Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs

Abstract

BackgroundAntiretroviral pre-exposure prophylaxis (PrEP) is clinically efficacious and recommended for HIV prevention among people who inject drugs (PWID), but uptake remains low and intervention needs are understudied. To inform the development of PrEP interventions for PWID, we conducted a qualitative study in the Northeastern USA, a region where recent clusters of new HIV infections have been attributed to injection drug use.MethodsWe conducted qualitative interviews with 33 HIV-uninfected PWID (hereafter, “participants”) and 12 clinical and social service providers (professional “key informants”) in Boston, MA, and Providence, RI, in 2017. Trained interviewers used semi-structured interviews to explore PrEP acceptability and perceived barriers to use. Thematic analysis of coded data identified multilevel barriers to PrEP use among PWID and related intervention strategies.ResultsAmong PWID participants (n = 33, 55% male), interest in PrEP was high, but both participants and professional key informants (n = 12) described barriers to PrEP utilization that occurred at one or more socioecological levels. Individual-level barriers included low PrEP knowledge and limited HIV risk perception, concerns about PrEP side effects, and competing health priorities and needs due to drug use and dependence. Interpersonal-level barriers included negative experiences with healthcare providers and HIV-related stigma within social networks. Clinical barriers included poor infrastructure and capacity for PrEP delivery to PWID, and structural barriers related to homelessness, criminal justice system involvement, and lack of money or identification to get prescriptions. Participants and key informants provided some suggestions for strategies to address these multilevel barriers and better facilitate PrEP delivery to PWID.ConclusionsIn addition to some of the facilitators of PrEP use identified by participants and key informants, we drew on our key findings and behavioral change theory to propose additional intervention targets. In particular, to help address the multilevel barriers to PrEP uptake and adherence, we discuss ways that interventions could target information, self-regulation and self-efficacy, social support, and environmental change. PrEP is clinically efficacious and has been recommended for PWID; thus, development and testing of strategies to improve PrEP delivery to this high-risk and socially marginalized population are needed.

Interest in linkage to PrEP among people who inject drugs accessing syringe services; Miami, Florida

“…cost) that have been documented in MSM populations [31,32]. Other studies support high acceptability of PrEP among PWID but note competing health priorities, including substance use disorders and need for treatment, as impediments to PrEP engagement [35].…”

Barriers to the Wider Use of Pre-exposure Prophylaxis in the United States: A Narrative Review

“…Of note, the disparity in PrEP clinic density in Southern USA also contradicts need in terms of underrepresentation in areas with lower income, higher Black and Latinx/Hispanic populations, and less insurance coverage [82]. Another barrier to PrEP access at the healthcare system level is limited delivery of PrEP to difficult-to-reach populations, such as PWID and homeless individuals, on account of inadequate infrastructure, which will need to be addressed through innovative strategies [83,84].…”

“…Negative experiences with healthcare providers was identified as a barrier to PrEP use [84] Age b Cross-sectional data from an ongoing cohort study of young sexual-minority men in New York City (N = 492)…”

“…Factors associated with starting PrEP included being Latina, recent STI, more concern over HIV, and a higher belief in PrEP effectiveness [ 159 ] Interview of women from six cities in the USA ( N = 89) Few HIV-negative women expressed an interest in PrEP because they did not consider themselves as at risk for HIV [ 173 ] Cross-sectional survey of HIV-negative cis women involved in the criminal justice system ( N = 125) Only 17% of PrEP-eligible participants perceived themselves to be at risk for HIV [ 37 ] Interview of women experiencing intimate partner violence ( N = 26) Potential barriers to PrEP use included low risk perception [ 35 ] Philadelphia residents undergoing rapid HIV testing (90% Black) ( N = 5606) Investigators categorized 71.6% of men and 60% of women as moderate/high risk; only 56.8% of men and 8.3% of women perceived themselves to be high/moderate risk [ 34 ] Race/ethnicity Survey of Black individuals in the USA ( N = 855) Among individuals at high risk, self-perceived risk was low in 65%, and only 35% would be willing to use PrEP. Those who saw a healthcare provider less frequently were less willing to use PrEP [ 162 ] Survey of individuals undergoing rapid HIV testing in Philadelphia ( N = 5606), the majority of whom were Black (90%) A large proportion of individuals at moderate or high risk for HIV infection did not perceive themselves to be at high risk [ 34 ] History of substance abuse Interview of HIV-negative PWID in Boston and Providence ( N = 33) Individual-level barriers to PrEP use included limited HIV risk perception [ 84 ] Interview of clinical and social service providers from Massachusetts and Rhode Island ( N = 18) who work with PWID Informants expressed concerns relating to low HIV risk perception among PWID [ 83 ] …”

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

“…Given that outreach efforts to expand PrEP awareness have not included PWID as much as other groups, and as a result non-GB PWID may not view PrEP as a treatment for themselves, we suggest that GB male PWID may have received information about PrEP through gay networks. Past research with PWID found that PWID viewed PrEP for MSM, not for PWID (Bazzi et al, 2018;Biello et al, 2018). We suggest that GB male PWID, given the important intersection of both injection drug use and sexual identity, may function as bridges for the wider diffusion of PrEP among and through PWID social networks (Rogers, 2010;Valente, 1995).…”