(3) HIV/PrEP Knowledge, Perceived Risk, and Attitudes Among PWID After a Hospital Intervention

Background & Introduction: Despite the proven efficacy of pre-exposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV), uptake remains disproportionately low among persons who inject drugs (PWID) [1]. Multi-level barriers were reported for PrEP in PWID. These include the individual, interpersonal, health system/clinic, and structural levels [2]. In addition, existing PrEP interventions focus on sexual transmission risk, with fewer tailored strategies addressing HIV prevention for PWID. As such, there is limited research on PrEP education specifically for PWID [3].

Hospitalization represents an underutilized opportunity to engage PWID in HIV prevention education, as patients may be medically stabilized and receptive to supportive interventions. However, standardized, feasible inpatient PrEP education models are limited. This pilot study evaluated changes of knowledge and risk perception of HIV, attitude to PrEP, as well as patient acceptability of a brief, bedside PrEP education intervention delivered to hospitalized PWID. We aimed to study and to improve PrEP knowledge, attitudes, and readiness.

Methods: We conducted a hospital-based pilot intervention among hospitalized adults with a history of injection drug use at Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania between April and September 2025. Eligible participants were ≥ 18 years old, HIV-negative, and medically stable to engage in a brief educational session. Participants were identified by certified recovery specialists within addiction consult services and provided written consent.

The University of Pennsylvania IRB determined the evaluation was a quality improvement initiative and did not meet the human subject research definition. Participants completed a REDCap pre-intervention survey assessing baseline PrEP knowledge, HIV risk perception, and attitudes toward HIV prevention. After standardization, one-on-one PrEP education interventions were delivered bedside during inpatient downtime by trained, non-physician educators. Sessions averaged 25 minutes and included verbal education paired with a visual online presentation. Immediately following the session, participants completed a post-intervention survey assessing changes in knowledge, risk perception, attitudes, confidence, and acceptability. Participants were given a 25-dollar gift card upon completion.

Demographics and clinical characteristics were collected through chart review. Descriptive statistics and paired analyses (McNemar and Wilcoxon signed-rank tests) were used to evaluate pre–post changes. Bivariate exploratory analyses were conducted via chi-square analyses.

Results: Baseline Characteristics: Forty-five hospitalized adult PWID completed both the pre- and post-intervention surveys. Participants had a mean age of 41 years, 87% were insured through Medicaid, and 58% reported polysubstance use. 51% were male and 49% were female. Participants were predominantly White (69%). Mean number of hospitalizations/ED visits in the past year was ten. Despite 69% having heard of PrEP, only 27% had ever discussed it with a healthcare provider. HIV risk behaviors were common, including sharing injection equipment (36%), transactional sex, (38%) and condomless sex (42%).

Pre/Post Knowledge, Perceived Risk, and Attitudes: Following the intervention, participants demonstrated significant improvements in fundamental PrEP knowledge. The proportion correctly identifying PrEP as HIV prevention increased from 62% to 82% (p = 0.02), and knowledge that oral PrEP must be taken daily increased from 31% to 80% (p < .01). Smaller, non-significant improvements were observed in knowledge of HIV transmission routes, including sharing needles, unprotected sex, and rejection of common misconceptions (e.g., kissing and toilet seats).

In contrast, self-perceived HIV risk did not significantly change following the intervention (p = 0.72), despite high baseline engagement in HIV risk behaviors. More than 50% of patients reported low to no perceived risk of HIV before the intervention and 70% reported low to no perceived risk after the intervention. Additionally, PrEP-related concerns and access barriers (e.g., cost, transportation, side effects, storage) showed little change following the intervention.

Participants reported high confidence and readiness for PrEP engagement. Post-intervention, 89% reported confidence in their ability to ask a healthcare provider about PrEP, and 80% felt more informed about reducing their HIV risk.

Although participants reported high motivation and confidence around HIV prevention, translation into care-seeking remained limited: 96% felt more motivated and 80% felt more informed, yet only 58% would consider taking PrEP if offered and just 24% were likely to follow up with a clinic or provider. Despite this gap, acceptability of the intervention was high, with 88% recommending the session and two participants initiating PrEP prior to discharge.

Exploratory Bivariate Associations: Willingness to take PrEP was significantly higher among participants reporting polysubstance use compared to opioid-only use (81% vs. 22%, p < 0.01) or with a history of transactional sex (76.5% vs. 38.5%, p = .03). Additionally, gender was significantly associated with transactional sex, with a higher proportion of female participants reporting prior transactional sex compared to male participants (57% vs. 19%, p = 0.03).

Conclusion & Discussion: Our study showed that a brief bedside PrEP education intervention delivered to hospitalized PWID significantly improved foundational PrEP knowledge and confidence in discussing PrEP with healthcare providers. The intervention was feasible and well received, supporting hospitalization as a key opportunity for HIV prevention engagement among PWID with frequent healthcare utilization. Despite improvements in knowledge and confidence, perceived HIV risk and readiness to initiate PrEP remained largely unchanged, highlighting a persistent disconnect between objective risk and subjective risk appraisal.

These findings suggest that PrEP education alone is insufficient to drive PrEP uptake. Consistent with prior literature, participants demonstrated increased awareness but continued ambivalence toward initiation, indicating that motivational, behavioral, and structural barriers influence prevention decision-making [4]. Exploratory analyses further suggested greater PrEP receptivity among participants reporting polysubstance use or transactional sex. Future interventions should incorporate navigation support, motivational interviewing, and linkage to outpatient care to improve PrEP uptake. Given the frequent healthcare utilization observed in this population, hospitals represent a critical and underutilized setting for PrEP evaluation for PWID.

Limitations of this pilot study included a small sample size leading to limited power for subgroup analyses, and lack of longitudinal follow-up on PrEP initiation.

References: [1] Streed CG Jr, Morgan JR, Gai MJ, Larochelle MR, Paasche-Orlow MK, Taylor JL. Prevalence of HIV Preexposure Prophylaxis Prescribing Among Persons With Commercial Insurance and Likely Injection Drug Use. JAMA Netw Open. 2022;5(7):e2221346. Published 2022 Jul 1. doi:10.1001/jamanetworkopen.2022.21346

[2] Biello KB, Mimiaga MJ, Valente PK, Saxena N, Bazzi AR. The Past, Present, and Future of PrEP implementation Among People Who Use Drugs. Curr HIV/AIDS Rep. 2021;18(4):328-338. doi:10.1007/s11904-021-00556-z

[3] Merle JL, Zapata JP, Quieroz A, et al. Pre-exposure prophylaxis (PrEP) among people who use drugs: a qualitative scoping review of implementation determinants and change methods. Addict Sci Clin Pract. 2024;19(1):46. Published 2024 May 30. doi:10.1186/s13722-024-00478-2

[4] Schneider KE, White RH, Musci RJ, et al. The Relationship Between Polysubstance Injection Drug Use, HIV Risk Behaviors, and Interest in Pre-Exposure Prophylaxis (PrEP) Among People Who Inject Drugs in Rural West Virginia. J Stud Alcohol Drugs. 2020;81(6):740-749. doi:10.15288/jsad.2020.81.740

[5] Nerlander LM, Hess KL, Rose CE, et al. Exchange Sex and HIV Infection Among Women Who Inject Drugs-20 US Cities, 2009. J Acquir Immune Defic Syndr. 2017;75 Suppl 3(Suppl 3):S333-S340. doi:10.1097/QAI.0000000000001408