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

Rapid initiation of antiretrovirals at a syringe services program for people with HIV who inject drugs

BACKGROUND

People who inject drugs (PWID) living with HIV are less likely to receive care at early disease stages and have low rates of viral suppression. This study examined the feasibility and acceptability of rapid antiretroviral therapy (ART) initiation among PWID with HIV at a syringe services program (SSP) and assessed retention in care after transition to a traditional HIV clinic.

PATIENTS/MATERIALS AND METHODS

A mixed-methods single-arm pilot study was conducted at an SSP in Miami, Florida. Participants with HIV viral load >200 copies/mL were immediately connected with an HIV care provider and received HIV care and peer navigation at the SSP for 6 months, then were transitioned to a traditional HIV clinic. Demographic data were abstracted from the SSP's administrative records. Laboratory assessments and qualitative interviews were conducted at 1, 3, 6, 9, and 12 months.

RESULTS

Sixty-nine percent, 70%, and 69% of participants were virally suppressed (<200 copies/mL) at 1, 3, and 6 months, respectively. Following transition to a traditional HIV clinic, viral suppression remained high at 74% and 79% at 9 and 12 months, respectively. Themes were identified on: 1) barriers to care in traditional HIV clinics, 2) the SSP as a 'safe haven', 3) benefits of the rapid ART initiation program, 4) acceptability of telehealth, and 5) persistent barriers to engaging in HIV care.

CONCLUSION

Rapid ART initiation for PWID at an SSP was acceptable and feasible and showed preliminary effectiveness in achieving HIV viral suppression and sustaining it after transition to a traditional HIV clinic.

Long-Acting Injectable Prep for People Who Inject Drugs at a Syringe Services Program: A Qualitative Acceptability and Feasibility Study

Although people who inject drugs (PWID) are at high risk of acquiring HIV, knowledge and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among this population remain low due to numerous psychosocial and structural barriers. Multiple implementation strategies have been proposed to address this gap, notably providing long-acting injectable (LAI) formulations of PrEP and offering PrEP at syringe services programs (SSPs). This qualitative study explores the acceptability and feasibility of offering LAI-PrEP for PWID at risk for HIV at Florida's first legal SSP. In-depth semi-structured interviews were conducted with PWID (n = 25) and healthcare providers (n = 5), and transcripts were analyzed using iterative thematic analysis. The provision of LAI-PrEP at the SSP was overwhelmingly acceptable to both PWID and providers, and specific advantages and disadvantages of LAI-PrEP compared to oral PrEP among this population were elucidated. Likewise, PWID and providers identified facilitators and barriers to offering LAI-PrEP at the SSP and proposed recommendations for implementation. Overall, this study adds to the growing evidence that provision of LAI-PrEP at SSPs is acceptable and feasible and holds promise in expanding access to and uptake of HIV prevention services among PWID.

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.

Patient and provider experiences with opioid use disorder care delivered via telehealth: A systematic mixed-studies review

INTRODUCTION

Since the onset of the COVID-19 pandemic and loosening of some opioid use disorder (OUD) treatment regulations in the U.S. and Canada, there has been a rapid rise in the use of telehealth for buprenorphine induction, maintenance, and counseling (tele-bupe). Previous reviews highlight that tele-bupe can expand access to OUD care and improve treatment retention, but none to date have synthesized patient and clinician experiences with and perceptions of this care.

OBJECTIVE

This review synthesized findings from quantitative, qualitative, and mixed-methods studies that examined patient and provider experiences with tele-bupe. We assessed the perceived effectiveness and acceptability of this treatment modality.

METHODS

Our systematic review followed PRISMA 2020 guidelines. In July 2023, we searched six databases using keywords 'telehealth AND opioid use disorder' (and related terms) for papers published in English. Papers were eligible for inclusion if they reported findings about patient or provider experiences. Two reviewers screened studies for inclusion; 40 studies were included. We used a data-based convergent synthesis design to extract and synthesize findings, and the Mixed-Methods Appraisal Tool to appraise studies.

RESULTS

Patients and providers hold generally positive views of tele-bupe and most support its continued use in some form, citing multiple benefits, including accessibility and convenience. Most studies also identified barriers to tele-bupe, including technological challenges. Patients and providers differed in how they thought telehealth affects the clinical relationship, with providers expressing more concern about rapport-building and patients stating that being in their own environments during visits facilitated comfort and openness. The findings also suggest that providers are conflicted about when and for whom tele-bupe is appropriate.

CONCLUSION

Overall, both patients and providers view tele-bupe favorably; however, providers are conflicted about the patients and situations for which it is appropriate, which may lead to inequities in who is offered this form of care.

Telehealth to increase healthcare access; perspectives of people who use drugs

BACKGROUND

People who use drugs (PWUD) often face restricted healthcare access despite their heightened healthcare needs. Factors such as stigma, mistrust of the healthcare system, competing priorities, and geographical barriers pose significant healthcare access challenges. Telehealth offers an innovative solution to expand healthcare access for better inclusion of underserved populations in healthcare. We aimed to explore PWUDs' perceptions of telehealth as a healthcare delivery modality.

METHODS

We utilized purposive sampling to recruit participants (N = 57) for nine focus group discussions (FGDs) in Athens, Greece. Eligibility criteria required participants to be at least 18 years, with current or prior injection drug use, and current internet access. The FGDs followed a semi-structured interview guide, were audio recorded, transcribed verbatim, translated into English, and de-identified. We applied thematic analysis to analyze FGD transcripts.

