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Co-located HIV Services Can Help Women
Who Inject Drugs Access PrEP, Study Shows
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"Our data suggest that women are interested in and willing to initiate PrEP. They also demonstrate the need to offer trauma-informed care for WWID and highlight the important role of SSP in providing postassault care to women."
One strategy that may mitigate barriers among WWID is integrating PrEP within SSP. Many SSP provide long-term treatments that require prescriptions and medical monitoring, such as medications for opioid use disorder. It stands to reason that PrEP interventions, delivered in settings already used and trusted by PWID, are more likely to be acceptable and could increase PrEP uptake and retention. For example, buprenorphine maintenance18 and antiretroviral medication adherence19have been higher among PWID receiving care in an SSP compared with traditional medical settings. Research has yet to assess the feasibility and acceptability of SSP-based PrEP care for PWID, and in particular, WWID. To address this gap, we conducted Project Sexual Health Equity (Project SHE), a community-based PrEP demonstration project for cisgender WWID incorporated into the SSP at Prevention Point Philadelphia (PPP), Pennsylvania.
Project SHE was conducted between April 2018 and June 2019 at PPP, one of the busiest SSP in the United States distributing over 3.2 million syringes in 2018 (Andres Freire, Director of Prevention Services, personal communication, September 9, 2019). Recruitment and eligibility screening were conducted face to face during PPP's Ladies Night, a weekly drop-in program that provides food, showers, clothing, and monthly social support programming (ie, free haircuts, self-defense classes, etc.). Marketing included hanging flyers throughout PPP, word of mouth from PPP staff to clients, and informal peer referral. Table 1 shows the schedule of research activities that occurred over 24 weeks of follow-up. The study was approved by the Drexel University Institutional Review Board and PPP Executive Board. Participants provided written informed consent before study activities and could receive up to $155 in compensation for their time if they completed all visits.
January 22, 2021
When taken daily, PrEP (pre-exposure prophylaxis medication), is proven to prevent HIV transmission from injection drug use or sex. Although rates of HIV among people who inject drugs have dropped since the early 1990s, recent outbreaks have been reported around the country. Women have been disproportionately represented in these outbreaks, and more information is needed about how to increase their access to these potentially life-saving medications.
A new NIDA funded study suggests that implementing PrEP distribution within a community-based syringe services program gets the much-needed medication into the hands of women who inject drugs. Syringe service programs have become an integral part of evidence-based harm reduction strategies, providing access to (and disposal of) sterile syringes and injection equipment, and providing much-needed linkages to helpful social services.
In the first demonstration project among women who inject drugs, known as “Project Sexual Health Equity (Project SHE),” the scientific team prescribed up to 24 weeks of daily PrEP to 95 adult cisgender women - those whose gender identity matches their sex assigned at birth. The study was based at the largest syringe services program in the mid-Atlantic - Prevention Point Philadelphia- located in the Kensington neighborhood, a center of the city’s opioid crisis.
Participants completed clinical assessments and surveys at three different timepoints; weeks 1, 12, and 24. To reflect real world health care, the women were required to use their own insurance to pay for PrEP. While about 63% identified as currently homeless with an annual income less than $4,999, nearly all (90.5%) were insured at enrollment and the rest were helped to sign up for insurance.
While only slightly over half of participants reported being aware of PrEP prior to the demonstration, most women (77.5%) went on to accept PrEP at their first return visit. While many participants did not consistently achieve prevention effective adherence levels (6 of 7 doses/weekly), this pilot project demonstrated that integrating syringe services with access to PrEP increased access to these important medicines.
The authors note that future studies should include more women of color, however the study showed how synergy can be achieved by cross-agency collaboration, especially important in the time of COVID-19. Now there is strong evidence that there is a demand for PrEP among women who inject drugs when clinical care is provided in tandem with syringe services programs, which has the potential to save lives in this population.
Integrating HIV Preexposure Prophylaxis With Community-Based Syringe Services for Women Who Inject Drugs: Results From the Project SHE Demonstration Study
JAIDS March 2021
Together, our findings challenge the idea that daily PrEP is not a viable HIV prevention tool for PWID. Rather, we demonstrate that SSP are promising locations to reach WWID who would benefit from and are interested in receiving PrEP in this setting. Importantly, but not surprisingly, WWID will likely need additional supports to adhere and persist in care. Findings have implications for future interventions and programs to expand PrEP to WWID, a population increasingly burdened by HIV yet underrepresented in all phases of PrEP research and stigmatized in health care settings. Across settings research has shown that without adequate coverage of HIV prevention and treatment services, HIV outbreaks can escalate quickly through dense injection networks.56 The emergence of HIV outbreaks during an unprecedented scourge of opioid-related overdose deaths in the United States signals the need to aggressively scale-up evidenced-based interventions to prevent HIV to curb infections, including PrEP, among PWID. This first US-based demonstration project with WWID provides some key insight for programs and has implications for the delivery of longer acting formulations when they become commercially available.
