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      Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs

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          Antiretroviral pre-exposure prophylaxis (PrEP) is clinically efficacious and recommended for HIV prevention among people who inject drugs (PWID), but uptake remains low and intervention needs are understudied. To inform the development of PrEP interventions for PWID, we conducted a qualitative study in the Northeastern USA, a region where recent clusters of new HIV infections have been attributed to injection drug use.


          We conducted qualitative interviews with 33 HIV-uninfected PWID (hereafter, “participants”) and 12 clinical and social service providers (professional “key informants”) in Boston, MA, and Providence, RI, in 2017. Trained interviewers used semi-structured interviews to explore PrEP acceptability and perceived barriers to use. Thematic analysis of coded data identified multilevel barriers to PrEP use among PWID and related intervention strategies.


          Among PWID participants ( n = 33, 55% male), interest in PrEP was high, but both participants and professional key informants ( n = 12) described barriers to PrEP utilization that occurred at one or more socioecological levels. Individual-level barriers included low PrEP knowledge and limited HIV risk perception, concerns about PrEP side effects, and competing health priorities and needs due to drug use and dependence. Interpersonal-level barriers included negative experiences with healthcare providers and HIV-related stigma within social networks. Clinical barriers included poor infrastructure and capacity for PrEP delivery to PWID, and structural barriers related to homelessness, criminal justice system involvement, and lack of money or identification to get prescriptions. Participants and key informants provided some suggestions for strategies to address these multilevel barriers and better facilitate PrEP delivery to PWID.


          In addition to some of the facilitators of PrEP use identified by participants and key informants, we drew on our key findings and behavioral change theory to propose additional intervention targets. In particular, to help address the multilevel barriers to PrEP uptake and adherence, we discuss ways that interventions could target information, self-regulation and self-efficacy, social support, and environmental change. PrEP is clinically efficacious and has been recommended for PWID; thus, development and testing of strategies to improve PrEP delivery to this high-risk and socially marginalized population are needed.

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          Most cited references 55

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          How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability

           G Guest (2006)
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            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.

            Antiretroviral pre-exposure prophylaxis reduces sexual transmission of HIV. We assessed whether daily oral use of tenofovir disoproxil fumarate (tenofovir), an antiretroviral, can reduce HIV transmission in injecting drug users. In this randomised, double-blind, placebo-controlled trial, we enrolled volunteers from 17 drug-treatment clinics in Bangkok, Thailand. Participants were eligible if they were aged 20-60 years, were HIV-negative, and reported injecting drugs during the previous year. We randomly assigned participants (1:1; blocks of four) to either tenofovir or placebo using a computer-generated randomisation sequence. Participants chose either daily directly observed treatment or monthly visits and could switch at monthly visits. Participants received monthly HIV testing and individualised risk-reduction and adherence counselling, blood safety assessments every 3 months, and were offered condoms and methadone treatment. The primary efficacy endpoint was HIV infection, analysed by modified intention-to-treat analysis. This trial is registered with, number NCT00119106. Between June 9, 2005, and July 22, 2010, we enrolled 2413 participants, assigning 1204 to tenofovir and 1209 to placebo. Two participants had HIV at enrolment and 50 became infected during follow-up: 17 in the tenofovir group (an incidence of 0·35 per 100 person-years) and 33 in the placebo group (0·68 per 100 person-years), indicating a 48·9% reduction in HIV incidence (95% CI 9·6-72·2; p=0·01). The occurrence of serious adverse events was much the same between the two groups (p=0·35). Nausea was more common in participants in the tenofovir group than in the placebo group (p=0·002). In this study, daily oral tenofovir reduced the risk of HIV infection in people who inject drugs. Pre-exposure prophylaxis with tenofovir can now be considered for use as part of an HIV prevention package for people who inject drugs. US Centers for Disease Control and Prevention and the Bangkok Metropolitan Administration. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.

              Previous reviews have examined the existence of HIV prevention, treatment, and care services for injecting drug users (IDUs) worldwide, but they did not quantify the scale of coverage. We undertook a systematic review to estimate national, regional, and global coverage of HIV services in IDUs. We did a systematic search of peer-reviewed (Medline, BioMed Central), internet, and grey-literature databases for data published in 2004 or later. A multistage process of data requests and verification was undertaken, involving UN agencies and national experts. National data were obtained for the extent of provision of the following core interventions for IDUs: needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other drug treatment, HIV testing and counselling, antiretroviral therapy (ART), and condom programmes. We calculated national, regional, and global coverage of NSPs, OST, and ART on the basis of available estimates of IDU population sizes. By 2009, NSPs had been implemented in 82 countries and OST in 70 countries; both interventions were available in 66 countries. Regional and national coverage varied substantially. Australasia (202 needle-syringes per IDU per year) had by far the greatest rate of needle-syringe distribution; Latin America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1 needle-syringes per IDU per year) had the lowest rates. OST coverage varied from less than or equal to one recipient per 100 IDUs in central Asia, Latin America, and sub-Saharan Africa, to very high levels in western Europe (61 recipients per 100 IDUs). The number of IDUs receiving ART varied from less than one per 100 HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than 100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated two needle-syringes (range 1-4) were distributed per IDU per month, there were eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received ART per 100 HIV-positive IDUs. Worldwide coverage of HIV prevention, treatment, and care services in IDU populations is very low. There is an urgent need to improve coverage of these services in this at-risk population. UN Office on Drugs and Crime; Australian National Drug and Alcohol Research Centre, University of New South Wales; and Australian National Health and Medical Research Council. Copyright 2010 Elsevier Ltd. All rights reserved.

                Author and article information

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                Harm Reduct J
                Harm Reduct J
                Harm Reduction Journal
                BioMed Central (London )
                12 November 2018
                12 November 2018
                : 15
                [1 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Departments of Behavioral and Social Sciences and Epidemiology, Center for Health Equity Research, , Brown University School of Public Health, ; Box G-S121-8, Providence, RI 02912 USA
                [2 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Center for Health Equity Research, , Brown University, ; Providence, RI USA
                [3 ]ISNI 0000 0004 0457 1396, GRID grid.245849.6, The Fenway Institute, Fenway Health, ; Boston, MA USA
                [4 ]ISNI 0000 0004 1936 7558, GRID grid.189504.1, Department of Community Health Sciences, , Boston University School of Public Health, ; Boston, MA USA
                [5 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Department of Psychiatry and Human Behavior, , Brown University Alpert Medical School, ; Providence, RI USA
                [6 ]ISNI 0000 0004 1936 7558, GRID grid.189504.1, Department of Health Law, Policy & Management, , Boston University School of Public Health, ; Boston, MA USA
                [7 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Department of Behavioral and Social Sciences, , Brown University School of Public Health, ; Providence, RI USA
                [8 ]ISNI 0000 0004 0367 5222, GRID grid.475010.7, Section of Infectious Diseases, Department of Medicine, , Boston University School of Medicine, ; Boston, MA USA
                [9 ]ISNI 0000 0004 0367 5222, GRID grid.475010.7, Evans Center for Implementation and Improvement Sciences, , Boston University School of Medicine, ; Boston, MA USA
                [10 ]ISNI 0000 0001 0626 1381, GRID grid.414326.6, Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, ; Bedford, MA USA
                © The Author(s). 2018

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: Providence/Boston Center for AIDS Research
                Award ID: P30AI042853
                Funded by: FundRef, National Institute on Drug Abuse;
                Award ID: K01DA043412
                Funded by: BU Peter Paul Career Development Professorship
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                © The Author(s) 2018

                Health & Social care

                hiv prevention, pre-exposure prophylaxis, pwid, intervention development


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