Inpatient Setting Offers HIV Pre-Exposure Prophylaxis to People Who Inject Drugs
Presenter: Terry A Marryshow, MD, AAHIVS, Fellow, Tufts Medical Center, Boston, Massachusetts
A summary of Pilot Study on Offering HIV Pre-exposure Prophylaxis (PrEP) to People Who Inject Drugs (PWID) in the Inpatient Setting, September 29, 2021
Despite significant progress in treating patients with HIV, the ongoing opioid epidemic in the United States has resulted in people who inject drugs (PWID) being at high-risk for HIV infections. In 2018, PWID comprised 10% of all new HIV diagnoses and accounted for 12.5% of all deaths among people living with HIV.
“Pre-exposure prophylaxis (PrEP) is a proven, effective means of preventing HIV. In 2019, the US Preventive Services Task Force recommended PrEP for all individuals at high risk for HIV. This includes PWID who share drug injection equipment and/or are at risk of sexual acquisition for HIV,” said Terry A. Marryshow, MD, Fellow, Tufts Medical Center, Boston, Massachusetts.
According to Marryshow, “A Centers for Disease Control and Prevention report estimated that 18.5% of all PWID in the United States are at risk for HIV and eligible for PrEP, and uptake of PrEP among at-risk populations, including PWID, has been low throughout the US.”
“PWID are commonly admitted for complications related to injection drug use. The inpatient setting represents an opportunity for healthcare contact. This may be a frequently missed opportunity to offer PrEP to PWID. Clinicians may not be offering PrEP sufficiently to patients in this setting,” said Marryshow.
Marryshow and colleagues initiated a pilot study in an inpatient setting where prescriptions of tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) were offered to PWID admitted from 9/2020 to 5/2021. Patients were approached at bedside, provided counseling on PrEP, and offered initiation prior to discharge. Prescriptions from 10/2019 to 8/2020 were used to analyze and assess baseline provision of PrEP to PWID. Physicians on the infectious diseases service at Tufts Medical Center were anonymously queried on perceived barriers and their practices regarding provision of PrEP to PWID. Patient perceptions and acceptance of PrEP were analyzed.
“A total of 16 prescriptions for TDF-FTC were provided at discharge, none for PrEP in PWID. The 8 physicians surveyed estimated caring for an average 4 PWID per week of service. Of the 8 physicians, 5 reported that at least one PWID was offered PrEP during their most recent week of service,” Marryshow said.
The most commonly reported physician barrier to prescribing PrEP was uncertainty regarding adherence and follow up. Other barriers included uncertain access to care, short length of stay, patients declined HIV testing, and short time since last high-risk exposure.
“Thirty patients were approached, with 14 patients reporting prior knowledge of PrEP. Eighteen patients were willing to engage in further education or counseling. Only 4 patients were accepting of PrEP, with 2 patients provided prescriptions for PrEP prior to discharge,” Marryshow added.
Of those who declined, 13 patients denied sharing of injection equipment, 7 patients stated a commitment to future abstinence, 4 patients denied active drug use, 3 patients were unwilling to adhere to a daily medication, 2 patients declined due to concerns of adverse effects, and 1 patient declined due to concerns regarding stigma.
Marryshow concluded, “A significant proportion of PWID were highly interested in learning more and considering initiation. Few PWID were ultimately accepting of a PrEP prescription. Clinicians often felt hesitant to offer PrEP owing primarily to concerns regarding follow-up and adherence. The inpatient setting may not be ideal, or this method of offering PrEP may not be effective for successful initiation at our institution. However, there may still be value in counseling and discussing PrEP, and this may still serve as point of referral to outpatient PrEP initiation, given high interest in additional information.”
Larger studies evaluating strategies for offering inpatient PrEP are warranted, as well as more research on optimizing outpatient adherence and follow-up after inpatient PrEP initiation, Marryshow added.
Disclosures
Terry A Marryshow, MD, AAHIVS: Nothing to disclose.
References
Marryshow, TA, Caro J. Pilot study on offering HIV pre-exposure prophylaxis (PrEP) to people who inject drugs (PWID) in the inpatient setting. Presented virtually at: 10th Annual IDWeek 2021; September 29, 2021. Abstract 50.
Smith D, Van Handel M, Wolitski MJ, et al. Vital signs: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition--United States, 2015. MMWR Morb Mortal Wkly Rep 2015; 64(46):1291-1295. doi: 10.15585/mmwr.mm6446a4
US Preventive Services Task Force. Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement. JAMA 2019; 321(22):2203-2213. doi:10.1001/jama.2019.6390