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PrEP for Individuals who Inject Drugs
Interestingly, we found that PrEP usage among IDUs in NYC may neither have as significant an impact nor provide the same value for resources expended as prioritization to the MSM population.......PrEP prioritized to IDUs alone results in 2% of new infections being averted over 20 years. The average annual cost is $610 million and the cost-per-infection averted is estimated to be more than $9 million. PrEP prioritized to only higher-risk heterosexuals, as defined earlier (Table 1) results in 5% of new infections averted with an average annual cost of $6500 million and a cost-per-infection averted estimated to be $43 million. Compared with PrEP for all at-risk persons, with a cost of $7600 million annually, these two strategies retain 8 and 21% of the maximal effect of PrEP at 8 and 85% of the annual cost, respectively." https://www.natap.org/2014/HIV/092914_01.htm
"Once-daily oral tenofovir decreased the risk of HIV infection by 48⋅9% in injecting drug users......We confirmed HIV infection in 52 participants (17 [33%] in the tenofovir group, 35 [67%] in the placebo group) indicating a 51⋅8% reduction in HIV incidence (95% CI 15⋅3-73⋅7; p=0⋅01) in the tenofovir group compared with the placebo group in the intention-to-treat analysis. https://www.natap.org/2013/HIV/061413_03.htm
We interviewed persons who inject drugs (PWID) to understand perceptions of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Knowledge of PrEP was poor. Patients felt that PrEP was for sexual intercourse rather than injection drug use, and PWID managed on medications for opioid use disorder felt that they had no need for PrEP. https://academic.oup.com/ofid/article/9/1/ofab541/6424885?searchresult=1
PrEP for Individuals who Inject Drugs
Efforts to expand PrEP access and uptake are urgently needed for individuals who inject drugs
few studies have examined the efficacy of PrEP to avert incident HIV infections, and there is a paucity of interventions to promote the implementation, uptake, and adherence to PrEP among individuals who inject drugs in the U.S.
By Jennifer L. Brown, PhD, Tanya L. Kowalczyk Mullins, MD, and Andrew M. Ferguson, BS Rates of new Human Immunodeficiency Virus (HIV) infections remain relatively stable with an estimated 38,739 incident infections in the United States (U.S.) in 2017 (CDC, 2018). Six percent of the incident HIV infections in 2017 were attributed to injection drug use (IDU) and an additional 3% were attributed to IDU and male-to-male sexual contact (CDC, 2018). Risk of HIV transmission and acquisition is elevated among individuals who use drugs, through specific drug use behaviors (e.g., IDU, sharing of needles and other drug paraphernalia; (CDC, 2018) and also by engagement in high risk sexual behaviors that may co-occur with drug use (e.g., unprotected sexual encounters; (Brown, Eriksen, Gause, Brody, & Sales, 2018). Increased IDU fueled by the opiate epidemic has also been linked to increased incident HIV infections in rural regions of the U.S. (e.g., 215 incident HIV infections in midwestern Scott County, Indiana; (Conrad et al., 2015).
Pre-exposure prophylaxis (PrEP) is the use of antiretroviral (ARV) medications by HIV-uninfected individuals before HIV exposure to prevent HIV acquisition (Young & McDaid, 2014). The U.S. Food and Drug Administration (FDA) approved emtrictabine/tenofovir disoproxyl fumarate (Truvada®) in 2012 for prevention of HIV infection in adults; this combination medication was subsequently approved for use in adolescents weighing 35 kg or more. In 2019, the U.S. FDA approved a second combination drug, emtricitabine/tenofovir alafenamide (Descovy®), for prevention of HIV infection by sexual acquisition among adults and adolescents weighing 35 kg or more, excluding people who are at risk of HIV through receptive vaginal sex. Thus, emtricitabine/tenofovir alafenamide is NOT currently approved for HIV prevention among cisgender women or people who at risk through injection drug use. Both medications are approved to be used in combination with behavioral HIV prevention approaches (e.g., safer sexual practices, use of sterile injection equipment). In 2017, the Centers for Disease Control and Prevention (CDC) published updated clinical practice guidelines for the use of PrEP (CDC, 2018).
