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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: AIDS Behav. 2020 Aug 5:10.1007/s10461-020-02987-y. doi: 10.1007/s10461-020-02987-y

Examining the potential of pre-exposure prophylaxis (PrEP) for HIV prevention in a community sample of persons who use stimulants living in the Southern United States

Sheri L Towe a, Catherine A Sullivan a, Mehri S McKellar b, Christina S Meade a
PMCID: PMC7862414  NIHMSID: NIHMS1618235  PMID: 32757101

Abstract

Pre-exposure prophylaxis (PrEP), a highly effective HIV prevention strategy, is currently underutilized by several at-risk groups, including both persons who inject drugs and those who use drugs via other routes. Stimulant use is associated with increased HIV risk due to both sexual and injection risk behaviors. In this study, we examined PrEP awareness and acceptability in persons with biologically confirmed HIV-negative status who use stimulant drugs. We also examined HIV risk behaviors to identify how many participants met behavioral eligibility for PrEP. The sample of 352 participants was 46% female, 87% African American, and 45.69 years old on average. Over half the sample (n = 213) met criteria for PrEP candidacy, but less than 20% had heard of PrEP. Ratings for willingness to take PrEP were high. PrEP candidates reported more frequent and problematic stimulant use relative to non-candidates. Our results show that persons who use stimulants are a high-risk population that could benefit significantly from PrEP. Efforts to increase PrEP awareness among high-risk populations are critical for facilitating PrEP implementation and ensuring effective HIV prevention within these communities.

Keywords: pre-exposure prophylaxis, HIV, cocaine, stimulants

INTRODUCTION

In 2012, the Food and Drug Administration approved pre-exposure prophylaxis (PrEP), a once-daily combination antiretroviral pill, for HIV prevention (1). PrEP has been shown to be a highly effective method of HIV prevention for persons who are at substantial risk for HIV (2–6). While PrEP has the potential to significantly shift the HIV epidemic by reducing new infections, it is still widely underutilized by at-risk groups and in regions with disproportionately high incidence rates of HIV infection, including the Southern United States (US) (7–9). It is estimated that over 1.2 million adults in the US could benefit from PrEP to reduce risk for HIV infection, yet only 18% with indications were prescribed PrEP in 2018 (8).

The Centers for Disease Control (CDC) and the U.S. Preventive Services Task Force (USPSTF) recommend PrEP for HIV-negative persons who are at substantial risk for HIV (10, 11). This includes men who have sex with men (MSM) and heterosexual persons who have an HIV-positive sex partner, a high number of sex partners, inconsistent use of condoms, and/or engage in commercial sex work, as well as people who inject drugs and have an HIV-positive injecting partner and/or share injection equipment. The CDC and USPSTF guidelines acknowledge the important role of drug use in HIV transmission, but the focus has largely been on injection drug use (10, 11). As a result, non-injection drug use has not been specifically targeted for PrEP roll-out.

The use of stimulant drugs, including cocaine, methamphetamine, and other amphetamines, is associated with increased HIV risk due to both sexual and injection risk behaviors. Injection drug use is a well-established risk factor, as sharing of injection equipment is a highly efficient mode of HIV transmission (12). However, recent US estimates from 2018 show that the vast majority new diagnoses were attributable to sexual contact, with 70% attributable to male-to-male sexual contact and 24% attributable to heterosexual contact (13). Among persons who use drugs, converging rates of HIV prevalence among persons who inject drugs (PWIDs) and persons who use drugs via other routes of administration underscores the important role of sexual transmission (14–16). Studies consistently find that persons who use stimulants like cocaine and amphetamine engage in high rates of risky sexual behaviors, including multiple sex partners, unprotected sex while high, and sex trading for drugs (17–22).

