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HIV pre-exposure prophylaxis (PrEP) use among Urban Canadian gay, bisexual and other men who have sex with men for whom PrEP is clinically recommended: baseline results from the Engage cohort study

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Abstract

Background: in Canada, gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by HIV. Use of HIV pre-exposure prophylaxis (PrEP) by GBM for whom PrEP is clinically recommended, is unknown. We report on PrEP access and factors associated with not using PrEP, among HIV-negative/unknown GBM in Montreal, Toronto and Vancouver. Methods: from 2017 to 2019, the Engage study recruited sexually-active GBM≥16 years in Montréal(M), Toronto(T), and Vancouver(V) via respondent-driven sampling (RDS). Participation included HIV/STI testing and a questionnaire. We examined PrEP access using a health services model and fit RDS-adjusted logistic regressions to determine correlates of not using PrEP among those who were PrEP-aware and clinically recommended. Results: a total of 2449 GBM were recruited. 2008 were HIV-negative/unknown with 1159 (n=511(M), n=247(T), n=401(V)) meeting PrEP recommendations. Of these, 1100 were PrEP-aware (RDS-adjusted %: M=85%, T=94%, V=93%), 678 felt the need for PrEP (M=39%, T=56%, V=49%), 406 tried to access it (M=21%, T=33%, V=30%) and 319 used PrEP (M=15%, T=22%, V=22%) in the past 6 months. Not using PrEP was associated with several factors, including not feeling at high enough risk, viewing PrEP as not completely effective, not having a primary care provider, and lacking medication insurance. Conclusion: while half of GBM from Canada’s three largest cities met clinical recommendations for PrEP, less than a quarter reported use. Despite high levels of awareness, a programmatic response that addresses PrEP-related perceptions and health system barriers is needed to scale-up PrEP access and ultimately end the HIV epidemic among GBM in Canada.<br/

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... Although optimal PrEP use reduces the risk of HIV acquisition via CAS by 86% (Sagaon-Teyssier et al., 2016), PrEP-protected CAS still presents risk for other STIs (e.g., Centers for Disease Control and Prevention, 2018b). Further, a large number of men who meet clinical recommendations for PrEP do not report using it (Cox et al., 2020;Finlayson et al., 2019), which suggests that these men may be at elevated risk for both STI and HIV transmission when they engage in CAS without PrEP. Given the increased diagnoses of bacterial STIs and other STIs in GBM (e.g., Centers for Disease Control and Prevention, 2018a; Haddad et al., 2018), CAS (with or without PrEP use) continues to have public health significance, particularly in the context of sex partners other than a main partner. ...
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Objective: Supportive social relationships can have direct positive effects on health and mitigate the negative impact of stressors. This study investigated the main effect of perceived social support on STI/HIV risk and prevention behaviors. The buffering effect of perceived social support on the impact of proximal minority stressors, like internalized homonegativity, was also examined on one risk behavior specifically, condomless anal sex (CAS) without HIV preexposure prophylaxis (PrEP) use. Method: HIV-negative gay, bisexual, and other men who have sex with men (GBM) were recruited using respondent driven sampling from three major Canadian urban centers (n = 1,409). GBM completed measures of perceived social support, proximal minority stress, and engagement in STI/HIV risk and prevention behaviors. Results: Higher perceived social support was positively associated with a several health behaviors, including recent STI and HIV testing, discussing HIV status with prospective partners, the use of behavioral HIV-risk reduction strategies during sexual encounters, and a lower likelihood of engaging in CAS without PrEP. There was evidence of moderation as well. Among GBM with higher perceived social support, internalized homonegativity was no longer associated with increased odds of engaging in CAS without PrEP. Conclusions: The results of the current study advance social support theory to GBM in the context of biomedical prevention, showing both evidence of both direct associations and buffering effects on STI/HIV risk and prevention behaviors. This highlights the importance of promoting social support seeking in interventions aimed at improving GBM health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... Recruitment details have been described in more detail elsewhere. 27 ...
