HIV pre-exposure prophylaxis for people who inject drugs: a review of current results and an agenda for future research

Patient and Provider Perspectives on a Novel, Low-Threshold HIV PrEP Program for People Who Inject Drugs Experiencing Homelessness

BACKGROUND

HIV outbreaks among people who inject drugs (PWID) and experience homelessness are increasing across the USA. Despite high levels of need, multilevel barriers to accessing antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention persist for this population. The Boston Health Care for the Homeless Program (BHCHP) initiated a low-threshold, outreach-based program to support engagement in PrEP services among PWID experiencing homelessness.

METHODS

To inform dissemination efforts, we explored patient and provider perspectives on key program components. From March to December 2020, we conducted semi-structured qualitative interviews with current and former BHCHP PrEP program participants and prescribers, patient navigators, and outreach workers (i.e., providers). Thematic analysis explored perspectives on key program components.

RESULTS

Participants (n = 21) and providers (n = 11) identified the following five key components of BHCHP's PrEP program that they perceived to be particularly helpful for supporting patient engagement in PrEP services: (1) community-driven PrEP education; (2) low-threshold, accessible programming including same-day PrEP prescribing; (3) tailored prescribing supports (e.g., on-site pharmacy, short-term prescriptions, medication storage); (4) intensive outreach and navigation; and (5) trusting, respectful patient-provider relationships.

DISCUSSION

Findings suggest that more patient-centered services formed the basis of BHCHP's innovative, successful PrEP program. While contextual challenges including competing public health emergencies and homeless encampment "sweeps" necessitate ongoing programmatic adaptations, lessons from BHCHP's PrEP program can inform PrEP delivery in a range of community-based settings serving this population, including syringe service programs and shelters.

Qualitative inquiry into perceptions of HIV pre-exposure prophylaxis among people who inject drugs living with hepatitis C in Seattle, WA, USA

BACKGROUND

The incidence of HIV among persons who inject drugs (PWID) in the USA has been increasing since 2014, signaling the need to identify effective ways to engage PWID in HIV prevention services, namely pre-exposure prophylaxis (PrEP). Yet, the uptake of PrEP in this population is minimal compared to other populations at risk of HIV acquisition. In this work, we sought to explore knowledge, attitudes, and perspectives of PrEP acceptability among PWID.

METHODS

In the context of a pilot study to explore the acceptability of pharmacy-based hepatitis C virus (HCV) treatment, we conducted semi-structured interviews (n = 24) and focus groups (n = 4, 16 participants) with people who were living with HCV and reported active injection drug use (≤ 90 days since last use). Participants were asked open-ended questions about their familiarity with and motivation to use PrEP. As part of a sub-analysis focused on PrEP, qualitative data were analyzed using a Rapid Assessment Process, where three coders used structured templates to summarize qualitative data and iteratively reviewed coded templates to identify themes. Participants also completed short quantitative questionnaires regarding drug use history and attitudes toward health concerns.

RESULTS

Forty-seven percent of participants expressed having little or no concern regarding HIV acquisition. Targeted analyses focused on HIV prevention identified three themes, which help characterize behavioral determinants of nonadoption. First, knowledge of PrEP was limited among PWID and influenced by infrequent open community discussions around HIV risk. Second, PWID perceived sexual behaviors-but not injection drug use-as a motivator for HIV risk prevention. Finally, PWID identified many individual and environmental barriers that hinder PrEP uptake.

CONCLUSION

Among PWID, PrEP is rarely discussed and concerns about the feasibility of using daily PrEP are common. Taken with the prevalent perception that drug use is not a high risk for HIV acquisition, our findings point to opportunities for public health work to target PrEP education to PWID and to leverage other successful interventions for PWID as an opportunity to provide PrEP to this vulnerable population.

Acceptability of injectable pre-exposure prophylaxis among people who inject drugs in three urban U.S. settings

Background

Outbreaks of new HIV transmission among people who inject drugs (PWID) are a major public health concern. Oral daily PrEP, has been identified as a critical addition to the biomedical toolkit for this population. However, limited research on the acceptability of long-acting injectable PrEP has been conducted with this population.