Despite substantial risk for HIV, uptake of PrEP among persons who use drugs has been low (23–25). One reason for this is a lack of awareness of PrEP. Current estimates of awareness of PrEP in persons who use drugs are generally low, ranging from 3–18% (26–29). While the reasons are likely complex, both low uptake and lack of awareness could be due to low willingness of providers to educate patients about and prescribe PrEP due to concerns about adherence (30). Another contributing factor is that there is a lack of tailored strategies for PrEP implementation designed to reach drug users specifically. Despite low awareness, research on PWIDs recruited from various settings, including long-term residential facilities, detoxification program, and the community, has shown acceptability rates for PrEP ranging from 35–47% (26, 27, 31). One study of persons who use opiates recruited from a methadone clinic in Connecticut reported that nearly two thirds of participants who reported HIV risk behaviors would be willing to begin PrEP (32). Similar rates of willingness have been found among women who use drugs (33). However, few studies have examined the implementation of PrEP for women, despite it being a promising method of prevention (34). Several studies have also shown that moderate to high perceived HIV risk is associated with higher willingness to use PrEP (29, 35, 36). Taken together, these findings support that the low uptake of PrEP may be due to a lack of PrEP awareness rather than a lack of willingness to take PrEP.

While there are a number of studies on PrEP awareness and willingness to use PrEP in populations of persons who use drugs, most studies have focused on MSM, excluding both women and non-MSM, and few have specifically examined persons who use stimulants (23, 37). The purpose of this study was to describe awareness and acceptability of PrEP in a sample of men and women who actively use illicit stimulant drugs (primarily non-injection cocaine) living in central North Carolina. We also aimed to describe how many individuals were potential candidates for PrEP, and whether there were gender differences on substance use and other characteristics among potential PrEP candidates. Given the well-established link between stimulant use and HIV risk behaviors, including both injection and sexual risk, persons who use stimulants are a population that may benefit significantly from PrEP.

METHODS

Participants

The sample included persons without HIV who use stimulants and who were recruited from the Raleigh-Durham area between October 2016 and September 2018. Participants were recruited via flyers in community settings and peer referral. The eligibility criteria were: ≥18 years of age, self-reported stimulant use in the past month, biologically-confirmed HIV-negative status (using a rapid HIV test), conversational English fluency, and sobriety at the time of the visit.

Procedures

After providing written informed consent, participants took an alcohol breathalyzer to ensure sobriety. Participants then completed clinical interviews and computerized questionnaires, and they provided a urine sample for drug testing. At the end of the visit, participants reported their history of HIV testing and completed a rapid test for HIV. The HIV test was OraQuick©, an oral swab test that tests for antibodies to HIV-1/2 and provides results in 20 minutes. Trained staff provided pre-test counseling, which included a description of the testing process, confidentiality of results, implications of a positive test, and oral consent for the test. Results were provided in the context of post-test counseling. All participants in this analysis had a non-reactive test result. Procedures were approved by the institutional review board at Duke University Health System.

Measures

A series of clinical interviews assessed substance use. The Addiction Severity Index-Lite assessed lifetime substance use and associated impairments (38). Timeline follow-back methodology was used to assess frequency of substance use in the past 90 days (39, 40). Participants completed a urine toxicology screen for cocaine, cannabis, amphetamine, methamphetamine, oxycodone, methadone, other opioids (including heroin), benzodiazepines, and barbiturates. Module E of the Structured Clinical Interview for DSM-5 identified current substance use disorders (41).

Participants also completed several questionnaires using audio computer-assisted self-interview (ACASI), which has been found to minimize biased reporting of potentially stigmatizing behaviors such as HIV risk (42–45). Participants reported on demographic factors (such as age, race, and ethnicity) and completed the Risk Assessment Battery (RAB) to assess their HIV risk behavior in the past 6 months. The RAB, which uses simple wording with discrete response categories, was designed for substance-using populations and has demonstrated reliability and validity (46, 47). The RAB produces two subscales: sex risk (9 items, e.g., number of sex partners, frequency of condom use; range 0–18) and drug risk (7 items, e.g., number of people shared needles/works with; range 0–22). Subscale scores are computed by summing the scores for each item within the subscale, and an overall score for total risk is computed by summing the two subscales (range 0–40). Higher scores indicate greater risk.

Behavioral eligibility for PrEP was determined using responses on the RAB and guided by the substantial risk criteria published in the CDC’s PrEP clinical practice guidelines and the USPSTF’s PrEP recommendation statement (10, 11). PrEP candidacy was defined as any of the following in the past 6 months: (1) injection drug use; (2) sex with a known HIV-positive partner; (3) sex with multiple partners; and/or (4) transactional sex. Of note, “any unprotected sex” was not considered as one of these criteria because we did not want to include participants who were in a monogamous ongoing sexual relationship. Any participant who met one or more of these four criteria was considered a candidate for PrEP. Given that this sample is drawn from a high HIV prevalence area, we elected for these criteria to be more inclusive.

