In rural areas, injecting drug users may have less knowledge and more stigma about HIV prevention for HIV prevention than in urban settings.


Pre-exposure prophylaxis (PrEP) for HIV prevention reduces the risk of HIV infection from sexual transmission by 99% and from injecting drug use by 74-84%. However, PrEP is used by only 1-2% of people who inject drugs (PWID).

The stigma of HIV-preventing drugs may discourage potential PrEP users. However, there is little research examining how this stigma works in rural and urban environments.

A new study conducted by the Center for Drug Use and HIV / HCV Research (CDUHR) at the NYU School of Global Public Health compares the awareness and knowledge of PrEP in rural Illinois and urban New York.

Previous studies have focused on the stigma associated with certain sexual orientations, and this study has focused on expanding previous research by examining how the stigma encountered by PWID often occurs at the intersection of sexuality, drug use, and HIV stigma. According to the study, “there is a hierarchy by type of drug that creates a stigma gradation, with injecting drug use being the most stigmatized, especially in terms of HIV risk.” Investigators examined how this particular type of stigma limited the involvement of PWID in health care in the first crucial steps of information and knowledge.

In 2019, 2.3% of new HIV diagnoses in New York were attributed to injecting drug use, and men with PWID who have sex with men accounted for 1.5%. In Illinois between 2013 and 2017, 2.1% of HIV infections were attributed to injecting drug use and 2.5% of men with PWID who had sex with men.

According to Suzan Walters, lead author of the study, a CDUHR researcher and associate researcher at the NYU School of Global Public Health: many injectors do not even know that PrEP exists, which is worrying. “

From August 2019 to February 2020, Walter and his colleagues conducted in-depth semi-structured qualitative interviews with 57 individuals identified through local syringe exchange programs. Of these participants, 18 were from Southern Illinois and 39 from New York City. To be included in the study, participants had to be at least 18 years old, fluent in English, and inject at least once last year (most participants had injected drugs more than once in the last 30 days).

After building a relationship and learning about HIV, investigators consistently asked four PrEP-related questions about awareness (whether they heard about it), knowledge (understanding what they were doing), willingness (whether to accept it), and acceptance (taking it).

Awareness and knowledge of PrEP clearly varied depending on the setting. In rural Illinois, only half of the participants heard about PrEP (September 18), mostly through television commercials. None of the Illinois participants have ever talked to PrEP about a doctor or health care provider. Because most respondents only knew PrEP from TV commercials, and these advertisements often target men who have sex with men, most Illinois participants (only two of whom were identified as bisexual) did not consider PrEP to be an option for them.

In New York, 77% (30/39) heard of PrEP. These respondents also saw various ads and PrEP ads, but unlike rural Illinois participants, some of these ads were placed in harm reduction settings, such as Syringe Service Programs (SSPs). City participants also reported more frequently that they discussed PrEP informally and / or formally with peers and doctors.

None of the rural participants could accurately describe PrEP, we commonly believe that PrEP was used to treat HIV, not to prevent it. Respondents from New York had a better knowledge of PrEP, but were sometimes incomplete or incorrect. None of the surveyed participants currently used PrEP.

Participants who had the best knowledge of PrEP learned about the medicine from several sources, such as interviews with healthcare professionals, friends, or through the SSP.

Investigators identified syringe service programs in the urban environment as one of the reasons why this population was more familiar with PrEP, as it is a pleasant space where PWID could socialize alleviated stigma and promote information sharing.

After receiving information on PrEP, there was a willingness to participate of about 50% in both rural and urban environments. Among the uninterested PWIDs, many still associated the risk of HIV exclusively with sexual orientation or used stereotypical and stigmatizing language to differentiate themselves from people at risk for HIV.

Doctors prescribing PrEP are more willing to prescribe PrEP to men from the sexual minority who do not use drugs, such as PWID, and this stigma has prevailed especially in rural areas. Some respondents from rural Illinois reported avoiding medical facilities because of a perceived or experiential belief that they would encounter a stigma like PWID.

Investigators have recommended more sexually and drug-positive reports to combat misinformation and encourage at-risk populations to use PrEP. They also suggested that PrEP be extended to SSP and packaged as a harm reduction tool to ensure that drugs are available to PWID.