Abstract
BackgroundAntiretroviral 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.MethodsWe 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.ResultsAmong 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.ConclusionsIn 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.
Highlights
People who inject drugs (PWID) are disproportionately affected by HIV/AIDS [1], accounting for 7–10% of new HIV infections in the USA annually [1, 2]
To understand barriers to pre-exposure prophylaxis (PrEP) uptake and inform the development of interventions to improve PrEP utilization among people who inject drugs (PWID) at risk for HIV acquisition, we conducted a qualitative study in the Northeastern USA, where injection of opioids and other drugs is increasingly widespread [9, 31] and has been linked to hepatitis C virus (HCV) transmission and recent clusters of new HIV infections attributed to injection drug use [32]
Study design and sample As previously described [30], to recruit high-risk PWID, we partnered with community-based organizations (CBOs) experienced in conducting outreach and service delivery to this population including Needle syringe programs (NSPs) and drop-in HIV/HCV testing centers in Boston, MA, and Providence, RI
Summary
People who inject drugs (PWID) are disproportionately affected by HIV/AIDS [1], accounting for 7–10% of new HIV infections in the USA annually [1, 2]. Transmission of hepatitis C virus (HCV), considered a harbinger of HIV outbreaks [6], has significantly increased over the past decade [7]. Combined with these emerging behavioral and epidemiologic trends [8], the increasing prevalence of opioid use and injection across the USA [9, 10] suggests that improved access to HIV and other prevention services for PWID are urgently needed [11]. 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
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