Methods

We conducted a cross sectional multi-site survey with 1127 participants from May 2019–February 2020 to assess the acceptability of novel PrEP regimens. We computed bivariate and multivariable logistic regressions to evaluate correlates of the outcome variable: acceptability of 3-month injectable-PrEP. SAS v.9.4 was used to conduct statistical analysis.

Results

Limited knowledge of or use of PrEP, past or present, was evident within the sample. Injection drug use in the past six months was significantly associated with LA injectable PrEP acceptability, with the odds of acceptability being 1.885 (CI: 1.376, 2.582) times greater than those who did not inject drugs. After adjusting for confounders, injection drug use was significantly associated with the outcome, such that the odds of acceptability of LA injectable PrEP were 1.705 (CI: 1.198, 2.427) times greater among PWID compared to those who did not inject drugs (p < 0.03). The results demonstrate acceptability (38.2%) in a durable (3-month) injectable PrEP modality among participants who also identified as PWID.

Conclusions

PrEP promotion efforts among PWID to increase access to long-acting injectable PrEP are necessary. Through efforts to increase acceptance and regular use of long-acting injectable PrEP, public health strategies may be able to effectively lessen chances of future HIV outbreaks among PWID.

PrEP for key populations: results from the first PrEP demonstration project in the Democratic Republic of the Congo

Oral pre-exposure prophylaxis (PrEP) is recommended for persons at substantial risk for HIV, including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender women (TGW). We report on a PrEP demonstration project at seven clinics in the Democratic Republic of the Congo. Routinely collected data were abstracted to assess PrEP uptake, scheduled visit attendance, and self-reported adherence. Between February and May 2018, 469 eligible clients were offered daily oral PrEP; 75.1% accepted: 78.7% FSW, 20.5% MSM, and 0.9% TGW. Two percent also identified as PWID. Attendance was 64.5% at one-month visits; 82.1% at three-month visits; and among 47.7% of clients who initiated PrEP at least six months before data abstraction, 85.8% at six-month visits. Among 66.3% of clients with at least one adherence assessment, 39% self-reported low adherence. Results demonstrate the acceptability of PrEP delivered in healthcare settings serving FSW, MSM, PWID, and TGW.

Evidence of Potential Discriminatory HIV Pre-Exposure Prophylaxis (PrEP) Prescribing Practices for People Who Inject Drugs Among a Small Percentage of Providers in the U.S

INTRODUCTION

A large percentage of people who inject drugs (PWID) are living with HIV. Yet, rates of HIV pre-exposure prophylaxis (PrEP) use among PWID remain low. Stigma surrounding substance use and PWID have been identified as potential barriers to PrEP. This study examined healthcare providers' concerns regarding PWID and willingness to prescribe PrEP to PWID.

METHODS

An online, cross-sectional survey of a diverse group of healthcare providers in the 10 U.S. cities with the greatest HIV prevalence was conducted between July 2014 and May 2015. Participants responded to a patient vignette of a PWID and asked to indicate whether the patient would be a candidate for PrEP and why via free-response text. Descriptive statistics are reported using frequency measures. Bivariate analyses were conducted using chi-squared comparisons and logistical regression.

RESULTS

Survey data from 480 providers were included in analyses. Of the 480 responses, 85.5% were classified as PrEP aware, while 14.2% were PrEP unaware. Additionally, 82.6% indicated the patient would be a good candidate for PrEP, 4.4% believed the patient was not a good candidate for PrEP, and 13% were unsure. Among those who were unsure or would not prescribe PrEP (n = 84), open-ended responses indicated lack of knowledge (42.9%), concern about adherence (27.4%), concern about cost (4.8%), and bias (7.1%) as the primary reasons.