Article
Background Some Canadian jurisdictions offer publicly funded HPV vaccine to gay, bisexual, and other men who have sex with men (GBM) aged ≤26 years. We characterized factors associated with being in different stages of HPV vaccination. Methods Engage is a sexual health study of GBM in the three largest Canadian cities recruited via respondent driven sampling (RDS). We categorized participants as: (1) unaware of HPV vaccine, (2) undecided/unwilling to get vaccinated, (3) willing to get vaccinated, (4) vaccinated with one or more doses. Our RDS-II weighted analyses used multinomial logistic regression to identify factors associated with being in earlier stages of the cascade compared to Stage 4. Results Across the cities, 26–40%, 7–14%, 33–39%, and 13–28% were in Stages 1 to 4, respectively. Compared to Stage 4, being in earlier stages of the cascade was associated with bisexual-identification (Stage 1: adjusted odds ratio[aOR] = 2.84, 95% confidence interval[CI] = 1.06–7.62; Stage 2: aOR = 3.09, 95%CI = 1.19–8.05), having immigrated to Canada (Stage 1: aOR = 1.79, 95%CI 1.07–2.99), preference to keep same-sex romantic relationships private (Stage 1: aOR = 1.25, 95% CI = 1.05–1.48; Stage 2: aOR = 1.24, 95%CI = 1.05–1.46), not receiving sexual health information (Stage 1: aOR = 0.31, 95% CI = 0.13–0.71; Stage 2: aOR = 0.27, 95%CI = 0.12–0.64), not accessing a health-care provider (Stage 2: aOR = 0.36, 95%CI = 0.15–0.83), and no past hepatitis A/B vaccination (Stage 1: aOR = 0.16, 95% CI = 0.09–0.30; Stage 2: aOR = 0.18, 95%CI = 0.09–0.35; Stage 3: aOR = 0.38, 95%CI = 0.21–0.61). Discussion Interventions are needed to reduce social and financial barriers, increase sexual health knowledge, and improve GBM-competent health-care access to increase vaccine uptake among GBM.
... This bodes well for future reductions in HIV diagnoses (and incidence) for GBM, a phenomenon which is currently being observed in BC, where the number of diagnoses among GBM recorded in 2017 was the lowest since the mid-1980s[30]. However, this also suggests that further improvements to the HIV care cascade, possibly 95-95-95 and the expansion of publicly funded pre-exposure prophylaxis programmes[36] for HIV, which is still limited in Canada[37] may be needed to further reduce HIV infections for GBM.A U T H O R S ' A F F I L I A T I O N S 1 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; 2 University of British Columbia, Vancouver, BC, Canada; 3 Ryerson University, Toronto, ON, Canada; 4 University of Victoria, Victoria, BC, Canada; 5 McGill University, Montr eal, QC, Canada; 6 Direction r egionale de sant e publique -Montr eal, CIUSSS Centre-Sud-de-l'Ile-de-Montr eal, Montr eal, QC, Canada; 7 Institut national de sant e publique du Qu ebec, Montr eal, QC, Canada; 8 School of Human Sciences, Louisiana State University Shreveport, Shreveport, USA; University of Toronto, Toronto, ON, Canada; 10 Community Based Research Centre, Vancouver, BC, Canada ...
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Introduction: Treatment as prevention strategies have been variously applied across provinces in Canada. We estimated HIV care cascade indicators and correlates of unsuppressed viral load (VL) among gay, bisexual and other men who have sex with men (GBM) recruited in Vancouver, Toronto and Montreal. Methods: Sexually active GBM, aged ≥16 years, were recruited through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview and tests for HIV and other sexually transmitted infections (STIs). We conducted bivariate analyses comparing RDS-adjusted proportions across cities. We used multivariable logistic regression to examine factors associated with having a measured VL ≥ 200 copies/mL with data pooled from all three cities. Results: We recruited 1179 participants in Montreal, 517 in Toronto and 753 in Vancouver. The RDS-adjusted HIV prevalence was 14.2% (95% CI 11.1 to 17.2) in Montreal, 22.1% (95% CI 12.4 to 31.8) in Toronto and 20.4% (95% CI 14.5 to 26.3) in Vancouver (p < 0.001). Of participants with confirmed HIV infection, 3.3% were previously undiagnosed in Montreal, 3.2% undiagnosed in Toronto and 0.2% in Vancouver (p = 0.154). In Montreal, 87.6% of GBM living with HIV were receiving antiretroviral therapy (ART) and 10.6% had an unsuppressed VL; in Toronto, 82.6% were receiving ART and 4.0% were unsuppressed; in Vancouver, 88.5% were receiving ART and 2.6 % were unsuppressed (p < 0.001 and 0.009 respectively). Multivariable modelling demonstrated that participants in Vancouver (adjusted odds ratio [AOR]=0.23; 95% CI 0.06 to 0.82), but not Toronto (AOR = 0.27; 95% CI 0.07 to 1.03), had lower odds of unsuppressed VL, compared to Montreal, as did older participants (AOR 0.93 per year; 95% CI 0.89 to 0.97), those at high-risk for hazardous drinking (AOR = 0.19; 95% CI 0.05 to 0.70), those with a primary care provider (AOR = 0.11; 95% CI 0.02 to 0.57), and those ever diagnosed with other STIs (AOR = 0.12; 95% CI 0.04 to 0.32). Conclusions: GBM living in Montreal, Toronto and Vancouver are highly engaged in HIV testing and treatment and all three cities have largely achieved the 90-90-90 targets for GBM. Nevertheless, we identified disparities which can be used to identify GBM who may require additional interventions, in particular younger men and those who are without a regular primary care provider.
