Although a third of people with hepatitis C surveyed in Washington, DC, and Baltimore were potentially eligible for HIV prevention pills or long-acting injections, most had not heard of pre-exposure prophylaxis (PrEP) and very few were using it, according to research published in Open Forum Infectious Diseases.

HIV and hepatitis C virus (HCV) share some of the same transmission routes, such as shared drug injection equipment and condomless sex, suggesting that many people living with HCV could benefit from HIV PrEP. In 2012, 68% of new HIV cases in the United States were attributed to sex between men, 7% to injection drug use and 4% to both risk factors, the study authors noted as background.

Kristi Hill, MD, of Harvard Medical School, and colleagues assessed PrEP awareness and use among participants in GRAVITY (Geomapping Resistance and Viral Transmission in Risky Populations), an observational study conducted between March 2016 and November 2020 that collected epidemiologic data and blood samples from people with HIV or hepatitis C in Washington, DC, and Baltimore.

Most participants were recruited from a harm reduction organization that provides services to sex workers, people who inject drugs and gender and sexual minorities. The organization also did community HIV and HCV testing at parks, community centers and shelters. Additional participants were recruited from two federally qualified health centers, two drug treatment centers and a city health department clinic.

This analysis was limited to 314 people with hepatitis C alone. Two thirds were cisgender men, and a third were cisgender women. Most (88%) were Black, and 78% self-identified as heterosexual. Most either had no income or relied on government support, and less than half said they had stable housing. However, most were covered by Medicaid or Medicare, and 63% said they had at least annual visits with a medical provider.

The researchers found that 109 of the 314 participants surveyed, or 35%, had an indication for PrEP. Within this group, 48 people (44% of those with an indication) reported HIV risk due to injection drug use, defined as sharing needles or other injection equipment during the past year. Forty people (37%) were at risk for HIV via sexual transmission, defined as more than one partner and inconsistent condom use for anal or vaginal sex, sex work or other transactional sex, or having an HIV-positive partner. Another 21 people (19%) had both drug use and sexual risk factors.

However, just 85 of the 314 participants (27%) had ever heard of PrEP, only 32 people (10%) had been offered PrEP by a provider and only six people (2%) were currently taking PrEP. Results were no better for the 15% of participants who considered themselves to be at high risk for HIV: 21% had heard of PrEP, 11% had been offered PrEP and three (6%) were using it.

More encouragingly, 114 survey participants overall (38%), and 47 of those with a PrEP indication (43%), said they were interested or maybe interested in PrEP, suggesting people may be receptive to efforts to increase PrEP uptake.

Consistent with previous research, only 28% of respondents with a PrEP indication considered themselves at high risk for HIV, the study authors noted. Among people with a PrEP indication, women were twice as likely as men to consider themselves at high risk, “likely reflecting public health messaging that has traditionally portrayed women as a vulnerable group and heterosexual men as a low-risk group,” they wrote.

“Considering oneself high risk for HIV was associated with higher interest in PrEP, though 26% of those who considered themselves high risk were not interested,” they continued. “More qualitative data are needed to explore the reasons for lack of interest in PrEP uptake among people who perceive themselves to be high risk and how interest may change with options for different PrEP modalities such as injectable PrEP.”

“Though indications for PrEP were prevalent among individuals with HCV in this cohort, most patients were unaware of PrEP, had never been offered PrEP and were not using PrEP,” the researchers concluded. “These data support the need for improved PrEP implementation among people with HCV.”

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