Hurdles in PrEP Use for HIV Prevention Among Injection Drug Users

Those who are HIV-negative but have risk factors for HIV can take pre-exposure prophylaxis (PrEP) with antiretroviral medications to protect themselves.

HIV-negative partners of HIV-positive patients are just 1 group that might use PrEP. Another is those who inject drugs—a population that experts estimate is approximately 12.7 million—and are also at increased risk of HIV. Approximately 21% of these patients carry the HIV virus, and needle sharing among them is common.

Numerous public health interventions could prevent HIV transmission in those who inject drugs, including clean needle programs, opioid substitution therapies, and liberal provision of proven antiviral therapies. Few countries or municipalities offer these interventions, and as the need increases, the likelihood that the intervention is available decreases.

The journal Addiction addressed this dilemma in an article published ahead of print. In it, an international team of researchers discussed an issue that plagues communities that have or are at risk for HIV: readiness.

Many studies have shown that PrEP works, but at-risk individuals may not be ready to use it. Injection drug users have many concerns that they’ve expressed individually and through organizations that represent them.

The researchers indicated that the health care community needs to engage with drug injection users and ensure that policy and strategy represent their views fairly.

Much of the information in the article was gleaned from an International Network of People Who Use Drugs (INPUD) report, which indicated that injection drug users have great interest in and enthusiasm for PrEP’s potential. However, they also have significant concerns, the 3 biggest of which are the following:

• PrEP’s feasibility and ethics
• PrEP’s potential use as a substitute for other harm reduction strategies
• Potential remedicalization of HIV

Many injection drug users raised the ethical issue of providing PrEP to HIV-negative patients when so many individuals who are already infected can’t afford antiretroviral therapy. Others indicated that large-scale educational programs will be necessary before they’ll understand and use PrEP.

Many injection drug users also believe that if PrEP were provided, it would undermine other harm reduction programs. Currently, many areas of the world either don’t provide clean needles or criminalize injection drug use.

Concerning remedicalization, some believe that PrEP moves the responsibility for transmission prevention to the individual, and so it would lessen community and government responsibility.

The bottom line for these researchers was that injection drugs users have concerns that research is promulgating biomedical interventions, rather than better community perspectives. The authors called for more attention to HIV prevention strategy that recognizes the structural drivers and social context underlying the spread of HIV.