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Awareness, knowledge of PrEP vary by rural vs. urban setting among people who inject drugs

For medication that prevents HIV, stigma is a barrier to use, especially in rural area.

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What you know about pre-exposure prophylaxis, or PrEP—a medication taken to prevent HIV—may depend on where you live, according to new research from the Center for Drug Use and HIV/HCV Research (CDUHR) at NYU School of Global Public Health. The study of people who inject drugs, published in the journal AIDS and Behavior, points to lower awareness and knowledge of PrEP in rural Illinois compared to urban New York City. 

PrEP is highly effective at preventing HIV, reducing the risk from sexual transmission by 99% and from injection drug use by 74-84%. However, its use is low among people who inject drugs, with only 1-2% of this population taking it. Research points to several barriers to PrEP use among people who inject drugs, including stigma—around drug use, sexuality, and HIV—and a lack of awareness.

“PrEP is a tool that could help drug-using populations manage their health. But in my prior research, I noticed a marked difference in PrEP awareness between sexual minority men and people who inject drugs; many who inject drugs do not even know that PrEP exists, which is troubling,” said Suzan Walters, associate research scientist at NYU School of Global Public Health, a CDUHR researcher, and the study’s lead author.

Walters and her colleagues wanted to better understand what people who inject drugs know about PrEP and their attitudes towards it, and whether this varied based on where people lived. Identifying participants through local syringe exchange programs, they conducted in-depth interviews with 57 individuals, including 18 from rural southern Illinois and 39 from New York City. The interviews took place from August 2019 through February 2020.

The researchers asked participants about four factors related to PrEP:

  • awareness (have they heard of it)
  • knowledge (understanding of what it does)
  • willingness (would they take it)
  • uptake (do they take it)

They found that awareness and knowledge of PrEP differed by setting. In rural Illinois, only half had heard of PrEP, mostly through television commercials. In contrast, 77 percent of New York City participants had heard of PrEP, both through commercials but also through flyers in community settings like syringe exchange programs. 

Knowledge of PrEP was low among rural participants, who could not accurately describe the drug; a common misconception was that PrEP is used to treat HIV, rather than prevent it. New York City participants were better able to articulate what PrEP is, but their knowledge was sometimes incomplete. People who had a better understanding of PrEP tended to hear about it from multiple sources, including in-person conversations with healthcare providers and at syringe exchange programs.

“I would like people to view PrEP as something that all people should be able to access and decide whether or not it is a valuable tool for them at that particular time. The fact that large portions of the population at risk for HIV are unaware of this drug nearly a decade after FDA approval reflects deeply rooted health inequities,” said Walters. 

In contrast, willingness and uptake of PrEP were similar in urban and rural settings. After learning about PrEP, about half of participants indicated that they would be interested in taking the drug to prevent HIV, but no one interviewed was currently using PrEP (although three New York City participants had previously taken it).

Stigma was a barrier to people’s willingness to take PrEP in both settings, although it was more pronounced in rural Illinois. Participants there were concerned about stigma surrounding their drug use, given the small-town dynamics of other community members knowing about their lives. Stigma about sexuality also moved people away from PrEP in both settings, as they considered it a drug only for sexual minority men.

The researchers recommend combating stigma to address the lack of engagement with PrEP among people who use drugs—for instance, marketing PrEP using both sex and drug positive messaging, instead of excluding people who use drugs from PrEP marketing. 

Another approach: creating social infrastructures for drug-using populations and investing in non-stigmatizing programs (e.g. syringe exchange) to prescribe PrEP alongside other harm reduction tools. Syringe exchange programs emerged as an important resource in the study, providing a welcoming space free of drug-use stigma where people can share resources and create community. However, these benefits were greater in New York City, which had a syringe exchange program in a fixed location, than in the southern Illinois community, which was served by a mobile program.  

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“Social infrastructures are critical in combating stigma. Our study adds to decades of research supporting syringe exchange programs as important community resources that reduce stigma and prevent disease,” said Walters. 

Additional study authors include David Frank and Danielle Ompad of NYU School of Global Public Health and CDUHR, Samuel Friedman of NYU Grossman School of Medicine and CDUHR, Brent Van Ham of Southern Illinois University School of Medicine, Jessica Jaiswal of the University of Alabama, Brandon Muncan of Renaissance School of Medicine at Stony Brook University, Valerie Earnshaw of the University of Delaware, and John Schneider of the University of Chicago.


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