Big Ideas: Innovative HIV Prevention and Care for People Who Use Drugs (PWUD)

 

A New Era in HIV Treatment and Prevention Requires an Inclusive Approach

Scientific advances in HIV prevention and treatment, including new longer-acting injectable medications that do not require daily pill taking, have created the opportunity to dramatically reduce new infections and improve outcomes for people living with HIV. These innovations offer alternatives to more rigid regimens, which may be difficult to maintain for many, such as people who use drugs (PWUD) including people who inject drugs (PWID). Yet PWUD remain underdiagnosed, undertreated, and overlooked in HIV policy efforts. Therefore, tailored and focused efforts are needed to ensure that PWUD benefit from these innovations.

Adapting Service Delivery Models for PWUD

Stigma among PWUD and lack of trust in healthcare providers reduces access to care and screening. This is exacerbated by limited capacity to provide HIV and other infectious disease screening, prevention, and treatment services or appropriate linkage to care for these other services.

POLICY ACTION: Expand education and outreach to increase PrEP awareness and demand among PWUD.

POLICY ACTION: Strengthen community-based PWUD health settings with drop-in care, services, and supplies for HIV care.

POLICY ACTION: Standardize screening for HIV, PrEP delivery, and linkage to care across SUD and re-entry systems.

Enhancing Clinical Management of Longer-Acting Medications for PWUD

Providers report hesitancy to prescribe injectable medications to PWUD, citing concerns about relapse, potential drug interactions, adherence, patient safety and tolerability, lack of standardization in screening, priority of other healthcare issues, and stigma. These concerns persist despite evidence that injectable medications for substance use disorders, such as medications for opioid use disorder (MOUD), improve adherence and retention in treatment services, and reduce relapse.

POLICY ACTION: Educate providers and consumers to overcome myths around longer-acting PrEP and ART.

Imagining New Ways to Meet the Needs of PWUD

Longer-acting HIV prevention and treatment options open the door to more flexible, person-centered care. For PWUD, this often means leveraging mobile health, telehealth, pharmacies, and re-entry support systems to provide consistent access to HIV care during periods of instability, transition, or disengagement.

POLICY ACTION: Leverage telehealth, mobile treatment, and pharmacies to expand HIV prevention and treatment options for PWUD.

POLICY ACTION: Use longer-acting therapies to support continuity of care during re-entry following incarceration.

POLICY ACTION: Pilot low-barrier access models, including homebased HIV testing and field-based injectable services.

MYTHS AND FACTS: Barriers to Longer-acting Injectable PrEP Uptake in People Who Use Drugs

Utilizing surveys and peer reviewed documents with providers and PWUD, below are some myths and facts on longer-acting PrEP and ART based on these discussions:

MYTH: Injectable medications cannot be prescribed to individuals who inject drugs.

FACT: Injectable medications for substance use disorders, such as MOUD, improve adherence and retention in treatment services and reduce relapse.

MYTH: PrEP creates safety and tolerability issues for PWUD.

FACT: Injectable buprenorphine, for example, is associated with reduced HIV risk and fewer drug-drug interactions with PrEP compared to methadone. If using methadone with longer-acting PrEP, clinical monitoring is recommended as methadone dosing may need to be adjusted in certain individuals.

 _{Please note that this discussion does not constitute clinical guidance and is provided as illustrative of considerations relevant to prescribers for PWUD.}  

 

THE TIME IS NOW Longer-acting medications for HIV treatment and prevention represent a breakthrough moment in the fight against HIV. Current policy proposals and threats to funding for physical, mental and behavioral health, however, place both progress and lives at risk. PWUD, especially PWID, face compounding barriers to care, yet remain central to ending the HIV epidemic. With the right investment in equitable delivery models and policies that include all vulnerable populations, we can close longstanding gaps in HIV outcomes and reduce HIV transmission in this high-risk population.