Acceptability of a hypothetical preventative HIV vaccine among people who use drugs in Vancouver, Canada

Background As research on HIV vaccines continues to advance, studies exploring the feasibility of this intervention are necessary to inform uptake and dissemination strategies with key populations, including people who use drugs (PWUD). Methods We conducted 25 in-depth qualitative interviews examining HIV vaccine acceptability among PWUD in Vancouver, Canada. Participants were recruited from an ongoing prospective cohort of HIV-negative PWUD. Data were coded using NVivo, and analyzed thematically. Results Acceptability was framed by practical considerations such as cost and side effects, and was influenced by broader trust of government bodies and health care professionals. While an HIV vaccine was perceived as an important prevention tool, willingness to be vaccinated was low. Results suggest that future vaccine implementation must consider how to minimize the burden an HIV vaccine may place on PWUD. Centering the role of health care providers in information dissemination and delivery may assist with uptake. Conclusions Our findings suggest improvements in care and improved patient-provider relationships would increase the acceptability of a potential HIV vaccine among this population.


DIRECTIONS
Thank you for agreeing to share your experiences as a person who uses drugs regarding your perspectives on a potential HIV vaccine. As we discussed during the consent process, today you will be taking part in an approximately 30-60-minute interview about your experiences in with drug use, sexual behaviour, and vaccinations, among other things. Please note that this interview will be audio recorded. Before we begin, please remember that everything that you share with us is confidential, and your information or identify will not be shared with anyone unless required by law. Also, please keep in mind that there are no right or wrong answers to these questions, and you do not have to answer any questions that you are not comfortable answering.

SOCIAL & STRUCTURAL ENVIRONMENT
Where have you been spending most of your time over the past month?
• Where do you stay most days?
• What do you do there? Who have you been spending time with over the past month?
• What friends, family or other people have you been seeing/mainly hanging out with?
• Tell me about these relationships?
• What kinds of things do you do with the people you spend time with?
Do you feel you can access harm reduction materials, if you want to?
• Why or why not?
• Where do you get your harm reduction materials?
• Is there anything that would make it easier for you to access harm reduction supplies?
Have you had any recent interactions with the police?
• Have you had a negative experience from using drugs in a public setting from the police?
• Do the police in any way influence your drug use? If so, how?
• Do the police in any way influence your day to day life? If so, how?
• Have you encountered more or less police since the overdose crisis became public?
• Have your interactions with the police changed at all since the overdose crisis became public?
• Do you think the police response to the overdose crisis has been good or bad?

INCOME GENERATION
What do you currently do to make money?

Note: Ask targeted follow-up questions on the specific types of formal/informal income generation engaged in.
• • How is it better than other ways?
• How is it worse than other ways? DRUG USE How would you describe your drug use in the past month?
• Which drugs do you use? How often?
• How long have you been using these drugs?
• Of the drugs you use, which is your drug of choice?
How often do you use it?
• If you can't find your drug of choice, do you use another? Which drug?
• Where do you use drugs? Can you walk me through the process of a typical time that you might use drugs in the last month?
• Do you have a routine you follow? What's your routine?
• What are you taking and how (smoking, ingesting, injecting, a combination)?
• Is there a clean surface needed, and if so, is one available to you?
• How about other supplies, are they available? For instance, clean needles/pipes, a washroom etc.
• (If applicable) Do you clean your skin before injecting?
• Would you describe it as a safe environment?
• Are people usually present?
• Do you do anything to limit your risk of overdose? What? Where do you get your drug use materials from?
• Do you find you can easily get needle/pipes/etc. when you need them? (If applicable) Do you inject yourself?
• If not, who does it for you?
• Do you share injecting equipment with your partner? Do you ever need assistance injecting?
• (If so) How do you find assistance? Who helps you?
• How does this impact where and when you inject drugs? Do you ever use drugs in public spaces?
• Can you describe these settings? (e.g. an alley, public bathroom) • Would you describe this as a safe environment? Why?
• • Do you share injecting equipment with your partner? (If applicable) Do you use your own pipe to smoke?
• Where do you get your pipes from?
• Are pipes easy to access for you?
• Do you and your partner share pipes? Do you share with other people also?

INDIGENOUS LIVED EXPERIENCE (IF APPLICABLE)
Do you think that being Indigenous impacts your drug use?
• Why or why not? •

II. PERCEPTIONS OF RISK AND RISK-REDUCTION STRATEGIES
Can you tell me about the sorts of activities that you view as being "risky" or "less risky" with regards to HIV transmission?

