HIV Preexposure Prophylaxis Care Continuum Among Individuals Receiving Medication for Opioid Use Disorder, South Carolina, 2020–2021

Abstract

We implemented the HIV preexposure prophylaxis (PrEP) care continuum among individuals receiving medication for opioid use disorder (MOUD). We screened HIV-negative MOUD participants for PrEP eligibility by assessing injection drug use risk factors and sexual behaviors. Implementation of the PrEP care continuum was challenging; less than a third of MOUD participants were aware of PrEP, and very few initiated PrEP. Findings should promote the development of effective interventions to increase engagement in PrEP during MOUD treatment. (Am J Public Health. 2022;112(1):34–37. https://doi.org/10.2105/AJPH.2021.306566)

The spread of HIV has been associated with a rise in injection drug use among individuals who misuse opioids.¹ People who inject drugs (PWID) are at a greater risk for contracting HIV when sharing needles, syringes, or other injection equipment and participating in sexual behaviors such as having sex while intoxicated and having condomless sex. Antiretroviral preexposure prophylaxis (PrEP) taken daily can effectively reduce PWID’s risk of acquiring HIV.^2,3 Although the US Department of Health and Human Services recommends PrEP be offered to PWID along with other harm-reduction services (e.g., medication for opioid use disorder [MOUD], syringe services programs),³ little is known about the PrEP care continuum in this high-risk population.⁴ Most researchers describe progression of the PrEP care continuum among populations of men who have sex with men (MSM)⁵; however, no studies have reported the implementation of the PrEP care continuum among individuals receiving MOUD.

INTERVENTION

Three authors (A. H. L., S. F. H., and P. R.) developed an eligibility screener containing 45 questions, adapting questions from the HIV Incidence Risk Index for MSM⁶ and the Assessment of the Risk of Contracting HIV for Injection Drug Use provided in the 2017 Centers for Disease Control and Prevention HIV PrEP Provider Supplement.⁷ Information for these scales can be found in Tables C–E (available as a supplement to the online version of this article at http://www.ajph.org).

Additional questions collected information for the HIV PrEP care continuum,⁵ which is made up of nine steps:

• 1.Identify individuals at highest HIV risk,
• 2.Enhance self-perceived HIV risk awareness,
• 3.Raise PrEP awareness,
• 4.Facilitate PrEP access,
• 5.Link to PrEP care,
• 6.Prescribe PrEP,
• 7.Initiate PrEP,
• 8.Adhere to PrEP, and
• 9.Retain in PrEP care.

PLACE AND TIME

We assessed PrEP eligibility in all patients seen between June 2, 2020, and February 2, 2021. The Prisma Health Recovery Clinic is a facility that offers MOUD in Greenville, South Carolina. An interdisciplinary team helps facilitate many services, including counseling, peer recovery coaching, and medication assistance.

PERSON

Consenting HIV-negative individuals aged 18 years and older with a diagnosis of opioid use disorder (determined using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [Washington, DC; American Psychiatric Association; 2013]) were eligible for MOUD if they were willing to engage in primary care and adhere to program policies. Individuals were eligible for PrEP if they met any of the following criteria: (1) vaginal or anal sexual intercourse with two or more partners in the past six months without using a condom or unsure about condom use, (2) HIV Incidence Risk Index for MSM score of 9 or higher, or (3) assessment of the Risk of Contracting HIV-Injection Drug Use Risk Index score of 46 or higher.

PURPOSE

The objective of this study was to assess PrEP eligibility criteria and implementation of the PrEP care continuum for individuals in the MOUD program.

IMPLEMENTATION

Before June 2, 2020, PrEP eligibility was not assessed and PrEP was not offered to individuals in the Prisma Health MOUD program. We assessed PrEP awareness with the questions “Have you ever heard of HIV PrEP (yes/no),” and “Have you ever been prescribed PrEP? (yes/no).” We determined interest in PrEP with the question “Would you be interested in starting PrEP (yes/no).” We did not use any questions to assess access to PrEP or linkage to PrEP care, as clinicians conducting the screener also prescribed PrEP.

