(2) PrEP Eligibility Among People Who Use Drugs Accessing Opioid Treatment Programs

Background & Introduction: People who use drugs (PWUD) experience heightened HIV risk; however, pre-exposure prophylaxis (PrEP) uptake is minimal (0-3%) in this population. Multilevel barriers at the patient, provider, and system levels, including inaccessible locations to receive PrEP, low provider willingness to prescribe PrEP to PWUD, limited awareness of PrEP, and competing priorities, such as food, housing, and economic insecurity, all inhibit PrEP uptake among PWUD. Opioid treatment programs (OTPs) are a promising setting with the potential to address these barriers and increase PrEP uptake for PWUD. However, little is known about PrEP eligibility among PWUD accessing OTPs. To address this gap, we assessed the prevalence of PrEP eligibility and the factors associated with PrEP eligibility among PWUD accessing OTPs to direct PrEP implementation efforts.

Methods: We conducted a cross-sectional secondary analysis of baseline data from a randomized controlled trial evaluating hepatitis C virus (HCV) treatment strategies from 2021 to 2023 at five North American OTPs (two in Baltimore, Maryland, and one in each of Alabaster, Alabama, San Francisco, California, and Toronto, Canada). We assessed PrEP eligibility among PWUD with reactive HCV antibodies who did not have HIV. PrEP eligibility was defined using adapted Centers for Disease Control and Prevention criteria for sex and/or injection-related HIV risk behaviors as either 1) sex-related [>1 sex partner with inconsistent condom use, sex partner with HIV, transactional sex, or a recent sexually transmitted infection (STI)] in the past 90 days and/or 2) injection-related (sharing needles/ drug use equipment) within the prior six months. Food insecurity was defined as a positive response to either of the two questions on the validated Hunger Vital Sign screening tool. Recent substance use (opioid/ cocaine/ amphetamine) and injection drug use (IDU) in the past month was self-reported. Univariable and multivariable logistic regression models were used to assess factors associated with PrEP eligibility.

Results: Of 177 participants, the mean age was 48 (standard deviation (SD): 12 years), 102 (58%) were male, 108 (61%) were white, 78% (138/176) had HCV viremia, and most were in Baltimore (72%; 127/177). Recent substance use was common: 38% (68/177) used opioids, 15% (26/177) used amphetamines, 41% (73/177) used cocaine, and 28% (49/177) had injected drugs. Twenty-one percent of PWUD (38/177) met PrEP eligibility criteria, based on injection-related (55%; 21/38) and/or sex-related criteria (50%; 19/38). Among them, 79% (30/38) had >1 sexual partner with inconsistent condom use, 21% (8/38) engaged in transactional sex, 21% (8/38) had a sex partner with HIV, 8% (3/38) had a recent STI, 53% (20/38) shared drug use equipment, and/or 24% (9/38) shared needles. Compared to non-PrEP-eligible PWUD, PrEP-eligible PWUD were younger (41 vs. 50 years old; p< 0.01), located in Toronto (29% vs. 5%; p< 0.01), unhoused (47% vs. 23%; p< 0.01), reported food insecurity (79% vs. 53%; p< 0.01), and had recent opioid (58% vs. 33%; p< 0.01) and amphetamine use (39% vs. 8%; p< 0.01). In adjusted analyses, PrEP eligibility was associated with younger age [adjusted odds ratio (95% confidence interval): 0.95 (0.90-0.99)], food insecurity [2.75 (1.02-7.42)], and recent amphetamine use [4.60 (1.55-13.7)].

Conclusion & Discussion: In a multi-site study, we found that PrEP eligibility was frequent and associated with food insecurity and amphetamine use among PWUD accessing OTPs. PrEP-eligible participants were also more likely to be from Toronto, underscoring the importance of tailoring PrEP implementation strategies to local epidemiology. Our study is limited by a history of HCV infection in all study participants, which may reflect heightened HIV risk factors compared to the general population of PWUD. Additionally, HIV infection status was not known for all sexual partners of study participants, which may have led to underestimating HIV risk among PWUD engaged in condomless sex with one sexual partner. Nonetheless, our study findings suggest that integrating PrEP services and medications for opioid use disorder, alongside services that address food insecurity and other social needs, may improve PrEP access for PWUD.

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