Patient and provider perspectives on a novel, low-threshold PrEP program for people who inject drugs and experience homelessness

BACKGROUND: New HIV clusters continue to be identified among people who inject drugs (PWID) and experience homelessness in the Northeastern U.S. and other regions. Antiretroviral pre-exposure prophylaxis (PrEP) is efficacious and recommended for HIV prevention; however, uptake remains low in this marginalized population. We explored patient and provider experiences with a novel, low-threshold program designed to support PrEP uptake, adherence, and persistence among PWID experiencing homelessness.
METHODS: Boston Health Care for the Homeless Program (BHCHP) implemented PrEP services for PWID experiencing homelessness in October 2018. From March-December, 2020, we conducted qualitative interviews with current and former adult PrEP program patients and providers (e.g., BHCHP clinicians, patient navigators, outreach workers; and collaborators from affiliated organizations). Semi-structured interviews were conducted in private outdoor areas using secure video-conferencing on tablets. Rapid thematic analysis identified common patient and provider experiences with BHCHP's PrEP program.
RESULTS: Among 21 PrEP program participants, median age was 35.5 years (IQR: 31-37.5), 15 (71%) identified as male, 6 (29%) as female. Thirteen (62%) identified as white, 4 (19%) Hispanic and 4 (19%) Black. Sixteen (76%) were currently taking PrEP. All participants reported past-month heroin/fentanyl and polysubstance use (commonly methamphetamine [n=19], cocaine/crack [n=18], non-prescribed benzodiazepines [n=17] and gabapentin [n=13]). Injection frequency was high: 12 reported injecting 4-9 times daily; 4 injected '¥10 times daily. Eleven providers had a median of 6 years working with PWID (IQR: 4.5-13). Program participants and providers expressed concerns about ongoing HIV transmission, linking it to polysubstance use and sexual behaviors (including transactional sex work and sex with HIV-positive partners). They described same-day and short-term prescribing (7-day prescriptions), on-site medication storage, and coordination with other local service agencies as particularly helpful elements of the PrEP program. Participants also discussed the approachability and persistent street presence of PrEP nurses and program staff in facilitating their PrEP uptake and ongoing adherence and retention.
CONCLUSIONS: Our findings illustrate how innovative, culturally-competent strategies can help engage and retain PWID experiencing homelessness in low-threshold, outreach-based PrEP services. Specific elements of this program could be considered in a range of community-based settings, including syringe service programs and shelter to mitigate future outbreaks.