The ACASI also included a series of questions to assess perceived HIV risk, PrEP awareness and knowledge, willingness to take PrEP, and possible motivators for and barriers to taking PrEP. Participants rated their perceived HIV risk (“How at risk for HIV do you think you are?”) on a 10-point scale (1 - Not at all to 10 - Extremely). The next screen showed the following statement: “PrEP, or pre-exposure prophylaxis, is the use of a medication called Truvada to prevent HIV infection in individuals who are HIV negative.” Participants were then asked “Have you heard of PrEP?” To assess PrEP knowledge, participants who had heard of PrEP then read statements about PrEP and indicated whether they agreed, disagreed, or were unsure about each statement. These statements assessed PrEP effectiveness (“Daily use of PrEP reduces the chances of HIV infection”), manageability of side effects (“The side effects of PrEP are manageable”), and affordability of PrEP (“PrEP is affordable for people like me”). To assess overall willingness, participants rated the following question on the same 10-point scale (1 - Not at all to 10 - Extremely): “If PrEP were available to you free of charge, how willing would you be to take PrEP to protect yourself from becoming infected with HIV?” To assess possible motivations for and barriers to taking PrEP, we also asked participants to select from a list of reasons for why they would or would not be willing (e.g., “I am scared of contracting HIV), or “I am not at risk for contracting HIV”). Finally, we asked participants whether they agreed, disagreed, or were unsure about whether they would be comfortable asking their doctor for PrEP.

Data analysis plan

To characterize the sample, we used two-tailed independent samples t-tests, Mann-Whitney U tests, chi-squared tests, and Fisher’s exact tests to compare PrEP candidates to non-candidates on demographic and key variables, including substance use, RAB score, perceived HIV risk, and PrEP awareness and willingness, and to examine gender differences among PrEP candidates on these variables. Pearson correlations were used to examine the relationship between willingness and other variables, including perceived HIV risk. Statistical significance was defined as p-value of less than 0.05. All analyses were conducted in SPSS 26.0. For any variables with missing values, the available sample size has been reported with the statistical test result.

RESULTS

Sample characteristics

The sample of 352 participants included 190 men and 162 women. Based on our criteria for PrEP candidacy, 213 participants (60%) met behavioral eligibility. Table 1 presents demographic and substance use characteristics by PrEP candidacy. Overall, the sample was primarily non-Hispanic (99%) and African-American (87%). Participants ranged in age from 19 to 70 years (M = 45.69, SD = 11.57) and most (52%) had completed at least a high school diploma. The majority of participants (87%) were heterosexual. The large majority (92%) of participants reported cocaine as the only stimulant drug used in the past 90 days. A total of 25 (7%) participants reported using cocaine and other stimulants, and two (1%) participants reported using other stimulants and no cocaine. The other stimulants used were ecstasy (n = 18), methamphetamine (n = 5), and prescription amphetamines (n = 4). For most participants (72%), inhalation was the primary route of administration; 25% used intranasally, 2% via injection, and 1% orally. On average, participants had used stimulants regularly for 14.94 years (SD = 10.78) in their lifetime and reported 35.64 (SD = 30.05) days of stimulant use in the past 90 days. On average participants endorsed 6.08 (SD = 3.08) of the 11 diagnostic symptoms, and nearly all participants (89%) met diagnostic threshold for a current stimulant use disorder. PrEP candidates endorsed more symptoms on average and were more likely to meet criteria for a severe stimulant use disorder compared to non-candidates.

Table 1.

Participant characteristics of PrEP candidates versus non-candidates (N = 352)

