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CATIE

CATIE statement on the use of HIV pre-exposure prophylaxis (PrEP) among people who use drugs

This CATIE statement summarizes the best available evidence on the effectiveness of PrEP to prevent HIV for people who use drugs.

This statement was developed to help service providers in Canada adapt their programs and incorporate this evidence into their messaging to clients.

Key message

The consistent and correct use of oral PrEP is a highly effective strategy to help prevent transmission of HIV through sex and from sharing equipment used to inject drugs. People who use drugs may benefit from using PrEP if they are at risk for HIV through sex, drug use or both. PrEP only helps to prevent HIV; it does not prevent other infections or other potential harms of drug use. It is one tool that can be used along with other sexual health and harm reduction tools.

For more information, see the evidence review at the end of this statement.

Recommendations for service providers

Service providers working with people who use drugs have an important role to play in promoting PrEP as a highly effective HIV prevention strategy. Below are recommendations on how you might better integrate PrEP into your programming.

1. Improve awareness of PrEP as a highly effective HIV prevention option among people who use drugs.

Discuss with clients their possible risk for HIV. A person may be at risk for HIV through shared injection drug use equipment or through sex. Educate clients about PrEP as one highly effective way to prevent HIV.

Canadian guidelines provide information about PrEP including the recommended medical follow-up and supports for people on PrEP. Education and counselling about PrEP for people who use drugs should include the following key points:

  • PrEP is a highly effective method to prevent HIV when it is taken as prescribed.
  • PrEP does not prevent any other sexually transmitted and blood-borne infections (STBBIs) besides HIV.
  • The only PrEP regimen currently recommended in the Canadian guideline for people who use drugs is a pill containing the drugs tenofovir disoproxil fumarate and emtricitabine (TDF + FTC), taken daily. There is another type of oral PrEP licensed in Canada, using the drugs tenofovir alafenamide and emtricitabine (TAF + FTC), but it is currently only recommended for gay, bisexual and other men who have sex with men (gbMSM).
  • Many people who take PrEP have no side effects, and for those who do, the side effects are usually mild and temporary. These side effects can include abdominal pain, nausea, headache and dizziness.
  • PrEP needs to be accessed from a healthcare provider. A person needs to get an HIV test before they start PrEP. It should be used only by people who are HIV negative.
  • It is recommended that people taking PrEP see a healthcare provider every three months to test for HIV and other STBBIs, to monitor for side effects and drug toxicity, and for adherence and risk reduction counselling.

Support clients to determine whether PrEP might be a good option for them. When deciding whether or not to take PrEP, a person should consider if they feel that they will be able to take a daily medication and attend regular follow-up appointments. Clients may have other concerns that they want to discuss, such as possible drug side effects.

Besides educating clients, you can lead or support efforts to improve awareness of PrEP as a prevention approach among a range of service providers in your area who may work with people who use drugs. This might include doctors, nurses, pharmacists and non-clinical staff at community-based organizations.

2. Support access to PrEP for people who use drugs in your community, and support people on PrEP to take it consistently and correctly.

You can help clients who wish to take PrEP to find a local PrEP program or prescriber. Try to help them find a provider who is non-judgmental and who is knowledgeable about care for people who use drugs. Some clients may benefit from support to prepare to talk to a healthcare provider about PrEP. Ask clients how you can support them to prepare for this conversation. You may offer to attend the initial appointment with them. Clients may also benefit from help determining how to find drug coverage for their PrEP medication.

Whenever possible, develop partnerships with local healthcare providers, clinics and health centres that provide care to people who use drugs and regularly prescribe PrEP. If options in your community are limited, you can consider advocating for some providers to begin prescribing. Consider where in your community people who use drugs can access PrEP. This includes getting a prescription, picking up medications and attending regular follow-up appointments. It may be easiest for people who use drugs to access PrEP and participate in PrEP follow-up if appointments are in a location where they already access services, such as at a clinic or program that provides services to people who use drugs (e.g., harm reduction services, hepatitis C treatment, opioid agonist therapy [OAT]). Some of these programs may have established strategies for providing care to people who use drugs, such as outreach or mobile services, and peer supports.

To maximize the effectiveness of PrEP, it needs to be taken consistently and correctly. This means taking the medication as prescribed and attending regular medical appointments. People who use drugs may benefit from supports to enable them to follow the PrEP regimen. They may experience barriers to taking a daily medication, safely storing their medications and/or going to frequent follow-up appointments.

Service providers can support clients to address challenges with taking PrEP and attending medical visits. Some possible strategies include:

  • using an adherence app or alarm reminder on their phone
  • using plastic pill boxes to store a week’s worth of pills or asking the pharmacy to package the medication in blister packs according to the daily dosing schedule
  • arranging to have PrEP dispensed daily along with other medications such as OAT and/or safer supply
  • getting peer support for help with medication adherence or attending follow-up appointments

3. Encourage a comprehensive plan for sexual health and harm reduction

PrEP is one tool to help prevent HIV for people who use drugs; however, it is just one option. Everyone should have access to comprehensive sexual health and harm reduction services.

