Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives.
Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives.
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DOI：
10.3389/fpsyt.2022.905314
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发表时间：
2022
影响因子：
4.7
通讯作者：
Walker, Tamara
中科院分区：
文献类型：
--
作者：
Surratt, Hilary L.;Yeager, Hannah J.;Adu, Akosua;Gonzalez, Evelyn A.;Nelson, Elizabeth O.;Walker, Tamara
注射吸毒者感染艾滋病毒的风险很高，但在农村地区，预防战略对注射吸毒者的研究不足。肯塔基州以农村艾滋病毒负担沉重和注射吸毒导致的新艾滋病毒诊断率上升而闻名。尽管有很高的需求和强有力的证据表明，暴露前预防（PrEP）是一种黄金标准的生物医学艾滋病毒预防工具，但在肯塔基州和其他地方的PWID中，扩大规模一直有限。本文探讨了个人，环境和结构性的障碍和便利的PrEP护理的角度PWID在农村肯塔基州。数据来自一项正在进行的NIH资助的研究，该研究旨在适应和整合肯塔基州东南部两个农村注射器服务项目（SSP）中护理点高风险PWID的PrEP启动干预。作为该倡议的一部分，在PRISM（实用、稳健、实施和可持续性模型）的指导下进行了一项定性研究，以收集SSP客户对与PrEP相关的干预需求、与物质使用障碍相关的竞争需求以及PrEP吸收的有形支持和障碍的观点。于2021年9月至11月期间，本集团与26名SSP客户进行招聘及面试，两个SSP地点各有13名。半结构化指南探讨了注射行为、SSP使用、PrEP知识、PrEP感知障碍以及风险环境的各个方面（例如，住房不稳定，社区耻辱），可能会影响PrEP的吸收。访谈进行了数字记录，逐字记录，并由项目工作人员核实。一个详细的编码方案的开发和应用独立的编码器使用NVivo。使用主题分析的原则，对编码的转录本进行合成，以确定数据中的突出主题。所有研究程序都得到了大学IRB的批准。参与者中96%为白色，42%为女性，中位年龄为41岁（范围21-62）;所有人都报告在过去一个月内使用过注射剂。总体而言，我们发现该样本中的PrEP意识较低，但对PrEP的兴趣很高，有几个表明PrEP是迫切需要的。客户在SSP报告了压倒性的积极经验，认为他们是接受卫生服务的可靠和安全的地点，并对整合共同定位的PrEP服务充满热情。缺乏基本的艾滋病毒和PrEP知识和健康知识是显而易见的，这导致了对艾滋病毒个人风险的普遍误解。与物质使用障碍有关的情境风险，特别是在戒断症状和渴望的背景下，往往导致艾滋病毒注射和性风险行为的增加。与物质使用和艾滋病毒相关的耻辱感是PrEP吸收的一个问题，一些参与者反映隐私问题会影响他们对PrEP教育，处方和监测的偏好。主要支持包括高水平的保险覆盖率，一致的药房访问，以及其他健康状况的成功药物管理的历史。利用物质使用障碍患者的关键观点，我们的研究结果提供了关于艾滋病毒感染高风险农村PWID中PrEP吸收的个人和环境障碍和促进因素的重要和可操作的信息。这些数据将推动以客户为中心的方法的适应和实施，以在农村地区的SSP环境中进行综合PrEP护理，以解决未满足的PrEP护理需求。
People who inject drugs (PWID) are at high risk for HIV infection, yet in rural areas PWID are understudied with respect to prevention strategies. Kentucky is notable for heavy rural HIV burden and increasing rates of new HIV diagnoses attributable to injection drug use. Despite high need and the strong evidence for Pre-Exposure Prophylaxis (PrEP) as a gold-standard biomedical HIV prevention tool, scale up has been limited among PWID in Kentucky and elsewhere. This paper explores individual, environmental, and structural barriers and facilitators of PrEP care from the perspective of PWID in rural Kentucky. Data are drawn from an ongoing NIH-funded study designed to adapt and integrate a PrEP initiation intervention for high-risk PWID at point of care in two rural syringe service programs (SSPs) in southeastern Kentucky. As part of this initiative, a qualitative study guided by PRISM (Practical, Robust, Implementation, and Sustainability Model) was undertaken to gather SSP client perspectives on intervention needs related to PrEP, competing needs related to substance use disorder, as well as tangible supports for and barriers to PrEP uptake. Recruitment and interviews were conducted during September-November 2021 with 26 SSP clients, 13 from each of the two SSP sites. A semi-structured guide explored injection behaviors, SSP use, knowledge of PrEP, perceived barriers to PrEP, as well as aspects of the risk environment (e.g., housing instability, community stigma) that may impact PrEP uptake. Interviews were digitally recorded, transcribed verbatim and verified by project staff. A detailed coding scheme was developed and applied by independent coders using NVivo. Coded transcripts were synthesized to identify salient themes in the data using the principles of thematic analysis All study procedures were approved by the University IRB. Participants were 96% white, 42% female, with a median age of 41 years (range 21–62); all reported injection use within the past month. Overall, we found low PrEP awareness among this sample, yet interest in PrEP was high, with several indicating PrEP is urgently needed. Clients reported overwhelmingly positive experiences at the SSPs, considering them trusted and safe locations to receive health services, and were enthusiastic about the integration of co-located PrEP services. Lack of basic HIV and PrEP knowledge and health literacy were in evidence, which contributed to common misperceptions about personal risk for HIV. Situational risks related to substance use disorder, particularly in the context of withdrawal symptoms and craving, often lead to heightened HIV injection and sexual risk behaviors. Stigma related to substance use and HIV arose as a concern for PrEP uptake, with several participants reflecting that privacy issues would impact their preferences for education, prescribing and monitoring of PrEP. Noted tangible barriers included inconsistent access to phone service and transportation. Primary supports included high levels of insurance coverage, consistent pharmacy access, and histories with successful medication management for other health conditions. Drawing on the critical perspectives of people with substance use disorder, our findings provide important and actionable information on individual and environmental barriers and facilitators of PrEP uptake among rural PWID at high risk for HIV infection. These data will drive the adaptation and implementation of a client-centered approach to integrated PrEP care within rurally located SSP settings to address unmet needs for PrEP care.
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