(33) Integration of Long-acting Injectable PrEP with MAT: A Pre-implementation Study

Background & Introduction: Early reports have demonstrated feasibility of long-acting injectable antiretroviral therapy (LAI-ART) implementation in populations with high rates of substance use.[1, 2] Less is known regarding strategies to integrate long-acting injectable pre-exposure prophylaxis (LAI-PrEP) with medications for addiction treatment (MAT) despite multiple studies demonstrating that people who use drugs (PWUD) are interested in and in some cases may prefer LAI-PrEP over an oral regimen.[3-5] The purpose of our study is to identify clinic-level barriers and facilitators to LAI-PrEP delivery and pilot its use at the Chemical Dependency Clinic (CDC) of PCC Community Wellness Center, a federally qualified health center serving the West and Northwest Sides of Chicago and the near west suburbs.

Methods: In 2023, we invited all providers, nurses, and behavioral health (BH) specialists (n=279) to participate in a survey regarding LAI vs. oral PrEP awareness, perceptions, and implementation preferences. We then conducted focus groups to further explore barriers and facilitators to and develop strategies for LAI-PrEP implementation through use of process mapping. We used descriptive statistics to stratify needs by MAT vs. non-MAT prescribers (using the framework of Positive Behavioral Interventions and Support), and rapid qualitative analysis to organize barriers and facilitators by inner setting, outer setting, innovation (Consolidated Framework for Implementation Research) and capability, opportunity, motivation (COM-B Model for Behavior Change).

Results: Of 50 prescribers surveyed, 24 (48%) prescribed and 26 (52%) did not prescribe MAT (although this group could have included some nurses and BH specialists who do not prescribe medications in their roles). 19/24 (79%) MAT prescribers and 16/26 (62%) of non-MAT prescribers were interested in serving as PrEP champions, and 17/24 (71%) MAT prescribers and 5/26 (19%) non-MAT prescribers had ever prescribed PrEP (of any type). 16/24 (67%) MAT prescribers and 16/26 (62%) non-MAT prescribers had heard of LAI-PrEP: 23/24 (96%) MAT prescribers and 23/26 (88%) non-MAT prescribers agreed or strongly agreed that LAI-PrEP is effective, and 23/24 (96%) MAT prescribers and 22/26 (85%) non-MAT prescribers agreed or strongly agreed that LAI-PrEP is safe. Lack of clinical workflows (e.g., how to obtain/administer LAI-PrEP) was the greatest barrier to implementation. Both focus groups (one of 12 CDC staff members, which also included peer support specialists, and the other of 12 self-identified PrEP champions from any site) reported limited time, competing priorities, and frequent follow-up as additional barriers. Facilitators included existing workflows for LAI-MAT and antipsychotics and HCV and STI treatment. Non-CDC staff reported need for a provider-driven implementation model (due to lack of additional resources) whereas CDC staff preferred a decentralized model including clinical care coordinators and peer support specialists. Staff members also requested additional clinical guidance for use of LAI-PrEP in pregnancy and adolescence.

Conclusion & Discussion: Our current work has identified clinic-level facilitators and barriers to LAI-PrEP implementation, and efforts to improve workflows, training, guidance on taking a sexual history, messaging, and electronic health record templates for MAT staff are in development. However, we have not yet been able to assess patient-level factors impacting LAI-PrEP uptake; next steps should include engagement of patients and community partners to support PrEP use among PWUD.

References: 1. Christopoulos KA, Grochowski J, Mayorga-Munoz F, Hickey MD, Imbert E, Szumowski JD, Dilworth S, Oskarsson J, Shiels M, Havlir D, Gandhi M. First Demonstration Project of Long-Acting Injectable Antiretroviral Therapy for Persons With and Without Detectable Human Immunodeficiency Virus (HIV) Viremia in an Urban HIV Clinic. Clin Infect Dis. 2023 Feb 8;76(3):e645-e651. 
2. Hill LA, Abulhosn KK, Yin JF, Bamford LP. Single-center experience evaluating and initiating people with HIV on long-acting cabotegravir/rilpivirine. AIDS. 2023 Mar 15;37(4):605-609.   
3. Biello KB, Edeza A, Salhaney P, et al. A missing perspective: injectable pre-exposure prophylaxis for people who inject drugs. AIDS Care 2019; 31(10): 1214-20.
4. Shrestha R, DiDomizio EE, Kim RS, Altice FL, Wickersham JA, Copenhaver MM. Awareness about and willingness to use long-acting injectable pre-exposure prophylaxis (LAI-PrEP) among people who use drugs. J Subst Abuse Treat 2020; 117: 108058.
5. Bazzi AR, Valasek CJ, Streuli SA, et al. Long-Acting Injectable Human Immunodeficiency Virus Pre-Exposure Prophylaxis Preferred Over Other Modalities Among People Who Inject Drugs: Findings from a Qualitative Study in California. AIDS Patient Care STDS 2022; 36(7): 254-62.