Pre-exposure prophylaxis (PrEP) indication and uptake among people receiving buprenorphine for the treatment of opioid use disorder

Perceptions of People Who Inject Drugs About Long-acting Medications for Opioid Use Disorder, Preexposure Prophylaxis, and Antiretroviral Therapy

Background

Long-acting injectable (LAI) forms of preexposure prophylaxis and antiretroviral therapy and extended-release medications for opioid use disorder (OUD) may reduce HIV and OUD treatment attrition, but community interest among people who inject drugs remains underexplored.

Methods

From September to December 2023, we conducted a cross-sectional survey of adults with OUD and a history of injection drug use who were attending a New Jersey syringe exchange program to assess their experiences with HIV and OUD care and their knowledge, attitudes, and preferences about LAI.

Results

Of 193 participants, 15 were persons with HIV (PWH), 72 were high risk for HIV (HRH), and 91 were low risk for HIV (LRH). Many participants had previously taken medications for OUD (60%), but knowledge of extended-release medications for OUD was low (40% PWH, 45.8% HRH, 41.6% LRH, P = .85). Participant interest in extended-release naltrexone (33.3% PWH, 27.8% HRH, 26.7% LRH, P = .91) and extended-release buprenorphine (33.3% PWH, 18.3% HRH, 20.9% LRH, P = .45) was also low. Preexposure prophylaxis knowledge was high (59.1% HRH, 63.9% LRH, P = .54), but prior usage (11.1% HRH, 6.7% LRH, P = .32) and interest (18.1% HRH, 21.1% LRH P = .63) in LAI preexposure prophylaxis were low. PWH had high awareness (66.7%) and interest (66.7%) in receiving LAI antiretroviral therapy. Interest in integrated care was greater for PWH (69.2%) than for those at HRH (29.8%) or LRH (33.9%; P = .03), and preferred treatment locations varied among the groups.

Conclusions

Targeted education and outreach are particularly needed for extended-release medications for OUD and LAI preexposure prophylaxis. A differentiated care model may better address the needs of people who inject drugs with OUD, whether at risk for or with HIV. Addressing barriers to LAI treatment remains essential.

Antiretroviral Drugs for Treatment and Prevention of HIV in Adults: 2024 Recommendations of the International Antiviral Society-USA Panel

Importance

New data and new antiretroviral drugs and formulations continue to become available for the prevention and management of HIV infection.

Objective

To provide updated recommendations for HIV treatment and clinical management and HIV prevention.

Methods

A panel of volunteer expert physician scientists were appointed to provide updated consensus recommendations for 2024. Relevant evidence in the literature since the last report was identified from PubMed and Embase searches (which initially yielded 3998 unique citations, of which 249 were considered relevant); from ongoing monitoring of the literature by the panel members; from data submitted by product manufacturers; and from studies presented at peer-reviewed scientific conferences between June 2022 and October 2024.

Findings

Antiretroviral therapy continues to be recommended for all individuals with HIV. For most people with HIV, initial regimens composed of an integrase strand transfer inhibitor (InSTI), specifically bictegravir or dolutegravir, with 2 (and in some cases 1) nucleoside or nucleotide reverse transcriptase inhibitors are recommended. Recommendations are made for those with particular clinical circumstances, such as pregnancy and active opportunistic diseases, as well as for those unable to take InSTIs. Regimens may need to be changed for virologic failure, adverse effects, convenience, or cost, among other reasons. Long-acting injectable therapy is available for those who prefer not to take daily oral medications and for people struggling with adherence to daily therapy. Recommendations are provided for laboratory monitoring, management of substance use disorders and weight changes, as well as use of statins for cardiovascular disease prevention. For HIV prevention, oral (daily or intermittent) and injectable long-acting medications are effective options for people at increased likelihood of HIV exposure. Further, new tools for maintaining health and well-being among people with HIV, such as doxycycline postexposure prophylaxis to avert sexually transmitted infection, and strategies to treat substance use disorders, are recommended. Disparities in HIV acquisition and care access are discussed and solutions proposed.

Conclusions

New approaches for treating and preventing HIV offer additional tools to help end the HIV epidemic, but achieving this goal depends on addressing disparities and inequities in access to care.

Facilitators and Barriers to Implementing HIV Testing and Pre-Exposure Prophylaxis in Substance Use Treatment Programs: Perspectives of Non-medical Staff

BACKGROUND

People with substance use disorder (SUD) are at increased risk of HIV infection. HIV testing and pre-exposure prophylaxis (PrEP) are evidence-based practices to prevent HIV infection, yet these approaches are not regularly provided in SUD treatment programs. To address this evidence-to-practice gap, this study aimed to identify facilitators and barriers to implementing PrEP services in SUD treatment programs from the perspective of non-medical staff and administrators.

METHODS

Semi-structured interviews were conducted from February to June 2022 with non-medical staff (N = 10) and administrators (N = 11) from 3 academic and 8 community-based SUD treatment programs in Philadelphia. Interview guides were developed using the Consolidated Framework for Implementation Research (CFIR). Qualitative descriptive techniques were used to examine interview data and identify key facilitators and barriers, which were grouped within CFIR domains and constructs.

