Skip to main content

Advertisement

Log in

Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

The opioid crisis has increased risks for injection drug use-associated HIV outbreaks in rural communities throughout the United States. Existing research has examined pre-exposure prophylaxis (PrEP) utilization among people who inject drugs (PWID); however, no studies have been conducted to explore barriers and facilitators of PrEP use among rural PWID in Appalachia. We conducted qualitative interviews with PWID (n = 48) in two rural counties in West Virginia to explore barriers and facilitators of PrEP use. Among our participants, the majority (68.8%) had never heard of PrEP. Upon learning about PrEP, most participants expressed willingness to use it. Rural PWID described several factors that may impede PrEP utilization (e.g., housing instability, forgetting to take PrEP). Participants also identified practical strategies to support sustained PrEP utilization, such as integrating PrEP services into venues PWID access. This research provides important insights into the barriers and facilitators of PrEP utilization among rural PWID.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Centers for Disease Control and Prevention. HIV among people who inject drugs. https://www.cdc.gov/hiv/group/hiv-idu.html. Accessed 19 Aug 2019.

  2. Centers for Disease Control and Prevention. Lifetime risk of HIV diagnosis: half of black gay men and a quarter of Latino gay men projected to be diagnosed within their lifetime [Press Release]. https://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html. Accessed 19 Aug 2019.

  3. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013. MMWR. 2015;64(26):719–25.

    PubMed  PubMed Central  Google Scholar 

  4. Zibbell JE, Asher AK, Patel RC, Kupronis B, Iqbal K, Ward JW, et al. Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018;108(2):175–81.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Van Handel MM, Rose CE, Hallisey EJ, Kolling JL, Zibbell JE, Lewis B, et al. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 2016;73(3):323–31.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Allen ST, Grieb SM, O’Rourke A, Yoder R, Planchet E, White RH, et al. Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs. Harm Reduct J. 2019;16(1):33.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Havens JR, Oser CB, Leukefeld CG. Injection risk behaviors among rural drug users: implications for HIV prevention. AIDS Care. 2011;23(5):638–45.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Reif S, Golin CE, Smith SR. Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences. AIDS Care. 2005;17(5):558–65.

    Article  CAS  PubMed  Google Scholar 

  9. Crosby RA, Yarber WL, DiClemente RJ, Wingood GM, Meyerson B. HIV-associated histories, perceptions, and practices among low-income African American women: does rural residence matter? Am J Public Health. 2002;92(4):655–9.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Gamm LD. Mental health and substance abuse services among rural minorities. J Rural Health. 2004;20(3):206–9.

    Article  PubMed  Google Scholar 

  11. Sung H-E, Mahoney AM, Mellow J. Substance abuse treatment gap among adult parolees: prevalence, correlates, and barriers. Crim Justice Rev. 2011;36(1):40–57.

    Article  Google Scholar 

  12. Sexton RL, Carlson RG, Leukefeld CG, Booth BM. Barriers to formal drug abuse treatment in the rural south: a preliminary ethnographic assessment. J Psychoact Drugs. 2008;40(2):121–9.

    Article  Google Scholar 

  13. Staton-Tindall M, Webster JM, Oser CB, Havens JR, Leukefeld CG. Drug use, hepatitis C, and service availability: perspectives of incarcerated rural women. Soc Work Public Health. 2015;30(4):385–96.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Centers for Disease Control and Prevention. PrEP. https://www.cdc.gov/hiv/basics/prep.html. Accessed 19 Aug 2019.

  15. Centers for Disease Control and Prevention. CDC statement on FDA approval of drug for HIV prevention [Press Release]. https://www.cdc.gov/nchhstp/newsroom/2012/fda-approvesdrugstatement.html. Accessed 19 Aug 2019.

  16. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 Update: a clinical practice guideline. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. Accessed 19 Aug 2019.

  17. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–34.

    Article  CAS  PubMed  Google Scholar 

  19. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Centers for Disease Control and Prevention. Injection drug use and hiv risk. https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf. Accessed 12 Dec 2019.