CONCLUSIONS

Although the majority of providers in this study did not demonstrate bias against PWID, our study found that limited PrEP knowledge and bias are barriers to PrEP prescription among PWID for some providers. Interventions are needed that increase PrEP awareness of CDC guidelines and reduce implicit bias among providers.

The Past, Present, and Future of PrEP implementation Among People Who Use Drugs

PURPOSE OF REVIEW

Recent HIV outbreaks among people who use drugs (PWUD) necessitate additional HIV prevention tools. Pre-exposure prophylaxis (PrEP) is highly efficacious yet uptake among PWUD remains exceedingly low. To address multilevel, complex barriers to PrEP use among PWUD, a range of intervention strategies are needed.

RECENT FINDINGS

The literature on interventions to optimize PrEP use among PWUD is nascent, comprising small pilots and demonstration projects in early phases of intervention development. Initial studies suggest that structural, healthcare, interpersonal, and individual-level interventions can improve PrEP use for PWUD, and a number of efficacy trials are underway. Future studies are needed to optimize the use of new PrEP modalities (e.g., injectable PrEP), simultaneously target multilevel challenges to PrEP use, and evaluate the integration of PrEP into other service settings and substance use treatment modalities.

Knowledge and Use of PEP and PrEP Among Key Populations Tested in Community Centers in Portugal

Background: Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) have been increasingly available in Europe. Due to the high burden of HIV in key populations, these could benefit from their use. In 2016, in Portugal, an open, non-interval, prospective cohort study was established in a network of 26 community-based voluntary HIV/STI counseling and testing centers. Data collected included questions on PEP and PrEP knowledge and use. We aimed to estimate the proportion of PEP and PrEP knowledge and its use among key populations, visiting the centers between 2016 and 2019. Method and results: Individuals who self-identify as being among at least one key population for HIV, men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), migrants, and male-to-female transgender individuals (MTF), responded to questions on PEP and PrEP knowledge and use while waiting for their test results between 2016 and 2019 (n = 12,893 for PEP; n = 10,973 for PrEP). Reported knowledge was low in all key populations for both tools: 15.7% of respondents reported knowing about PEP and 10.9% about PrEP over the course of 4 years. PEP was used by 1.8% and PrEP by 0.4% of the respondents, MSM being 88.9% of PrEP users, and 52.8% of PEP users. Multivariate logistic regression showed multiple factors associated with knowing the tools, including age, education, country of birth, gender, year of test, having a reactive HIV test in the same visit, reporting an STI or condomless sex in the last 12 months, and identifying with being MSM or SW. Conclusions: Knowledge and use of PEP and PrEP remain low among key populations in Portugal. The need remains to increase knowledge and use among those at risk for HIV infection.

Perspectives on pre-exposure prophylaxis for people who inject drugs in the context of an hiv outbreak: A qualitative study

BACKGROUND

There is an ongoing HIV outbreak amongst people who inject drugs (PWID) in Glasgow, Scotland, and one response which has not yet been widely implemented is the provision of Pre-exposure prophylaxis (PrEP). PrEP is the use of HIV anti-retrovirals prior to HIV infection to provide a barrier to infection. This has been shown to be effective amongst various at-risk populations in preventing HIV spread. The present study aimed to explore views of PWID who might benefit from PrEP provision and Service Providers working with PWID to understand will to use PrEP and literacy of PrEP, contributing to the development of a PrEP service.

METHODS

A qualitative approach was taken, with semi structured interviews conducted in Glasgow at two third sector service sites. 11 Service Providers and 21 PWID participated in the study. Data was analysed thematically.

RESULTS

Participants, both PWID and Service Providers, were keen to engage with PrEP and perceived substantial potential benefits of PrEP for this population. Potential barriers to engagement were identified as a lack of health literacy, motivation, and self-ascribed risk, as well as the overwhelming unpredictability of substance use. Participants wanted PrEP to be provided within already existing structures, particularly community pharmacies, and for promotion and provision to involve peers.

