Integrated Rapid Access to HIV Prevention Program for People Who Inject Drugs (RAPID)

项目总结 注射吸毒者(PWID)中的艾滋病毒流行一直在下降，但在迅速增长的情况下 随着阿片类药物的流行，社区现在越来越容易受到艾滋病毒传播的影响。最近爆发的艾滋病病毒 与注射毒品有关的问题将艾滋病毒引入了PWID网络，从而有可能扭转数十年的艾滋病毒 预防方面的成功。虽然阿片类激动剂治疗(OAT)和注射器服务计划(SSP)可以减少艾滋病毒 此类节目的传播、获取和利用是不可用的或可用有限的；性和 与注射有关的艾滋病毒风险在许多PWID中持续存在。将暴露前预防(PrEP)整合到 现有的循证方案(如OAT、SSP)被认为是加强艾滋病毒的机会 PWID的预防工作。然而，尽管PWID是理想的，但其摄取率仍然很低 候选人，并有兴趣开始PrEP。我们正在进行的PWID中的PrEP依从性试验的数据显示， 从最初的PrEP资格筛查到PrEP开始(通常为1-3周)之间的自然减少率(43.7%)。 此外，定性访谈表明，选择PrEP分娩将减少等待时间或 反复就诊共开出PrEP处方。这些早期的发现，在其他人的支持下，指导了快速 准备启动集成在现有的减少伤害服务中，以减少或消除患者、临床医生、 和结构性障碍。最近的试点研究结果表明，早期可接受性、可行性和安全性 男男性行为者(MSM)和变性人女性(TGW)快速(当天)启动PrEP，但 其中没有一个包括PWID，这是一个在当前阿片类药物危机中非常需要的群体。快速预诱发电位启动 对于PWID可能特别重要，因为它们更有可能在治疗开始前丢失。充分地 优化艾滋病毒预防，PrEP护理应与燕麦片相结合。将燕麦片与艺术相结合是从 医生，如果他们正在使用药物，将停止抗逆转录病毒治疗(ART)；如果患者 燕麦片、ART处方均增加。鉴于高级执业护士(APN)更有可能 以患者为中心询问他们的药物使用情况，并提供更多支持性咨询，这是一种新的 PWID的联合同日PrEP/OAT差异化护理模式非常适合从APN开始。我们, 因此，建议在实施科学框架内开发和试运行该模型。具体的 目的是：1)目标1：检查PWID和临床利益相关者对 APN提供的适用于PWID的快速艾滋病毒预防计划(IRaPID)，集成了当天的PrEP 和燕麦片；以及2)目标2：评估PrEP和燕麦片摄取的初步疗效 在无HIV的PWID中进行iRaPID与常规治疗的对照试验。这些目标加在一起，将 解决艾滋病毒预防方面的巨大差距，解决当天配药的多层次障碍 预防。从PWID的成功当天PrEP/OAT模型中学到的元素可以指导未来的纵向扩展 在资源有限的城市和非城市环境中将APN和医生结合在一起的模式。

PROJECT SUMMARY The HIV epidemic among people who inject drugs (PWID) has been on the decline, but amidst a burgeoning opioid epidemic, communities are now increasingly vulnerable to HIV transmission. Recent HIV outbreaks linked to drug injection has introduced HIV into PWID networks and thus, potentially reverse decades of HIV prevention successes. While opioid agonist therapy (OAT) and syringe services programs (SSPs) reduce HIV transmission, access to and utilization of such programs are unavailable or with limited availability; sexual and injection-related HIV risks persist in many PWID. The integration of pre-exposure prophylaxis (PrEP) into existing evidence-based programs (e.g., OAT, SSPs) has been presented as an opportunity to strengthen HIV prevention efforts in PWID. Uptake, however, remains stubbornly low in PWID despite them being ideal candidates and interested in starting PrEP. Data from our ongoing PrEP adherence trial in PWID show high rates of attrition (43.7%) between the initial PrEP eligibility screening visit and PrEP initiation (usually 1-3 weeks). Further, qualitative interviews indicate preferences for PrEP delivery that would decrease waiting times or repeated visits altogether PrEP prescription. These early findings, supported by others, guide the need for rapid PrEP initiation integrated within an existing harm reduction services that reduce or eliminates patient, clinician, and structural barriers. Results from recent pilot studies have shown early acceptability, feasibility, and safety of rapid (same-day) PrEP initiation in men who have sex with men (MSM) and transgender women (TGW), but none of them include PWID, a group with extraordinary need in the current opioid crisis. Rapid PrEP initiation may be particularly important for PWID as they are more likely to be lost before treatment initiation. To fully optimize HIV prevention, PrEP care should be combined with OAT. Combining OAT with ART evolved from physicians who would withhold antiretroviral therapy (ART) from PWID if they were using drugs; if patients were OAT, ART prescription increased. Given the findings that advanced practice nurses (APNs) are more likely to inquire in a patient-centered manner about their drug use and provide more supportive counseling, a new differentiated care model of combined, same-day PrEP/OAT for PWID is well-suited to start with APNs. We, therefore, propose to develop and pilot test this model within an implementation science framework. The specific aims are to: 1) Aim 1: examine feasibility and acceptability among PWID and clinical stakeholders for an adapted APN-delivered, rapid HIV prevention program for PWID (iRaPID) that integrates same-day PrEP and OAT; and 2) Aim 2: estimate the preliminary efficacy of PrEP and OAT uptake in a pilot randomized controlled trial of the iRaPID vs. treatment as usual strategy in PWID without HIV. Together, these aims will address a wide gap in HIV prevention by addressing multilevel barriers to dispensing same-day combination prevention. Elements learned from a successful same-day PrEP/OAT model for PWID can guide future scale-up models that incorporate both APNs and physicians in urban and non-urban settings where resources are limited.