RESULTS

Of the 11 SUD treatment programs, 5 provided PrEP services. Most interviewees at programs without PrEP services reported high levels of receptivity to implementing PrEP and identified leadership engagement as a key determinant, but several lacked comfort with PrEP counseling. Inner setting facilitators included compatibility with workflows (eg, intake assessments), alignment with cultures of holistic care, and programs' longstanding community trust. Inner setting barriers included limited time to discuss PrEP, insufficient resources and staff (eg, phlebotomy), perception of clients' HIV risk, and lower prioritization of HIV prevention versus other services. Intervention facilitators included robust evidence and addressing costs through grants and drug pricing programs, and barriers included the time needed to initiate PrEP, loss to follow-up, and HIV stigma.

CONCLUSIONS

Successful implementation of HIV testing and PrEP in SUD treatment programs requires addressing multi-level barriers. Including perspectives of non-medical staff and administrators is important for implementation. Potential strategies include supporting organizational networks, leveraging peer specialists' expertise, and packaging PrEP to better meet client priorities and needs.

Correlates of Transactional Sex Among Black Men and Women Who Misuse Opioids

The rise in opioid misuse coincides with increased sexually transmitted infection (STI) and HIV incidence. Transactional sex is an under-researched phenomenon among Black Americans who misuse opioids, and may increase their risk of STI or HIV transmission. Given the disproportionate impact of the opioid epidemic on Black Americans and the risks associated with opioid misuse, the current study aims to investigate sociostructural factors, history of violence, and sexual risk factors associated with transactional sex among Black men and women. A sample of n = 375 Black adult Kentuckians reporting opioid misuse completed a survey including transactional sex, sociostructural, violence history, and sexual risk measures. Results of chi-squares and independent samples t-tests revealed that compared to men who did not report engaging in transactional sex, men who engaged in transactional sex were less educated, reported being sexually assaulted or having an unwanted sexual experience in their lifetime, and were more likely to use opioids or cocaine before or during sex in the last year. Women who engaged in transactional sex had a history of violence, more structural barriers, higher psychological distress, and engaged in more sexual risk behaviors compared to women who did not engage in transactional sex. Implications for future research and interventions with this population are discussed.

Community-Based Services for Hospitalized Patients With Serious Injection-Related Infections in Alabama: A Brief Report

Injection-related infections continue to rise, particularly in the South. People who inject drugs are increasingly utilizing hospital services for serious injection-related infections but may be discharged to areas without harm reduction services. We explored the availability and travel time to services for HIV and substance use in Alabama.

Facilitators and Barriers to PrEP Acceptability and Initiation Among Opioid Treatment Program Patients and Staff

The Centers for Disease Control and Prevention recommends PrEP (pre-exposure prophylaxis) for people who use drugs, yet uptake remains low. This study explores the acceptability and potential uptake of PrEP among participants in an opioid treatment program (OTP). We conducted 26 in-depth, semistructured interviews with staff and patients at an OTP in Baltimore, Maryland. Overall, participants felt that providing PrEP within the program would be beneficial, but they noted competing priorities among populations engaging in high-risk behaviors and lack of willingness among groups with lower risk behaviors. Participants reported several barriers to PrEP use among people who use drugs and who use medications for opioid use, including cost, competing priorities, stigma, and misconceptions about who should use PrEP. Facilitators to PrEP use were described as health benefits, trusted relationships with providers, and existing resources in the opioid treatment program. Practitioners should consider addressing barriers to access and stigma within an OTP setting for HIV prevention tools.

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

BACKGROUND

Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration.

METHODS

PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation.

RESULTS

Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles.

CONCLUSIONS

Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

PrEP and HIV prevention decision-making among social network members of women who have experienced incarceration: a qualitative study

ABSTRACTIncarceration and HIV are a syndemic for US women, yet very few women who have experienced incarceration use pre-exposure prophylaxis (PrEP) for HIV. We conducted semi-structured interviews with 32 participants recruited by women who have experienced incarceration from their social networks, informed by the modified social ecological model for PrEP. Emergent themes from the interviews included individual-level (low personal HIV risk assessment, personal responsibility for HIV prevention, and decisions in addiction versus recovery), network-level (influential sex partners and the importance of trust, supportive treatment peers, and high-risk but indifferent drug use networks), community-level (stigma, and mitigation of stigma in supportive substance use disorder treatment environments), and public policy-level (incarceration and PrEP cost and access) determinants. PrEP interventions for women who have experienced incarceration and their networks will need to incorporate contingency planning into HIV risk assessment, navigate complex network dynamics, and be situated in trusted contexts to address structural barriers.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel

Importance

Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice.

Objective

Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection.

Evidence Review

A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered.

Findings

Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential.

Conclusions and Relevance

Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.

Low Knowledge of HIV PrEP Within a Midwestern US Cohort of Persons who Inject Drugs

We interviewed persons who inject drugs (PWID) to understand perceptions of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Knowledge of PrEP was poor. Patients felt that PrEP was for sexual intercourse rather than injection drug use, and PWID managed on medications for opioid use disorder felt that they had no need for PrEP.