Stuck in the window with you: HIV exposure prophylaxis in the highest risk people who inject drugs

Abstract

The opioid and polysubstance epidemics could drive a surge in new HIV infections among people who inject drugs (PWID). Longstanding strategies to reduce HIV incidence, including syringe service programs, condom distribution, medications for opioid use disorder, and low-barrier HIV testing and treatment have not been adequate to eliminate transmission in this population. Although HIV pre-exposure prophylaxis (PrEP) is an evidence-based intervention that reduces HIV incidence among PWID, uptake in PWID has lagged due to limited PrEP knowledge, discrepancies between perceived and actual HIV risk, stigma, and structural barriers to adherence including homelessness and incarceration. In our efforts to deploy PrEP to PWID in our low-barrier substance use disorder bridge clinic, we have encountered another barrier: the HIV testing window period. We discuss challenges in delivering HIV exposure prophylaxis to the highest risk PWID, our current approach, and the need for more data to guide best practices.

Keywords:

• HIV prevention
• PrEP
• PEP
• people who inject drugs
• opioid use disorder
• injection drug use

Acknowledgments

The authors thank Dr. Alison Rapoport and members of Boston University School of Medicine’s General Internal Medicine Writers’ Collaborative for their review of the manuscript.

Disclosure statement

The authors have no financial or other conflicts of interest to disclose.

Author contributions

J.T. designed and drafted the initial manuscript and contributed to revisions. A.W. contributed to interim drafts and revised the final manuscript. A.B. contributed to the design of the initial draft and to interim drafts and revised the final manuscript.

Additional information

Funding

This work was supported by a grant from the Massachusetts Department of Public Health Bureau of Substance Addiction Services to develop Opioid Urgent Care Centers [RFR #163274] (Taylor, Walley) and by a National Institutes of Health Career Development Award [K01DA043412] (Bazzi).