Library

Research & Resources

This brochure lists research projects with African Americans and helpful resources produced by CAPS/PRC. You might use it to:

• Stay up-to-date on research and learn what we found out from research
• Provide materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects. Lead researchers (PIs) are listed for each study. Contact us below to connect.

Questions? Comments? Contact Daryl Mangosing at 415-514-4590 or [email protected] This brochure was prepared by the CAPS Community Engagement (CE) Core, which is previously known as the Technology and Information Exchange (TIE) Core.

Acronyms

MSM: Men who have sex with men PI: Principal Investigator (lead researcher on the study)

Research & Resources

This brochure lists research projects with Youth or young adults as well as helpful resources produced by CAPS/PRC. You might use it to:

• Stay up-to-date on research and learn what we found out from research
• Provide materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects. Lead researchers (PIs) are listed for each study. Contact us below to connect.

Questions? Comments? Contact Daryl Mangosing via phone at 1-415-514-4590 or email at [email protected] This brochure was prepared by the CAPS Community Engagement (CE) Core, which is previously known as the Technology and Information Exchange (TIE) Core.

Acronyms

MSM: Men who have sex with men PI: Principal Investigator (lead researcher on the study)

How can Pre-Exposure Prophylaxis (PrEP) help in HIV prevention?

Prepared by Pamela DeCarlo and Kimberly Koester, CAPS/PRC/CHPRC Community Engagement (CE) Core | May 2017

What is PrEP?

Pre-Exposure Prophylaxis (PrEP) is an HIV prevention method for people who do not have HIV but are concerned about getting HIV. Currently, PrEP involves taking one pill (Truvada) a day on a consistent basis.[1] Clinical guidelines for PrEP recommend that people be tested for HIV and kidney function before starting medication. While on medication, people should be tested and treated for sexually transmitted infections (STIs) every 3 months, for HIV every 6 months, and for kidney function as indicated.[1] Anyone newly diagnosed with an STI or HIV should be offered treatment.

Does PrEP work?

Yes! PrEP can work to prevent transmission of HIV, when the medication is taken consistently every day. Daily PrEP reduces the risk of getting HIV from sex by more than 90%. Among people who inject drugs, it reduces the risk by more than 49%.[2] A Kaiser Permanente study followed 972 patients over 3 years and found that no HIV infections occurred among those who took PrEP; however, 2 infections occurred in individuals who stopped taking PrEP after losing health insurance coverage.[3] At Magnet, a community clinic in San Francisco, CA, there have been no new HIV infections among 1,196 patients enrolled in their PrEP program.[4] PrEP may work differently to prevent transmission through vaginal sex than through anal sex. In the iPrEX clinical trial, protection from anal transmission was achieved taking the medication 4-5 times a week.[5] A clinical trial with cisgender women found that taking the pill 6-7 times a week provided protection from vaginal transmission.[6]

Is PrEP safe?

Absolutely. Most of the people who take PrEP do not experience side effects. For those people who do, the side effects are generally mild and go away within a month. The most common side effects are nausea, digestive problems, kidney issues and bone loss. One study found that taking PrEP generally was safer than taking aspirin.[7]

How else can PrEP help?

PrEP can provide mental health benefits. Several studies and many PrEP service providers report that PrEP use appears to decrease HIV-related stress and anxiety as well as increase the potential for greater intimacy and sexual pleasure. In fact, some people stated that after starting PrEP, they were able to have sex without the fear of HIV for the first time in their lives. Others felt hope for the future and optimistic about their love lives.[8,9]

PrEP can increase self-efficacy. PrEP is the first reliable method for HIV prevention that provides people with a relatively easy way to take an active role in preventing HIV. It does not require telling, showing or negotiating with partners, and does not need to be used during sexual activity.[10]

PrEP can facilitate access to healthcare. Many PrEP programs are serving young, healthy people—populations that otherwise may not access healthcare or health insurance. Because PrEP involves frequent laboratory testing and prescription medication, programs are training PrEP navigators to help patients sign up for insurance coverage, pay for medication, find a medical provider, encourage medication and appointment adherence, and access other social services that can help with staying healthy.

How can PrEP access be improved?