CONCLUSION

This sample reported willingness to engage with PrEP, and suggested there is a specific need amongst PWID for PrEP. However, PWID have specific lived experienced contexts and needs, and are burdened by social and economic marginalisation and inequality at every level. This contrasts them from other populations currently being provided with PrEP, and must be considered in the development of provision.

Optimizing HIV prevention and treatment outcomes for persons with substance use in Central Asia: what will it take?

Purpose of review

To summarize the status of HIV and substance use in Central Asia and discuss potential ways to move forward to effective epidemic control among people who inject drugs (PWID) in the region and beyond.

Recent findings

PWID and their partners remain the population most affected by HIV in Central Asia. Lack of effective substance use prevention and treatment options and limited involvement of PWID-led community-based organizations in HIV programs, combined with the requirement for official registration, stigma and discrimination of PWID, and criminalization of drug use remain key barriers to effective HIV prevention and treatment.

Summary

Sustainable HIV epidemic control among PWID will not be feasible without decriminalization of drug use, addressing stigma and discrimination and policy changes to enhance uptake of HIV-related prevention, treatment and support services by PWID. It is also critical to ensure adoption of innovations, particularly those that combine evidence-based biomedical, behavioral and structural interventions tailored to the needs of the PWID.

Responding to global stimulant use: challenges and opportunities

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast

Background: People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. Objectives: To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. Methods: We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Results: Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Conclusions: Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.

A missing perspective: injectable pre-exposure prophylaxis for people who inject drugs

The efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention has been established among people who inject drugs (PWID). HIV uninfected, at risk PWID, could likely benefit from long-acting injectable formulations of PrEP ("LAI-PrEP"); however, its acceptability in this population has not been previously documented. Thirty-three HIV-uninfected PWID in the U.S. Northeast completed an in-depth interview regarding perceived acceptability of LAI-PrEP. Coded data were synthesized using deductive thematic analysis. The majority of PWID interviewed believed LAI-PrEP would be acceptable. Participants perceived that receiving injections every two months would reduce barriers to daily oral PrEP adherence, including forgetting while "high" and safeguarding pills when homeless. A few participants expressed concerns regarding LAI-PrEP, including medical mistrust, a concern that injections could alter their "high" or be "triggering" for PWID. LAI-PrEP has the potential to reduce HIV among PWID; however, their perspectives are largely absent from research examining its efficacy, representing a missed opportunity.

Medical Providers and Harm Reduction Views on Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs

Despite high pre-exposure prophylaxis (PrEP) acceptability among people who inject drugs (PWID) and PrEP providers, PrEP uptake is low and little is known about how to promote PrEP among PWID. This qualitative study with providers in North Carolina explored views on PrEP delivery approaches for PWID. Interviewers conducted semistructured interviews with 10 PrEP providers and 10 harm reduction (HR) providers. Interviews were transcribed and analyzed. Many participants expressed acceptability for providing PrEP referrals at syringe exchange sites, stationing PrEP providers at syringe exchange sites to provide PrEP prescriptions, and providing standing orders for PrEP at syringe exchange sites. Barriers were identified, including low PrEP awareness and limited resources. Many advocated for co-location of HR and PrEP services and scaled-up outreach services. PrEP providers emphasized maintenance of clinical requirements, while HR providers emphasized flexibility when treating PWID. Promoting PrEP uptake and adherence among PWID likely requires integration of HR and PrEP services.

Factors Associated with Awareness of Pre-exposure Prophylaxis for HIV Among Persons Who Inject Drugs in Philadelphia: National HIV Behavioral Surveillance, 2015

