Combination primary care and prevention services for women who inject drugs and exchange sex in Seattle, Washington

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ABSTRACT Women account for nearly 20% of new HIV cases in the United States but experience significant barriers to accessing HIV prevention, addiction, and sexual health services. Women who inject drugs (WWID) are particularly vulnerable to HIV due to a combination of social, biologic, and structural risk factors, and women comprise many of the new HIV diagnoses in recent outbreaks among people who inject drugs (PWID). Similarly, WWID are disproportionately impacted by major medical issues requiring hospitalization and leading to premature death, especially when injection drug use is compounded by transactional sex and unstable housing. HIV pre-exposure prophylaxis (PrEP), medications for opiate use disorder (MOUD), and treatment of sexually transmitted infections (STIs) are proven strategies for HIV prevention and addiction treatment among WWID; however, uptake remains low. Our preliminary data suggests that a co-located neighborhood clinic offeringwalk- in appointments dramatically improves uptake of HIV prevention and addiction treatment but does not result in sustained use of these evidenced-based interventions. Globally, delivery of HIV prevention and sexual healthcare at venues for exchange sex is an effectivetool for engaging marginalized populations, such as female sex workers; however, this strategy has not yet been implemented in the U.S. In direct contrast to traditional models of healthcare, an evening, drop-in clinic, co-located at a venue for exchange sex and drug use provides increased opportunity to access care in a client-centered environment. Leveraging a global to local approach, we propose a pilot venue-based pop-up primary and preventative care clinic for WWID. Formative, qualitative research and a bi-directional community engagement plan will inform the adoption of global models for HIV prevention and addiction services (e.g. PrEP, MOUD, STI screening, etc.), with the goal of supporting sustained us of evidence-based interventions. We hypothesize that venue-based care will be acceptable to WWID and improve uptake of preventive care. We also hypothesize that implementation of participant designed support strategies will improve adherence to PrEP, MOUD, and STI treatment. Aim 1 will assess barriers and facilitators to uptake and sustained use of PrEP and MOUD and inform conversations with our community advisory board to adapt a global to local venue-based care model, tested in Aim 2. In Aim 2, we will pilot a venue-based model of care for 50 WWID. Using novel rigorous laboratory science methods, we will measure the impact of venue- based care on sustained use of PrEP and MOUD (Aim 2a), and we will similarly measure the acceptability and feasibility associated with venue-based care for WWID. If successful, our study will provide data on a feasible model of care for reducing HIV acquisition among WWID, which can be assessed for cost-effectiveness and further tested at scale.