Educate clients about all the highly effective methods for preventing HIV so they can determine which approach (or combination of approaches) will work best for them. This should include information about PrEP, condoms and the importance of not sharing drug use equipment, as well as post-exposure prophylaxis (PEP) and effective HIV treatment for people living with HIV. Ensure that clients have access to all of these highly effective methods, including free condoms and harm reduction supplies (e.g., new needles, syringes, filters, sterile water and cookers). If access to any of these prevention tools is limited or if there are barriers to access, this should be a priority to address.

Discuss with clients their sexual health broadly, including sexually transmitted infections (STIs). Encourage the use of prevention strategies (such as using condoms), and regular STI testing for people at ongoing risk. Also, discuss sexual and reproductive health options and plans with clients. This should include a range of birth control options for people who want to prevent pregnancy.

Service providers should also provide education on safer substance use. Offer education about how to inject, smoke and snort drugs as safely as possible. This includes providing education about the risk of hepatitis C and other infections (e.g., bacterial infections) that can be transmitted between people if drug use equipment is shared. It should also include discussing strategies for reducing the risk of drug overdose and poisoning, such as using drugs at a supervised consumption site, accessing OAT and/or safer supply, carrying take-home naloxone and avoiding using drugs alone.

4. Address underlying risk for HIV

HIV prevention counselling offers an opportunity to engage individuals in other services and supports beyond those that are directly related to HIV.

In conversations with a client, you might identify challenges in their life that are negatively impacting their health and well-being. Be prepared to suggest supports available in your community that can help to address common challenges among people who use drugs. This may include support with nutritious food, stable housing, mental health supports, substance use treatment, culturally safe supports for Indigenous people who use drugs, and services for people experiencing intimate partner violence. These types of services and supports can improve people’s health and well-being generally and reduce their risk of HIV. You may be able to provide some of these services, or you may need to refer clients to relevant support services in your community.

Client resources

PrEP to prevent HIV: Your questions answered – brochure

Is PrEP right for me? – pocket card

Did you know there’s a pill that can prevent HIV? – poster

How does PrEP prevent HIV? – video

Safer substance use – video series

Service provider resources

Pre-exposure prophylaxis – fact sheet

Safer substance use – series of fact sheets

Harm reduction fundamentals: A toolkit for service providers – self-directed course

Guidelines and position papers

Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational post-exposure prophylaxis

Pre-Exposure Prophylaxis (PrEP) for People who Inject Drugs: Community Voices on Pros, Cons, and Concerns – International Network of People who Use Drugs (INPUD)

Evidence

Epidemiology of HIV among people who use drugs

The prevalence of HIV among people who inject drugs is high in Canada. A study called the Tracks survey of people who inject drugs collected data from 2,383 people who inject drugs from 14 locations across Canada between 2017 and 2019.1 Among 2,162 participants who provided a blood sample, 10.3% had HIV.1

We do not have national data on the epidemiology of HIV among people who use drugs through routes other than injection. Some small studies done in Canada have found a high prevalence of HIV among people who smoke crack cocaine,2,3 though in some of these studies participants had also injected drugs. Some studies done in other countries including the United States have compared the prevalence of HIV among people who inject drugs, and those who use drugs by routes other than injection, by surveying people accessing OAT.4 Those studies found that the prevalence of HIV was similar between the two groups.4–6

Risk for HIV among people who use drugs

People who inject drugs may be at risk for HIV both from sharing equipment used to inject drugs and from having sex without using any HIV prevention method. However, there are also a number of structural and social factors that indirectly contribute to the risk of HIV for people who use drugs.

In the Tracks survey,1 11.6% of participants reported that in the past six months they had injected drugs using a needle and/or syringe that had been used by someone else. Sharing other injection equipment (such as cookers, filters and water) was more common, with 38% of participants saying they had done so in the past six months. The Tracks survey also asked about sex practices. Of participants who reported having a casual sex partner in the last six months, 59.2% reported having condomless vaginal or anal sex with a casual partner. Of those with a regular sex partner, 84.9% reported having condomless vaginal or anal sex with a regular sex partner. Also, 15.7% of participants reported that they had engaged in transactional sex in the past six months.

It may be possible that HIV could be passed from sharing smoking equipment, especially if one or both people sharing a pipe have sores, cuts or burns on their mouths.2 However, it is more likely that sex is the main route of HIV transmission among people who smoke drugs such as crack cocaine or crystal meth and do not inject.2

Besides individuals’ behaviours, there are structural and social factors that contribute to risk for HIV among people who use drugs.7 Structural factors, such as the criminalization of drug use and colonialism, can lead to conditions that negatively impact a person’s health, such as poverty, social exclusion and various forms of discrimination. These conditions are referred to as social factors or the social determinants of health.

