Abstract
BackgroundPeople 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.MethodsTo 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.ResultsAfter 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.ConclusionsHIV 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.
Highlights
People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP)
Review of 90 full texts resulted in exclusion of 70 studies, resulting in a final sample of 20 studies (Table 1)
Despite evidence that PrEP can help prevent HIV acquisition among high risk PWID [9], limited data suggest that PrEP adherence could be challenging for this population [11], Given the paucity of research on PrEP adherence among HIV-uninfected PWID, we critically reviewed available evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID, a population that has been characterized by assumed and known challenges with accessing and using medications [35]
Summary
People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). Antiretroviral pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV acquisition among PWID and its provision has been recommended for high risk PWID (along with other essential health and harm reduction services) by the World Health Organization [6] and an increasing number of national health departments [7, 8]. Among participants in the open-label extension of this clinical trial, three quarters self-reported taking less than 90% of daily PrEP doses [12] While these data suggest that taking PrEP daily could be challenging for PWID, little is known about real-world challenges with PrEP adherence among PWID because uptake in this population has been low [13]. With efforts to improve PrEP access and delivery to PWID currently underway [14], understanding adherence to medications in this population, defined here as the process by which patients take medications as prescribed (including initiation, implementation, and discontinuation) [15], could help inform future research and interventions to promote PrEP adherence
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