A Qualitative Study of Service Providers' Reactions Toward Implementation of Pre-Exposure Prophylaxis (PrEP) in Community Based Substance Use Treatment

Background: In the United States, there are approximately three million substance users in community treatment programs who are at risk for HIV acquisition, through injection drug use and/or unprotected sex. The recent FDA approval of Pre-Exposure Prophylaxis (PrEP), a medication for people who do not have HIV to reduce their risk of infection by taking a daily antiretroviral pill may help avert HIV among substance users. Substance use (SU) treatment providers (e.g., social workers, nurses) are positioned to recommend PrEP. The National Institute on Drug Abuse’s (NIDA) Clinical Trials Network (CTN) may conduct trials in community SU settings to determine PrEP’s feasibility and acceptability in this population. Providers are the gatekeepers without whom this would not be possible. Despite excitement in the scientific community, there is little understanding of provider attitudes toward PrEP and toward being involved in PrEP clinical trials. This study helps to advance knowledge of the potential impact of this new HIV prevention method.

 

Methods: Semi-structured qualitative interviews recorded and transcribed, with 36 providers: one clinic director, one medical provider (e.g., nurse, psychiatrist) and 4 counselors (e.g., social workers), from each of six CTN-affiliated outpatient SU clinics.  Participants were each given a brief introduction to PrEP through written materials and didactic presentation and were asked to discuss their reactions toward delivering PrEP to their clients and toward being involved in clinical trials. Interviews were read and coded line-by-line independently by the principal investigator, a social work researcher, and two social workers that provide HIV and SU services, according to thematic content analysis, within identified domains of interest. Coders met in person to resolve differences in coding and reached 100% agreement.  

 

Results: Findings within the six domains of inquiry were the following: 1) Limited awareness: 4 providers were aware of PrEP. 2) Attitudes: most agreed that PrEP is beneficial yet only 7 were willing to offer/recommend PrEP, mainly due to risk compensation. 3) Challenges in delivering PrEP: training providers, educating clients, making referrals to primary care, prescribing and/or monitoring PrEP, and determining eligibility criteria (e.g., risk factors). 4) Adherence: most providers doubted clients’ ability to comply with daily dosing 5) Safety/side effects. 6) Barriers to conducting clinical trials: maintaining confidentiality, informed consent, and managing clients’ mistrust toward research. Providers recommended financial incentives to overcome challenges.

Conclusions: Given how few had ever heard of PrEP, comprehensive training for social workers and medical providers about PrEP, and HIV risk assessment will be necessary for implementation in SU treatment settings. PrEP delivery will require linkages between SU and primary care clinics since prescribing and monitoring PrEP was not feasible in some SU settings due to lack of medically qualified staff. Targets for provider training include: PrEP eligibility criteria, adherence counseling and monitoring guidelines for substance-using clients. Protecting confidentiality within clinic settings is a concern for researchers seeking to use this venue for PrEP trials.  This study informs best practices for engaging providers in the implementation of PrEP and PrEP research, and helps identify targets for service provider training.