Remove structural barriers. Like most medications and behavioral prevention efforts, PrEP only works if it is taken as prescribed. It appears that many people accessing PrEP are highly motivated to take the pill, and that structural issues, not individual level issues, may be bigger barriers to adherence. Some of these barriers include being unable to pay for PrEP and clinical/laboratory services, problems finding providers that will prescribe PrEP in a nonjudgmental manner, difficulty attending clinic every 3 months, as well as concerns related to having experienced and perceived HIV-related stigma.

Reduce costs. PrEP medications cost $1200 - $1500 per month. Most insurance, including Medicaid, will cover PrEP, but some insurance plans have high co-pays and out-of-pocket expenses. Changing jobs or health care plans can often result in a gap in insurance when people may not be able to afford PrEP. Some states and Gilead, manufacturer of Truvada, have medication assistance programs to help offset these costs.[11] Increase use of PrEP navigators. PrEP navigators work in a variety of public and private health care settings to connect people to PrEP services and gain access to insurance and other programs to pay for PrEP.

Increase provider comfort and knowledge. Some healthcare providers are unaware of HIV pre-exposure prophylaxis or are uncomfortable prescribing PrEP for their patients. Providers may have misconceptions about the efficacy of PrEP, or assume that their patients will not be adherent.[12] Prejudice and bias around race, gender, sexuality, age, condom use and drug use may make providers unlikely to offer and/or prescribe PrEP to some patients. One study found that providers were most willing to prescribe PrEP to MSM with an HIV+ partner, and less likely to prescribe to heterosexuals and people who inject drugs.[13]

Address health disparities. While PrEP use increased over 500% between 2013 and 2015, disparities exist. Current use only covers a small percentage all the people who could benefit from PrEP, and PrEP uptake has been low among African Americans, Latinos, women and young adults.[14]

What's being done?

There are a variety of places such as, primary care clinics, STD and HIV clinics, family planning clinics, pharmacies and websites as well as a variety of providers such as physicians, nurse practitioners and pharmacists, offering PrEP services. Many service agencies across the US have created PrEP programs to help those who want and need PrEP, with a focus on underserved communities such as Black and Latino gay men, transgender women and youth. Some of these agencies include Callen-Lorde Community Health Center, Chicago PrEP Working Group, HIVE, Philly FIGHT, and Houston Area Community Services.[15] In Seattle, WA, the Kelley-Ross community pharmacies have implemented One-Step PrEP, a program where patients can meet with a pharmacist, be screened and prescribed PrEP, get follow-up lab tests and pick up prescriptions all in one place. Kelley-Ross also helps navigate insurance, and 98% of their patients pay $0 for their medication. Several programs are delivering PrEP via telehealth, such as Nurx.com (available in 11 states). People interested in PrEP sign up on the website by answering a few key questions that are reviewed by a doctor. Clients are then directed to a local lab to seek HIV, STI and kidney testing. Once labs are reviewed by a Nurx doctor, PrEP medications are either delivered to their door or can be picked up at a local pharmacy. Because finding a provider who knows about PrEP can be challenging, three services pleasePrEPme.org, pleasePrEPme. global and PrEPlocator.org offer a directory of public and private PrEP providers. You can search for providers that accept uninsured patients and for navigation services.

What needs to be done?

When new medications are introduced to the general public, health disparities are often highlighted, as underserved populations may be unaware of, unable to access and be suspicious of new medications. PrEP presents an opportunity to address and reduce these disparities. While many healthcare providers have championed PrEP for their patients, providers also can be a major stumbling block. Successful PrEP providers are likely to engage in shared decision-making with their patients, providing accurate information about PrEP, and trust that their patients will be positioned to make the best decisions about their own health. New medications and methods for delivering and monitoring PrEP that can lower barriers to access are being developed and tested. These include new, longer-lasting medications; drugs delivered via injection, vaginal and rectal microbicides and vaginal rings; and self-screening for HIV and STIs.[16] With the changing landscape of healthcare and policy in the US, we need continued advocacy for PrEP access and funding.

---

Says Who?