  21. Alpren C, Dawson EL, John B, Cranston K, Panneer N, et al. Opioid use fueling HIV transmission in an urban setting: an outbreak of HIV infection among people who inject drugs-Massachusetts, 2015-2018. Am J Public Health. 2020;110(1):37–44.

    Article  PubMed  PubMed Central  Google Scholar 

  22. US Preventive Services Task Force. Preexposure prophylaxis for the prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;321(22):2203–13.

    Article  Google Scholar 

  23. Centers for Disease Control and Prevention. HIV prevention pill not reaching most Americans who could benefit—especially people of color [Press Release]. https://www.cdc.gov/nchhstp/newsroom/2018/croi-2018-PrEP-press-release.html. Accessed 19 Aug 2019.

  24. AIDSVu. Mapping PrEP: first ever data on PrEP users across the U.S. https://aidsvu.org/prep/. Accessed 19 Aug 2019.

  25. Stein M, Thurmond P, Bailey G. Willingness to use HIV pre-exposure prophylaxis among opiate users. AIDS Behav. 2014;18(9):1694–700.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Walters SM, Reilly KH, Neaigus A, Braunstein S. Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention. Harm Reduct J. 2017;14(1):40.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Walters SM, Rivera AV, Starbuck L, Reilly KH, Boldon N, Anderson BJ, et al. Differences in awareness of pre-exposure prophylaxis and post-exposure prophylaxis among groups at-risk for HIV in New York State: New York City and Long Island, NY, 2011-2013. J Acquir Immune Defic Syndr. 2017;75(Suppl 3):S383–91.

    Article  PubMed  Google Scholar 

  28. Kuo I, Olsen H, Patrick R, Phillips G 2nd, Magnus M, Opoku J, et al. Willingness to use HIV pre-exposure prophylaxis among community-recruited, older people who inject drugs in Washington, DC. Drug Alcohol Depend. 2016;164:8–13.

    Article  PubMed  Google Scholar 

  29. Sherman SG, Schneider KE, Park JN, Allen ST, Hunt D, Chaulk CP, et al. PrEP awareness, eligibility, and interest among people who inject drugs in Baltimore, Maryland. Drug Alcohol Depend. 2019;195:148–55.

    Article  PubMed  Google Scholar 

  30. Escudero DJ, Kerr T, Wood E, Nguyen P, Lurie MN, Sued O, et al. Acceptability of HIV pre-exposure prophylaxis (PREP) among people who inject drugs (PWID) in a Canadian Setting. AIDS Behav. 2015;19(5):752–7.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Pinto RM, Berringer KR, Melendez R, Mmeje O. Improving PrEP implementation through multilevel interventions: a synthesis of the literature. AIDS Behav. 2018;22(11):3681–91.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Mayer KH, Chan PA, Patel RR, Flash CA, Krakower DS. Evolving models and ongoing challenges for HIV preexposure prophylaxis implementation in the United States. J Acquir Immune Defic Syndr. 2018;77(2):119–27.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mack N, Odhiambo J, Wong CM, Agot K. Barriers and facilitators to pre-exposure prophylaxis (PrEP) eligibility screening and ongoing HIV testing among target populations in Bondo and Rarieda, Kenya: results of a consultation with community stakeholders. BMC Health Serv Res. 2014;14(1):231.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ojikutu BO, Bogart LM, Higgins-Biddle M, Dale SK, Allen W, Dominique T, et al. Facilitators and barriers to pre-exposure prophylaxis (PrEP) use among black individuals in the United States: results from the National Survey on HIV in the Black Community (NSHBC). AIDS Behav. 2018;22(11):3576–87.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rice WS, Stringer KL, Sohail M, Crockett KB, Atkins GC, Kudroff K, et al. Accessing pre-exposure prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama. AIDS Behav. 2019;23:2966–79.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Petroll AE, Walsh JL, Owczarzak JL, McAuliffe TL, Bogart LM, Kelly JA. PrEP awareness, familiarity, comfort, and prescribing experience among US primary care providers and HIV specialists. AIDS Behav. 2017;21(5):1256–67.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Bazzi AR, Biancarelli DL, Childs E, Drainoni ML, Edeza A, Salhaney P, et al. Limited knowledge and mixed interest in pre-exposure prophylaxis for HIV prevention among people who inject drugs. AIDS Patient Care STDs. 2018;32(12):529–37.

