Lyle Cooper is an Associate Professor at Meharry Medical College. His research includes harm reduction for people who inject drugs, HIV prevention, and substance abuse prevention and treatment.

Background: Preventive efficacy against HIV infection has been demonstrated in randomized controlled trials for people who inject drugs (PWID). PrEP implementation for PWID has lagged in comparison to other vulnerable groups. Studies examining barriers and facilitators to real world implementation of PrEP for PWID are lacking, and virtually non-existent for PWID residing in rural communities.
Methods: We conducted a pre-implementation study consisting of a survey of 315 PWID and 13 interviews with PrEP and syringe service program (SSP) personnel in Appalachian Tennessee, a region with extremely high overdose rates and several recent HIV clusters among PWID. We utilized the Consolidated Framework for Implementation Research (CFIR) to organize findings from both the survey and the qualitative interviews to develop a PrEP for PWID implementation strategy.
Results: Survey findings indicated a high willingness to use injectable PrEP, and a higher perceived risk for HIV infection was associated with 1.069 greater odds of willingness to take PrEP, when adjusted for age, race, and gender. Qualitative findings indicated that inner setting factors that facilitated PrEP linkage included compatibility with the harm reduction model, agency wide prioritization of PrEP, non-judgmental communication from the providers and no-cost HIV testing. A lack of funding for supportive services and labs were identified as inner setting barriers. Several outer setting barriers to PrEP were identified, including HIV stigma, inaccurate risk perception (noted in the survey findings), and difficulty prioritizing PrEP over other more immediate needs.
Discussion: CFIR inner and outer setting factors that could affect PrEP adoption for PWID were identified and provide needed data to develop implementation plans. Our findings, when mapped to the Expert Recommendations for Implementing Change (ERIC), a compendium of implementation strategies developed to be consistent with CFIR constructs fill a key knowledge gap in implementing PrEP for PWID in real world settings.