"PrEP just isn't my priority": Adherence challenges among women who inject drugs participating in a pre-exposure prophylaxis (PrEP) demonstration project in Philadelphia, PA USA

Oral pre-exposure prophylaxis (PrEP) receipt and persistence among opioid-dependent people who inject drugs initiating PrEP for HIV prevention

BACKGROUND

The opioid crisis in the United States has led to climbing overdose rates, alongside HIV outbreaks among people who inject drugs (PWID). One area of the pre-exposure prophylaxis (PrEP) cascade that has received little attention is the persistence of PrEP, especially among PWID. To address this gap, this study examined the receipt, persistence, and factors associated with PrEP persistence among opioid-dependent PWID.

METHODS

Between December 2020 and July 2022, we enrolled 100 opioid-dependent PWID. Eligible participants received a 90-day PrEP prescription from a community-based syringe services program and were followed up at 3 and 6 months. We assessed sociodemographic characteristics, PrEP use, and behaviors related to sex and drug use. We evaluated persistence on PrEP by calculating how many times each participant continued to pick up their PrEP prescription. To identify factors associated with persistence on PrEP, we used a multivariable ordinal logistic regression.

RESULTS

On average, participants were in their early 40s (mean age: 44.5, SD: 10.0 years), male (63.0 %), and unemployed (89.0 %). The majority (64.0 %) reported injecting drugs at least once per week in the past month, and 79.0 % had never used PrEP before. A total of 60 participants picked-up PrEP at least once during the 6-month follow-up period, with 42 (70.0 %) retrieving it only once, 16 (26.7 %) twice, and 2 (3.3 %) picking it up three times. In the multivariable model, unemployment (aOR = 7.819; 95 % CI: 1.538-39.751) and prior PrEP use (aOR = 3.381; 95 % CI: 1.210-9.443) were associated with higher persistence on PrEP, whereas participants who injected drugs once a week or less (aOR = 0.039; 95 % CI: 0.008-0.182) or more than once a week in the past month (aOR = 0.098; 95 % CI: 0.029-0.329) were less likely to consistently retrieve PrEP.

CONCLUSIONS

Despite a high willingness to use PrEP among opioid-dependent, PrEP-naïve PWID in general, the adoption and persistence of PrEP were low in this study. Given that PWID represent a marginalized group at significant risk for HIV, these findings highlight the urgent need for comprehensive strategies to enhance the PrEP continuum of care by addressing the unique and diverse needs of this subgroup.

PrEP Awareness, Interest, and Use among Women Who Inject Drugs in Seattle, Washington: A Mixed Methods Study

Women who inject drugs (WWID) are disproportionately affected by HIV and experience multiple barriers to PrEP use. We conducted a mixed methods study to assess PrEP awareness, interest, and use, and determinants of PrEP utilization among WWID at three community sites in Seattle, Washington from March-May 2023. Participants were ≥ 18 years old, spoke English, identified as women, had a history of injecting drugs, and self-reported a negative or unknown HIV status. We describe survey participant characteristics (n = 30) by PrEP candidacy based on behaviors associated with HIV acquisition. We concurrently recruited 16 WWID for semi-structured interviews, which were analyzed using the Rapid Assessment Process. Survey and interview data were triangulated to enhance interpretations. Among 30 WWID, 25 (83%) were PrEP candidates, of whom 19 (76%) had heard about PrEP; only 2 (8%) were currently using PrEP. Among PrEP candidates, 13 (57%) reported interest in daily oral PrEP and almost half (n = 12, 48%) reported interest in injectable PrEP. Qualitative data revealed cursory PrEP knowledge and a strong interest in daily oral and injectable PrEP among those who perceived they were at risk for HIV. Several barriers to PrEP use were noted including housing instability, adherence challenges, limited perceived risk, and competing priorities like safety and substance use. While most WWID were aware of PrEP, qualitative data suggested significant misconceptions about PrEP, and many described complex, intersecting barriers to use. Our findings highlight the need for increased low-barrier, population-specific interventions to improve uptake and sustained use of PrEP among WWID.

