(34) A Longitudinal Analysis of PrEP Eligibility Among Women who Inject Drugs

Background & Introduction: Addressing HIV risk in women who inject drugs (WWID) is key to ending the HIV epidemic. WWID experience heightened HIV risk due to structural, interpersonal, and psychosocial factors, including socioeconomic instability, housing and food insecurity, caretaking responsibilities, gender based violence, and transactional sex. Pre-exposure prophylaxis (PrEP) is a critical strategy for HIV prevention in WWID, as it does not require negotiation with sexual partners, which can be challenging for WWID due to underlying power dynamics. However, only 1-2% of WWID are currently taking PrEP. We aim to characterize the factors associated with longitudinal PrEP eligibility in WWID to inform PrEP implementation efforts.

Methods: Women participating in the AIDS Linked to the Intravenous Experience (ALIVE) Cohort Study from 2014-2020 in Baltimore, MD who were HIV-negative and had a history of injection drug use were included. Data on socio-demographic characteristics, substance use, depressive symptoms, and sexual and injection related HIV risk behaviors was collected at semi-annual visits with interviewer-administered and audio-computer-assisted standardized surveys. Symptoms of severe depression were defined as a score >23 on the Center for Epidemiologic Studies Depression Scale (CES-D). PrEP eligibility was defined using adapted Centers for Disease Control and Prevention criteria: 1) sex-related (2 or more sex partners with inconsistent condom use, partner with known HIV or who injects drugs, transactional sex, or bacterial sexually transmitted infection) and/or 2) drug-related (sharing needles or drug use equipment) in the past 6 months. Associations between individual factors and PrEP eligibility were estimated using unadjusted and adjusted logistic regression analysis with generalized estimating equations.

Results: Among 382 WWID, the average follow up was 3.1 ± 2.1 years. At baseline, women had a mean age of 49 years old, 69% were Black, 18% were married, and 41% were PrEP eligible. PrEP-eligible WWID frequently remained PrEP-eligible for 71% of study enrollment or a total of 2.2 ± 1.3 years. PrEP eligible WWID were younger (44 v. 52 years old; p< 0.01), more likely to be White (40% v. 13%; < 0.01), more frequently working (14% v. 8%; < 0.01), and more often had childcare responsibilities (32% v. 17%; < 0.01) compared to non PrEP-eligible WWID. Most PrEP eligible WWID (89%) met sex-related eligibility criteria secondary to a sex partner who injects drugs (79%), multiple sex partners with inconsistent condom use (41%), and transactional sex (40%). Injection related PrEP eligibility was also frequent (41% shared needles or drug use equipment). Notably, 62% of PrEP-eligible WWID reported minimal to no self-perceived risk of HIV. In adjusted analysis, younger age [adjusted odds ratio (95% confidence interval): 1.08 (1.06-1.10)], a high school education [1.45 (1.06-1.99)], being unhoused [1.42 (1.09-1.84)], recent incarceration [2.15 (1.24-3.73)], severe depression [1.28 (1.07-1.53)], and recent overdose [1.57 (1.13-2.18)] were associated with longitudinal PrEP eligibility.

Conclusion & Discussion: PrEP-eligibility, primarily driven by sex-related HIV risk behaviors, is common among WWID and persisted for nearly three quarters of study enrollment. WWID frequently underestimated their own HIV risk highlighting the importance of addressing HIV risk discordance when improving PrEP services for WWID. Longitudinal PrEP eligibility was associated with unstable housing, criminal legal involvement, severe depression and recent overdose, emphasizing the complexities of daily lives of PrEP-eligible WWID. PrEP implementation strategies could consider incorporating substance use disorder & mental health treatment, housing services, and legal assistance for justice-involved women to meet the most salient needs of WWID and increase PrEP uptake in this high priority population.

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