The United States has made important strides to reduce the incidence and negative outcomes of HIV, including increasing the availability of effective treatment and prevention in the form of pre-exposure prophylaxis (PrEP). While the incidence of new HIV infections fell significantly from 130,000 in 1985, progress has stalled at approximately 39,000 new infections per year since 2013.
One challenge has been the transmission of HIV through shared injection equipment. PrEP has been shown to reduce HIV incidence by 74% among persons who inject drugs (PWID). However, the implementation and uptake of PrEP among PWID have been inadequate. To better understand trends in PrEP use among people who inject drugs, especially in the context of a worsening drug overdose epidemic, we investigated PrEP prescribing rates in a national database of commercially insured persons with an opioid or stimulant use disorder from January 1, 2010, and December 31, 2019.
Jake Morgan, PhD, CHERISH investigator and Research Assistant Professor at Boston University School of Public Health.
We used an established algorithm to include in our cohort individuals who were at least 16 years of age with a documented diagnosis of opioid or stimulant use disorder. We excluded those with evidence of HIV or hepatitis B to ensure any PrEP medication we found was not being prescribed for HIV treatment. We also used the algorithm to observe the association between injection drug use and PrEP uptake.
We found that injection drug use was associated with 1.5 times greater odds of having received PrEP compared to those with no evidence of injection drug use. However, the actual number of individuals receiving PrEP was abysmally low. Only 0.15% of individuals with evidence of injection use and 0.08% of individuals with no evidence of injection received at least one prescription during the study period. These findings suggest that this evidence-based prevention strategy is gravely underused.
"We need better ways of identifying those who would benefit from PrEP in claims data, but even an imperfect approach shows striking gaps."
This study also highlights urgent data challenges that need to be addressed to foster more accurate research on HIV and substance use disorder, particularly research conducted with observational data. For example, diagnosis codes for tracking opioid use disorder and injection behaviors are imperfect, and medical claims do not fully capture those in need of care because individuals do not seek care for these issues. Therefore, our study may have missed individuals with opioid use disorder or individuals who inject drugs who were misclassified as having no evidence of injecting.
These data challenges suggest that the individuals we included in our study were those with the most severe substance use issues including people who feel they need to seek care for their substance use, those who have providers who decide the use is worthy of documentation, and individuals who seek treatment for injection-related complications of substance use. These are also individuals with some of the greatest risks of becoming infected with HIV, which increases our concern about the alarmingly low PrEP prescribing we found.
To achieve the public health goal of reducing new HIV infections, we need to meaningfully engage with people who inject drugs and employ evidence-based prevention strategies. We need better ways of identifying those who would benefit from PrEP in claims data, but even an imperfect approach shows striking gaps. Aggressive expansion of PrEP for people who inject drugs is urgently needed.
The study, “Prevalence of HIV Preexposure Prophylaxis Prescribing Among Persons With Commercial Insurance and Likely Injection Drug Use,” was published in JAMA Network Open on July 12, 2022. Authors include Carl G. Streed Jr, MD, MPH; Jake R. Morgan, PhD; Mam Jarra Gai, MPH; Marc R. Larochelle, MD, MPH; Michael K. Paasche-Orlow, MD, MPH; and Jessica L. Taylor, MD.