilla","sequence":"first","affiliation":[{"name":"University of California San Francisco San Francisco CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Vlahov","sequence":"additional","affiliation":[{"name":"Yale University West Haven CT USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David V","family":"Glidden","sequence":"additional","affiliation":[{"name":"University of California San Francisco San Francisco CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"K Rivet","family":"Amico","sequence":"additional","affiliation":[{"name":"University of Michigan Ann Arbor MI USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Megha","family":"Mehrotra","sequence":"additional","affiliation":[{"name":"University of California San Francisco San Francisco CA USA"},{"name":"J. 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