Effectiveness of PrEP for preventing HIV

A large body of evidence shows that daily oral PrEP medication (using TDF + FTC) is highly effective at reducing the risk of getting HIV when it is used consistently and correctly.8

Randomized controlled trials (RCTs) have shown daily PrEP (using TDF + FTC) to be highly effective at preventing the sexual transmission of HIV.8 When taken consistently and correctly, PrEP appears to prevent nearly 100% of sexual HIV transmission.9 Among all the studies and several million people who have used PrEP globally, including all genders and sexual orientations, there have been very few documented cases of sexual HIV transmission in people who are adherent to PrEP (i.e., taking it consistently as prescribed).9

One RCT investigated the efficacy of PrEP among people who inject drugs.10 In this study, people who inject drugs were given daily TDF as PrEP. The study found an 84% reduction in the risk of HIV infection among those who were adherent to PrEP.11 It should be noted that TDF alone does not provide the same level of protection as TDF + FTC12 and is not recommended as PrEP for any population in Canada.13 Only daily PrEP with TDF and FTC is currently recommended for use by people who inject drugs.13

Possible side effects of PrEP

The drugs used in PrEP are generally well tolerated.14 A minority of people in research trials have reported side effects, and these side effects often resolve within the first few weeks of taking PrEP. Some of the most common side effects include abdominal pain, nausea, headache and dizziness.14 The use of PrEP has been associated with more concerning toxicities in a small number of people, such as small decreases in kidney, bone and, rarely, liver health.8 Promisingly, these changes were reversible after stopping PrEP.8 PrEP providers monitor for side effects and other possible reactions to the medications with laboratory tests and by asking clients if they are experiencing any new symptoms.

Awareness of PrEP and willingness to use PrEP among people who use drugs

Studies show that awareness of PrEP and use of PrEP are low among people who inject drugs.15–18 In the Tracks study of people who inject drugs, only 14.3% of participants said they had heard of PrEP.1 Among those who were HIV negative or who did not know their status, 0.3% had used PrEP in the last year. Though awareness is low, studies have shown that once PrEP is explained, many people who inject drugs report that they would be interested in taking it.15 For example, in a study of 543 HIV-negative people who inject drugs in Vancouver, 34.5% expressed an interest in taking PrEP after being told about it.19

Barriers to PrEP for people who use drugs, and possible ways to address them

Studies have highlighted several barriers to accessing PrEP and to staying on PrEP among people who use drugs.15,20–22 Some common barriers include:

  • not feeling comfortable being open with a healthcare provider because of stigma related to using drugs or to HIV
  • concerns about side effects and possible interactions with other drugs (including unregulated and prescription drugs)
  • drug use and other competing priorities necessary for survival making it challenging for people to maintain a regular schedule, including remembering to take PrEP every day and attending regular appointments
  • difficulty safeguarding medication from getting lost or stolen, particularly for people who are not stably housed

People who use drugs may be more likely to start PrEP and to stay on PrEP if it is integrated into harm reduction or substance use treatment programs, or if PrEP is dispensed in locations where people pick up OAT or safer supply medications.23,24 In a pilot study in Ottawa, PrEP was offered to people who were accessing a safer supply program.24 In that program, 42 people were offered PrEP, and 23 of them accepted the offer. Of the 23 people who started taking PrEP, 15 stayed on PrEP for the six-month study period. The researchers credit this success in part to the program’s integration into the existing safer supply program.

Integrating PrEP into existing services for people who use drugs may help to address some of the barriers to accessing PrEP in the following ways:

  • It can provide an option that does not require the person to go to a new healthcare provider. People who use drugs may feel more comfortable accessing PrEP from an organization that they are familiar with and where they do not feel judged for their drug use.22,23
  • It can offer convenience and the ability to access PrEP alongside other services.21,22,24
  • It can offer flexibility tailored to people who use drugs, such as by dispensing medication daily or weekly (as opposed to providing the typical three-month supply) to support people who have trouble taking a daily pill or who don’t have a place to safeguard a three-month supply of pills.21,24