PrEP candidate Overall total Statistic p value
No (n = 139) Yes (n = 213)
Demographic and other characteristics
 Male, n (%) 69 (50%) 121 (57%) 190 (54%) Χ2(1) = 1.74 0.187
 Age in years, M (SD) 46.73 (11.33) 45.01 (11.70) 45.69 (11.57) t(350) = 1.36 0.173
 Sexual Orientation, n (%) Fisher’s test 0.006
  Straight 125 (90%) 181 (85%) 306 (87%)
  Gay or lesbian 10 (7%) 8 (4%) 18 (5%)
  Bisexual 4 (3%) 24 (11%) 28 (8%)
 Race, n (%) Fisher’s test 0.288
  African American 125 (90%) 182 (85%) 307 (87%)
  Caucasian 10 (7%) 17 (8%) 27 (8%)
  Other/Mixed 4 (3%) 14 (7%) 18 (5%)
 Hispanic ethnicity, n (%) 1 (1%) 2 (1%) 3 (1%) Fisher’s test 1.000
 Highest degree, n (%) Χ2(2) = 0.14 0.931
  Less than high school or GED 65 (47%) 103 (48%) 168 (48%)
  High school diploma 54 (39%) 82 (38%) 136 (39%)
  Some college or more 20 (14%) 28 (13%) 48 (14%)
Stimulant use characteristics
 Stimulants used in past 90 days, n (%) Fisher’s test 0.920
  Cocaine only 129 (93%) 196 (92%) 325 (92%)
  Stimulants other than cocaine 1 (1%) 1 (<1%) 2 (1%)
  Cocaine and other stimulants 9 (6%) 16 (8%) 25 (7%)
 Days of stimulant use in past 90 days, M (SD) 25.78 (26.69) 42.07 (30.44) 35.64 (30.05) t(350) = 5.15 <0.001
 Primary route of administration for stimulants, n (%)* Fisher’s test 0.054
  Inhalation 97 (71%) 153 (73%) 250 (72%)
  Nasal 39 (28%) 49 (23%) 88 (25%)
  Injection 0 (0%) 8 (4%) 8 (2%)
  Oral 1 (1%) 1 (<1%) 2 (1%)
 Urine positive for any stimulant, n (%)** 105 (76%) 161 (77%) 266 (76%) Χ2(1) = 0.06 0.809
 Current stimulant use disorder symptoms, M (SD) 5.04 (2.85) 6.77 (3.03) 6.08 (3.08) t(350) = 5.35 <0.001
 Current severe stimulant use disorder, n (%) 58 (42%) 149 (70%) 207 (59%) Χ2(1) = 27.66 <0.001
 Years of stimulant use, M (SD) 13.70 (10.61) 15.75 (10.84) 14.94 (10.78) t(350) = 1.75 0.081
Other substance use characteristics
 Any alcohol use, n (%) 113 (81%) 191 (90%) 304 (86%) Χ2(1) = 5.01 0.025
  Days of use, M (SD) 30.02 (31.05) 41.32 (32.41) 37.12 (32.33) t(302) = 2.99 0.003
 Any marijuana use, n (%) 88 (63%) 145 (68%) 233 (66%) Χ2(1) = 0.85 0.356
  Days of use, M (SD) 34.35 (36.97) 43.24 (38.12) 39.88 (37.86) t(231) = 1.75 0.082
 Any heroin use, n (%) 11 (8%) 38 (18%) 49 (14%) Χ2(1) = 6.92 0.009
  Days of use, M (SD) 31.64 (38.52) 34.84 (34.61) 34.12 (35.13) t(47) = 0.26 0.793
HIV testing, risk, and PrEP awareness
 Ever tested for HIV, n (%) 134 (96%) 202 (95%) 336 (95%) Χ2(1) = 0.48 0.490
 HIV test within past 6 months, n (%)+ 36 (26%) 65 (31%) 101 (29%) Χ2(1) = 0.99 0.321
 Perceived HIV risk, Mdn (IQR)+ 1.00 (1.00, 1.00) 2.00 (1.00, 5.00) 1.00 (1.00, 3.00) U = 9255.00 <0.001
 RAB sex risk score, M (SD)*** 4.22 (1.94) 6.74 (2.62) 5.74 (2.67) t(349) = 9.72 <0.001
 RAB drug risk score, Mdn (IQR)*** 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) U = 13066.00 <0.001
 Ever heard of PrEP, n (%)+ 15 (11%) 30 (14%) 45 (13%) Χ2(1) = 0.77 0.379
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*

Primary route of administration was missing for 4 participants.

**

Three participants were unable to provide a urine sample.

^

Seven participants did not know the date of their last HIV test.

+

Three participants refused to report their perceived HIV risk on the PrEP questionnaire, and one participant did not complete the PrEP questionnaire.

***

One participant did not complete all RAB items, so their overall scores were not computed.

Note. M = Mean; SD = Standard deviation; Mdn = Median; IQR = interquartile range.