Once informed about PrEP, most of our participants expressed a desire to initiate it, and many went on to do so without additional intervention to increase uptake. Our results are consistent with survey work suggesting that PWID are interested in and willing to initiate PrEP.15 Uptake was associated with 2 critical HIV risk factors, sexual assault and inconsistent condom use within 6 months of enrollment. Others have described the important role of sexual transmission of HIV in this population and suggested that sexual risk reduction strategies, delivered within the context of existing harm reduction programs, such as SSP, could help curb infections.33 Our data suggest that women are interested in and willing to initiate PrEP. They also demonstrate the need to offer trauma-informed care for WWID and highlight the important role of SSP in providing postassault care to women. Findings from qualitative interviews with a subset (n = 25) of this sample suggest that experiences with sexual assault, a form of risk that women are susceptible to but unable to control, is an important motivating factor for PrEP uptake in this population.34 Studies to better understand the role of trauma on PrEP uptake and persistence would be helpful for designing gender-specific prevention programs for WWID.
Engagement in later stages of the PrEP care continuum was more common than expected given the multitude of destabilizing factors reported by the participants (eg, high frequency drug use, homelessness, low income) known to decrease health care utilization.35,36Despite these challenges, most women attended their visit scheduled at week 1, although this dropped by more than half over the study follow-up period. Retention in the pilot project was comparable (ie, men who have sex with men in the United States)37 or higher than those reported in numerous PrEP projects with women in sub-Saharan Africa.29,30 We speculate that retention in care in our study was driven in part by streamlining PrEP programming into known and needed services (eg, SSP).38 A recent study among ciswomen offering PrEP in a community sexual health setting reported retention of 61% at 3 months and 37.5% at 6 months.39 A community university–affiliated PrEP program reported comparably lower retention (49%) among ciswomen and transgender men.40More focused research is needed to determine the implementation factors that may promote higher engagement in PrEP programs nested within high-value, existing services. Degree of trust, and mistrust of both the services providing PrEP and PrEP itself, community information, misinformation, and stigma are important to consider when positioning PrEP programs.41,42

To guide future preexposure prophylaxis (PrEP) implementation for women who inject drugs (WWID), a population increasingly represented in new HIV cases in the United States, we present results from a demonstration project integrated within a syringe services program (SSP) in Philadelphia, PA.
WWID ≥18 years were educated about and offered 24 weeks of daily PrEP. Participants completed surveys and clinical assessments at baseline and at weeks 1, 3, 12, and 24. We used descriptive statistics to estimate feasibility/acceptability, engagement in the care cascade, HIV/sexually transmitted diseases (STI) and pregnancy, issues of safety/tolerability, and preferences/satisfaction with PrEP services. Multivariable logistic regression with generalized estimating equations was used to identify factors associated with PrEP uptake and retention.
We recruited 136 WWID. Of those, 95 were included in the final sample, and 63 accepted a PrEP prescription at week 1. Uptake was associated with greater baseline frequency of SSP access [adjusted odds ratio (aOR) = 1.85; 95% confidence interval (CI): 1.24 to 2.77], inconsistent condom use (aOR = 3.38; 95% CI: 1.07 to 10.7), and experiencing sexual assault (aOR = 5.89; 95% CI: 1.02, 33.9). Of these 95, 42 (44.2%) were retained at week 24. Retention was higher among women who reported more frequent baseline SSP access (aOR = 1.46; 95% CI: 1.04 to 2.24). Self-reported adherence was high but discordant with urine-based quantification of tenofovir. Baseline STI prevalence was 17.9%; there were 2 HIV seroconversions and 1 pregnancy. Safety/tolerability issues were uncommon, and acceptability/satisfaction was high.
Engagement in the PrEP Care Cascade
Women's engagement in the PrEP care cascade varied over time as depicted in Figure 1. At baseline, 88.4% (84 of 95) WWID intended to accept a PrEP prescription, and over follow-up, 70.8% (63 of 89) accepted PrEP at week 1, 81.4% (48 of 59) at week 12, and 59.5% (25 of 42) at week 24. After adjusting for age, race/ethnicity, and housing status, 3 baseline factors were associated with increased odds of PrEP uptake, averaged over the 24 weeks of follow-up: inconsistent condom use, experiencing sexual assault, and frequency of SSP access within 6 months (Table 3, A). WWID who used condoms inconsistently (aOR = 3.38; 95% CI: 1.07 to 10.7), experienced sexual assault (aOR = 5.89; 95% CI: 1.02 to 33.9), and accessed the SSP more frequently (aOR = 1.85; 95% CI: 1.24 to 2.77), on average, had higher odds of PrEP uptake over follow-up compared with WWID who did not.
Integrating PrEP with SSP services is feasible and acceptable for WWID. This suggests that daily PrEP is a viable prevention tool for this vulnerable population.

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