References                                                                                                                                 

  1. Tarasuk J, Zhang J, Lemyre A et al. National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, 2017–2019. Canada Communicable Disease Report. 2020;46(5):138-48. Available from: https://doi.org/10.14745/ccdr.v46i05a07
  2. Strike C, Miskovic M, Perri M et al. Best Practice Recommendations for Canadian Programs that Provide Harm Reduction Supplies to People Who Use Drugs and Are at Risk for HIV, HCV, and Other Harms: 2021. Toronto (ON): Working Group on Best Practice for Harm Reduction Programs in Canada; 2021. Available from: https://www.catie.ca/best-practice-recommendations-for-canadian-harm-reduction-programs
  3. Bayoumi AM, Strike C, Jairam J et al. Report of the Toronto and Ottawa Supervised Consumption Assessment Study. Toronto (ON): St. Michael’s Hospital and the Dalla Lana School of Public Health, University of Toronto; 2012. Available from: https://www.catie.ca/sites/default/files/TOSCA%20report%202012.pdf
  4. Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and non-injecting drug users: current trends and implications for interventions. Current HIV/AIDS Reports. 2010 May;7:99-106.
  5. Des Jarlais DC, Arasteh K, Perlis T et al. Convergence of HIV seroprevalence among injecting and non-injecting drug users in New York City. AIDS. 2007 Jan 11;21(2):231-5.
  6. Strathdee SA, Sherman SG. The role of sexual transmission of HIV infection among injection and non-injection drug users. Journal of Urban Health. 2003 Sep;80(Suppl 3):iii7-14.
  7. Rhodes T, Singer M, Bourgois P et al. The social structural production of HIV risk among injecting drug users. Social Science & Medicine. 2005 Sep 1;61(5):1026-44.
  8. Fonner VA, Dalglish SL, Kennedy CE et al. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016 Jul 7;30(12):1973-83.
  9. To KW, Lee SS. A review of reported cases of HIV pre‐exposure prophylaxis failure with resultant breakthrough HIV infections. HIV Medicine. 2021 Feb;22(2):75-82.
  10. Choopanya K, Martin M, Suntharasamai P et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. The Lancet. 2013 Jun;381(9883):2083-90.
  11. Martin M, Vanichseni S, Suntharasamai P et al. The impact of adherence to preexposure prophylaxis on the risk of HIV infection among people who inject drugs. AIDS. 2015 Apr 24;29(7):819-24.
  12. Garrett KL, Chen J, Maas BM et al. A pharmacokinetic/pharmacodynamic model to predict effective HIV prophylaxis dosing strategies for people who inject drugs. Journal of Pharmacology and Experimental Therapeutics. 2018 Nov 1;367(2):245-51.
  13. Tan DHS, Hull MW, Yoong D et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. Canadian Medical Association Journal. 2017 Nov 27;189(47):E1448-58. Available from: http://www.cmaj.ca/content/189/47/E1448
  14. Conniff J, Evensen A. Preexposure prophylaxis (PrEP) for HIV prevention: the primary care perspective. Journal of the American Board of Family Medicine. 2016 Jan 1;29(1):143-51.
  15. Mistler CB, Copenhaver MM, Shrestha R. The pre-exposure prophylaxis (PrEP) care cascade in people who inject drugs: a systematic review. AIDS and Behavior. 2021 May; 25(5):1490-506.
  16. Johnson J, Gormley MA, Bentley S et al. HIV preexposure prophylaxis care continuum among individuals receiving medication for opioid use disorder, South Carolina, 2020–2021. American Journal of Public Health. 2022 Jan;112(1):34-7.
  17. Streed CG, Morgan JR, Gai MJ et al. Prevalence of HIV preexposure prophylaxis prescribing among persons with commercial insurance and likely injection drug use. JAMA Network Open. 2022 Jul 1;5(7):e2221346.
  18. Walters SM, Frank D, Van Ham B et al. PrEP care continuum engagement among persons who inject drugs: rural and urban differences in stigma and social infrastructure. AIDS and Behavior. 2022 Apr 1:1-3.
  19. Escudero DJ, Kerr T, Wood E, et al. Acceptability of HIV pre-exposure prophylaxis (PrEP) among people who inject drugs (PWID) in a Canadian setting. AIDS and Behavior. 2015 May;19:752-7.
  20. Footer KH, Lim S, Rael CT et al. Exploring new and existing PrEP modalities among female sex workers and women who inject drugs in a US city. AIDS Care. 2019;31(10):1207-13.
  21. Allen ST, O’Rourke A, White RH et al. Barriers and facilitators to PrEP use among people who inject drugs in rural Appalachia: a qualitative study. AIDS and Behavior. 2020 Jun;24:1942-50.
  22. Biello KB, Bazzi AR, Mimiaga MJ et al. Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs. Harm Reduction Journal. 2018 Dec;15:1-2.
  23. Hershow RB, Gonzalez M, Costenbader E et al. Medical providers and harm reduction views on pre-exposure prophylaxis for HIV prevention among people who inject drugs. AIDS Education and Prevention. 2019 Aug;31(4):363-79.
  24. Haines M, O’Byrne P. Nurse-led safer opioid supply and HIV pre-exposure prophylaxis: a novel pilot project. Therapeutic Advances in Infectious Disease. 2022 Apr;9:20499361221091418.