Limited Knowledge and Mixed Interest in Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs

Abstract

People who inject drugs (PWID) experience sexual and injection-related HIV risks, but uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among PWID has been low. Improving PrEP uptake in this population will require understanding of PrEP knowledge and interest. In 2017, we conducted in-depth, semistructured interviews with HIV-uninfected PWID and key informants (PrEP and harm reduction providers) in the US Northeast. Thematic analysis of coded data explored PrEP knowledge and the factors that influence PrEP interest. Among PWID (n = 33), median age was 36 years, 55% were male, 67% were white, and 24% identified as Hispanic/Latino. Accurate PrEP knowledge among PWID was low, which key informants (n = 12) attributed to PrEP marketing focused on other risk populations, as well as healthcare providers' lack of time and unwillingness to discuss PrEP with PWID. There was a discrepancy between self-reported HIV risk behaviors, which were common, and HIV risk perceptions, which varied and strongly influenced PrEP interest. Most PWID and key informants thought that PrEP would be most beneficial for those who shared syringes, used discarded syringes, engaged in transactional sex, or were homeless. Improving uptake of PrEP for HIV prevention among high-risk PWID will require education to increase PrEP knowledge and addressing factors that negatively influence PrEP interest such as perceptions regarding low HIV risk and the process for obtaining PrEP. This may require specialized PrEP marketing and outreach efforts and improved capacity of healthcare providers to effectively assess HIV risk (and perceptions) and communicate the benefits of PrEP to at-risk PWID.

Healthcare practitioner experiences and willingness to prescribe pre-exposure prophylaxis in the US

“…Moreover, our findings suggest that practitioners might be more willing to prescribe PrEP as a best first clinical step for PWID than previously indicated [11,[14][15][16]. Practitioner specialty also mattered for the PWID case vignette, as internal and family medicine practitioners were twice as likely as infectious disease practitioners to view PrEP as an important first step for PWID.…”

“…Treating different priority groups also adds another layer of complexity to practitioner PrEP prescribing practices. For example, studies have found varying levels of confidence and willingness among practitioners to prescribe PrEP across patient groups, with practitioners expressing greater inclination to prescribe to MSM than to behaviorally vulnerable heterosexuals or PWID [14][15][16]. Moreover, routine risk assessments occur infrequently in primary care, which can influence practitioner prescribing of PrEP if patients are not assessed for HIV risk [11,17].…”

The role of syringe exchange programs and sexual identity in awareness of pre-exposure prophylaxis (PrEP) for male persons who inject drugs

“…Studies focusing on PrEP awareness among PWID have shown low rates of PrEP awareness (from 13% to 31%), indicating that PrEP awareness is a significant barrier to PrEP uptake among PWID (Kuo et al, 2016;Roth, Tran et al, 2018;Sherman et al, 2019;. The lack of PrEP awareness among PWID, in general, might be attributed to the fact that past campaigns about PrEP have mostly target MSM and were not accessible to many PWID, including some MSM-PWID who may identify as heterosexual (Bazzi et al, 2018). Another barrier to PrEP awareness among PWID could be a lack of willingness to prescribe PrEP to PWID by physicians (Adams & Balderson, 2016;Edelman et al, 2016).…”

“…Another barrier to PrEP awareness among PWID could be a lack of willingness to prescribe PrEP to PWID by physicians (Adams & Balderson, 2016;Edelman et al, 2016). The lack of willingness might be attributed to competing priorities for physicians, such as the need to treat a substance use disorders or other immediate health concerns, and/or drug use stigma, such as the belief that PWID cannot adhere to medications (Bazzi et al, 2018).…”

“I think everybody should take it if they’re doing drugs, doing heroin, or having sex for money”: A qualitative study exploring perceptions of pre-exposure prophylaxis among female participants in an opioid intervention court program

“…However, to maximize its prevention potential, PrEP uptake among sub-populations at risk of HIV acquisition is essential. Although PrEP utilization has grown substantially since its FDA approval in 2012, PrEP awareness and access, among women and PWID in particular, are low (11)(12)(13)(14)(15). Estimates indicate that nearly 170,000 women and 73,000 PWID are clinically eligible for PrEP (16); however, the medication is underutilized, speci cally among women (17), as PrEP coverage is three times as high among men relative to women (18).…”