Photo Credit: Diego_cervo

PrEP uptake in MSM who inject drugs is low, although research shows this group is at higher risk for HIV acquisition through drug injections, sex, or both.

Men who inject drugs and who have sex with men (MWIDSM) are at higher risk for HIV through multiple pathways—drug injections, sex, or both—but awareness of and access to PrEP is low among this group, according to a study published in AIDS.

“PrEP awareness increased among gay/bisexual-identifying MWIDSM, but not among heterosexual-identifying MWIDSM. PrEP awareness and use were low regardless of sexual identity,” wrote Patrick C. Eustaquio, MD, MPH, and colleagues. “Public health initiatives catered to MWIDSM should focus on improved campaigns and expanding PrEP accessibility in existing healthcare, harm reduction, and social services.”

Using data from the National HIV Behavioral Surveillance among PWID in 19 urban areas in the United States, the researchers compared PrEP awareness and use in 2018 and 2022 according to sexual identity among HIV-negative MWIDSM. The study included HIV-negative males who injected drugs, who had at least one male sex partner in the past 12 months, and who reported their sexual identity.

More Than 90% of Patients Had Indication for PrEP

Of the 758 HIV-negative MWIDSM (463 in 2018; 295 in 2022), 331 (71.5%) in 2018 and 197 (66.8%) in 2022 identified as gay or bisexual. Over this time, participants 40 years of age or above increased from 51.2% to 60%, and health insurance coverage rose from 67.0% to 81.4%. Overall, 29.8% of study participants were Black, 24.9% were Hispanic, 73.2% were at or below the federal poverty level, and 82.8% reported homelessness in the past 12 months.

Using log-linked Poisson regression models with an interaction term between year and sexual identity, Dr. Eustaquio and his research team found that:

• 2% of participants in 2018 and 92.9% in 2022 were likely indicated for PrEP due to risky sexual or drug-related behaviors or both.
• PrEP awareness increased from 45.5% in 2018 to 64.5% in 2022 among gay- or bisexual-identifying MWIDSM (aPR, 1.49; 95% CI, 1.30-1.70) but remained stable at 39.4% and 40.8%, respectively, among heterosexual-identifying MWIDSM (aPR, 1.01; 95% CI, 0.75-1.36).
• PrEP use remained low among all MWIDSM (7.7% in 2018 and 2.5% in 2022 among heterosexually identifying;15.3% in 2018 and 10.2% in 2022 among gay- or bisexual-identifying).

Dr. Eustaquio and colleagues acknowledged the study’s limitations, including the recruitment approach, which restricts the broader generalizability of the findings; self-reported data, which may have introduced social desirability and recall biases; misclassification of self-reported sexual behavior and identity, which may have influenced associations; and potential overestimates of participants likely indicated for PrEP.

Increasing Access to PrEP and Other Services

“Known barriers to PrEP use include behavioral and structural factors, e.g., lack of knowledge about PrEP, adherence, healthcare apathy, discrimination, cost, and homelessness,” the researchers wrote. “MWIDSM is a heterogenous population with varied networks and sexual identity, and thus, further understanding of these men and the implications for HIV prevention are warranted.”

Further actions suggested by Dr. Eustaquio and colleagues include the following:

• Health and social services that serve MWIDSM, such as syringe service programs, substance use services, food pantries, and shelters, could also provide PrEP education, navigation, and dispensing.
• Co-location and consolidation of these services would decrease the number of visits needed to prevent HIV transmission and improve the overall health and wellness of PWID.
• Primary care could provide PrEP, potentially decreasing the stigma of HIV, drug use, MSM, or PWID clinics. Providers should include sexual and drug use assessments into routine care and offer PrEP to all MWIDSM.
• Efficacy and safety studies of long-acting injectable PrEP among PWID should be conducted.
• Social determinants of health that disadvantage MWIDSM should be addressed.