In the first instance, people who inject drugs (PWID) should be advised of and provided with options for using sterile needles, syringes and other injecting equipment, and offered opioid substitution therapy for those who use opioids. People who inject drugs can be referred to local needle and syringe programs, or the Australian Injecting and Illicit Drug Users League affiliates in their state or territory.
Because PWID are susceptible to a range of infections and injuries, PrEP and other HIV-prevention interventions should be integrated into prevention and clinical care services for hepatitis A, B and C infection and other infectious diseases, and overdose prevention. These interventions include screening for hepatitis A, B and C viruses and providing incentivised vaccination for hepatitis A and B where clinically
indicated, as well as screening for injection-related injuries and infections including abscesses, septicaemia and endocarditis (5).
The ASHM PrEP Guidelines Panel is cognisant of the concerns of the International Network of People who Use Drugs. The Network cautions against prioritising PrEP at the expense of other proven interventions
as the prime HIV-prevention strategy for people who inject drugs, and emphasises that access to harm- reduction services remains a critical component of HIV prevention in people who inject drugs (6). This approach is particularly relevant in Australia where sterile needle and syringe coverage is high and HIV prevalence and incidence among people who inject drugs remains low and stable (7, 8).
A recent systematic review of HIV-treatment adherence among PWID in the United States and Canada, undertaken to inform potential PrEP adherence interventions for people who inject drugs, found that younger age, female sex, homelessness and incarceration were obstacles to HIV treatment adherence (9). By comparison, self-sufficiency, use of opioid substitution therapy, and high quality patient-provider relationships were facilitators for adherence (9). Self-reports from HIV-negative people who inject drugs were that HIV–related stigma in social networks, negative experiences with health-care providers, lack of money, homelessness and the criminal justice system were likely barriers to PrEP access (10). These
factors should be considered when providing support to people commencing PrEP when they are at risk of HIV through injecting drug use.
The ASHM PrEP Guidelines Panel will continue to monitor the outcomes of the few ongoing studies of HIV PrEP in PWID.
Box 14.3 PrEP suitability criteria for people who inject drugs
HIV risk in the previous 3 months and the future 3 months
The clinician should prescribe PrEP if the patient describes a history of any of the following HIV acquisition risks in the previous 3 months and if the patient foresees that there are likely to be similar acquisition risks in the next 3 months:
• Shared injecting equipment with an HIV-positive person or with a gay or bisexual man of unknown HIV status
• At least one episode of condomless anal or vaginal intercourse (insertive or receptive) with a regular HIV-positive partner who is either not on treatment, or who is on treatment but has a detectable HIV viral load
• At least one episode of receptive anal or vaginal condomless intercourse with any casual HIV-positive partner or a male homosexual or bisexual partner of unknown status.
HIV risk in the future 3 months
The clinician should prescribe PrEP if the patient foresees that they will have HIV acquisition risk in the upcoming 3 months, despite not having had HIV acquisition risk in the previous 3 months.
• A person has recently (re)commenced injecting drugs and is injecting with a person who is HIV positive, or with a gay or bisexual man whose HIV status is unknown
• When a person plans to travel to countries with high HIV prevalence during which time they anticipate injecting drugs with other people who are HIV positive or of unknown HIV serostatus
• When a person reports that they will be entering, or leaving institutional or correctional facilities in the near future during which time they may inject drugs with people who are HIV positive or of unknown HIV serostatus