Integrating harm reduction and addiction care in HIV prevention among persons who inject drugs in the United States-a narrative review.

Abstract

New human immunodeficiency virus (HIV) cases related to injection drug use (IDU) in the United States increased between 2016 and 2022. The uptake of preexposure prophylaxis (PrEP) is exceedingly low in persons who inject drugs (PWID) despite its efficacy to prevent HIV. There are multilevel barriers in the PrEP care cascade for PWID. We need a combination of effective HIV prevention strategies, including PrEP, treatment for substance use disorder, and syringe services programs (SSP) to reverse the trend. A major challenge is the lack of knowledge and skills in harm reduction practices and addiction care in the infectious disease (ID) workforce. ID clinicians could benefit from education in harm reduction and addiction, including taking on the responsibility of prescribing buprenorphine or navigating the resources for it. Addiction clinicians could benefit from education on PrEP and related program implementation knowledge. Both specialties need to comprehensively evaluate and address the risks for HIV acquisition in PWID. We should create integrated clinical programs between ID and addiction. We should improve HIV screening for hospitalized PWID. We should expand low-barrier integrated clinics with flexible hours, walk-in appointments, same-day PrEP starts, and collocated laboratory and pharmacy services. Other entities that could provide integrated care include substance detoxification and rehabilitation programs, SSPs, opioid treatment programs (OTP), community pharmacies, and mobile health clinics. Long-acting injectable PrEP for PWID is an attractive option for HIV prevention, but robust implementation programs are necessary for roll-out. We still need to address upstream barriers to care for PWID, including stigma and health disparities. We need to continue to advocate for policy changes and funding for SSPs and OTPs to provide comprehensive HIV prevention.