Pre-exposure Prophylaxis (PrEP) for HIV in Persons Who Inject Drugs

With more persons dying from opioid overdose than ever before, the vulnerability of HIV outbreaks requires innovative and multifaceted solutions to avert a new epidemic. Pre-exposure prophylaxis (PrEP) is one underused tool that can prevent new HIV infections among people who inject drugs (PWID). PrEP is a medication that can be taken daily to prevent HIV transmission and has been studied in a variety of vulnerable populations including PWID, men who have sex with men, and sex workers. According to a 2013 randomized placebo-controlled trial among PWID, PrEP was effective in preventing HIV for both male and female PWID (Choopanya et al., 2013). The CDC issued recommendations that persons who may be exposed to HIV (e.g., via shared injection equipment, unprotected sex) consider using PrEP for HIV prevention (CDC, 2021). Recently, the U.S. Preventative Services Task Force (Owens et al., 2019) issued a Grade A recommendation that clinicians offer PrEP to all individuals at high risk for HIV. Despite the CDC and United States Preventative Services Task Force recommendations, programs designed to increase PrEP use among PWID have not been broadly implemented. Given the lack of SSPs and routine HIV testing services, PrEP could carry significant HIV prevention utility for PWID.

Existing research on PrEP interest among PWID is limited. In Vancouver, a study found that increased risks for HIV acquisition among PWID was associated with greater willingness to use PrEP (Escudero et al., 2015). Relatedly, a study in New York City found that PWID were less likely to be aware of PrEP than groups with high sexual risks for HIV acquisition (Walters et al., 2017). A recent study of PWID in Baltimore found that PrEP awareness was low (24%) and interest was reasonably high (63%) once PrEP was described to participants (Sherman et al., 2019). This study also found that being eligible for PrEP, based on HIV risk behaviors, was associated with increased interest in PrEP. Overall, PrEP awareness is low among PWID, whereas interest varies. Research is needed to better understand PrEP awareness and interest among PWID and how interest may relate to HIV risk behaviors.

In 2012, PrEP was first approved by FDA, and in 2014, CDC published the first PrEP guidelines. Pharmacists can play a key role in supporting the national and international goals to end the HIV epidemic and increase PrEP use. It is unclear how many board-certified psychiatric pharmacists work to provide PrEP for PWID. In general, many practicing pharmacists have not received formal education in PrEP. A survey of community pharmacists found that almost 70% were not familiar with the guidelines, while another survey found that approximately 71% did not have sufficient knowledge to counsel on PrEP (Okura, et al., 2013 and Shaer et. Al, 2003). In a 2019 study, student pharmacists were unable to properly demonstrate knowledge of the guidelines by identifying that an HIV test is required for PrEP initiation. (Przybyla et al. 2019). Therefore, pharmacists, including psychiatric pharmacists, would benefit from receiving continuing education training in PrEP, including its pharmacology, potential drug interactions, and CDC guidelines.