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Objectives To eliminate the hepatitis C virus (HCV) by 2030, Canada must adopt a microelimination approach targeting priority populations, including gay, bisexual and other men who have sex with men (MSM). Accurately describing HCV prevalence and risk factors locally is essential to design appropriate prevention and treatment interventions. We aimed to estimate temporal trends in HCV seroprevalence between 2005 and 2018 among Montréal MSM, and to identify socioeconomic, behavioural and biological factors associated with HCV exposure among this population. Methods We used data from three cross-sectional surveys conducted among Montréal MSM in 2005 (n=1795), 2009 (n=1258) and 2018 (n=1086). To ensure comparability of seroprevalence estimates across time, we standardised the 2005 and 2009 time-location samples to the 2018 respondent-driven sample. Time trends overall and stratified by HIV status, history of injection drug use (IDU) and age were examined. Modified Poisson regression analyses with generalised estimating equations were used to identify factors associated with HCV seropositivity pooling all surveys. Results Standardised HCV seroprevalence among all MSM remained stable from 7% (95% CI 3% to 10%) in 2005, to 8% (95% CI 1% to 9%) in 2009 and 8% (95% CI 4% to 11%) in 2018. This apparent stability hides diverging temporal trends in seroprevalence between age groups, with a decrease among MSM <30 years old and an increase among MSM aged ≥45 years old. Lifetime IDU was the strongest predictor of HCV seropositivity, and no association was found between HCV seroprevalence and sexual risk factors studied (condomless anal sex with men of serodiscordant/unknown HIV status, number of sexual partners, group sex). Conclusions HCV seroprevalence remained stable among Montréal MSM between 2005 and 2018. Unlike other settings where HCV infection was strongly associated with sexual risk factors among MSM, IDU was the pre-eminent risk factor for HCV seropositivity. Understanding the intersection of IDU contexts, practices and populations is essential to prevent HCV transmission among MSM.
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Respondent-driven sampling is a commonly used method for sampling from hard-to-reach human populations connected by an underlying social network of relations. Beginning with a convenience sample, participants pass coupons to invite their contacts to join the sample. Although the method is often effective at attaining large and varied samples, its reliance on convenience samples, social network contacts, and participant decisions makes it subject to a large number of statistical concerns. This article reviews inferential methods available for data collected by respondent-driven sampling.
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The response many gay men took to the HIV epidemic in the United States was largely informal, especially given distant state and federal governments. The condom code, a set of informal norms that encouraged the use of condoms, is one instance of this informal response, which was wholly uncoordinated. Yet, it is not clear why these informal norms emerged or why they have since eroded. This paper explores how gay men in particular generated expectations and normative beliefs regarding condom usage, which helped to establish the condom code as an informal norm. Furthermore, the erosion of the condom code is viewed as a result of changing expectations, which change as bio-medical means of HIV treatment and prevention develop and as online and digital communities facilitate serosorting, all of which provide alternatives to condoms as a means of prevention and their associated informal norms. Future HIV prevention campaigns should recognize the extent to which informal norms coordinate and encourage preventative behavior, as well as how beliefs and expectations alter the informal norms people adopt.
Article
Objectives: This exploratory study examined the facilitators of and barriers to acceptance of pre-exposure prophylaxis (PrEP) and potential risk compensation behaviour emerging from its use among men who have sex with men (MSM) and transgender individuals (TGs) in India. Methods: A questionnaire was administered to 400 individuals registered with a targeted intervention programme. Logistic regression models were used to identify facilitators of and barriers to PrEP acceptance. Results: The respondents consisted of 68% MSM and 32% TGs. Risk behaviour categorization identified 40% as low risk, 41% as medium risk and, 19% as high risk for HIV infection. About 93% of the respondents were unaware of PrEP, but once informed about it, 99% were willing to use PrEP. The facilitators of PrEP acceptance were some schooling [odds ratio (OR) 2.16; P = 0.51], being married or in a live-in relationship (OR 2.08; P = 0.46), having a high calculated risk (OR 3.12; P = 0.33), and having a high self-perceived risk (OR 1.8; P = 0.35). Increasing age (OR 2.12; P = 0.04) was a significant barrier. TGs had higher odds of acceptance of PrEP under conditions of additional cost (OR 2.12; P = 0.02) and once-daily pill (OR 2.85; P = 0.04). Individuals identified as low risk for HIV infection showed lower odds of potential risk compensation, defined as more sexual partners (OR 0.8; P = 0.35), unsafe sex with new partners (OR 0.71; P = 0.16), and decreased condom use with regular partners (OR 0.95; P = 0.84), as compared with medium-risk individuals. The associations, although not statistically significant, are nevertheless important for public health action given the limited scientific evidence on PrEP use among MSM and TGs in India. Conclusions: With high acceptability and a low likelihood of risk compensation behaviour, PrEP can be considered as an effective prevention strategy for HIV infection among MSM and TGs in India.
