 I think one thing that's really underappreciated is that sexual risk and injection risk sort of go hand in hand among people who inject drugs, just when we're thinking about HIV. And I think as addiction medicine providers, we often do a good job of assessing the injection related risk, the substance related risk, the overdose risk, but I think sometimes we're not as thorough at asking about sexual practices, asking about partners, and asking about other risks for HIV, but we do know that they go hand in hand. So there are a lot of strategies to prevent HIV among people who inject drugs and other folks, and some of them have been around for a long time, condoms, condom distribution, clean injection equipment availability, syringe exchange. So those are all really, really important pieces of the puzzle right now and will continue to be. And there are some other strategies that have not been used as often that I think are also very important, namely HIV pre-exposure prophylaxis or PrEP. PrEP is a medication, it's a single pill, a combination tablet of tenofovir and emtracitabine that can be taken once a day to prevent HIV infection, and people who are at high risk, it's very effective. And what we've seen with PrEP is that it's been very advertised in certain communities. So among men who have sex with men, there's just much more knowledge about PrEP. It's been advertised to that community, it's known, it's talked about. But as medical professionals, we really haven't done a good job of including all populations that might be eligible. So specifically people who inject drugs, women, young people of color have not necessarily been included in the messaging about PrEP. And so communities may not know about it. On the provider end, a lot of providers also don't know very much about it. And so what that's led to is just a real disparity in who's able to access PrEP and who even knows about it. One of the things that's devastating to me when I'm on the receiving end of a patient with a new HIV diagnosis is that I look through their chart, I talk to them about their history, and they're touching the healthcare system. And yet haven't necessarily been offered this HIV prevention tool, or really even had a good conversation with the provider about all the strategies they could use to prevent HIV. So I think it's really important that we start to offer PrEP at the places where our patients are already accessing care. The healthcare system is very intimidating to a lot of our patients, and they've dealt with a lot of stigma in healthcare. And so I think moving these tools towards lower barrier programs is really important, and that's going to be key to making it more available. The overall number of new HIV infections in the United States is declining. However, in 2017, there were 39,000 new HIV diagnoses, and the number of new diagnoses remains high in certain groups. People who inject drugs accounted for one in ten of all new HIV diagnoses in 2017. It is estimated that one in 42 males who inject drugs and one in 26 females who inject drugs will be diagnosed with HIV in their lifetimes. The introduction of illicitly manufactured fentanyl to the heroin supply has made drug injection even riskier. Illicitly manufactured fentanyl is shorter acting than traditional street-level heroin, so it requires more injections per day, eight to ten injections, or more in some cases. The higher number of injection events makes it less likely that people will have access to clean needles and equipment for each injection. This could drive a surge of new HIV infections. HIV outbreaks among needle-sharing networks have recently impacted people who inject drugs in Indiana, Massachusetts, and other parts of the country. HIV risk among people who inject drugs is not just about needle-sharing. People who inject drugs also have high rates of sexual risk factors that include sexual assault, condomless sex with partners at high risk, and transactional sex. How can we help prevent HIV in people who inject drugs? Strategies that help to decrease new HIV infections in people who inject drugs include syringe service programs, medications for opioid use disorder, condom distribution, and low barrier access to HIV testing and treatment. HIV pre-exposure prophylaxis, also referred to as PREP, is another evidence-based strategy that reduces new HIV infections. PREP involves taking one pill every day that contains two HIV medications to prevent HIV infection in people at high risk. Among people who inject drugs, daily PREP decreases the chance of getting HIV by 74%. In spite of recommendations by medical professionals and growing public health concerns, the use of PREP by people who inject drugs has lagged behind other groups. What can healthcare providers do to increase the use of PREP? 1. Ask all patients about sexual and injection-related HIV risk behaviors. 2. Educate patients and colleagues about PREP as a tool for HIV prevention. 3. Make PREP available to people who inject drugs in the same settings where they already receive care. When starting PREP, healthcare providers should order baseline labs to ensure that patients are HIV negative. Screened for hepatitis B or other infections, that they are not pregnant and do not have renal insufficiency. People who have had a high-risk exposure to HIV should be given post-exposure prophylaxis or PREP within 72 hours as a bridge to PREP. Patients should be counseled that PREP does not protect against other infections and must be taken daily for it to be effective. Patients should be seen for follow-up every three months. Many people with injection-related risk will benefit from being seen more often. In summary, people who inject drugs continue to experience high rates of HIV infections. To reduce the risk of HIV infections, providers should familiarize themselves with evidence-based HIV prevention strategies like PREP.