A New Tool to Prevent HIV Among People Who Use Drugs

Once-a-day HIV prevention pill is rarely offered to injection drug users

In December 2016, the CDC published a report on HIV and injection drug use. Its terse conclusion? “Decreases in HIV diagnoses among PWID [People Who Inject Drugs] indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success.”

For those of you not keeping track at home, there has been significant recent progress in reducing HIV infection among PWID. Between 2008 and 2014, the rate of HIV infection among PWID decreased by 50%. Community-based Syringe Services Programs (SSPs; also known as needle exchanges) have a lot to do with this positive story. But since 2014, the HIV infection rate among PWID has plateaued. Why has progress stalled? It seems the opioid crisis may have a lot to do with that story.

Here in the United States, not only is opioid use becoming more widespread, injection is becoming an increasingly common route of administration. Injecting drugs can transmit infections to both the user and, eventually, his or her sexual partners. And we’re seeing this happen in real time.

We know that opioid use has contributed to a rise in the blood borne infection hepatitis C. Teens and twentysomethings are getting hepatitis C like never before, especially east of the Mississippi river. And we know injection opioid use has caused HIV outbreaks, as it did in 2015 in the small town of Austin, Indiana. One of the important lessons from Austin is that there’s nothing special about Austin. Last year, the CDC released an analysis locating 220 counties in the United States–primarily in Appalachia, primarily rural–at high risk of a similar spike in new HIV infections. If it can happen in Austin, it can happen in a whole lot of other places.

Although SSPs are an effective way to prevent HIV transmission, the CDC points out that “the supply of sterile syringes available to most PWID is likely to be insufficient to meet their needs, and barriers remain to accessing SSPs, including lack of SSPs in rural areas and absence of legal support in many states.” Given the barriers to SSPs, particularly in rural areas, what more should we be doing to prevent HIV among people PWID, as we watch the opioid epidemic unfold around us?

If you work with people who use substances, PrEP should be on your radar. It’s a a once-a-day pill that prevents HIV and one of its target populations is PWID.

What is PrEP?

PrEP stands for “pre-exposure prophylaxis.” It is sold under the brand name Truvada. Although it’s not guaranteed protection against HIV infection, several well-designed studies have showed that it may reduce HIV risk by about 75%, if taken correctly each day. As you can imagine, PrEP is an extremely important technology in countries with high rates of HIV infection. However, it can also benefit Americans at high risk of acquiring HIV, including our growing population of PWID.

Who is a good candidate for PrEP?

The CDC recommends that PrEP be offered to patients with “ongoing, very high risk for acquiring HIV infection.” This consists of three main groups: 1) Men who have Sex with Men (MSM), 2) high risk heterosexual people (this is a mishmash category that includes people whose sexual partner(s) is HIV positive, sex workers, or people with many sex partners that do not use condoms), and 3) injection drug users. See below for more specific guidance from the CDC about individuals within these categories who may benefit most from PrEP.

CDC Guidance on PrEP (click on the image to read the whole document)

Of the three target populations, PWID are lagging behind in PrEP utilization. PrEP has been marketed heavily to MSM but rarely integrated into settings that serve PWID. Primary care providers are less likely to prescribe PrEP to people with substance use-related HIV risks. Although some prescribers express concerns that people who use drugs won’t adhere to the daily medication schedule, this theory is not borne out in the research.

How does PrEP fit into addiction treatment?

We don’t know yet how PrEP fits into addiction treatment. Exploratory research suggests that addiction treatment providers and patients think PrEP could be beneficial, but most have no idea that it exists.

In 2015, researchers interviewed 36 treatment providers in six outpatient addiction treatment facilities in New York City about PrEP. Only 10% of the treatment providers (clinical directors, medical providers, and counselors) had ever heard of PrEP. Once introduced to the concept, the majority of the providers said it was a positive development in HIV prevention that could help their clients. They thought PrEP might be particularly helpful for younger clients with a higher number of sexual partners, especially sex workers. While most of the providers interviewed didn’t see a role for PrEP prescribing onsite, they did think it was feasible to provide information about PrEP to clients they identified as higher risk. Some of the providers had concerns about daily medication adherence, but others pointed out that many clients took daily medication for mental health or substance use disorders, and that taking another medication would not be too difficult.

And would patients even be open to PrEP? A 2014 study of people with opioid use disorders showed that although pretty much no one had ever heard of PrEP, nearly half would be willing to take the pill daily.

PrEP is just one of several important HIV prevention methods for people who use drugs

At the top of this article, we said PrEP should be on the radar of anyone who works with people who use substances. We stand by that. But perhaps more importantly, HIV should be on your radar. Particularly for those of us who live in or near the Appalachian region, it’s time to consider HIV prevention strategies.

Injection drug use can lead to HIV infection and while people can (and do) recover from addiction, they don’t recover from HIV. We have the technology prevent HIV, which makes it an issue of health equity to get the same tools to drug users that we do to men who have sex with men and other higher risk groups. And right now, PWID are underrepresented both in research on HIV prevention and access to current HIV prevention tools. Not only is HIV a health equity issue, it’s also a public health issue. The proliferation of HIV puts everyone at higher risk of infection and we all bear the burden of HIV-related health costs.

What is your organization doing to address HIV in a time of heightened injection drug use? In 2012, UNAIDS outlined nine effective methods to prevent HIV among PWID, including:

– Access to syringes and other injection equipment

– Routine HIV testing and counseling

– Opioid agonists known to reduce HIV transmission, i.e., methadone and buprenorphine

– Condom distribution

– Antiretroviral therapy for HIV positive individuals

The national and local resources listed below may help jump start your thinking about integrating HIV prevention into the services you’re already providing.