HIV Prevention in Syringe Service Programs Since the Start of COVID-19: Where Do We Go From Here?

PURPOSE

This narrative review addresses post-2020, specific, complex challenges for use of and adherence to pre-exposure prophylaxis (PrEP) for HIV prevention among out-of-treatment people who use drugs (PWUD) at syringe services programs (SSPs).

RECENT FINDINGS

The COVID-19 pandemic and its associated changes to the provision of healthcare have significantly impacted HIV prevention, especially for PWUD. Through a synthesis of literature and clinical experience, we (1) characterize the operational changes imposed by the pandemic on SSPs that shaped the current HIV prevention landscape; (2) describe three levels of current challenges for PWUD, including consumer attitudes, non-medical and medical provider attitudes, and structural and scalability barriers; (3) characterize current models for PrEP in SSPs; and (4) offer practical recommendations for HIV prevention in harm reduction programs. PrEP is a highly effective prevention tool if taken as prescribed. It has been enthusiastically promoted by members of the research, public health and provider communities. Despite its efficacy, PWUD struggle to engage with the PrEP care continuum. We highlight opportunities to advance HIV prevention for PWUD by enhancing tailored, whole-person approaches that may set aside PrEP in favor of other risk reduction routes. For most PWUD who receive services at SSPs, PrEP is a single tool and not realistic until other social and structural determinants of health are addressed.

Readiness to implement contingency management to promote PrEP initiation and adherence among people who inject drugs: results from a multi-site implementation survey

BACKGROUND

Contingency management (CM), an incentive-based intervention to encourage target behaviors, effectively promotes medication adherence. However, efforts to extend CM to HIV pre-exposure prophylaxis (PrEP) have been lacking. As part of a randomized clinical trial to promote HIV Prevention among people who inject drugs (PWID), we examined the readiness of staff in community-based organizations serving PWID to implement CM for PrEP uptake and adherence in this population.

METHODS

From April to August 2022, we conducted a survey of staff from four community-based organizations providing HIV testing, harm reduction, and outreach services in the northeastern United States. We assessed knowledge and attitudes regarding PrEP for PWID on five-point Likert scales (e.g., Poor to Excellent, Not at all to Extremely). Using a modified version of the Contingency Management Beliefs Questionnaire, we assessed the degree to which attitudes about CM for HIV prevention influenced interest in its adoption on a scale from "1-No influence at all" to "5-Very strong influence". We explored endorsement patterns, along with average values of individual items and subscale scores.

RESULTS

Among 271 staff invitations, 123 (45.4%) responded. The majority (88.6%) of respondents reported prior PrEP awareness, with a mean self-rated knowledge of 2.98 out of 5 (SD = 1.1). Attitudes towards PrEP, including its relevance to and importance for clients (both means = 4.3), efficacy (mean = 4.5), and safety (mean = 4.2), were positive. Items related to practicality and confidence in providing PrEP-related care had relatively lower ratings. Respondents endorsed influential generalized (mean = 2.1) and training-related (mean = 2.5) CM implementation barriers less frequently than positive attitudes towards CM (mean = 3.6). Staff favored adding CM to existing services (mean = 3.8), and highly endorsed it as "useful for targeting HIV prevention with PrEP" (mean = 3.7).

CONCLUSIONS

Respondents generally supported the use of CM to promote HIV prevention among PWID and favored adding it to their existing services. Though respondents understood the value of both PrEP and CM to support HIV prevention activities, findings corroborate research citing relative lack of knowledge and confidence regarding PrEP management among clients, potentially detracting from implementation readiness.

TRIAL REGISTRATION NUMBER

NCT04738825.

Centering autonomy and choice to support oral PrEP utilization among people who inject drugs: qualitative lessons from HPTN 094 INTEGRA

BACKGROUND

Oral Pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission. However, despite high rates of HIV risk behaviors among people who inject drugs (PWID), this population remains underserved by current HIV prevention efforts in the United States. To address this challenge, we conducted an in-depth exploration of perspectives on using oral PrEP among PWID engaged in the HIV Prevention Trials Network (HPTN) 094 INTEGRA Study.

