The number of people being infected with HIV in Philadelphia is increasing due to the city’s opioid epidemic. Unlike other areas of the country where ingesting and snorting pills are principal routes of opioid abuse, Philadelphia witnesses a uniquely high rate of people who inject drugs. That puts injection drug users in Philadelphia at increased risk for HIV.
One response by the Philadelphia health department has been to train providers who prescribe medication-assisted treatment (MAT) — the gold standard in treatment for opioid addiction — in the use of Pre-Exposure Prophylaxis (PrEP), a daily pill that can prevent HIV infection.
Recently, the health department released data that found 61 people acquired HIV through injection drug use in 2018 versus 45 cases the year before. A study by the National HIV Behavioral Surveillance System of Injection Drug Users in Philadelphia suggests that this increase in infections may be due to a high rate of sex work in Philadelphia, noting that 51 percent of the women they surveyed, and 30 percent of the men, had “exchanged sex for money, drugs, or other goods in the past 12 months.” Despite this vulnerability to infections, local providers in treatment centers related to HIV and/or opioid use are consistently met with surprise and a lack of awareness in their patients about the utility and availability of PrEP.
Because of this increase, there is a growing professional consensus that Philadelphia-area MAT patients should be evaluated for PrEP. It is 99 percent effective when taken as prescribed, but it is not commonly used in Philadelphia[OK1] . If providers consistently offer PrEP and MAT together, Philadelphia could be a national leader in treating those at risk of acquiring HIV, exceeding the minimum standards set by the Centers for Disease Control and Prevention (CDC).
The advantages are twofold: not only is an at-risk population receiving a needed prevention service but those at-risk are already seeing a prescribing medical provider who can initiate this process. These types of local emerging best practices offer a way of bridging national policy, clinical guidelines, local contexts, and patient choice.
Currently, CDC guidelines are much more conservative, recommending the use of a decision tool that has been widely criticized as too clinically cumbersome. This is an unnecessary step before having a conversation about PrEP and identifying risk factors such as whether or not the person has access to buprenorphine maintenance, injects fentanyl, trades sex for drugs, and engages in sexual networks of people who inject drugs.
Local health departments typically avoid making recommendations that go beyond CDC guidelines, but Philadelphia has an opportunity to innovate in a way that would save lives. In a similar move that exceeded CDC guidelines, the Philadelphia health department previously recommended prophylactic doxycycline, which can prevent sexually transmitted infections if taken 72 hours after unprotected sex, for people at risk of acquiring syphilis.
PrEP is fully covered by most health plans including Pennsylvania Medicaid. PrEP is straightforward to prescribe, and when monitored by a medical provider, is reported to have few to no side effects. than When compared with the expensive and life-long HIV medications that would be required for each new infection, PrEP is cost effective and significantly cheaper.