Persons who inject drugs (PWID) continue to experience disproportionate HIV burden. Though studies demonstrate PWID find pre-exposure prophylaxis (PrEP) acceptable, awareness and uptake remains low. Data from the 2015 PWID cycle of the National HIV Behavioral Surveillance (n = 612) in Philadelphia, Pennsylvania (USA) were analyzed to evaluate how socio-demographics and behavioral factors impact PrEP awareness. Only 12.4% of PWID surveyed were PrEP-aware and 2.6% reported receiving a prescription. Factors associated with PrEP awareness included having at least some college education (aOR 2.13, 95% CI 1.03, 4.43), sharing paraphernalia (aOR 2.37, 95% CI 1.23, 4.56), obtaining syringes/needles primarily from a syringe exchange program (aOR 2.28, 95% CI 1.35, 3.87), STI testing (aOR 1.71, 95% CI 1.01, 2.89) and drug treatment (aOR 2.81, 95% CI 1.62, 4.87). Accessing prevention and health services increased the odds of being PrEP-aware; however, awareness was low overall. Additional promotion efforts are warranted.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Limited Knowledge and Mixed Interest in Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs

People who inject drugs (PWID) experience sexual and injection-related HIV risks, but uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among PWID has been low. Improving PrEP uptake in this population will require understanding of PrEP knowledge and interest. In 2017, we conducted in-depth, semistructured interviews with HIV-uninfected PWID and key informants (PrEP and harm reduction providers) in the US Northeast. Thematic analysis of coded data explored PrEP knowledge and the factors that influence PrEP interest. Among PWID (n = 33), median age was 36 years, 55% were male, 67% were white, and 24% identified as Hispanic/Latino. Accurate PrEP knowledge among PWID was low, which key informants (n = 12) attributed to PrEP marketing focused on other risk populations, as well as healthcare providers' lack of time and unwillingness to discuss PrEP with PWID. There was a discrepancy between self-reported HIV risk behaviors, which were common, and HIV risk perceptions, which varied and strongly influenced PrEP interest. Most PWID and key informants thought that PrEP would be most beneficial for those who shared syringes, used discarded syringes, engaged in transactional sex, or were homeless. Improving uptake of PrEP for HIV prevention among high-risk PWID will require education to increase PrEP knowledge and addressing factors that negatively influence PrEP interest such as perceptions regarding low HIV risk and the process for obtaining PrEP. This may require specialized PrEP marketing and outreach efforts and improved capacity of healthcare providers to effectively assess HIV risk (and perceptions) and communicate the benefits of PrEP to at-risk PWID.

Serodiscordant partnerships and opportunities for pre-exposure prophylaxis among partners of women and men living with HIV in St. Petersburg, Russia

Objective

To describe the frequency of being partnered and having an HIV-negative partner, and whether this differed by gender, among a cohort of persons living with HIV (PLWH) who have ever injected drugs; to describe awareness of HIV pre-exposure prophylaxis (PrEP) and perceived partner interest in PrEP.

Setting

Secondary analyses of an observational cohort study of PLWH who have ever injected drugs in St. Petersburg, Russia.

Methods

Primary outcomes were 1) being partnered and 2) being in a serodiscordant partnership. The main independent variable was gender. Multivariable GEE logistic regression models were fit for binary outcomes, adjusted for age, income, education, and recent opioid use. Descriptive analyses were performed for partners’ HIV status, substance use, sex risk behaviors, and awareness of PrEP for a subset of participants.

Results

At baseline, 50% (147/296) reported being in a partnership, and of those, 35% were in a serodiscordant partnership. After adjustment, women had significantly higher odds of being partnered compared to men (aOR = 3.12; 95% CI: 1.77, 5.51), but there were no significant gender differences in the odds of being in a serodiscordant partnership (aOR = 0.58; 95% CI: 0.27, 1.24). Among a sub-sample of participants queried (n = 56), 25% were aware of PrEP for prevention of sexual HIV transmission and 14% for prevention of injection-related transmission.

Conclusion

Although half of our sample were partnered and one third of these partnerships were serodiscordant, PrEP awareness was low. Substantial opportunities for HIV prevention exist among PLWH who have ever injected drugs in Russia and their HIV-negative partners. Given the high proportion of HIV-negative partners among this ART-naïve sample, efforts to address the associated inherent risks, such as couples-based interventions, are needed to increase condom use, PrEP awareness, or uptake of other HIV-prevention modalities (e.g., ART for the HIV-positive partner).

Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs

Background

Antiretroviral pre-exposure prophylaxis (PrEP) is clinically efficacious and recommended for HIV prevention among people who inject drugs (PWID), but uptake remains low and intervention needs are understudied. To inform the development of PrEP interventions for PWID, we conducted a qualitative study in the Northeastern USA, a region where recent clusters of new HIV infections have been attributed to injection drug use.

Methods

We conducted qualitative interviews with 33 HIV-uninfected PWID (hereafter, “participants”) and 12 clinical and social service providers (professional “key informants”) in Boston, MA, and Providence, RI, in 2017. Trained interviewers used semi-structured interviews to explore PrEP acceptability and perceived barriers to use. Thematic analysis of coded data identified multilevel barriers to PrEP use among PWID and related intervention strategies.

Results

Among PWID participants (n = 33, 55% male), interest in PrEP was high, but both participants and professional key informants (n = 12) described barriers to PrEP utilization that occurred at one or more socioecological levels. Individual-level barriers included low PrEP knowledge and limited HIV risk perception, concerns about PrEP side effects, and competing health priorities and needs due to drug use and dependence. Interpersonal-level barriers included negative experiences with healthcare providers and HIV-related stigma within social networks. Clinical barriers included poor infrastructure and capacity for PrEP delivery to PWID, and structural barriers related to homelessness, criminal justice system involvement, and lack of money or identification to get prescriptions. Participants and key informants provided some suggestions for strategies to address these multilevel barriers and better facilitate PrEP delivery to PWID.

Conclusions

In addition to some of the facilitators of PrEP use identified by participants and key informants, we drew on our key findings and behavioral change theory to propose additional intervention targets. In particular, to help address the multilevel barriers to PrEP uptake and adherence, we discuss ways that interventions could target information, self-regulation and self-efficacy, social support, and environmental change. PrEP is clinically efficacious and has been recommended for PWID; thus, development and testing of strategies to improve PrEP delivery to this high-risk and socially marginalized population are needed.

Differences in awareness of and willingness to use pre-exposure prophylaxis and anticipated condom use among serodiscordant couples in Taiwan

Pre-exposure prophylaxis (PrEP) has proven to be effective in reducing the risk of HIV transmission in uninfected individuals who engaged in sexual activity with HIV-infected partners. Serodiscordant couples are the key targets of PrEP implementation. The study aimed to compare awareness of and willingness to use PrEP and anticipated condom use among 112 HIV-serodiscordant couples: 32 heterosexuals couples, 70 men who have sex with men (MSM) couples, and 10 people who inject drugs (PWID) couples. A cross-sectional study was conducted in an AIDS designated hospital in Taiwan. The PrEP survey for discordant couples included questions on awareness of non-occupational post-exposure prophylaxis (nPEP) and PrEP, attitudes toward PrEP, anticipated condom use if using PrEP, and sexual behaviors. Overall, 46.2% were aware of PrEP, only 33% were willing to take PrEP, and 44.6% would continue condom use if they were taking PrEP. Among the three key populations, MSM couples had the highest awareness of and willingness to use PrEP. Awareness of and willingness to use PrEP did not differ by HIV status, with moderate agreement (Cohen's Kappa coefficient: 0.56) between HIV-serodiscordant partners. Both HIV-serodiscordant partners' willingness to use PrEP was significantly associated with being MSM (adjusted odds ratio (AOR), 4.28 [1.28-14.30], p = 0.018), previous receipt of nPEP (AOR, 6.98 [1.23-39.65], p = 0.028), anticipated condom use (AOR, 0.14 [0.05-0.41], p < 0.001), and income ≥ NT$30,000 per month (AOR, 2.25 (0.99-5.04), p = 0.05). Policy makers need to consider the differences among key populations to scale up PrEP implementation. More efforts should be focused on improving awareness of and willingness to use PrEP among heterosexual and PWID serodiscordant couples to scale up PrEP implementation in Taiwan.

