"I'm a really hard stick": barriers, facilitators, and preferences in emergency department HIV testing among people who inject drugs.

Suffolk County, Massachusetts is an Ending the HIV Epidemic priority area with an ongoing cluster of HIV transmission among people who inject drugs, many of whom accessed care in emergency departments prior to diagnosis but were not offered HIV testing. Emergency-department-based HIV testing and pre-exposure prophylaxis initiation have thus become local public health priorities. We conducted a content analysis of in-depth interviews with 26 people who inject drugs recruited from a substance use disorder clinic in Suffolk County serving people who received initial care in the emergency department. Interview questions investigated acceptability, barriers, and facilitators to HIV testing and pre-exposure prophylaxis initiation in the emergency department for people who inject drugs. Mean age was 38y (SD 9.4); 62% were male, with 69% identifying as white and 27% as Latinx. We identified five themes: 1) Support for emergency-department-based HIV testing, 2) Need for multimodal HIV testing, 3) Creating a safe and supportive environment, 4) Pre-exposure prophylaxis misconceptions, and 5) Addressing competing priorities. People who inject drugs are supportive of HIV testing and pre-exposure prophylaxis initiation in emergency departments but acknowledge reasons for declining. Possible modifications to increase acceptance include offering multiple HIV testing modalities and creating safe, confidential spaces to discuss testing and pre-exposure prophylaxis.