1. CDC. Preexposure prophylaxis for the prevention of HIV infections in the United States—2014: a clinical practice guideline. Atlanta, GA: US Department of Health and Human Services, CDC, US Public Health Service; 2014. CDC fact sheet for providers
2. CDC. PrEP 101 Consumer Info Sheet. 2016.
3. Volk JE, Marcus JL, Phengrasamy T, et al. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis. 2015;61:1601-1603.
4. Gibson S, Crouch P-C, Hecht J, et al. Eliminating barriers to increase uptake of PrEP in a communitybased clinic in San Francisco. 21st International AIDS Conference. July 2016. Durban, South Africa. Abstract FRAE0104.
5. Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-Tenofovir concentrations and preexposure prophylaxis efficacy in men who have sex with men. Science Trans Med. 2012:4;151-
6. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410.
7. Kojima N, Klausner JD. Is emtricitabine-tenofovir disoproxil fumarate pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection safer than aspirin? Open Forum Infect Dis. 2016 Jan 6;3(1):ofv221.
8. Koester K, Amico RK, Gilmore H, et al. Risk, safety and sex among male PrEP users: time for a new understanding. Culture, Health & Sexuality. 2017.
9. Golub SA, Radix A, Hilley A, et al. Developing and implementing a PrEP demonstration/ implementation hybrid in a community-based health center. 11th International Conference on HIV Treatment and Prevention Adherence, May 9-11, 2016, Fort Lauderdale, FL. ADH9_OA409.
10. Seidman D, Weber S. Integrating PrEP for HIV prevention into women’s health care in the United States. Obstetrics and Gyn. 2016;127:37-43.
11. CDC. Paying for PrEP. 2015.
12. Elion R, Coleman M. The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA. Curr Opin HIV AIDS. 2016;11:67-73.
13. Adams LM, Balderson BH. HIV providers’ likelihood to prescribe pre-exposure prophylaxis (PrEP) for HIV prevention differs by patient type: a short report. AIDS Care. 2016;8:1154-1158.
14. Bush S, Magnuson D, Rawlings MK, et al. Racial characteristics of FTC/TDF for Pre-exposure Prophylaxis(PrEP) users in the US #265. ICAAC 2016. Boston, MA; June 16-20, 2016.
15. http://hivprepsummit.org/index.php/prepresources/
16. Mayer KH. PrEP 2016: What will it take to generate demand, increase access, and accelerate uptake? 11th International Conference on HIV Treatment and Prevention Adherence, May 2016, Fort Lauderdale, FL. ADH11.

---

Special thanks to the following reviewers of this Fact Sheet: Leah Adams, Pierre Crouch, Rick Elion, Nathan Fecik, Jayne Gagliano, Barbara Green-Ajufo, Colleen Kelley, Jeffry Klausner, Daryl Mangosing, Alan McCord, Karishma Oza, Rupa Patel, Jim Pickett, Rebecca Sedillo, Dominika Seidman, Aaron Siegler, Jill Tregor, Jonathan Volk, Shannon Weber. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Many Fact Sheets are also available in Spanish.

©2017, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. 

This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.

This brochure lists research focusing on HIV testing and helpful resources produced by CAPS/PRC. You might use it to:

• Stay up-to-date on research and learn what we found out from research
• Use the materials in trainings/presentations
• Advocate for services/funding
• Write grants
• Develop new or modify existing HIV prevention programs
• Evaluate current programs
• Connect with CAPS/PRC to develop new projects.

Lead researchers (PIs) are listed for each study. This brochure was prepared by the Community Engagement (CE) Core, previously known as the Technology and Information Exchange (TIE) Core: “Tying research and community together.”

How do prescription pain pills (opioids) affect HIV?

Prepared by Kathleen Clanon, MD and Pamela DeCarlo Community Engagement (CE) Core | July 2017

Are prescription opioids a concern?

Yes. Prescription pain pills (opioids) such as oxycodone, hydrocodone and methadone have helped millions of people effectively manage chronic pain. But for some, opioids have become a complex, tangled web of misuse and abuse that has led to dramatic increases in addiction, overdose, hepatitis B and C infection, and potentially, HIV infection in the US.[1] Prescription opioids sold in the US more than doubled from 2001 to 2015, yet there has not been a decrease in the amount of pain reported. The amount of oxycodone and hydrocodone alone tripled from 2000 to 2015. Healthcare providers wrote 259 million prescriptions for opioid painkillers in 2012—enough for every adult in the US.[2] The CDC recommends that prescription opioids should not be considered first-line or routine therapy for chronic pain.[3]

Why are prescription opioids a concern?