PrEP is recommended for HIV-uninfected adults who report any injection of drugs not prescribed by a clinician in the past 6 months and at least one of the following: a) any sharing of injection or drug preparation equipment in the past 6 months; or b) report risk of sexual HIV acquisition (CDC, 2018). One study estimated that approximately 18.5% of U.S. injection drug users were at significant HIV risk and would meet eligibility for PrEP according to the CDC guidelines (Smith et al., 2015).
PrEP has demonstrated efficacy to prevent HIV among high-risk groups including serodiscordant heterosexual couples (Baeten et al., 2012), heterosexual men and women (Thigpen et al., 2012), and men who have sex with men (MSM) and transgender women (Grant et al., 2010). A meta-analysis of seven randomized controlled trials of PrEP efficacy (N=14,804) indicated an HIV infection rate of 2.03% in the PrEP conditions and an HIV infection rate of 4.07% in the control conditions (Jiang et al., 2014). Furthermore, in the seminal randomized controlled trial of PrEP among individuals who inject drugs in Thailand, results indicated a 51.8% reduction in HIV incidence among individuals receiving tenofovir relative to placebo (Choopanya et al., 2013). A subsequent analysis demonstrated a 83.5% reduction in new HIV infections among participants who had 97.5% or greater adherence (Martin et al, 2015). Despite accumulating evidence regarding the efficacy of PrEP to prevent new HIV infections, the widespread access and uptake of PrEP among at-risk populations in the U.S., particularly among people who inject drugs, has been limited (Hacker, Cohn, Golden, & Heumann, 2017).
Limited PrEP uptake among individuals who inject drugs may be in part due to lack of awareness among this population. For example, among a sample of individuals who had injected drugs in the last year, there was low awareness of PrEP with only 13.4% reporting they had heard of PrEP and no participants indicating they knew of anyone who had used PrEP in the past year (Kuo et al., 2016). Similarly, only one-quarter of individuals seeking syringe exchange services had heard of PrEP, with only two out of 265 participants endorsing current PrEP usage (Sherman et al., 2019). Despite limited awareness of PrEP, several studies point to potential willingness to use PrEP among individuals who inject drugs. For example, among those with an injection drug use history in the past year, 42.7% indicated they would be "very likely" to use PrEP, 23.5% were "somewhat likely", and 29.3% were "not likely" to use PrEP (Kuo et al., 2016). Similarly, among HIV-negative individuals who inject drugs in Vancouver, Canada, one third (35.4 %) expressed willingness to use PrEP (Escudero et al., 2015). Sherman and colleagues (2019) noted higher levels of willingness to use PrEP among individuals seeking syringe exchange services with 63% endorsing interest in using PrEP.
Additional challenges to widespread utilization of PrEP among individuals who inject drugs may stem from provider attitudes towards PrEP for this population coupled with structural barriers. For instance, HIV care providers reported that they were less likely to prescribe PrEP to individuals who inject drugs relative to men who have sex with men, citing concerns related to PrEP adherence and consistent attendance for follow-up care (Adams & Balderson, 2016). Concerns have also been noted about the capacity to bring PrEP to scale among individuals who inject drugs and the worry that PrEP expansion efforts could undermine the widespread implementation of other community-based HIV harm reduction programs (e.g., access to syringe exchange services; (Guise, Albers, & Strathdee, 2017).
PrEP is one of many HIV prevention approaches that should be considered among individuals who inject drugs, along with facilitating access and adherence to HIV treatment (Undetectable = Untransmittable; U=U), access to harm reduction programs including syringe exchange programs, and improving access to evidence-based substance use treatment programs (e.g., medication for opioid use disorder; (Karim, 2013;Shoptaw, 2013). PrEP should also be considered in combination with extant behavioral risk reduction strategies (e.g., interventions to bolster consistent condom use; (Brown, Sales, & DiClemente, 2014;Shoptaw, 2013). Despite heightened HIV risk among individuals who inject drugs, few studies have examined the efficacy of PrEP to avert incident HIV infections, and there is a paucity of interventions to promote the implementation, uptake, and adherence to PrEP among individuals who inject drugs in the U.S. Interventions to promote awareness and access to PrEP among individuals who inject drugs are urgently needed, particularly in regions most significantly affected by the opiate epidemic. Further, little research has examined the optimal setting to prescribe and monitor the use of PrEP among individuals who inject drugs; thus, examination of strategies to implement PrEP within substance use treatment or at harm reduction/syringe exchange programs are needed.

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