METHODS

Guided by the Practical, Robust, Implementation, and Sustainability Model (PRISM), our qualitative study drew on semi-structured interviews conducted as part of the embedded implementation science evaluation of HPTN 094 INTEGRA. Seventy-seven PWID participants from five sites across New York City, Houston, Los Angeles, Philadelphia, and Washington DC were interviewed to assess intervention delivery, care access, and engagement sustainability. Audio files were transcribed verbatim and analyzed via an inductive and deductive thematic approach.

RESULTS

Most participants (n = 46, 59.7%) discussed oral PrEP during their interview, though not directly prompted. Participants discussing PrEP had a mean age of 41.6 years and were predominantly white (54.3%) and cisgender men (60.9%). Among these, 15 participants described using PrEP. All participants had facilitated access to oral PrEP. Yet, the choice to use PrEP was influenced by personal risk perceptions, (mis)information about PrEP, and external factors (i.e. housing, financial security), which, for some, limited the autonomy to use PrEP. Two key themes emerged among participants using PrEP: ease of access and perceptions of high HIV risk. Those not using PrEP described two themes: low risk perception and prioritizing more urgent needs. Among participants not using PrEP a subgroup commonly described ambivalent interest, PrEP knowledge gaps, and PrEP readiness (i.e., contemplation).

CONCLUSIONS

Qualitative findings highlight that facilitated PrEP access was insufficient to motivate use for many participants. Rather, PrEP decision-making process (i.e., choice) was linked to risk perception and individuals' capability to leverage PrEP as a resource based on their circumstances (i.e., autonomy). Participants' descriptions of the centrality of choice and autonomy for PrEP use underscore that ease of access is a necessary pre-condition, but person-centered interventions should also address housing, financial stability, and urgent medical conditions to promote PrEP utilization among PWID.

CLINICAL TRIAL REGISTRATION

NCT04804027.

Type 1 Human Immunodeficiency Virus (HIV-1) Incidence, Adherence, and Drug Resistance in Individuals Taking Daily Emtricitabine/Tenofovir Disoproxil Fumarate for HIV-1 Pre-exposure Prophylaxis: Pooled Analysis From 72 Global Studies

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (F/TDF) has high efficacy against HIV-1 acquisition. Seventy-two prospective studies of daily oral F/TDF PrEP were conducted to evaluate HIV-1 incidence, drug resistance, adherence, and bone and renal safety in diverse settings.

METHODS

HIV-1 incidence was calculated from incident HIV-1 diagnoses after PrEP initiation and within 60 days of discontinuation. Tenofovir concentrations in dried blood spots (DBS), drug resistance, and bone/renal safety indicators were evaluated in a subset of studies.

RESULTS

Among 17 274 participants, there were 101 cases with new HIV-1 diagnosis (.77 per 100 person-years; 95% confidence interval [CI]: .63-.94). In 78 cases with resistance data, 18 (23%) had M184I or V, 1 (1.3%) had K65R, and 3 (3.8%) had both mutations. In 54 cases with tenofovir concentration data from DBS, 45 (83.3%), 2 (3.7%), 6 (11.1%), and 1 (1.9%) had average adherence of <2, 2-3, 4-6, and ≥7 doses/wk, respectively, and the corresponding incidence was 3.9 (95% CI: 2.9-5.3), .24 (.060-.95), .27 (.12-.60), and .054 (.008-.38) per 100 person-years. Adherence was low in younger participants, Hispanic/Latinx and Black participants, cisgender women, and transgender women. Bone and renal adverse event incidence rates were 0.69 and 11.8 per 100 person-years, respectively, consistent with previous reports.

CONCLUSIONS

Leveraging the largest pooled analysis of global PrEP studies to date, we demonstrate that F/TDF is safe and highly effective, even with less than daily dosing, in diverse clinical settings, geographies, populations, and routes of HIV-1 exposure.