People often don’t know the risk involved in taking prescribed opioids. Opioids make people feel good, the side effects often are not bothersome, and patients tend to think that doctors would not prescribe something that is dangerous. Patients may not understand they can become physically dependent on them, and providers may not understand or adequately explain this. People being prescribed opioids should ask their providers if opioids are really the safest way to manage their pain.

Overdose. From 2000 to 2014, nearly half a million people died from drug overdoses, and more than 60% of drug overdose deaths involve an opioid. Every day, 46 people in the US die from prescription opioid overdose.[2]

Opioids are highly addictive. As many as 25% of people using opioids long-term struggle with opioid dependence.[4] And people become dependent on them extremely quickly. The chances of chronic use begin to increase as early as after the third day taken, and rise rapidly with each day after.[5]

What is their effect on HIV?

Potential negative effects on PLWH. For people living with HIV (PLWH), long-term opioid use may lead to depression, can trigger relapse, and actually can increase chronic pain.[6]

Increased risk behavior. Like alcohol and other drugs, prescription opioids can interfere with judgment and decision-making, and can result in users doing things they wouldn’t do when not in an altered state. People using opioids may have lowered inhibitions and be less likely to use condoms and more likely to share syringes, behaviors that increase the risk of transmitting and acquiring HIV as well as hepatitis C (HCV) and hepatitis B.[7]

Transition to injecting and heroin. The epidemic of prescription opioid misuse has resulted in a large population of people who are new to injecting. Almost 80% of new heroin users report using prescription opioids prior to heroin.[8]

What are concerns for PLWH?

Long-term opioid use. Chronic pain occurs in as many as 85% of PLWH and many use prescription opioids to manage their pain. Side effects from long-term and regular use of opioids include: decreased libido and testosterone, depression, neurological and heart rhythm problems. Repeated use of opiate pain medicines can, in fact, heighten—instead of alleviate—chronic pain in PLWH.[6]

Opioid misuse. Problematic prescription opioid use may be common among PLWH especially persons with a history of substance use, mental health issues, and poor adherence to ART. One study of PLWH prescribed opioids found that 62% had problematic use.[9]

Relapse and overdose. For PLWH with a history of alcohol and drug abuse, opioids may cause relapse. Accidental overdose is common, especially when opioids are combined with alcohol or benzodiazepines (such as Valium and Xanax), or with anti-depression and seizure medications.[3]

HIV healthcare. For many HIV providers, the unique factors in HIV care can influence whether they adopt federal guidelines for prescribing opioids. For example, goals such as retaining patients in HIV care or being an ally with patients, may be seen as more important than conservative opioid prescribing guidelines. Specialized training on opioid prescribing may be warranted for HIV providers.[10]

What are concerns for person at risk for HIV?

Lack of safer injecting knowledge and programs. The opioid epidemic has led to an increase in people who inject drugs (PWID). These new injectors tend to be mostly White, live in rural and suburban areas, have little knowledge of safe injecting practices or HCV and HIV risks, and have little or no access to education or services for injectors, such as syringe access programs.[11] This creates the potential for rapid spread of HIV once introduced into communities.

Hepatitis C. Currently, HCV infection is a major concern for injectors, especially among young adults and those living in small towns and rural areas in the US who inject opioids. In 2013, 30,000 new cases of HCV occurred, and 28 states reported increases in HCV infections. This was an increase of more than 150% from 2010 to 2013.[11]

Potential rapid spread of HIV. In 2015, the first HIV outbreak associated with injecting prescription opioids occurred in rural Indiana. HIV infection spread quickly in this small community, with 135 people testing positive, and 80% of those reporting dissolving and injecting tablets of oxymorphone.[12]

What needs to be done?

