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Delivering Preexposure Prophylaxis to People Who Use Drugs and Experience Homelessness, Boston, MA, 2018-2020
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Download the PDF here
Download the PDF here
In Boston, MA, where HIV transmission among PWID experiencing homelessness has increased,41,42 the Boston Health Care for the Homeless Program (BHCHP) developed a low-threshold PrEP program that successfully linked 239 individuals to PrEP services in less than 2 years, with a cumulative probability of PrEP persistence at 6 months (assessed via prescription refills) of 44%,43 a level similar to those observed in other, more stably housed populations.44
While strategies deployed in BHCHP's PrEP program, including same-day PrEP prescribing and street-based navigation supports, likely contributed to these promising results, from the quantitative assessment described above, little information was available on the acceptability or perceived effectiveness of key program components. We thus conducted a qualitative study to identify key program components that participants and providers perceived as most helpful in supporting PrEP utilization, with the ultimate goal of informing subsequent research and programmatic efforts involving innovative PrEP delivery for PWID experiencing homelessness.
Despite high need, HIV preexposure prophylaxis (PrEP) utilization among people who use drugs (PWUD) remains low. Boston Health Care for the Homeless Program implemented an innovative "low-threshold" PrEP Program for PWUD experiencing homelessness in Boston, Massachusetts. From October 1, 2018 to February 29, 2020, 239 clients were linked to PrEP services, and 152 were prescribed PrEP (mean = 8.9/month), over twice the number of PrEP prescriptions over the previous 12 months (n = 48; mean = 4/month). The cumulative probability of remaining on PrEP for 6 months was 44% (95% confidence interval = 36%, 52%). (Am J Public Health. 2021;111:1045-1048
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Patient and Provider Perspectives on a Novel, Low-Threshold HIV PrEP Program for People Who Inject Drugs Experiencing Homelessness
Abstract
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.
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