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.

Access to and acceptability of sexual and reproductive health, harm reduction and other essential health services among people who inject drugs in Durban, South Africa

BACKGROUND

People who inject drugs (PWID) are at risk of HIV acquisition. The number of PWID in South African cities is increasing, and in spite of an advanced HIV prevention and treatment programme, there are PWID who experience challenges accessing sexual and reproductive health (SRH) and HIV related services. Access to and acceptability of SRH and harm reduction services by PWID needs to be further understood and explored.

METHODS

In-depth interviews (IDIs) were conducted with 10 key stakeholders and 11 PWID, in Durban, South Africa. Interviews were transcribed and translated. Data were thematically analysed using Dedoose software.

RESULTS

Participants described stigma/discrimination from healthcare workers and other clients accessing services as barriers to accessing healthcare services. They were concerned about long waiting times at healthcare facilities because of possibilities of withdrawal, as well as lost opportunities to "hustle". Targeted, non-discriminatory services, as well as mobile clinics existed in the city. Non-governmental organisations reportedly worked together with the public sector, facilitating access to HIV and TB prevention and treatment services. There were also needle exchange programmes and a harm reduction clinic in the city. However, there was limited access to contraceptive and STI services. Although there was reportedly good access to HIV and TB and harm reduction services in the city of Durban, uptake was low.

CONCLUSIONS

The integration of services to enable PWID to access different services under one roof is critical. There is also a need to strengthen linkages between public and private healthcare, and ensure services are provided in a non-discriminatory environment. This will facilitate uptake and access to more comprehensive SRH and harm reduction services for PWID in Durban, South Africa.

A data-driven approach to implementing the HPTN 094 complex intervention INTEGRA in local communities

BACKGROUND

HIV burden in the US among people who inject drugs (PWID) is driven by overlapping syndemic factors such as co-occurring health needs and environmental factors that synergize to produce worse health outcomes among PWID. This includes stigma, poverty, and limited healthcare access (e.g. medication to treat/prevent HIV and for opioid use disorder [MOUD]). Health services to address these complex needs, when they exist, are rarely located in proximity to each other or to the PWID who need them. Given the shifting drug use landscapes and geographic heterogeneity in the US, we evaluate a data-driven approach to guide the delivery of such services to PWID in local communities.

METHODS

We used a hybrid, type I, embedded, mixed method, data-driven approach to identify and characterize viable implementation neighborhoods for the HPTN 094 complex intervention, delivering integrated MOUD and HIV treatment/prevention through a mobile unit to PWID across five US cities. Applying the PRISM framework, we triangulated geographic and observational pre-implementation phase data (epidemiological overdose and HIV surveillance data) with two years of implementation phase data (weekly ecological assessments, study protocol meetings) to characterize environmental factors that affected the viability of implementation neighborhoods over time and across diverse settings.

RESULTS

Neighborhood-level drug use and geographic diversity alongside shifting socio-political factors (policing, surveillance, gentrification) differentially affected the utility of epidemiological data in identifying viable implementation neighborhoods across sites. In sites where PWID are more geographically dispersed, proximity to structural factors such as public transportation and spaces where PWID reside played a role in determining suitable implementation sites. The utility of leveraging additional data from local overdose and housing response systems to identify viable implementation neighborhoods was mixed.

CONCLUSIONS

Our findings suggest that data-driven approaches provide a contextually relevant pragmatic strategy to guide the real-time implementation of integrated care models to better meet the needs of PWID and help inform the scale-up of such complex interventions. This work highlights the utility of implementation science methods that attend to the impact of local community environmental factors on the implementation of complex interventions to PWID across diverse drug use, sociopolitical, and geographic landscapes in the US.

TRIAL REGISTRATION

ClincalTrials.gov, Registration Number: NCT04804072 . Registered 18 February 2021.