Use of substances other than stimulants in the past 90 days was common. Alcohol was most prevalent, with 86% of participants reporting use. A larger proportion of PrEP candidates reported alcohol use compared to non-candidates, and among those who used alcohol, PrEP candidates reported more days of alcohol use than non-candidates. Marijuana use was prevalent as well, with 66% of the sample reporting use, but marijuana use did not differ based on PrEP candidacy. While heroin use was less frequent (14% overall), a larger proportion of PrEP candidates reported heroin use relative to non-candidates, though the average number of days used among users did not differ between candidates and non-candidates.

HIV testing, risk, and PrEP awareness

Nearly all participants (95%) reported having an HIV test in their lifetime, but only 29% reported having a test within the past 6 months. Perceived HIV risk was generally low (Mdn = 1.00, IQR = 2.00), though PrEP candidates reported significantly higher perceived risk than non-candidates. Consistent with their behavioral eligibility, PrEP candidates also had significantly higher scores on the RAB compared to non-candidates.

Of the 352 participants, 45 (13%) reported that they had ever heard of PrEP. The most common source was news or social media (31%), followed by a healthcare provider (27%), other people (22%), and community outreach (16%); 4% didn’t remember how they heard about PrEP. Only one participant reported that they had been prescribed PrEP but they were no longer taking it. This participant self-identified as an MSM and stated this was the reason they initiated PrEP.

Characteristics of PrEP candidates

Among the 213 PrEP candidates, there were generally few gender differences on demographic and substance use characteristics (Table 2). Women reported significantly more days of stimulant use in the past 90 days compared to men (p <0.05). Participants met 1.56 (SD = 0.59) of the 4 criteria for PrEP candidacy on average, with no difference by gender. Alcohol, marijuana, and heroin use did not differ by gender, both for overall proportion using each substance and the days of use amongst those who had used (all p > 0.05). Slightly more than half the sample (51%) met more than one of the criteria for PrEP candidacy. The most common risk behaviors were sex trading (75%) and sex with multiple partners (67%). Injection drug use was less common (12%), and sex with an HIV-positive partner was the least common (3%). None of these risk factors differed by gender. However, when sex trading was split into sub-categories of selling and buying, there were significant gender differences. A significantly larger proportion of women reported selling sex for drugs, money, or other goods, while a significantly larger proportion of men reported buying sex with drugs, money, or other goods (both p <0.001). On the RAB, women had significantly higher sex scale scores relative to men, but their drug scale scores were equivalent. Women reported slightly higher HIV perceived risk than men, though this difference was not significant. HIV testing also did not differ by gender, with about a third reporting testing within the past 6 months.

Table 2.

Participant characteristics of PrEP candidates by gender (N = 213)

Gender Overall total Statistic p value
Female (n = 92) Male (n = 121)
Demographic characteristics
 Age, M (SD) 42.97 (11.42) 46.57 (11.71) 45.01 (11.70) t(211) = 2.25 0.026
 Education in years, Mdn (IQR) 12.00 (10.00, 12.00) 12.00 (11.00, 13.00) 12.00 (11.00, 13.00) U = 5152.00 0.334
HIV risk behaviors, past 6 months
 Multiple partners, n (%) 65 (71%) 78 (65%) 143 (67%) 0.341
 Sex with an HIV-positive partner, n (%) 4 (4%) 2 (2%) 6 (3%) Fisher’s test 0.406
 Any sex trading, n (%) 69 (75%) 90 (74%) 159 (75%) Χ2(1) = 0.01 0.918
  Selling sex for drugs, money, or other goods, n (%) 68 (74%) 34 (28%) 102 (48%) Χ2(1) = 43.96 <0.001
  Buying sex with drugs, money, or other goods, n (%) 16 (17%) 84 (69%) 100 (47%) Χ2(1) = 56.80 <0.001
 Any injection drug use, n (%) 12 (13%) 13 (11%) 25 (12%) Χ2(1) = 0.27 0.605
 Total number of risk behaviors 1.63 (0.61) 1.51 (0.58) 1.56 (0.59) t(211) = 1.44 0.150
 RAB sex risk score, M (SD)* 7.29 (2.84) 6.32 (2.38) 6.74 (2.62) t(210) = 2.69 0.008
 RAB drug risk score, Mdn (IQR)* 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) U = 5446.00 0.807
 Perceived HIV risk, Mdn (IQR)+ 3.00 (1.00, 5.00) 1.00 (1.00, 3.75) 2.00 (1.00, 5.00) U = 4763.00 0.069
 HIV test within past 6 months, n (%)^ 30 (34%) 35 (29%) 65 (31%) Χ2(1) = 0.44 0.508
Stimulant use characteristics
 Days of stimulant use in past 90 days, M (SD) 47.28 (31.69) 38.11 (28.95) 42.07 (30.44) t(211) = 2.20 0.029
 Primary route of administration for stimulants, n (%)** Fisher’s test 0.166
  Inhalation 72 (78%) 81 (68%) 153 (73%)
  Nasal 16 (17%) 33 (28%) 49 (23%)
  Injection 3 (3%) 5 (4%) 8 (4%)
  Oral 1 (1%) 0 (0%) 1 (<1%)
 Urine positive for any stimulant, n (%)*** 73 (81%) 88 (73%) 161 (77%) Χ2(1) = 1.74 0.187
 Current stimulant use disorder symptoms, M (SD) 6.82 (3.06) 6.73 (3.03) 6.77 (3.03) t(211) = 0.21 0.835
 Current severe stimulant use disorder, n (%) 66 (72%) 83 (69%) 149 (70%) Χ2(1) = 0.25 0.620
 Years of stimulant use, M (SD) 16.53 (10.77) 15.16 (10.90) 15.75 (10.84) t(211) = 0.92 0.360
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*