    Article  PubMed  PubMed Central  Google Scholar 

  38. US Census Bureau. 2010 Census Urban and Rural Classification and Urban Area Criteria.

  39. Bernard HR, Wutich A, Ryan GW. Analyzing qualitative data: systematic approaches. Thousand oaks: SAGE; 2016.

    Google Scholar 

  40. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.

    Article  Google Scholar 

  41. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37–46.

    Article  Google Scholar 

  42. Nash B. Cabell County HIV cluster climbs to 53 cases. Huntington Hearld-Dispatch. 2019-06-22. https://www.herald-dispatch.com/news/cabell-county-hiv-cluster-climbs-to-cases/article_0d1f73cc-9491-11e9-8bc2-431f0c058403.html. Accessed 19 Aug 2019.

  43. Allen ST, O’Rourke A, White RH, Schneider KE, Kilkenny M, Sherman SG. Estimating the number of people who inject drugs in a rural county in Appalachia. Am J Public Health. 2019;109(3):445–50.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Biello KB, Bazzi AR, Mimiaga MJ, Biancarelli DL, Edeza A, Salhaney P, et al. Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs. Harm Reduct J. 2018;15(1):55.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Calabrese SK, Earnshaw VA, Underhill K, et al. Prevention paradox: medical students are less inclined to prescribe HIV pre-exposure prophylaxis for patients in highest need. J Int AIDS Soc. 2018;21(6):e25147.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Adams LM, Balderson BH. HIV providers’ likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report. AIDS Care. 2016;28(9):1154–8.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet. 2010;376(9737):285–301.

    Article  PubMed  Google Scholar 

  48. Canary L, Hariri S, Campbell C, Young R, Whitcomb J, Kaufman H, et al. Geographic disparities in access to syringe services programs among young persons with hepatitis C virus infection in the United States. Clin Infect Dis. 2017;65(3):514–7.

    Article  PubMed  Google Scholar 

  49. Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas—United States, 2013. MMWR. 2015;64(48):1337–41.

    PubMed  Google Scholar 

  50. Brown R. Cabell-Huntington Health Department to begin prescribing PrEP to curb spread of HIV. WCHSTV. 2019-04-25. https://wchstv.com/news/local/cabell-huntington-health-department-to-begin-prescribing-prep-to-curb-spread-of-hiv. Accessed 19 Aug 2019.

  51. US Census Bureau. QuickFacts: Cabell County, West Virginia. US Census Bureau, 2018. https://www.census.gov/quickfacts/cabellcountywestvirginia. Accessed 19 Aug 2019.

  52. US Census Bureau. QuickFacts: Kanawha County, West Virginia. US Census Bureau, 2018. https://www.census.gov/quickfacts/kanawhacountywestvirginia. Accessed 19 Aug 2019.

Download references

Acknowledgements

This research was supported by a Grant from the Bloomberg American Health Initiative at the Johns Hopkins Bloomberg School of Public Health to Dr. Sean T. Allen. This research has been facilitated by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), and by the District of Columbia Center for AIDS Research, an NIH funded program (AI117970). STA and GML are supported by the National Institutes of Health (K01DA046234, K24DA035684). The funders had no role in study design, data collection, or in analysis and interpretation of the results, and this paper does not necessarily reflect views or opinions of the funders. We are grateful to our study participants.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sean T. Allen.

Ethics declarations

Conflict of interest

Dr. Susan Sherman is an expert witness in ongoing opioid litigation. No other authors have any conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Allen, S.T., O’Rourke, A., White, R.H. et al. Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study. AIDS Behav 24, 1942–1950 (2020). https://doi.org/10.1007/s10461-019-02767-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10461-019-02767-3

Keywords

Navigation