While opioid prescriptions, use, addiction and overdose have skyrocketed in the past few years, federal, state and local agencies have responded with guidelines, regulations and programs to promote safety. In 2016, the CDC issued guidelines intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, to improve the safety and effectiveness of pain treatment, and to reduce the risks associated with long-term opioid therapy, including addiction, overdose, and death.[3]

Healthcare providers Non-opioid pain management. Providers working with PLWH should consider age, gender, socioeconomic status, current mental health, and substance use, as addressing pain without looking at these may have limited success. As the CDC recommends that opioids should not be a first-line therapy for chronic pain, providers should consider non-opioid means of managing pain. PLWH may get relief from pain with cognitive behavioral therapy, physical therapy, hypnosis or medical marijuana.[13] Overdose prevention. If providers and patients wish to use opioids, providers should discuss and provide written materials on the risks of dependence and overdose, and consider co-prescribing naloxone to reverse potentially fatal overdose.

People living with HIV PLWH who are prescribed opioids by their doctor should discuss any concerns and ask about non-opioid pain relief methods. If prescribed an opioid, they should use it for shortest period of time possible and be aware that dependence can happen right away, within 3 days of use.[5] PLWH who have been taking opioids for a long time should talk to their doctor about weaning off, or reducing their use.

Policymakers We know how to prevent HIV, and we have multiple effective HIV prevention interventions. The HIV outbreak among rural PWID in Indiana has shown what can happen when states and local communities do not invest in prevention. We need to make a serious commitment to expanding education; harm reduction services such as syringe access programs; overdose prevention including access to naloxone; and drug treatment.[14] Despite years of scientific evidence of their need, cost-effectiveness and effectiveness, there exist political and legislative barriers to implementing programs for PWID. We need to support, protect and expand existing laws and programs for the health and wellbeing of people who use and misuse prescription opioids, including PWID and their partners.

---

Says Who?

1. RTI International. Opioids In America: A complex crisis. A comprehensive response. 
2. CDC. Opioid painkiller prescribing: Where you live makes a difference. CDC Vital Signs. July 2014. www.cdc.gov/vitalsigns/opioid-prescribing
3. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR. 2016;65:1-49.
4. CDC. Injury prevention and control: Opioid overdose. Drug overdose deaths in the United States continue to increase in 2015. www.cdc.gov/drugoverdose/epidemic/
5. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use — United States, 2006–2015. MMWR. 2017;66:265–269. http://dx.doi.org/10.15585/mmwr.mm6610a1
6. Liu B, Liu X, Tang SJ. Interactions of opioids and HIV infection in the pathogenesis of chronic pain. Front Microbiol. 2016;7:103.
7. Zule WA, Oramasionwu C, Evon D, et al. Event-level analyses of sex-risk and injection-risk behaviors among nonmedical prescription opioid users. Am J Drug Alcohol Abuse. 2016;42:689-697.
8. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
9. Turner AN, Maierhofer C, Funderburg NT, et al. High levels of self-reported prescription opioid use by HIV-positive individuals. AIDS Care. 2016;28:1559-1565.
10. Starrels JL, Peyser D, Haughton L, et al. When human immunodeficiency virus (HIV) treatment goals conflict with guideline-based opioid prescribing: A qualitative study of HIV treatment providers. Subst Abus. 2016;37:148-153.
11. National Institute on Drug Abuse. Prescription opioids and heroin. NIDA Research Report Series. 2015. www.drugabuse.gov/publications/research-reports/prescription-opioids-heroin
12. Conrad C,  Bradley HM,  Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone — Indiana, 2015. MMWR. 2015;64:443-444. www.cdc.gov/mmWr/preview/mmwrhtml/mm6416a4.htm
13. Merlin JS. Chronic pain in patients with HIV infection: What clinicians need to know. Topics in Antiviral Medicine. 2015;23:120-124.
14. Raymond D. Injecting opana: Indiana’s HIV outbreak and America’s opioid epidemic. Harm Reduction Coalition. March 2015. https://medium.com/addiction-unscripted/injecting-opana-indiana-s-hiv-outbreak-and-america-s-opioid-epidemic-65501f9aa6c8

---

Special thanks to the following reviewers of this Fact Sheet: Rachel Anderson, Emily Behar, Neisha Becton, Holvis Delgadillo, Linda Gowing, Barbara Green-Ajufo, Renata Henry, Daryl Mangosing, Savannah O’Neill. Kathleen Clanon is affiliated with the Alameda County Health Care Services Agency. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Many Fact Sheets are available in Spanish.

©2017, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. 

This publication is a product of a Prevention Research Center and was supported by Cooperative Agreement Number 5U48DP004998 from the Centers for Disease Control and Prevention.