One participant did not complete all RAB items, so their overall scores were not computed and some data points are missing.

+

One participant refused to report their perceived HIV risk on the PrEP questionnaire.

^

Five participants did not know the date of their last HIV test.

**

Primary route of administration was missing for 2 participants.

***

Three participants were unable to provide a urine sample.

Note. M = Mean; SD = Standard deviation; Mdn = Median; IQR = interquartile range.

While few PrEP candidates (14%) had ever heard of PrEP, participants overall expressed willingness to take PrEP (Table 3). Among those who had heard of PrEP, 50% of participants agreed with the statement about PrEP’s effectiveness and 50% were unsure. The majority of participants were unsure about the manageability of PrEP side effects (67%), and the remaining 33% agreed that the side effects are manageable. Most participants (73%) were unsure about the affordability of PrEP. There were no gender differences on the ratings for willingness to take PrEP, with both men and women reporting average ratings above 7 on the 10-point willingness scale. In total, 120 participants (56%) selected the highest possible rating, and only 24 participants (12%) selected the lowest possible rating. Willingness to take PrEP was positively correlated with perceived HIV risk (r = 0.19, p = 0.006), but willingness was not significantly correlated with other factors, including age (r = 0.01, p = 0.924), RAB sex risk score (r = −0.05, p = 0.447), or days of stimulant use in the past 90 days (r = 0.09, p = 0.183). Willingness also did not significantly differ based on stimulant use disorder severity [t(206) = 0.87, p = 0.386], with the ratings of participants with severe stimulant use disorder (M = 7.66, SD = 3.24) similar to those of participants without severe stimulant use disorder (M = 8.08, SD = 3.16). Regarding motivators, participants frequently endorsed the items “I am scared of contracting HIV” (60%) and “It would help me protect myself against HIV” (54%), but very few participants endorsed the item “I am at high risk for contracting HIV” (14%). About a third of participants (35%) endorsed “PrEP and condoms together are better than just condoms alone,” and 30% of participants said they would take PrEP if their doctor recommended it.

Table 3.

Willingness to take PrEP and PrEP knowledge among PrEP candidates by gender (N = 213)

