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An Exploration of Pre-exposure Prophylaxis (PrEP) Initiation Among Women Who Inject Drugs

Abstract

Pre-exposure prophylaxis (PrEP) is an effective but understudied tool for preventing HIV among women who inject drugs (WWID). This article is the first to explore WWID’s rationale for PrEP initiation (or refusal) in a real-world setting. Purposive sampling was used to recruit 25 WWID, participating in a PrEP demonstration project operating within a syringe services program, based on whether they initiated or declined PrEP care. Content analysis of qualitative interviews was used to explore decisions to initiate PrEP (or not). We found that WWID view HIV as severe, perceive themselves to be susceptible to HIV, and believe PrEP is beneficial for HIV prevention. For some, however, real and perceived barriers outweighed benefits, leading to decisions not to initiate PrEP. Barriers included HIV stigma, fear of side effects, and needing assurance that PrEP care will be available long-term. Despite viewing PrEP as an important HIV prevention tool, not all WWID who were offered PrEP initiated it. For these women, supports to buffer perceived barriers to initiation and access to post-exposure prophylaxis may be warranted. For women who initiate, it is possible that adherence will wane if perceived risk does not remain high. Research to understand PrEP persistence is needed.

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References

  1. Auerbach, J. D., Kinsky, S., Brown, G., & Charles, V. (2015). Knowledge, attitudes, and likelihood of Pre-Exposure Prophylaxis (PrEP) use among US women at risk of acquiring HIV. AIDS Patient Care and STDs,29(2), 102–110.

    Article  Google Scholar 

  2. Baeten, J. M., Donnell, D., & Ndase, P. (2012). Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. New England Journal of Medicine,367, 399–410.

    Article  Google Scholar 

  3. Bazeley, P., & Jackson, K. (2013). Qualitative data analysis with NVivo. London: Sage Publications Limited.

    Google Scholar 

  4. Becher, M. (1974). The health belief model and personal health behavior. Health Education Monographs,2, 324–373.

    Article  Google Scholar 

  5. Biello, K., Bazzi, A., Mimiaga, M., Biancarelli, D., Edeza, A., Salhaney, P., … Drainoni, M. (2018). Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs. Harm Reduction Journal,15(1), 55. https://doi.org/10.1186/s12954-018-0263-5.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bourgois, P., Prince, B., & Moss, A. (2004). The everyday violence of hepatitis C among young women who inject drugs in San Francisco. Human Organization,63(3), 253–264.

    Article  Google Scholar 

  7. Bryant, J., Brener, L., Hull, P., & Treloar, C. (2010). Needle sharing in regular sexual relationships: An examination of serodiscordance, drug using practices, and the gendered character of injecting. Drug and Alcohol Dependence,107(2–3), 182–187.

    Article  Google Scholar 

  8. Bush, S., Magnuson, D., Rawlings, M., Hawkins, T., McCallister, S., & Mera Giler, R. (2016). Racial characteristics of FTC/TDF for pre-exposure prophylaxis (PrEP) users in the US. Paper presented at ASM Microbe 2016, Boston, MA.

  9. Centers for Disease Control and Prevention. (2017). Preexposure prophylaxis for the prevention of HIV infection in the United States–2017 update. Retrieved January 5, 2017 from https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf.

  10. Centers for Disease Control and Prevention. (2018). HIV surveillance report, 2017. Retrieved December 1, 2018 from http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

  11. Centers for Disease Control and Prevention. (2019). HIV in the United States and dependent areas. Retrieved September 15, 2019 from https://www.cdc.gov/hiv/statistics/overview/ataglance.html.

  12. Chan, P. A., Glynn, T. R., Oldenburg, C. E., Montgomery, M. C., Robinette, A. E., Almonte, A., … Nunn, A. S. (2016). Implementation of preexposure prophylaxis for human immunodeficiency virus prevention among men who have sex with men at a New England sexually transmitted diseases clinic. Sexually Transmitted Diseases,43(11), 717–723.

    Article  Google Scholar 

  13. Choopanya, K., Martin, M., & Suntharasamai, P. (2013). Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): A randomised, double-blind, placebo-controlled phase 3 trial. The Lancet,381, 2083–2090.

    Article  Google Scholar 

  14. Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry,71(7), 821–826.

    Article  Google Scholar 

  15. Davey-Rothwell, M. A., & Latkin, C. A. (2007). Gender differences in social network influence among injection drug users: Perceived norms and needle sharing. Journal of Urban Health,84(5), 691–703.

