Table 3 PrEP Care Continuum Experiences Among Bridge Clinic and Harm Reduction Health Service Providers and Women who Engage in Sex Work and Use Drugs in Boston, 2021/2022

Awareness

Promotion

Education/ Engagement

Many noted:

1. Public health campaigns and advertisements were not tailored to WSWUD

2. Substance use services were key to HIV prevention education for WSWUD

Most had knowledge about PrEP through social networks and substance use services, barriers included:

1. Lack of tailored messaging to WSWUD

2. Low HIV risk perceptions

All felt PrEP education was important but noted the following competing priorities:

1. Survival

2. Substance use treatment

Incentives facilitated engagement in PrEP education

Uptake

Evaluation/

Counseling

Prescribing

All had counseling experience.

1. Note templates facilitated HIV risk assessments

2. Discomfort discussing sex work was a barrier

3. Injection drug use made phlebotomy challenging

Most had prior/current experience with PrEP/PEP:

1. Trust in care facilitated PrEP discussions

2. Stigma was a barrier to PrEP evaluations

Providers had differing levels of comfort prescribing PrEP

1. Challenges with follow and adherence deterred initiating prescriptions

PrEP uptake was facilitated by:

1. Wrap-around substance use and HIV services

2. Same day PrEP

Adherence and Retention

Counseling/ Follow-up

Prescribing

Bridge clinic providers had less experience with PrEP adherence. Barriers to adherence across settings:

1. Lack of housing

2. Active substance use

Most WSWUD cited difficulty adhering to PrEP/PEP:

1. Competing survival priorities (drug use/safety)

2. Drug storage when unhoused

For some, having a PrEP routine facilitated PrEP adherence

Community outreach facilitated ongoing PrEP prescribing