Gender Overall total Statistic p value
Female (n = 92) Male (n = 121)
Ever heard of PrEP, n (%) 11 (12%) 19 (16%) 30 (14%) Χ2(1) = 0.61 0.436
 PrEP reduces chances of HIV infection, n (%) Χ2(1) = 0.14 0.705
  Agree 5 (45%) 10 (53%) 15 (50%)
  Unsure 6 (55%) 9 (47%) 15 (50%)
  Disagree 0 (0%) 0 (0%) 0 (0%)
 The side effects of PrEP are manageable, n (%) Fisher’s test 0.702
  Agree 3 (27%) 7 (37%) 10 (33%)
  Unsure 8 (73%) 12 (63%) 20 (67%)
  Disagree 0 (0%) 0 (0%) 0 (0%)
 PrEP is affordable, n (%) Fisher’s test 0.500
  Agree 2 (18%) 3 (16%) 5 (17%)
  Unsure 9 (82%) 13 (68%) 22 (73%)
  Disagree 0 (0%) 3 (16%) 3 (10%)
Willingness to take PrEP, M (SD)* 7.76 (3.15) 7.80 (3.28) 7.78 (3.22) t(206) = 0.09 0.928
Reasons for willingness to take PrEP+
 I am scared of contracting HIV 60 (65%) 68 (57%) 128 (60%) Χ2(1) = 1.59 0.207
 It would help me protect myself against HIV 53 (58%) 61 (51%) 114 (54%) Χ2(1) = 0.96 0.327
 I am at high risk for contracting HIV 13 (14%) 17 (14%) 30 (14%) Χ2(1) = <0.01 0.994
 PrEP and condoms together are better than just condoms alone 30 (33%) 44 (37%) 74 (35%) Χ2(1) = 0.38 0.539
 If my doctor recommended it, I would trust them 27 (29%) 36 (30%) 63 (30%) Χ2(1) = 0.01 0.918
Reasons for unwillingness to take PrEP+
 I am not at risk for contracting HIV 12 (13%) 29 (24%) 41 (19%) Χ2(1) = 4.13 0.042
 I am worried about the side effects 23 (25%) 36 (30%) 59 (28%) Χ2(1) = 0.65 0.421
 I would prefer using condoms or other methods of 18 (20%) 28 (23%) 46 (22%) Χ2(1) = 0.44 0.509
 I do not want to take a medication daily 5 (5%) 16 (13%) 21 (10%) Χ2(1) = 3.64 0.056
 I do not trust my doctor, medicine, or the government 4 (4%) 13 (11%) 17 (8%) Fisher’s test 0.125
Would feel comfortable asking provider for PrEP, n (%)+ Fisher’s test 0.632
 Agree 81 (88%) 101 (84%) 182 (86%)
 Unsure 9 (10%) 13 (11%) 22 (10%)
 Disagree 2 (2%) 6 (5%) 8 (4%)
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*

Five participants did not provide a response to the PrEP willingness question.

+

One participant did not provide a response for the items on reasons for willingness, reasons for unwillingness, and agreement with whether they would be comfortable asking their doctor about PrEP.

Note. M = Mean; SD = Standard deviation.

The most common reason endorsed for being unwilling to take PrEP was concern about the side effects (28%). Less than a fifth of PrEP candidates (19%) said they would be unwilling to take PrEP because they are not at risk of contracting HIV, and about a fourth (22%) said they would prefer to use other methods of prevention. Only 10% of participants reported that they did not want to take a medication daily, and only 8% reported being unwilling due to distrust. Overall, more than 85% of participants said they would feel comfortable asking their doctor for a prescription if they wanted to begin PrEP.

DISCUSSION

Our primary finding is that persons who use stimulants, most of whom were not injecting drugs, are a high risk population that could benefit from PrEP. In this sample of 352 persons, nearly all participants used cocaine. The majority of participants met behavioral eligibility for PrEP, but less than one fifth of participants had ever heard of PrEP. While demographic characteristics between candidates and non-candidates were largely similar, PrEP candidates reported more frequent stimulant use, endorsed more stimulant use disorder symptoms, and were more likely to use alcohol and heroin compared to non-candidates. PrEP candidates also endorsed higher perceived risk for HIV than non-candidates. Among PrEP candidates, the most common risk behavior was sex trading, and about half the sample reported engaging in more than one risk behavior. PrEP candidates had very limited knowledge about PrEP, but willingness to take PrEP was high and those ratings significantly correlated with perceived HIV risk.

Among PrEP candidates in our sample, the majority were either women or heterosexual men. Injection drug use was also relatively uncommon, and HIV risk in the sample was driven by sexual behaviors. There were few gender differences on demographic and substance use characteristics, though women were significantly younger and did report more days of stimulant use. However, in terms of HIV risk behaviors, women were more likely to sell sex for drugs, money, or other goods, whereas men were more likely to buy sex with drugs, money, or other goods. Women also had overall higher scores on the RAB sex risk scale, indicating more frequent engagement in sex risk behaviors relative to men. Taken together, these findings indicate that women who use stimulants may particularly benefit from PrEP for HIV prevention. Given that 2018 estimates show that PrEP prescription coverage was three times higher amongst men than women (21% versus 7%), our results suggest that campaigns to increase PrEP awareness and utilization should consider focusing on women as a target audience (8).