RESULTS

Participants' mean (standard deviation) age was 47.9 (8.9) years, 89.5% (51/57) were male, 91.2% (52/57) were of Greek origin, and 61.4% (35/57) had attended at least 10 years of school. Three main themes emerged from the FGDs: (1) high internet utilization for healthcare-related purposes among PWUD, (2) highlighting telehealth benefits despite access obstacles and PWUDs' concerns about diagnostic accuracy, and (3) approaches to overcome access obstacles and build digital trust. Participants extensively used the internet for healthcare-related processes, such as accessing healthcare information and scheduling provider appointments. Despite being telehealth-inexperienced, most participants expressed a strong willingness to embrace telehealth due to its perceived convenience, time-saving nature, and trusted digital environment. Some participants recognized that the inability to conduct physical examinations through telehealth reduces its diagnostic accuracy, while others expressed concerns about digital literacy and technological infrastructure accessibility. Most participants expressed a preference for video-based telehealth encounters over audio-only encounters. To build trust in telehealth and promote patient-centeredness, participants recommended an initial in-person visit, virtual eye contact during telehealth encounters, patient education, and partnerships with PWUD-supportive community organizations equipped with appropriate infrastructure.

CONCLUSIONS

PWUD frequently use the internet for health-related purposes and suggested several approaches to enhance virtual trust. Their insights and suggestions are practical guidance for policymakers seeking to enhance healthcare access for underserved populations through telehealth.

TRIAL REGISTRATION

NCT05794984.

Effectiveness of PrEPTECH: Findings From a 180-Day Randomized Controlled Trial of a Pre-Exposure Prophylaxis Telehealth Intervention

BACKGROUND

Telehealth approaches are increasingly being used to provide access to pre-exposure prophylaxis (PrEP), an effective but underused HIV prevention modality. This randomized controlled trial of PrEPTECH, a telehealth intervention for the provision of HIV PrEP, seeks to assess its effects on PrEP access.

METHODS

Young men who have sex with men and transgender women in Florida and California with an indication for PrEP were randomly assigned in a 1:1 allocation to receive access to PrEPTECH or a control condition, access to an online listing of PrEP resources in their communities. This intent-to-treat analysis used logistic and linear regression to compare self-reported PrEP initiation, use, and coverage between control and intervention arm participants at 90 days and 180 days of follow-up.

RESULTS

A total of 229 participants with a mean age of 23.7 years, 77.3% people of color enrolled in PrEPTECH. At 90 days, postbaseline initiation of PrEP was significantly higher among those in the PrEPTECH arm than among controls (odds ratio [OR]: 6.63, 95% confidence interval [CI]: 2.54 to 17.35), and this held true by 180 days post baseline. The count of sex acts for which participants were not protected by PrEP, PrEP adherence, and recent PrEP use at 180 days post baseline were not significantly different between the study arms.

CONCLUSIONS

Receiving access to a telehealth platform for PrEP access increased PrEP initiation in this cohort of young, predominantly non-White sexual and gender minorities. PrEP telehealth may be a worthy avenue for providing access to PrEP for these populations, but additional strategies may be needed to promote adherence and persistence of PrEP use.

Providing medication for opioid use disorder and HIV pre-exposure prophylaxis at syringe services programs via telemedicine: a pilot study

BACKGROUND

People who inject drugs (PWID) are at high risk for opioid overdose and infectious diseases including HIV. We piloted PARTNER UP, a telemedicine-based program to provide PWID with medication for opioid use disorder (MOUD) with buprenorphine/naloxone (bup/nx) and oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine through two syringe services programs (SSP) in North Carolina. We present overall results from this project, including participant retention rates and self-reported medication adherence.

METHODS

Study participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly until program end at month 6. Participants were asked to start both MOUD and PrEP at initiation but could choose to discontinue either at any point during the study. Demographics and health history including substance use, sexual behaviors, and prior use of MOUD/PrEP were collected at baseline. Follow-up surveys were conducted at 3- and 6-months to assess attitudes towards MOUD and PrEP, change in opioid use and sexual behaviors, and for self-reported medication adherence. Participant retention was measured by completion of visits; provider notes were used to assess whether the participant reported continuation of medication.

RESULTS

Overall, 17 persons were enrolled and started on both bup/nx and PrEP; the majority self-identified as white and male. At 3 months, 13 (76%) remained on study; 10 (77%) reported continuing with both MOUD and PrEP, 2 (15%) with bup/nx only, and 1 (8%) with PrEP only. At 6 months, 12 (71%) remained on study; 8 (67%) reported taking both bup/nx and PrEP, and 4 (33%) bup/nx only. Among survey participants, opioid use and HIV risk behaviors decreased. Nearly all reported taking bup/nx daily; however, self-reported daily adherence to PrEP was lower and declined over time. The most common reason for not continuing PrEP was feeling not at risk for acquiring HIV.

CONCLUSIONS

Our study results show that MOUD and PrEP can be successfully administered via telemedicine in SSPs. PrEP appears to be a lower priority for participants with decreased continuation and adherence. Low perception of HIV risk was a reason for not continuing PrEP, possibly mitigated by MOUD use. Future studies including helping identify PWID at highest need for PrEP are needed.

TRIAL REGISTRATION

Providing Suboxone and PrEP Using Telemedicine, NCT04521920. Registered 18 August 2020. https://clinicaltrials.gov/study/NCT04521920?term=mehri%20mckellar&rank=2 .