Improving Access and Acceptance of HIV PrEP for People Who Inject Drugs

Key Takeaways

Access and acceptability of PrEP among PWID can be increased by:

• Integrating PrEP with services that PWID are already aware of and/or connected to (eg, harm reduction/syringe services and substance use disorder treatment programs, peer-based training/education initiatives, healthcare for the homeless programs, and emergency departments)
• Staffing PrEP programs with people who are trusted by PWID and delivering PrEP in settings where patients feel respected, comfortable, and safe
• Tailoring prescribing practices and interventions (eg, same-day medication initiation, on-site pharmacies and/or medication storage, and intensive outreach and navigation) to support the care needs of PWID

People who inject drugs (PWID) are a priority for the National HIV/AIDS Strategy and Ending the HIV Epidemic initiatives, yet pre-exposure prophylaxis (PrEP) awareness and use among PWID remain low despite multiple injection drug use (IDU)–associated HIV outbreaks. This likely involves multiple factors including limited access to accurate information, personal risk perceptions, overlapping stigmas and provider bias/discrimination, competing priorities, insurance barriers, and limited engagement with traditional medical settings. Regardless, studies demonstrate that when PWID gain knowledge about PrEP and its availability, many are highly interested, especially in long-acting injectable PrEP. Qualitative research and implementation science efforts offer us a more nuanced, comprehensive, and much-needed understanding of facilitators to PrEP uptake among PWID. 

Among other key factors, 3 considerations may support increased access and acceptability. First, PrEP may be most successful when integrated with services that PWID are already aware of and/or connected to; this includes not only harm reduction/syringe services and substance use disorder treatment programs, but also peer-based training/education initiatives, healthcare for the homeless programs, and emergency departments. Second, PrEP programs should be staffed by people who are trusted by PWID and delivered in settings where patients feel respected, comfortable, and safe. Third, tailored prescribing practices and interventions such as same-day medication initiation, on-site pharmacies and/or medication storage, and intensive outreach and navigation (including transportation and/or phone access assistance) may help support care needs.

Best PrEP Option for PWID?
An encouraging shift is occurring with more focus placed on clinical approaches which are not only person centered, but also pragmatic. Which PrEP option is best for a person who injects drugs? Simply stated, it is probably the option that individual is most comfortable with and will take. As healthcare professionals, everyday habits we can develop are to listen more and avoid assumptions. We can open conversations with general questions such as, “Are you interested in medications that prevent HIV?” We can offer to share information on PrEP effectiveness, medication and dosing, possible adverse events, and recommended monitoring. Also, we can ask about what else could support someone’s overall HIV prevention and health goals and adapt to patients’ experiences and needs. For example, appointment scheduling flexibility may facilitate engagement.

We can also acknowledge the unknowns: PWID are consistently underrepresented in most PrEP research and programming, including the HPTN083 and HPTN084 trials examining efficacy of long-acting injectable cabotegravir. For healthcare professionals serving PWID with HIV, we can ask patients if they have partners who might be interested in PrEP. Services will look different depending on local resources and health systems; thus, community input on program design and implementation is invaluable. Marcus and colleagues found that PrEP use may increase primary care utilization, such that its benefits might include the prevention and treatment of additional infectious and chronic diseases and increased use of behavioral and mental health resources. July 2022 marks the 10-year milestone since initial FDA approval of emtricitabine/tenofovir disoproxil fumarate as PrEP. In my practice, the PWID I care for all acquired HIV before PrEP was available—with highly effective, long-acting agents now expanding our options, we have a collective opportunity to not only continue advancing innovation, but also to try and close the gaps where less attention has been placed.

Your Thoughts?
In your community, what strategy (or strategies) would be most useful in closing the gaps in PrEP access and acceptability among PWID? Join the discussion by posting a comment.