While most of participants were unaware of PrEP and unsure about its effectiveness, side effects, and affordability, they expressed willingness to take PrEP, which is consistent with prior research among persons who use drugs (32, 33). Taken together, these results show why strategies designed to increase awareness and education about PrEP are critical to increasing uptake of PrEP in this population. Additionally, among the 30 PrEP candidates who had previously heard of PrEP, only one had ever been prescribed PrEP, which suggests that simple awareness of PrEP is not adequate to facilitate PrEP uptake. As other research has noted, there are a number of barriers beyond PrEP awareness that must be addressed to facilitate PrEP utilization, including lack of knowledge about PrEP and its side effects, interpersonal-level barriers such as stigma, low perceptions of HIV risk, and lack of engagement with the healthcare system, and structural barriers including homelessness and lack of resources to acquire prescriptions (35, 48). Community outreach programs and public advertising may effectively increase awareness of PrEP, but additional education about PrEP is necessary to ensure that the community understands the benefits and side effects of PrEP. Implementation strategies targeting people who use drugs will also need to address some unique challenges, including provider ambivalence related to prescribing PrEP for this population and barriers to medication adherence (49–53).

Healthcare access and utilization are also important factors to consider. To date, implementation models have focused on delivering services in clinic-based settings (54). Since preventative care services are underutilized by persons who use drugs, strategies that actively seek out this population for risk screening and HIV testing are urgently needed (55). A recent survey of local health departments in North Carolina showed that only 16% were engaged in PrEP activities (56). Expanding PrEP implementation beyond healthcare settings (e.g., harm reduction and syringe exchange programs) could also reduce HIV in at-risk groups.

While this study has a number of strengths, including biological verification of HIV-negative status to confirm PrEP candidacy and a moderately large sample size, it is not without limitations. First, our definition of PrEP candidacy was based on participant responses to the RAB. While the RAB assesses important transmission risk behaviors, it does not map exactly onto the CDC’s and USPSTF’s criteria for behavioral eligibility for PrEP. For example, we did not test for bacterial STIs. Therefore, it is possible that someone identified as a PrEP candidate would not qualify for PrEP after comprehensive evaluation in a clinical setting. Alternatively, it is possible that we may not have identified some PrEP candidates due to underreporting of risk behaviors. Second, our questions related to HIV risk, PrEP awareness, PrEP knowledge, and willingness to take PrEP were developed for the present study based on the literature but have not been previously validated. Third, our sample included very few MSM, who are a priority population for HIV prevention efforts and for whom PrEP is a recommended prevention strategy (10, 57) and our sample was relatively older. Fourth, our sample consisted primarily of persons who use cocaine, which may limit how our results generalize to persons who use methamphetamine and other stimulants. Finally, because these data were collected in a single city in the Southern US, it is not clear whether our results would generalize to other regions of the US.

In summary, our results show that a large proportion of persons who use illicit stimulants engage in significant HIV risk behaviors, despite the majority of participants reporting non-injection drug use. PrEP may be an effective intervention for reducing HIV transmission within these communities. Within stimulant-using populations, evaluation for PrEP eligibility should extend beyond focusing on injection drug use. Additional research is needed to address the challenges related to implementing PrEP in this population.

Acknowledgments:

We thank all the individuals who participated in this study.

Funding: This study was funded by grants DP2-DA040226 from the United States National Institutes of Health. The NIH had no further role in study design, data collection, analysis and interpretation of data, writing the report, or in the decision to submit the paper for publication.

Footnotes

Conflict of interest: Sheri L. Towe declares no conflicts of interest. Catherine A. Sullivan declares no conflicts of interest. Mehri S. McKellar declares no conflicts of interest. Christina S. Meade declares that no conflicts of interest.

Ethical approval: All study procedures were in accordance with the ethical standards of institutional research board at the Duke University Health System and with the 1964 Helsinki declaration and its later amendments.

Informed consent: Informed consent was obtained from all participants included in the study.

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