Continued Transmission of HIV Among Young Adults Who Inject Drugs in San Francisco: Still Room for Improvement

We measured HIV incidence rate, trend and risk factors in 564 HIV-negative young people (< 30 years) who inject drugs (PWID) in San Francisco between 2000 and 2014. HIV incidence was 0.93/100 person-years (PY; 95% CI 0.50, 1.73). Incidence varied between 0.62/100 PY in 2000-2002 and 1.06/100 PY in 2012-2014 (P for trend = 1.0). HIV incidence varied significantly (P < 0.01) by race/ethnicity: among Hispanics it was 8.19/100 PY (95% CI 3.41, 19.68), African-Americans 4.59/100 PY (95% CI 1.15, 18.37), and Whites 0.26/100 PY (95% CI 0.06, 1.03). Male participants who reported sex with men (MSM) had higher HIV incidence (2.63/100 PY; 95% CI 1.31, 5.25) compared to males who did not report MSM (0.50/100 PY; 95% CI 0.12, 1.99) (P = 0.01). Despite an overall stable HIV incidence trend, incidence was elevated among African-American and Hispanic PWID, and men who have sex with men. Addressing prevention needs in these key populations is critical for the goal of eliminating HIV transmission.

Continuing Links Between Substance Use and HIV Highlight the Importance of Nursing Roles

Links between HIV and substance use were identified early in the U.S. HIV epidemic. People who use drugs are at risk of HIV infection through shared injection equipment and risky sexual behaviors. In addition, substance use has negative health consequences for people living with HIV. The prescription opioid misuse epidemic, linked to injection drug use, hepatitis C infection, and HIV, poses a new threat to declining HIV rates. We reviewed evidence-based interventions that decrease HIV risk in people who use drugs (needle/syringe programs, medication-assisted treatment, engagement in HIV care, and preexposure prophylaxis/postexposure prophylaxis). The critical roles of nurses in HIV prevention/care for this population are described, including applying the principles of harm reduction, screening for substance use, and undertaking implementation and research efforts. As the nation's largest health care profession, nurses are positioned to contribute to the quality of HIV-related prevention/care for people who use drugs and to lead practice initiatives.

Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention

BACKGROUND

Women who inject drugs (WWID) are at heightened risk for HIV due to biological, behavioral, and structural factors. Pre-exposure prophylaxis (PrEP) could aid in HIV prevention for WWID. However, little is known about WWID awareness of PrEP, which is a necessary step that must occur before PrEP uptake. We report factors associated with greater awareness among WWID to identify efficient means of awareness dissemination.

METHODS

Data from the 2015 National HIV Behavioral Surveillance (NHBS) system cycle on injection drug use collected in New York City (NYC) were used. Bivariable analyses, using chi-squared statistics, were conducted to examine correlates of awareness of PrEP with socio-demographic, behavioral, and health care variables. Multivariable logistic regression was used to estimate adjusted associations and determine differences in awareness of PrEP.

RESULTS

The analysis consisted of 118 WWID. Awareness of PrEP was relatively low (31%), and risk factors were high. In the last 12 months, almost two thirds (65%) reported condomless sex, approximately one third (31%) reported transactional sex, and one third (32%) reported sharing injection equipment. In multivariable logistic regression, increased PrEP awareness was associated with reported transactional sex (AOR 3.32, 95% CI 1.22-9.00) and having a conversation about HIV prevention at a syringe exchange program (SEP) (AOR 7.61, 95% CI 2.65-21.84). We did not find race, education, household income, age, binge drinking, or sexual identity to be significantly associated with PrEP awareness.

CONCLUSIONS

Large proportions of WWID were unaware of PrEP. These findings suggest that social networks (specifically sex work and SEP networks) are an efficient means for disseminating messaging about prevention materials such as PrEP. We recommend that SEP access increase, SEP processes be adopted in other health care settings, and WWID networks be utilized to increase PrEP awareness.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND

Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

METHODS

We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

FINDINGS

From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

INTERPRETATION

There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

FUNDING

Bill & Melinda Gates Foundation.

