HIV Exposure Prophylaxis Delivery in a Low-barrier Substance Use Disorder Bridge Clinic during a Local HIV Outbreak at the Onset of the COVID-19 Pandemic

Abstract

Objectives: People who inject drugs (PWID) may experience high human immunodeficiency virus (HIV) risk and inadequate access to biomedical HIV prevention. Emerging data support integrating HIV post-exposure and pre-exposure prophylaxis (PEP, PrEP) into services already accessed by PWID. We describe PEP/PrEP eligibility and receipt in a low-barrier substance use disorder bridge clinic located in an area experiencing an HIV outbreak among PWID at the onset of the COVID-19 pandemic. Methods: Retrospective chart review of new patients at a substance use disorder bridge clinic in Boston, MA (January 15, 2020-May 15, 2020) to determine rates of PEP/PrEP eligibility and prescribing. Results: Among 204 unique HIV-negative patients, 85.7% were assessed for injection-related and 23.0% for sexual HIV risk behaviors. Overall, 55/204 (27.0%) met CDC criteria for HIV exposure prophylaxis, including 7/204 (3.4%) for PEP and 48/204 (23.5%) for PrEP. Four of 7 PEP-eligible patients were offered PEP and all 4 were prescribed PEP. Thirty-two of 48 PrEP eligible patients were offered PrEP, and 7/48 (14.6%) were prescribed PrEP. Additionally, 6 PWID were offered PrEP who lacked formal CDC criteria. Conclusions: Bridge clinics patients have high rates of PEP/PrEP eligibility. The majority of patients with identified eligibility were offered PEP/PrEP, suggesting that upstream interventions that increase HIV risk assessment may support programs in initiating PEP/PrEP care. Additional work is needed to understand why patients declined PEP/PrEP. PrEP offers to PWID who did not meet CDC criteria also suggested provider concern regarding the sensitivity of CDC criteria among PWID. Overall, bridge clinics offer a potential opportunity to increase biomedical HIV prevention service delivery.

Peer recovery coaching for comprehensive HIV, hepatitis C, and opioid use disorder management: The CHORUS pilot study

“…For example, a PrEP program at a community health center for people experiencing homelessness that provided directly observed therapy and flexible navigation tailored to the client's need achieved a PrEP retention rate of 44% after 6 months ( Biello et al., 2021 ). In the bridge clinic setting, our finding that 43% of PrEP-eligible patients were on PrEP compares favorably to prior clinic work showing 66% of eligible patients were offered and 14% prescribed PrEP, suggesting important synergy between PRC and the low-barrier clinical settings model ( Braun et al., 2022 ). The impact of the PRC intervention may be less robust in settings without resources designed to meet the clinical needs of PWID.…”

Substance use disorder bridge clinics: models, evidence, and future directions

“…In addition to MOUD, bridge clinics generally offer pharmacotherapy for other types of SUD, such as naltrexone and acamprosate for alcohol use disorder, and some bridge clinics incorporate HIV, viral hepatitis, and bacterial sexually transmitted infection (STI) screening, treatment, and prevention services like HIV pre-and post-exposure prophylaxis (PrEP, PEP) to address unmet need [23,33]. On-site access to vaccines and commonly used antibiotics for STI treatment facilitates ready delivery of these services at the point of care.…”

“…In addition, bridge clinics also offer low-barrier STI, viral hepatitis, and HIV screening, treatment, and prevention, including point-of-care rapid HIV testing, PrEP, and PEP [33]. Some clinics also offer an array of wrap-around clinical services ranging from emergency contraception, long-acting reversible and injectable contraception, wound care, and interim primary care to support engagement and address unmet needs.…”

“…Finally, bridge clinic teams have identified ways in which national HIV PrEP guidelines fall short and highlighted the need for improved access to HIV rapid testing to reduce new HIV infections among PWID [33,34,40]. Bridge clinic patients have high rates of eligibility for HIV PEP and PrEP, and work at a bridge clinic in Boston, MA has demonstrated that PEP/PrEP delivery in a bridge clinic is feasible, though opportunities to standardize HIV risk assessments and increase PEP/PrEP uptake remain [33].…”

PrEP facilitators and barriers in substance use bridge clinics for women who engage in sex work and who use drugs

“…Bridge clinics have emerged as a model for transitional care that engages people who use drugs at risk of HIV, including WSWUD [ 22 ]. Some bridge clinics have the clinical infrastructures supportive of PrEP initiation, namely access to phlebotomy and providers with prescribing privileges [ 23 ]. Studies from a single Boston-based bridge clinic demonstrated successful PrEP initiation within this clinical setting [ 23 , 24 ].…”