The value of PrEP for people who inject drugs

This article summarises a commentary in the Journal of the International AIDS Society co-authored by Susie McLean, formerly Senior Advisor: Drug Use & HIV at the Alliance.

What does the WHO recommendation of PrEP for all people at substantial risk of HIV mean for people who inject drugs? 

One option to reduce HIV among people who inject drugs is pre-exposure prophylaxis (PrEP): the use of antiretroviral drugs by people not infected with HIV to prevent the infection. It has massive potential to reduce HIV among people who inject drugs; and yet critical enabling factors are currently missing.

Several consultations with people who inject drugs show that PrEP is not always supported by the population in question.

Remove barriers to harm reduction

Although a myriad of harm reduction initiatives have long been suggested for those who inject drugs, implementation is far from reaching every corner of the globe. Programmes including opioid substitution therapy (OST), needle and syringe exchange programmes (NSPs), and naloxone to prevent overdose lack the sustainable funding and political support needed to guarantee their success in many countries.

An enabling political environment, integration with public health policy, the presence of supportive laws, and opposition to violence are vital foundations that need to be in place for a new HIV prevention option to work for this population, who currently find it extremely challenging to access such services.

<p>Fishermen harbour-side during a needle exchange in Terengganu, Malaysia.</p>Fishermen harbour-side during a needle exchange in Terengganu, Malaysia. ©International HIV/AIDS Alliance

PrEP must not replace harm reduction

These factors would affect the chance of a sustainable roll-out of PrEP for people who inject drugs in certain countries. But perhaps of more critical concern is the real prospect that it could divert attention away from existing or planned harm reduction initiatives.

In the consultations, people expressed concern about the possibility of non-committed governments using PrEP as a ‘magic bullet’ for reducing HIV among the injecting drug user population – and ignoring other harm reduction programmes.

Make harm reduction the focus of PrEP access

The focus needs to be on the improvement of harm reduction provision and access so that it can act as an implementation platform for PrEP, and ensure that it complements existing initiatives rather than becoming a substitute for clean needles or OST.

People consulted for this research said that PrEP must be rolled out alongside existing harm reduction programmes and combination HIV prevention initiatives.

Involve people who inject drugs in the conversation

As with all targeted health initiatives, inclusion of the population in question is key to designing an effective response. Many who were questioned believed that PrEP would never reach those who needed it most, due to the lack of access to healthcare services that so many people face, and expressed preference for a more sustainable and accessible range of harm reduction services first.

PrEP is not their highest priority

The need to disclose illegal behaviour, hostile health services and the potential to be treated as a criminal all act as barriers to a person who injects drugs in accessing PrEP.

More work needs to be done to enable a supportive political environment, a well-established harm reduction presence, and secure funding – before PrEP can be effectively included in the mix of programmes for people who inject drugs, and certainly before they are likely to considerer PrEP a high priority.

For now, it was felt that PrEP would more likely be considered by the sexual partners of this key population, non-opioid users who do not have a substitution choice, or those who are unable to negotiate safer sex and therefore have an even greater risk of HIV.

Read the full commentary.