III. VACCINE HISTORY AND KNOWLEDGE Can you tell me what a vaccine is?
Read to participant when they've answered: A vaccine is a product that produces immunity from a disease, meaning it prevents disease, but does not cure it. The kinds of vaccines that we often get through needles are an injection of a killed or weakened disease that produce immunity by preparing the immune system to fight that disease in the future.
• What does a vaccine do to the body?
• What makes a vaccine effective or not?
Were you vaccinated as a child?
• (If yes) Where did you get vaccinated as a child? In school? In a clinic?
• What did you think about vaccines when you were a child? For example, were you scared?
• Do you feel that the vaccines you received as a child were necessary to prevent disease? Why or why not?
• • Would being vaccinated against HIV make you more or less likely to talk with potential sex partners or the people you use drugs with? Why or why not?
• Some people think that being vaccinated against HIV might lead people to engage in more risky behaviours.

What do you think about this?
What kind of information would you need to decide whether or not to receive an HIV vaccine?
• SECTION THREE: PERSPECTIVES ON PreP Introduction: Another risk-reduction strategy that is becoming available in some settings is Preexposure prophylaxis (or PrEP). Within this approach to HIV prevention, people who are not HIV positive can take medication and reduce their likelihood of getting HIV. It requires the HIV negative person to take a pill once a day, including before and after the risk exposure. And, it is very important that the pill is taken each day, or it becomes less and less effective as doses are missed. At this point, PrEP is not freely available in BCbut, there are ongoing discussions by the province to potentially do so in the near future. Other settings have begun to make it available. We want to hear your thoughts on PrEP. • What would you need in your life in order to make sure you were able to meet with your doctor regularlyif you had toto be on PrEP? Intermittent/"on-demand" PrEP: Using PrEP "on demand" is also effective at preventing the • Could you see yourself planning in advance to take PrEP (e.g., before having sex with someone)?
sexual transmission of HIV. This means that, prior to having sex, two pills are taken two and 24 hours before sex, and then one pill 24 and 48 hours later. How does this version of "on demand" PrEP make you think differently (or not) about PrEP?
• Do you feel that you would be able to plan in advance of a sexual experience in this kind of a way? Tell me about how this sort of an experience might take place, given your current situation (e.g., where you're living, how you plan your sexual activities).

Long-Acting PrEP:
Scientists are currently working on improved versions of PrEP that could come in a variety of different forms. For example, future forms of PrEP could be longer acting (e.g., it could last up to a many weeks or months).
• How does a longer-lasting kind of PrEP influence whether or not this is something you would consider taking?
• Would you be more or less likely to consider using PrEP if it could last for a "longer" time? Why?
• How long would you want PrEP to last if you were going to use it as a way to prevent getting HIV? Tell me about that. Long-Acting Injectable PrEP: Future versions of PrEP might also come in the form of an injectable, rather than a pill. It is possible that this would be a longer-acting form of PrEP, and that it might act for weeks or even months before the next dose is needed. What are your thoughts on taking a form of PrEP that is injectable?
• Do you think an injectable form of PrEP would be something you might benefit from? Tell me about that.
• Would you be more or less likely to consider using PrEP if it could be given to you in the form of an injection (e.g., rather than a pill)? Why?
• What would be the ideal wayfor youof taking PrEP to prevent HIV? Why? Injection-related risks and PrEP: Some settings are recommending that people who use various forms of drugs (e.g., injection drugs) take PrEP to reduce the risk of HIV acquisitions.
• Do you think PrEP is something that you would like to take to prevent yourself from getting HIV through injection drug use? Why?
• Some people have told us that PrEP would lead people to engage in more risky behaviour, as they would feel "bullet proof". What are your thoughts on that?
• What types of risks do you feel that people would take if they were on PrEP? What are your thoughts on that?
• What, if any, risks do you feel that you would be more likely to take if you were on PrEP?
• How would you think about someone who injects drugs and who is on PrEP? Why? Sexual-related risks and PrEP: Some groups are viewed as being 'higher risk' for sexual transmission of HIV. For example, gay and bisexual and other men who have sex with men are usually considered to be at a higher risk. As a result, doctors may recommend young MSM engage in various risk-reduction practices (e.g., regular condom use). Do you feel like you are somebody who should be offered PrEP to prevent the sexual transmission of HIV?
• What are your thoughts on being offered PrEP if you are thought to be "high-risk" by your health care provider because you are involved with sex work or identify as gay, bisexual or other MSM?
• Which groups do you think should be 'targeted' to go on PrEP to prevent sexual transmission of HIV? Tell me why you think this.
• Some people have told us that it is not fair to target specific groups of people for these kinds of HIV interventions, as this could be based on hurtful assumptions and/or stereotypes. What do you think about this?
If you were to plan a campaign for PreP, what would it look like?
• What age do you feel should be targeted?
• Which groups of people should be targeted?
• Where do you think would be the most effective place for a PreP campaign?
• Who do you think would be the most difficult to engage with?
• What information should be included in a public PreP vaccination campaign? • What information should not be included?
• What information should be given by a medical professional if someone is interested in PreP? V. WRAP UP QUESTIONS "Thank you for sharing your experiences with us? We have a couple of final questions about your views on stimulant treatments…" • Is there anything we haven't discussed about HIV vaccines or other methods of HIV prevention that you feel is important for us to know?