We extracted information for the final stages of the PrEP care continuum from the patient chart. We considered patients who were eligible and interested as having been prescribed PrEP if their clinician wrote a prescription for PrEP during the appointment. We determined PrEP initiation by assessing whether an individual retrieved the PrEP prescription at the pharmacy. We considered an individual adherent to medication if they picked up their prescription at the pharmacy each month for three months, and we considered an individual retained in treatment if they arrived for their follow-up appointment for PrEP at three months. All patients were seen weekly, biweekly, or monthly based on MOUD stability.

We used descriptive statistics to describe PrEP eligibility in the MOUD population and show progression through the PrEP care continuum. We performed all statistical analysis using SAS version 9.4 (SAS, Cary, NC).

EVALUATION

Of the 140 individuals assessed for eligibility, 83 (59.3%) met at least one of the three eligibility criteria for PrEP. Most were eligible owing only to their Assessment of the Risk of Contracting HIV-Injection Drug Use score (91.6%), few were eligible because of sexual behaviors (18.1%), and 9.6% were eligible because of both their Assessment of the Risk of Contracting HIV-Injection Drug Use score and sexual behaviors. No individuals were eligible because of a high MSM score. Additional characteristics for the overall cohort can be found in Tables A and B (available as a supplement to the online version of this article at http://www.ajph.org).

ADVERSE EFFECTS

Figure 1 illustrates the implementation of the PrEP care continuum for individuals in the MOUD program. Less than a third (30.1%) had heard of PrEP before their appointment, no one reported previous use of PrEP, and only one individual stated that they were not sure if they had ever taken PrEP. Although 18.1% of the population were interested in PrEP, only six (7.2%) were prescribed PrEP during their appointment. Only two initiated PrEP, but neither was adherent or retained in PrEP care.

FIGURE 1—

The Preexposure Prophylaxis (PrEP) Care Continuum Among PrEP Eligible Individuals Receiving Medication for Opioid Use Disorder: South Carolina, June 2020–February 2021

Note. Study size was n = 83 participants. The figure shows the proportion who were eligible of all individuals assessed (n = 140).

Half of the six individuals who received a PrEP prescription never arrived to the pharmacy to pick up the medication, and one arrived but was unable to fill the prescription because of lack of financial aid. Neither of the two individuals who initiated PrEP returned to the pharmacy to refill the prescription after one month; one discontinued the medication because of adverse side effects (e.g., headache), and the other dropped out of the MOUD program.

SUSTAINABILITY

To our knowledge, no previous studies have investigated the PrEP care continuum in a population receiving MOUD, yet half of the current population was eligible for PrEP. Adherence and retention to PrEP in this study were low, whereas results of previous studies have shown higher adherence and retention. This illustrates the PrEP care continuum in specific clinical settings (e.g., sexual health clinics, sexually transmitted infection and HIV centers, lesbian, gay, bisexual, and transgender [LGBT] clinics). The differences in these results may be attributed to motivation, as the primary motivation of individuals seeking care at sexually transmitted infections clinics, HIV centers, and LGBT clinics is to safeguard their sexual health. By contrast, individuals with opioid use disorder prioritize treatment with MOUD and may not be willing to engage in additional care that does not directly address their opioid use disorder.

However, findings of this study show that clinicians would be wise to take advantage of the frequency of MOUD visits to provide PrEP to this high-risk population. Screening and implementing the PrEP care continuum to patients receiving MOUD may increase the number of opportunities for clinicians to promote awareness of a patient’s HIV risk through regular discussions about PrEP and HIV risk factors and engage patients in PrEP during follow-up MOUD visits. Lack of adherence and retention in this study highlights a need for additional research to understand how to improve PrEP care during MOUD treatment.

PUBLIC HEALTH SIGNIFICANCE

To our knowledge, this is the first study to illustrate the progression of the PrEP care continuum for patients receiving MOUD. These findings support the need for improvement in PrEP education and clinician engagement to increase PrEP interest, uptake, and adherence in this high-risk population. Future research should identify barriers along the PrEP care continuum that are unique to those receiving MOUD. Additional efforts should be directed to initiating PrEP in MOUD programs to mitigate high-risk behaviors and reduce the spread of HIV among individuals with opioid use disorder.