PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

Abstract

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Structural and community changes during COVID-19 and their effects on overdose precursors among rural people who use drugs: a mixed-methods analysis

“…For example, many participants did not know that naloxone was available from pharmacies without an individual prescription [ 73 ]. Similarly, past research on awareness about pre-exposure prophylaxis for HIV prevention has highlighted how stigmatizing drug use serves as a barrier to obtaining needed prevention information among people who use drugs [ 74 – 77 ]. Stigma may be a barrier to acquiring information about naloxone, which could translate into reduced access at pharmacies.…”

Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives

“…Consistent with other recent research ( 37 , 50 , 51 ), participants of all ages and genders reported experiences of enacted stigma and dignity attacks in multiple settings, which they associated with reduced engagement with healthcare and treatment. As noted by Walters et al ( 52 ), pervasive social exclusion is likely to play a large role in inequitable access to PrEP. Our findings resonate with recent research that has identified exclusion from safety as a driver of risk in marginalized populations ( 53 ) resulting from overt surveillance and discriminatory practices.…”

Participant perceptions on the acceptability and feasibility of a telemedicine-based HIV PrEP and buprenorphine/naloxone program embedded within syringe services programs: a qualitative descriptive evaluation

“…Despite approval by the US Food and Drug Administration in 2012, awareness [ 3 – 5 ] and use [ 4 – 6 ] of PrEP among PWID is currently limited, although PWID have reported interest in or willingness to use PrEP [ 5 – 8 ] or viewed it positively after learning about it [ 3 ]. Stigma [ 8 – 10 ], negative provider interactions [ 9 ], limited provider willingness to provide PrEP to PWID [ 11 ], difficulties in accessing healthcare [ 7 ], and costs/co-pays [ 6 , 7 ] have been identified as factors that may make it difficult for PWID to obtain PrEP care.…”

“…PWID have suggested or supported combining PrEP services with other PWID-related services, such as syringe services programs (SSPs) [ 7 , 8 , 10 ]. SSPs are programs that reduce PWID’s risk of acquiring HIV and other blood-borne infections, such as hepatitis C, by providing unused syringes and injection equipment, education, and referrals for testing and treatment [ 12 ].…”