Pre-exposure prophylaxis (PrEP) among people who use drugs: a qualitative scoping review of implementation determinants and change methods

Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States, particularly among people who use drugs (PWUD). PrEP research among PWUD is scarce, and the factors that impact implementation are largely unknown. Therefore, we conducted a scoping review of implementation determinants (i.e., barriers and facilitators), as well as the change methods (implementation strategies and adjunctive interventions) that have been evaluated to increase PrEP implementation and use among PWUD. We identified 32 peer-reviewed articles assessing determinants and five that evaluated change methods. Determinants were coded using the updated Consolidated Framework for Implementation Research (CFIR), which is an established framework to understand the multilevel barriers and facilitators associated with implementation. Findings indicate that most research was conducted among PrEP recipients (i.e., patients), focusing on awareness and willingness to use PrEP, with less focus on factors impacting clinicians and service delivery systems. Moreover, very few change methods have been evaluated to improve clinician adoption and adherence to CDC guidelines for PrEP provision and/or recipient uptake and adherence to PrEP. Future research is needed that focuses on factors impacting implementation from a clinician standpoint as well as innovative change methods to increase PrEP awareness, reach, adoption, and sustained adherence to guidelines. Implementation Science offers a wealth of knowledge to speed up the effort to end the HIV epidemic in the United States.

Barriers to HIV Pre-Exposure Prophylaxis Use Among Women in the US: A Systematic Literature Review

Introduction

The high acquisition rate of HIV infection among women in the United States is concerning. Despite the FDA approving the first pre-exposure prophylaxis (PrEP) drug in 2012, PrEP utilization remains significantly lower among women. This literature review aims to analyze the current body of research concerning HIV PrEP usage among women in the US.

Methods

A search of three medical databases was conducted. After the screening, 19 studies were selected for analysis. A risk of bias assessment was performed.

Results

A final set of records meeting the inclusion criteria (n=19) was included in the review for data collection and analysis. The study methodology for these research articles included interview-based designs (semi-structured and brief formats) in 1-on-1 meetings, focus groups, surveys, and retrospective data analysis. Participants' HIV risk characteristics were reported by way of sexual behavior, drug use, combined sexual behavior and drug use, and living in a high HIV rate neighborhood. Nineteen themes were identified and organized into three categories: (1) Common medication administration barriers, (2) PrEP-specific barriers, and (3) Situational barriers. The three most common themes reported by participants included a concern about side effects, low perceived risks of HIV, and lack of PrEP information. The CASP Qualitative Checklist and risk assessment summary showed acceptable validity among studies.

Discussion

This review identifies significant barriers hindering women's PrEP utilization, which would benefit from more prevalent stakeholder communication and education directed to at-risk populations. Inconsistently reported descriptive data on participants and the low patient populations make it difficult to generalize outcomes.

HIV preexposure prophylaxis and postexposure prophylaxis in women: a comprehensive guide for healthcare providers

Great disparities and inequities in the delivery and acceptance of human immunodeficiency virus (HIV) prevention exist globally among women. Various barriers, such as societal stigma, low perceived risk, relationship dynamics, and lack of education on routes of HIV transmission can cause low utilization in HIV preexposure prophylaxis (PrEP) adoption and use. In addition, socioeconomic and structural factors, such as financial burden, lack of provider knowledge and willingness to prescribe, absence of insurance coverage, and limited access to healthcare services are additional barriers to PrEP use among cisgender women. The goal of this review is to highlight current and prospective PrEP options, attitudes, and views of PrEP use among cisgender women and healthcare providers, and the role of PrEP in special populations of cisgender women.

State same-sex marriage policies and pre-exposure prophylaxis implementation among men who have sex with men in the United States

INTRODUCTION

More than 70% of new HIV diagnoses in the United States were among men who have sex with men (MSM) in 2019. Pre-exposure prophylaxis (PrEP) is a transformative innovation for reducing human immunodeficiency virus (HIV) infections. Structural stigma against sexual minorities, including in the form of state-level policies, may affect PrEP implementation. We evaluated whether lower structural stigma reflected by earlier year of state same-sex marriage legalization was associated with increased male PrEP prescriptions and male PrEP-to-need ratio (PnR), a ratio of PrEP prescriptions to new HIV diagnoses.

