Patient and Provider Perspectives on a Novel, Low-Threshold HIV PrEP Program for People Who Inject Drugs Experiencing Homelessness

Abstract

Background HIV outbreaks among people who inject drugs (PWID) and experience homelessness are increasing across the USA. Despite high levels of need, multilevel barriers to accessing antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention persist for this population. The Boston Health Care for the Homeless Program (BHCHP) initiated a low-threshold, outreach-based program to support engagement in PrEP services among PWID experiencing homelessness. Methods To inform dissemination efforts, we explored patient and provider perspectives on key program components. From March to December 2020, we conducted semi-structured qualitative interviews with current and former BHCHP PrEP program participants and prescribers, patient navigators, and outreach workers (i.e., providers). Thematic analysis explored perspectives on key program components. Results Participants (n = 21) and providers (n = 11) identified the following five key components of BHCHP’s PrEP program that they perceived to be particularly helpful for supporting patient engagement in PrEP services: (1) community-driven PrEP education; (2) low-threshold, accessible programming including same-day PrEP prescribing; (3) tailored prescribing supports (e.g., on-site pharmacy, short-term prescriptions, medication storage); (4) intensive outreach and navigation; and (5) trusting, respectful patient-provider relationships. Discussion Findings suggest that more patient-centered services formed the basis of BHCHP’s innovative, successful PrEP program. While contextual challenges including competing public health emergencies and homeless encampment “sweeps” necessitate ongoing programmatic adaptations, lessons from BHCHP’s PrEP program can inform PrEP delivery in a range of community-based settings serving this population, including syringe service programs and shelters.

PrEP disclosure and discussions within social networks of people who inject drugs experiencing homelessness: a brief report

“…Four interviewers and a lead qualitative investigator developed a codebook collaboratively and iteratively [6]. We first independently read selected transcripts to develop potential codes and definitions.…”

“…Ongoing HIV transmission among PWID experiencing homelessness led BHCHP to develop a low-threshold program to increase PrEP access for their patient population [5]. Using data from qualitative interviews with a sample of BHCHP PrEP program participants [6], we conducted an initial exploration of the social experiences surrounding PrEP use among PWID experiencing homelessness. Although participants' median duration of PrEP use (six weeks) was relatively short, we found that, overall, most avoided disclosing their PrEP use widely in public or large group settings, but were much more willing to share their PrEP experiences with close social contacts such as friends and family members.…”

“…As detailed elsewhere [6], between March and December 2020, we conducted in-person qualitative interviews with current and former adult participants of BHCHP's PrEP program who were purposively sampled for diversity in socio-demographic characteristics and level of engagement in PrEP services. To recruit participants, BHCHP staff described the study during routine service encounters and, if interested, introduced participants to study personnel who were present via videoconferencing on tablet computers.…”

“…Due to COVID-19 protocols, we conducted virtual (videoconference) or in-person interviews, which lasted ~ 30 min and were audio-recorded for professional transcription, in private outdoor locations (e.g., picnic tables in the facility parking lot). We ceased recruiting and interviewing participants after deciding (through team discussion and preliminary codebook testing, described below) that that we had reached thematic saturation regarding our primary research question, pertaining to participants' experiences with BHCHP's PrEP program [6].…”

“…An evaluation of patient medical records from this program, which involves tailored PrEP education, patient navigation, same-day PrEP prescribing, short-term prescriptions, medication storage, and intensive adherence supports including street-based daily medication dosing, suggested that it effectively increased PrEP uptake and persistence [5]. To assess the acceptability of key components of this program, we conducted qualitative interviews exploring patients' experiences with the program and PrEP use more generally [6]. During these interviews, social experiences using PrEP (e.g., PrEP disclosure and discussions within their social networks) emerged as a key topic of importance to participants.…”