An Exploration of Pre-exposure Prophylaxis (PrEP) Initiation Among Women Who Inject Drugs.

Pre-exposure prophylaxis (PrEP) is an effective but understudied tool for preventing HIV among women who inject drugs (WWID). This article is the first to explore WWID's rationale for PrEP initiation (or refusal) in a real-world setting. Purposive sampling was used to recruit 25 WWID, participating in a PrEP demonstration project operating within a syringe services program, based on whether they initiated or declined PrEP care. Content analysis of qualitative interviews was used to explore decisions to initiate PrEP (or not). We found that WWID view HIV as severe, perceive themselves to be susceptible to HIV, and believe PrEP is beneficial for HIV prevention. For some, however, real and perceived barriers outweighed benefits, leading to decisions not to initiate PrEP. Barriers included HIV stigma, fear of side effects, and needing assurance that PrEP care will be available long-term. Despite viewing PrEP as an important HIV prevention tool, not all WWID who were offered PrEP initiated it. For these women, supports to buffer perceived barriers to initiation and access to post-exposure prophylaxis may be warranted. For women who initiate, it is possible that adherence will wane if perceived risk does not remain high. Research to understand PrEP persistence is needed.

"PrEP just isn't my priority": Adherence challenges among women who inject drugs participating in a pre-exposure prophylaxis (PrEP) demonstration project in Philadelphia, PA USA.

Pre-exposure prophylaxis (PrEP) has the ability to curb HIV transmission among women if they are highly adherent (e.g. 6/7 weekly doses). In a recent PrEP demonstration project with 95 women who inject drugs (WWID) in Philadelphia, PA, USA, PrEP uptake was high but adherence was low. This qualitative study draws upon the Behavioral Model for Vulnerable Populations (BMVP) to describe how the context of 23 WWID's lives challenged PrEP adherence using narrative data from in-depth interviews. Content analysis suggests that women's need to organize their day around predisposing survival needs made it difficult to prioritize PrEP. Adherence was further challenged by dis-enabling structural forces such as entry into institutions that do not provide PrEP (e.g., drug treatment and correctional facilities) and medication diversion to illicit marketplaces. Overtime, women's perceived need for PrEP was dynamic: in periods they characterized as risky, women considered PrEP highly beneficial and described enhanced motivation to adhere. In periods of low perceived risk, women were less committed to continuing daily PrEP in the context of their competing survival needs. In sum, WWID faced challenges to PrEP adherence that correspond to all of the BMVP domains. To optimize PrEP for WWID, multi-level programs are needed that address the determinants that both increase HIV susceptibility and undermine adherence.