METHODS

We used 2012-2019 AIDSVu data on male PrEP prescriptions and male PnR in each US state and year. We used generalized estimating equations to evaluate the relationship between the timing of implementing state same-sex marriage policies and the outcomes of male PrEP prescriptions per 100,000 people and the male PnR. We adjusted for calendar year, Medicaid expansion and the political party of the governor in each state.

RESULTS

State implementation of same-sex marriage policies in earlier, relative to later, periods was associated with increases in the rate of male PrEP prescriptions and in the male PnR. Specifically, implementing state same-sex marriage policies between 2004 and 2011 and between 2012 and 2013 were each associated with greater rates of male PrEP prescriptions relative to implementing same-sex marriage policies between 2014 and 2015. Implementing state same-sex marriage policies between 2004 and 2011 as well as between 2012 and 2013 were both significantly associated with a greater male PnR relative to implementing same-sex marriage policies between 2014 and 2015. By 2019, the difference in male PrEP prescriptions was 137.9 (97.3-175.5) per 100,000 in states that implemented same-sex marriage in 2004-2011 and 27.2 (23.3-30.5) per 100,000 in states that implemented same-sex marriage from 2012 to 2013, relative to states that implemented same-sex marriage in 2014-2015.

CONCLUSIONS

Earlier implementation of state same-sex marriage policies was associated with greater rates of male PrEP prescriptions. Reducing state-level structural stigma may improve HIV prevention among MSM in the United States.

A Note on Preexposure Prophylaxis Preferences Among Women Who Inject Drugs

ABSTRACT

We informed women who inject drugs about different preexposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake.

Acceptability and Feasibility of a Mobile Phone Application to Support HIV Pre-exposure Prophylaxis Among Women with Opioid Use Disorder

Despite evidence supporting HIV pre-exposure prophylaxis (PrEP) effectiveness, very few women with opioid use disorder (OUD) take PrEP. Interventions that improve medication assisted treatment (MAT) uptake and adherence may also be beneficial for PrEP. The reSET-O mobile phone app is a component of the evidence-based Therapeutic Education System, which improves retention and abstinence for people with OUD. To better understand use of this mobile health tool as a support for PrEP among women with OUD, pre-implementation contextual inquiry is needed. Therefore, we set out to assess target user characteristics, implementation barriers, feasibility, and acceptability of reSET-O. We recruited women with OUD receiving care from a community-based organization in Philadelphia to complete semi-structured interviews. All participants were prescribed reSET-O. We interviewed 20 participants (average age 37 years; 70% white, 15% Hispanic, 5% Black) from 5/2021 to 2/2022. We used an integrated analysis approach combining modified grounded theory and implementation science constructs. Half reported recent injection drug use, and 6 were taking buprenorphine. Mental health symptoms were common, and half described engaging in transactional sex. The majority expressed strong interest in PrEP. Participants reported the app would be highly acceptable for PrEP and MAT adherence support, but only two redeemed the prescription. The most common barriers included phone and internet access. Our findings highlight potential implementation challenges for the use of such an app to support PrEP use in this population. Poor uptake of the app at follow-up indicates that initial prescription redemption is a major barrier to reSET-O implementation.

Barriers to Pre-Exposure Prophylaxis (PrEP) use for HIV: an integrative review

OBJECTIVES

to identify and synthesize scientific evidence on the barriers and difficulties for Pre-exposure Prophylaxis (PrEP) use and compliance for HIV.

METHODS

an integrative literature review, using the MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier and Scopus (Elsevier) databases.

RESULTS

all (100%) the articles included identified that PrEP users experience some type of structural barrier related to health services such as long distance from the units, suboptimal logistics for taking pills and professional resistance to prescribing PrEP. Furthermore, 63.21% identified social barriers, such as stigma about sexuality and HIV, in addition to individual barriers such as alcohol use, adverse effects, and concerns about long-term toxicity.

