HIV risk and attitudes toward PrEP among MSM-PWID in the U.S. Northeast
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BACKGROUND: Although the total number of new documented HIV diagnoses annually decreased from 2008-2018, the rate of decrease started to slow in 2013, and substantial variation exists across at-risk groups. People who inject drugs (PWID) account for 9% of new diagnoses annually, with increasing incidence in this population starting in 2015. Among PWID, 34% of new HIV diagnoses occurred in individuals who were also classified as men who have sex with men (MSM), indicating that MSM-PWID have elevated HIV risk. Data on MSM-PWID are scarce, and programmatic and advocacy efforts in HIV prevention do not specifically target MSM-PWID, with no CDC-recommended interventions existing for this population. OBJECTIVE: We sought to characterize the complex, intersecting and unique HIV risks faced by MSM-PWID, including perceptions of HIV risk and attitudes toward antiretroviral pre-exposure prophylaxis (PrEP) among MSM-PWID in urban and non-urban areas of Massachusetts and Rhode Island. METHODS: We recruited PWID through community-based organizations (CBOs; e.g. syringe service programs) in 18 urban centers and smaller cities and towns across Massachusetts and Rhode Island. Participants completed semi-structured interviews exploring substance use behaviors and HIV prevention needs. This in-depth analysis focused on describing the experiences and HIV prevention needs and attitudes of nine participants in the sample who reported a sexual orientation other than “heterosexual.” RESULTS: Most participants identified as cisgender, bisexual men. However, the context of their sexual behaviors varied, with some participants only engaging in same-sex behavior during sex work. The relationship between identity and behavior is explored in the context of reported risk behavior. All participants engaged in at least one behavior that increased risk of HIV acquisition, including syringe sharing, inconsistent condom use, and sex work. Participants also described heightened risk when these behaviors overlapped, particularly within contexts of “sex parties” that some individuals described. At the same time, experiences of isolation and exclusion were common in the sample, indicating a potential vulnerability in this population. HIV risk perception varied among participants, but was not consistently aligned with the behaviors described. Many participants did not perceive needing HIV prevention services “yet,” indicating that they did not view their risk to be high enough to warrant prevention services. Alternatively, some described needing to prioritize daily survival and mental health over HIV prevention efforts. Although knowledge of PrEP was low, acceptability of PrEP was high in this sample, and several participants provided specific suggestions for improving the feasibility of PrEP. CONCLUSION: Data from this study illustrate the HIV risks and prevention needs of this at-risk population and highlight mechanisms to engage them in preventative care. Our main findings are (1) participants had low knowledge of PrEP, but were largely enthusiastic after learning about it from interviewers, (2) varying identity related to same-sex behavior among men who have sex with men and inject drugs may play a role in shaping HIV risk and prevention needs, (3) specific healthcare and prevention service needs of this population emerged, including reducing risk at sex parties and improving access to non-stigmatizing mental health services. An in-depth understanding of the ways in which sexual orientation and gender identity shape HIV risk and prevention needs remains crucial in providing treatment and prevention services to MSM-PWID.