    Article  Google Scholar 

  16. Decker, M. R., Wirtz, A. L., Baral, S. D., Peryshkina, A., Mogilnyi, V., Weber, R. A., … Beyrer, C. (2012). Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. Sexually Transmitted Infections,88(4), 278–283.

    Article  Google Scholar 

  17. El-Bassel, N., Shaw, S. A., Dasgupta, A., & Strathdee, S. A. (2014). People Who Inject Drugs in intimate relationships: It takes two to combat HIV. Current HIV/AIDS Reports,11(1), 45–51.

    Article  Google Scholar 

  18. Escudero, D. J., Kerr, T., Wood, E., Nguyen, P., Lurie, M. N., Sued, O., & Marshall, B. D. L. (2015). Acceptability of HIV Pre-exposure Prophylaxis (PrEP) among people who inject drugs (PWID) in a Canadian setting. AIDS and Behavior,19(5), 752–757.

    Article  Google Scholar 

  19. Felsher, M., Szep, Z., Krakower, D., Martinez-Donate, A., Tran, N., & Roth, A. M. (2018). “I don’t need PrEP right now”: A qualitative exploration of the barriers to PrEP care engagement through the application of the Health Belief Model. AIDS Education and Prevention,30(5), 369–381.

    Article  Google Scholar 

  20. Galea, J. T., Kinsler, J. J., Salazar, X., Lee, S.-J., Giron, M., Sayles, J. N., … Cunningham, W. E. (2011). Acceptability of Pre-Exposure Prophylaxis (PrEP) as an HIV prevention strategy: Barriers and facilitators to PrEP uptake among at-risk Peruvian populations. International Journal of STD and AIDS,22(5), 256–262.

    Article  Google Scholar 

  21. Gelberg, L., Andersen, R. M., & Leake, B. D. (2000). The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Services Research,34(6), 1273–1302.

    PubMed  PubMed Central  Google Scholar 

  22. Gowing, L., Ali, R., & White, J. M. (2017). Opioid antagonists with minimal sedation for opioid withdrawal. Cochrane Database of Systematic Reviews,5, CD002021. https://doi.org/10.1002/14651858.CD002021.pub4.

    Article  PubMed  Google Scholar 

  23. Grant, R. M., Lama, J. R., & Anderson, P. L. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine,363, 2587–2599.

    Article  Google Scholar 

  24. Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015). Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013. Morbidity and Mortality Weekly Report,64(26), 719–725.

    PubMed  PubMed Central  Google Scholar 

  25. Kelesidis, T., & Landovitz, R. J. (2011). Preexposure prophylaxis for HIV prevention. Current HIV/AIDS Reports,8(2), 94–103.

    Article  Google Scholar 

  26. Koechlin, F. M., Fonner, V. A., Dalglish, S. L., O’Reilly, K. R., Baggaley, R., Grant, R. M., … Kennedy, C. E. (2017). Values and preferences on the use of oral pre-exposure prophylaxis (PrEP) for HIV prevention among multiple populations: a systematic review of the literature. AIDS and Behavior,21(5), 1325–1335.

    Article  Google Scholar 

  27. Miles, M. B., Huberman, A. M., & Saldana, J. (2013). Qualitative data analysis. Thousand Oaks, CA: Sage.

    Google Scholar 

  28. Mustanski, B., Johnson, A. K., Garofalo, R., Ryan, D., & Birkett, M. (2013). Perceived likelihood of using HIV pre-exposure prophylaxis medications among young men who have sex with men. AIDS and Behavior,17(6), 2173–2179.

    Article  Google Scholar 

  29. Nyamathi, A. M., Lewis, C., Leake, B., Flaskerud, J., & Bennett, C. (1995). Barriers to condom use and needle cleaning among impoverished minority female injection drug users and partners of injection drug users. Public Health Reports,110(2), 166–172.

    PubMed  PubMed Central  Google Scholar 

  30. Philbin, M. M., Parker, C. M., Parker, R. G., Wilson, P. A., Garcia, J., & Hirsch, J. S. (2016). The promise of pre-exposure prophylaxis for black men who have sex with men: an ecological approach to attitudes, beliefs, and barriers. AIDS Patient Care STDs,30(6), 282–290.

    Article  Google Scholar 

  31. Roth, A. M., Goldshear, J. L., Martinez-Donate, A. P., Welles, S., Chavis, M., & Van Der Pol, B. (2016). Reducing missed opportunities: Pairing sexually transmitted infection screening with syringe exchange services. Sexually Transmitted Diseases,43(11), 706–708.