CONCLUSIONS

the barriers to PrEP use are multifactorial. Effective interventions are needed to support PrEP users in accessing, complying with, and retaining health services.

The relationship of PrEP beliefs to perceived personal, interpersonal and structural benefits and barriers to PrEP use in women who inject drugs

BACKGROUND

Women who inject drugs (WWID) have significant biological, behavioral, and gender-based barriers to accessing HIV prevention services, including Pre-Exposure Prophylaxis (PrEP) medication. Little is known about how beliefs about PrEP impact both perceived barriers and benefits of PrEP use and how they may be related to the decision-making process.

METHODS

Surveys were conducted with 100 female clients of a large syringe services program in Philadelphia, Pennsylvania. The sample was categorized into three groups based on mean PrEP beliefs scores using terciles: accurate beliefs, moderately accurate beliefs, and inaccurate beliefs. Oneway ANOVA tests were used to compare groups by perceived benefits and barriers to PrEP, drug use stigma, healthcare beliefs, patient self-advocacy, and intention to use PrEP.

RESULTS

Participants had a mean age of 39 years (SD 9.00), 66% reported being White, 74% finished high school, and 80% reported having been homeless within the past 6 months. Those with the most accurate PrEP beliefs reported highest intent to use PrEP and were more likely to agree that benefits of PrEP included it preventing HIV and helping them "feel in charge". Those with inaccurate beliefs were more likely to strongly agree that barriers, such as fear of reprisal from a partner, potential theft, or feeling they "might get HIV anyway", were reasons not to use PrEP.

CONCLUSIONS

Results indicate perceived personal, interpersonal and structural barriers to PrEP use are associated with accuracy of beliefs is, pointing to important intervention targets to increase uptake among WWID.

HIV awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study

Background

People who exchange sex for money, favors, goods or services, combat higher risk of acquiring sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Understanding barriers to STD and HIV related healthcare from the perspective of this stigmatized and marginalized community may improve access to sexual health services including pre-exposure prophylaxis (PrEP). 

Methods

We used community-partnered participatory and qualitative methods to conduct anonymous one-on-one interviews with people who exchange sex to understand their perspectives and experiences related to pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. We conducted twenty-two interviews and coded them to perform thematic analysis. 

Results

We identified five themes: (1) Appreciation of HIV risk and prevention strategies grew from information accumulated over time. (2) PrEP information came from a variety of sources with mixed messages and uncertain credibility. (3) Decision-making about use of PrEP was relative to other behavioral decisions regarding exchange sex. (4) The multi-step process of obtaining PrEP presented multiple potential barriers. (5) Healthcare providers were seen as powerful facilitators to PrEP utilization.

Conclusions

Our findings suggest that PrEP education and care needs to be made more relevant and accessible to individuals who exchange sex.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14235-0.

PrEP Familiarity, Interest, and Usage Among 364 Black and Hispanic Adults in Indiana

Pre-exposure prophylaxis, or PrEP, is a once-daily preventative prescription pill against HIV for adults or adolescents who have sex or inject drugs. PrEP may be especially useful among Black and Hispanic Americans, who are particularly at risk for HIV in the United States. In spite of this vulnerability, rates of PrEP use in Black and Hispanic communities are low. Here, we examined familiarity with, prior usage of, and future interest in PrEP among 364 Black and Hispanic Indiana residents. Indiana is an important context for this work, due to severe HIV outbreaks in the area over the last 8 years. Around half of all participants had never heard of PrEP, with Hispanic participants being less familiar than Black participants. Prior PrEP use was low, at around 10%, and was lower for Hispanic than Black participants. Around 21% of all participants reported interest in PrEP after learning of it in our study. Further, participants identified strategies that would make discussions about PrEP with a medical provider more comfortable. Black and Hispanic participants reported feeling the most comfortable with addressing PrEP usage with providers if: (a) the provider was the one who brought up the subject of PrEP, (b) there was written information available to the patient (i.e., brochures), and (c) the patient already knew they qualified for the prescription in terms of personal eligibility and insurance coverage. Additional provider and patient education, as well as openness on the part of the provider, can help to lessen the disparities associated with PrEP need and actual PrEP usage.

