Oral pre-exposure prophylaxis (PrEP) receipt and persistence among opioid-dependent people who inject drugs initiating PrEP for HIV prevention

Abstract

Background: The opioid crisis in the United States has led to climbing overdose rates, alongside HIV outbreaks among people who inject drugs (PWID). One area of the pre-exposure prophylaxis (PrEP) cascade that has received little attention is the persistence of PrEP, especially among PWID. To address this gap, this study examined the receipt, persistence, and factors associated with PrEP persistence among opioid-dependent PWID.

Methods: Between December 2020 and July 2022, we enrolled 100 opioid-dependent PWID. Eligible participants received a 90-day PrEP prescription from a community-based syringe services program and were followed up at 3 and 6 months. We assessed sociodemographic characteristics, PrEP use, and behaviors related to sex and drug use. We evaluated persistence on PrEP by calculating how many times each participant continued to pick up their PrEP prescription. To identify factors associated with persistence on PrEP, we used a multivariable ordinal logistic regression.

Results: On average, participants were in their early 40s (mean age: 44.5, SD: 10.0 years), male (63.0 %), and unemployed (89.0 %). The majority (64.0 %) reported injecting drugs at least once per week in the past month, and 79.0 % had never used PrEP before. A total of 60 participants picked-up PrEP at least once during the 6-month follow-up period, with 42 (70.0 %) retrieving it only once, 16 (26.7 %) twice, and 2 (3.3 %) picking it up three times. In the multivariable model, unemployment (aOR = 7.819; 95 % CI: 1.538-39.751) and prior PrEP use (aOR = 3.381; 95 % CI: 1.210-9.443) were associated with higher persistence on PrEP, whereas participants who injected drugs once a week or less (aOR = 0.039; 95 % CI: 0.008-0.182) or more than once a week in the past month (aOR = 0.098; 95 % CI: 0.029-0.329) were less likely to consistently retrieve PrEP.

Conclusions: Despite a high willingness to use PrEP among opioid-dependent, PrEP-naïve PWID in general, the adoption and persistence of PrEP were low in this study. Given that PWID represent a marginalized group at significant risk for HIV, these findings highlight the urgent need for comprehensive strategies to enhance the PrEP continuum of care by addressing the unique and diverse needs of this subgroup.

Keywords: HIV; Opioid use disorder; People who inject drugs; Pre-exposure prophylaxis; Syringe services program.