    Article  Google Scholar 

  32. Roth, A. M., Kral, A. H., Mitchell, A., Mukherjee, R., Davidson, P., & Lankenau, S. E. (2019). Overdose prevention site acceptability among residents and businesses surrounding a proposed site in Philadelphia, USA. Journal of Urban Health,96, 394–404.

    Article  Google Scholar 

  33. Shrestha, R., & Copenhaver, M. (2018). Exploring the use of Pre-exposure Prophylaxis (PrEP) for HIV prevention among high-risk people who use drugs in treatment. Frontiers in Public Health,6, 195. https://doi.org/10.3389/fpubh.2018.00195.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Smith, D. K., Toledo, L., Smith, D. J., Adams, M. A., & Rothenberg, R. (2012). Attitudes and program preferences of African-American urban young adults about Pre-Exposure Prophylaxis (PrEP). AIDS Education and Prevention,24(5), 408–421.

    Article  Google Scholar 

  35. Spinner, C. D., Boesecke, C., Zink, A., Jessen, H., Stellbrink, H.-J., Rockstroh, J. K., & Esser, S. (2016). HIV pre-exposure prophylaxis (PrEP): A review of current knowledge of oral systemic HIV PrEP in humans. Infection,44(2), 151–158.

    Article  Google Scholar 

  36. Stein, J. A., Andersen, R., & Gelberg, L. (2007). Applying the Gelberg-Andersen behavioral model for vulnerable populations to health services utilization in homeless women. Journal of Health Psychology,12(5), 791–804.

    Article  Google Scholar 

  37. Syvertsen, J. L., Robertson, A. M., Strathdee, S. A., Martinez, G., Rangel, M. G., & Wagner, K. D. (2014). Rethinking risk: Gender and injection drug-related HIV risk among female sex workers and their non-commercial partners along the Mexico–US border. International Journal of Drug Policy,25(5), 836–844.

    Article  Google Scholar 

  38. Thigpen, M. C., Kebaabetswe, P. M., & Paxton, L. A. (2012). Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. New England Journal of Medicine,367, 423–434.

    Article  Google Scholar 

  39. Tyler, K. A., & Wright, J. D. (2019). Homelessness and sexual assault. In W. T. O’Donohue & P. A. Schewe (Eds.), Handbook of sexual assault and sexual assault prevention (pp. 693–707). New York: Springer.

    Chapter  Google Scholar 

  40. Ulin, P. R., Robinson, E. T., & Tolley, E. E. (2012). Qualitative methods in public health: A field guide for applied research. San Francisco: Wiley.

    Google Scholar 

  41. Worth, D. (1989). Sexual decision-making and AIDS: Why condom promotion among vulnerable women is likely to fail. Studies in Family Planning,20(6), 297–307.

    Article  Google Scholar 

  42. Young, I., Flowers, P., & McDaid, L. M. (2014). Barriers to uptake and use of pre-exposure prophylaxis (PrEP) among communities most affected by HIV in the UK: findings from a qualitative study in Scotland. BMJ Open,4(11), 1–8. https://doi.org/10.1136/bmjopen-2014-005717

    Article  Google Scholar 

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Acknowledgements

The authors thank the participants, Prevention Point Philadelphia especially former/current staff members: Jennie Coleman, Jade McKnight, Samantha Sitrin, Rose Lurano, Elby Katumkeeryil, and the dedicated research staff: Brogan Piecara, Bolutife Odeniyi, Brenna Aumaeir-Aredas, Dr. Annette Gadebeku, and Dr. Alicia Tucker.

Funding

This study was supported by the National Institute on Drug Abuse (1R21DA043417-01A1) and the American STD Association Developmental Award Program.

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Correspondence to Alexis M. Roth.

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Study procedures were approved by the Drexel University Institutional Review Board (ID 1704005331) and the Prevention Point Philadelphia Executive Board.

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Felsher, M., Ziegler, E., Smith, L.R. et al. An Exploration of Pre-exposure Prophylaxis (PrEP) Initiation Among Women Who Inject Drugs. Arch Sex Behav 49, 2205–2212 (2020). https://doi.org/10.1007/s10508-020-01684-0

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Keywords

  • HIV
  • Pre-exposure prophylaxis
  • Women who inject drugs
  • Health belief model