Limited Risk Compensation Among Women Who Inject Drugs: Results From the Project Sexual Health Equity Preexposure Prophylaxis Demonstration Study in Philadelphia

ABSTRACT

The impact of preexposure prophylaxis uptake on sexual and injection-related behaviors among women who inject drugs is poorly understood. Over 24 weeks, preexposure prophylaxis uptake among women who inject drugs was associated with increased sharing of injection equipment but not syringes and no changes in condomless sex, providing limited evidence of risk compensation in this vulnerable population.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

Pharmacy-Based Interventions to Increase Use of HIV Pre-exposure Prophylaxis in the United States: A Scoping Review

HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.

The HIV pre-exposure prophylaxis continuum of care among women who inject drugs: A systematic review

INTRODUCTION

People who inject drugs have a substantial risk for HIV infection, especially women who inject drugs (WWID). HIV pre-exposure prophylaxis (PrEP), a highly-effective HIV prevention drug, is uncommonly studied among WWID, and we aimed to synthesize existing knowledge across the full PrEP continuum of care in this population.

METHODS

We systematically searched for peer-reviewed literature in three electronic databases, conference abstracts from three major HIV conferences, and gray literature from relevant sources.Eligibility criteria included quantitative, qualitative or mixed-methods studies with primary data collection reporting a PrEP-related finding among WWID, and published in English or Spanish between 2012 and 2021. The initial search identified 2,809 citations, and 32 were included. Data on study characteristics and PrEP continuum of care were extracted, then data were analyzed in a narrative review.

RESULTS

Our search identified 2,809 studies; 32 met eligibility requirements. Overall, awareness, knowledge, and use of PrEP was low among WWID, although acceptability was high. Homelessness, sexual violence, unpredictability of drug use, and access to the healthcare system challenged PrEP usage and adherence. WWID were willing to share information on PrEP with other WWID, especially those at high-risk of HIV, such as sex workers.

CONCLUSIONS

To improve PrEP usage and engagement in care among WWID, PrEP services could be integrated within gender-responsive harm reduction and drug treatment services. Peer-based interventions can be used to improve awareness and knowledge of PrEP within this population. Further studies are needed on transgender WWID as well as PrEP retention and adherence among all WWID.

The Influence of PrEP-Related Stigma and Social Support on PrEP-Use Disclosure among Women Who Inject Drugs and Social Network Members

Pre-exposure prophylaxis (PrEP) is a promising but underutilized HIV prevention strategy for Women who Inject Drugs (WWID). Stigma and disclosure concerns have been key barriers to PrEP use among women in PrEP efficacy trials. Social support has been found to buffer against some PrEP stigma, though these factors have been largely unexplored among WWID. Investigating how WWID disclose PrEP use is important given evidence that disclosure is associated with higher adherence. We aimed to identify the impact of stigma and support on PrEP disclosure within social networks of WWID participating in a PrEP demonstration project in Philadelphia, PA, USA. PrEP-using WWID ≥ 18 years completed social network surveys. Generalized estimating equations were used to account for the correlation of network structure. Thirty-nine WWID (i.e. egos) named an average of 9.5 ± 3.3 network members (i.e. alters), for a total sample of 371 unique relationships. Egos disclosed their PrEP use to an average of 4.0 alters (SD = 2.8). Related to PrEP stigma, participants had 0.4 times decreased odds of PrEP disclosure with alters who would disapprove of them taking PrEP (95% CI: 0.1-0.9). Related to support, participants had 2.5 times higher odds of disclosure among peers who could provide PrEP advice (95% CI: 1.0-6.0). Interventions that increase social support and decrease stigma are pivotal for increasing PrEP use disclosure among WWID.