There are almost 40,000 new Human Immunodeficiency Virus (HIV) diagnoses every year in the United States (US Centers for Disease Control and Prevention, 2017). In 2012, Truvada, the medication used for Pre-exposure Prophylaxis, (PrEP) was approved by the Food and Drug Administration (FDA) for use in the prevention of the sexual transmission of HIV (CDC, 2014). Truvada has also been shown to be effective for HIV prevention among persons who inject drugs (PWID) and others with Substance Use Disorders (SUD) (Choopanya et al., 2013). These populations have been shown to be at increased risk for contracting HIV resulting from both high-risk injection and sexual practices (Burnett, Broz, Spiller, Wejnert, & Paz-Bailey, 2018). The CDC has created screening and prescription recommendations for providing PrEP to PWID or people who are in treatment for SUD; however, there is currently little research in the area of PrEP use amongst these populations, especially when looking outside of men who have sex with men (CDC, 2014; Goldstein, Carter-Davis & Seymour, 2018). The National HIV Strategy for the United States recommends full access to PrEP services as a critical focus area (White House Office of National AIDS Policy, 2015). With nine-percent of new HIV infections being attributable to injection drug use, increasing identification of persons with SUD who are at-risk for contracting HIV within the outpatient setting and linking them to PrEP has the potential to decrease the rates of new HIV diagnoses (CDC, 2017). This study looks at current practices for identifying patients at risk for contracting HIV in the outpatient SUD treatment setting.
Objective
The objective of this research is to increase health care providers identification of persons with SUD who are at-risk for contracting HIV and who may benefit from PrEP, in the setting of an outpatient treatment clinic in Baltimore, Maryland.
Methods
The health history and physical (H&P) was reviewed for each patient who began treatment at an outpatient treatment clinic for persons with SUD over a 3-month period. Each H&P was reviewed for information on the patient’s HIV status, HIV testing history, drug use history, sexual/relationship history, and use of medication assisted treatment, as well as demographic information. This information assisted with identification of patients at-risk for contracting HIV. The Recommended Indications for PrEP Use published by the US Center for Disease Control and Prevention (2014) were the basis for the criteria used to determine if patients were at-risk.
Results
The final sample consisted of 68 patients and 58 of those reported being HIV-negative. We evaluated the HIV-negative patients for risk factors for contracting HIV and 38.2 percent (n=26) of the clinic’s patients were found to be appropriate for further referral to PrEP services. Referral to PrEP services was indicated for 35.3 percent (n=24) of patients based on their drug use behaviors and 2.9 percent (n=2) of patient referrals were based on their sexual behaviors. Based on the information recorded in the H&Ps, several risk factors for the contraction of HIV were identified that providers did not commonly address with patients, including sharing of drug preparation equipment, sex of their recent sexual partners, recent condom use, sex in exchange for drugs or money, HIV-status of recent partners, and history of high-risk sexual behaviors.
Conclusions
There is a need for PrEP services/referrals in the outpatient SUD treatment setting. Furthermore, there is an opportunity to increase the identification of persons with SUD who are at-risk for contracting HIV, by consistently asking patients for information regarding: sharing of drug preparation equipment, sex of their recent sexual partners, recent condom use, and history of high-risk sexual behaviors. The implementation of a standardized screening tool is a potential way to capture these risk factors amongst patients and normalize screening for HIV risk factors.
Future Directions for Research
Next steps include linkage to PrEP services for at-risk patients in outpatient treatment for substance use and to begin evaluation of the factors that influence PrEP uptake and adherence in this community.
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