Barriers and facilitators to integrating medications for opioid use disorder (moud) and hiv pre-exposure prophylaxis (prep) foradolescents and young adults (aya)

The syndemic of substance use and HIV is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the national "Ending the HIV Epidemic" initiative. There has been a resurgence of HIV among people who inject drugs which, by extension, affects marginalized youth who enter shared sexual and drug use networks. The increasing availability of biomedical prevention options for both opioid use disorder (OUD) and HIV represents an important opportunity to improve care for youth placed at risk. This qualitative study used in-depth, semi-structured interviews with 19 purposively sampled, academic and community-based AYA healthcare providers who had previously prescribed MOUD and/or PrEP. Barriers and facilitators to integrated MOUD and HIV prevention services were explored using a chart-stimulated recall technique, which enables the use of clinicians’ own documentation of actual patient encounters to stimulate recall of their medical decision-making and clinical recommendations. Interviews were audio-recorded and transcribed. All interview transcripts were imported into NVivo 12.0, double coded, and analyzed using modified grounded theory. Of the providers sampled, the majority were medical doctors (63%), with the remainder representing physician assistants and nurse practitioners. Nearly half of the study population (47%) had completed their professional training in the last 5 years, with the most sampled specialties being internal medicine (37%) and family medicine (26%). All participating clinicians recommended HIV screening at varying intervals depending on risk assessment. However, few counseled on or prescribed PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (e.g., stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider-level (e.g., provider perception of low risk and lack of training/experience) and system-level factors (e.g., restricted visit types). Facilitators of PrEP prescriptions in this population included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (i.e., PrEP navigators, certified recovery specialists). Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. The barriers and facilitators identified in this study will inform the development of provider-informed, youth-centered, multi-level interventions to increase the integration of PrEP delivery within the context of OUD care among AYA populations.