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Among people who inject drugs (PWID), decisions around PrEP are impeded by more pressing needs, and focusing on autonomy may help to engage PWID in PrEP uptake.

“It is estimated that 1.46% of the US population injects drugs, yet [people who inject drugs (PWID)] represent 7% of new HIV infections in the US,” researchers wrote in Addiction Science & Clinical Practice. “Despite the disproportionate burden of HIV suggesting the need for PrEP, engagement in the PrEP care continuum among PWID remains low. Complex factors influence PWID engagement in the PrEP care continuum, including limitations in their ability to engage in independent decision-making (ie, autonomy).”

However, existing research indicates that PWID can successfully access and adhere to PrEP “when services are tailored to their diverse needs,” Laramie Smith, PhD, and colleagues wrote.

Dr. Smith and colleagues conducted a qualitative study to assess “the complexities of PrEP utilization and active injection drug use” even with facilitated access to oral PrEP. Data were drawn from semi-structured interviews conducted as part of HPTN 094 INTEGRA.

Impact of More Urgent Needs

The study included interviews with 77 PWID at five sites in New York City, Houston, Los Angeles, Philadelphia, and Washington, DC. According to the study results, more than half of those interviewed (59.7%) mentioned oral PrEP during their interviews, though they were not directly prompted. Those who discussed PrEP had a mean age of 41.6, were primarily White (54.3%), and identified as cisgender men (60.9%).

In total, 15 participants described using PrEP. These respondents cited two main reasons for use: PrEP being able to access (healthcare organizational determinants) and perceiving themselves to be at high risk for HIV.

Researchers identified two key themes among those not using PrEP: low perceptions of risk and prioritizing more urgent needs. Respondents who described a low perceived risk for HIV acquisition discussed transmission through both injection equipment and risky sexual behaviors.

Some of the more urgent needs cited by participants included unstable housing, pressing medical conditions (ie, wound care), and addiction treatment.

Choice to Use PrEP “Not a Simple Task”

“From an implementation perspective, and in the context of facilitated access to oral PrEP for PWID, our qualitative findings underscore that the choice to use PrEP was not a simple task,” Dr. Smith and colleagues wrote. “Rather, factors affecting the PrEP decision-making process were linked to whether and/or how participants leveraged PrEP as a resource, contingent upon their circumstances.”

The researchers noted that “person-centered interventions” are important for engaging PWID in PrEP care, focusing on housing, financial stability, and urgent medical conditions in addition to PrEP.

Suggestions for such interventions included:

• Mobile health delivery units that improve access and privacy, thereby contributing to a better overall healthcare experience;
• Integrated services for both medications for opioid use disorder and HIV services in brick-and-mortar settings alongside mobile delivery;
• Comprehensive social services that support basic needs, which can improve structural stability for PWID and augment harm reduction and HIV prevention; and
• Integrated referrals within community services to address the health risks associated with drug use as well as the risk for infectious disease among PWID, such as clinician-facilitated linkage to social services that could address housing and economic needs

Individualizing Strategies to Improve PrEP Use

Dr. Smith and colleagues also noted that some participants had significant gaps in knowledge around PrEP and HIV prevention, including “misconceptions about the target population for PrEP, perceiving oneself as low risk for HIV transmission despite acknowledging that they engage in behaviors that increase their vulnerability to HIV, and lack of PrEP literacy as a preventive medication for HIV-negative individuals.”

Such gaps may impact the reluctance or ambivalence among PWID to consider using PrEP.

“Greater attention to patient-centered narratives can help illuminate low self-perceived HIV vulnerability among PWID,” the researchers wrote.

Together, the results indicate that, among PWID, PrEP should be promoted as part of a larger, more extensive HIV prevention toolkit, with room for individualized strategies based on user needs and preferences.

“By recognizing the significance of autonomy in PrEP decision-making, patient-centered interventions can be tailored to better support modifiable factors in addition to integrated care access to facilitate utilization of HIV prevention strategies among PWID,” Dr. Smith and colleagues wrote.