Primary Care Physicians' Willingness to Prescribe HIV Pre-exposure Prophylaxis for People who Inject Drugs

Pre-exposure prophylaxis for HIV (PrEP) is recommended for people who inject drugs (PWID). Despite their central role in disease prevention, willingness to prescribe PrEP to PWID among primary care physicians (PCPs) is largely understudied. We conducted an online survey (April-May 2015) of members of a society for academic general internists regarding PrEP. Among 250 respondents, 74% (n = 185) of PCPs reported high willingness to prescribe PrEP to PWID. PCPs were more likely to report high willingness to prescribe PrEP to all other HIV risk groups (p's < 0.03 for all pair comparisons). Compared with PCPs delivering care to more HIV-infected clinic patients, PCPs delivering care to fewer HIV-infected patients were more likely to report low willingness to prescribe PrEP to PWID (Odds Ratio [95% CI] = 6.38 [1.48-27.47]). PCP and practice characteristics were not otherwise associated with low willingness to prescribe PrEP to PWID. Interventions to improve PCPs' willingness to prescribe PrEP to PWID are needed.

Pre-exposure prophylaxis: a useful tool to prevent human immunodeficiency virus infection?

The aim of preventive measures against human immunodeficiency virus (HIV) is to reduce the incidence of HIV infection in the general population and in high-risk groups, such as men having sex with men (MSM), and to reduce the risk that a given individual will contract or spread the virus. Male and female condoms, post-exposure prophylaxis and circumcision are preventive methods currently recognized or promoted worldwide. Although modest success has been reported in a phase-III vaccine trial, other methods are being evaluated, such as vaginal and rectal microbicides, and pre-exposure prophylaxis (PrEP). Herein, we discuss results from prevention trials, especially those focusing on PrEP and particularly on recent results from 'on-demand' PrEP regimens. The efficacy of PrEP (rates of 0%-86%) is strongly correlated with adherence and plasma concentrations of antiretrovirals. Adverse events are rare. Selection of emtricitabine-resistant strains is mainly reported in individuals with an undiagnosed HIV infection using PrEP. PrEP is now strongly recommended in WHO prevention programmes for individuals at substantial risk for HIV with a view to controlling this epidemic by 2030.

Update on the Epidemiology and Prevention of HIV/AIDS in the United States

This update on the epidemiology and prevention of HIV in the United States is intended to provide contextual background that will help inform an understanding of recent developments in the domestic HIV epidemic. We describe the epidemiology of HIV disease in the US and the HIV continuum of care based on data collected primarily through HIV surveillance systems led by the Centers for Disease Control and Prevention including HIV incidence, prevalence, comorbidities and death. Populations and geographic regions disparately impacted by HIV are also highlighted. The HIV prevention armamentarium is also described including behavioral approaches to prevention, the emerging availability of biomedical prevention interventions such as pre-exposure prophylaxis, and structural and population-level interventions including treatment as prevention. Finally gaps in our understanding of the epidemic are underscored and suggestions for future epidemiologic research are proposed.

Acceptability of HIV Pre-exposure Prophylaxis (PREP) Among People Who Inject Drugs (PWID) in a Canadian Setting

A recent clinical trial provided evidence that pre-exposure prophylaxis (PrEP) has the potential to prevent HIV infection among people who inject drugs (PWID). We examined willingness to use PrEP among HIV-negative PWID in Vancouver, Canada (n = 543) to inform PrEP implementation efforts. One third (35.4 %) expressed willingness to use PrEP, with adjusted models indicating that younger age, no regular employment, requiring help injecting, engaging in sex work, and reporting multiple recent sexual partners were positively associated with willingness to use PrEP. Although willingness to use PrEP was low, PrEP was acceptable to some PWID at heightened risk for HIV infection.

Tailored combination prevention packages and PrEP for young key populations

INTRODUCTION

Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.

OBJECTIVE

In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.

METHODS

We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.

RESULTS AND DISCUSSION

Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.

CONCLUSIONS

Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.