Article
The purpose of this study was to evaluate the ability of men who have sex with men (MSM) testing for HIV at commercial sex venues to assess the following: their candidacy for pre-exposure chemoprophylaxis (PrEP) as defined by meeting entry criteria for the iPrEx (Iniciativa Profilaxis Pre-Exposicion) phase III clinical trial of PrEP, and their perception of their own HIV risk and candidacy for PrEP. Interviewers surveyed 629 MSM at three NYC commercial sex venues from June 2011 through June 2012. Questions focused on demographics, sexual activity, and drug use in the three months prior to testing, as well as perceived risk of HIV acquisition and perceived candidacy for PrEP use. Data were analyzed by Chi square and Fisher's exact test. Results show that a majority of clients (80.3%) met entry criteria for the iPrEX. Most of these men (78.0%), however, did not perceive their risk to be significant enough to warrant PrEP use (P = .000). Factors were identified which associated with a risk perception that correlated with eligibility for iPrEX.
Article
Background: Preexposure prophylaxis (PrEP) is the first biomedical intervention with proven efficacy to reduce HIV acquisition in men who have sex with men (MSM) and transgender women. Little is known about levels of interest and characteristics of individuals who elect to take PrEP in real-world clinical settings. Methods: The US PrEP Demonstration Project is a prospective open-label cohort study assessing PrEP delivery in municipal sexually transmitted disease clinics in San Francisco and Miami and a community health center in Washington, DC. HIV-uninfected MSM and transgender women seeking sexual health services at participating clinics were assessed for eligibility and offered up to 48 weeks of emtricitabine/tenofovir for PrEP. Predictors of enrollment were assessed using a multivariable Poisson regression model, and characteristics of enrolled participants are described. Results: Of 1069 clients assessed for participation, 921 were potentially eligible and 557 (60.5%) enrolled. In multivariable analyses, participants from Miami (adjusted Relative Risk [aRR]: 1.53; 95% confidence interval [CI]: 1.33 to 1.75) or DC (aRR: 1.33; 95% CI: 1.2 to 1.47), those who were self-referred (aRR: 1.48; 95% CI: 1.32 to 1.66), those with previous PrEP awareness (aRR: 1.56; 95% CI: 1.05 to 2.33), and those reporting >1 episode of anal sex with an HIV-infected partner in the last 12 months (aRR: 1.20; 95% CI: 1.09 to 1.33) were more likely to enroll. Almost all (98%) enrolled participants were MSM, and at baseline, 63.5% reported condomless receptive anal sex in the previous 3 months. Conclusions: Interest in PrEP is high among a diverse population of MSM at risk for HIV infection when offered in sexually transmitted disease and community health clinics.
Article
Many populations of interest present special challenges for traditional survey methodology when it is difficult or impossible to obtain a traditional sampling frame. In the case of such "hidden" populations at risk of HIV/AIDS, many researchers have resorted to chain-referral sampling. Recent progress on the theory of chain-referral sampling has led to Respondent Driven Sampling (RDS), a rigorous chain-referral method which allows unbiased estimation of the target population. In this article we present new probability-theoretic methods for making estimates from RDS data. The new estimators offer improved simplicity, analytical tractability, and allow the estimation of continuous variables. An analytical variance estimator is proposed in the case of estimating categorical variables. The properties of the estimator and the associated variance estimator are explored in a simulation study, and compared to alternative RDS estimators using data from a study of New York City jazz musicians. The new estimator gives results consistent with alternative RDS estimators in the study of jazz musicians, and demonstrates greater precision than alternative estimators in the simulation study.
Article
Nations across the globe face significant public heath challenges in optimizing sexual health, including reducing human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), sexually transmitted infections (STIs), unintended pregnancies, and sexual violence, and mitigating the associated adverse social and economic impacts. In response, some countries have implemented national strategies and other efforts focused on promoting more holistic and integrated approaches for addressing these syndemics. This article describes opportunities for national leadership to use a more holistic approach to improve the sexual health of individuals and communities.
Article
To implement biomedical and other intensive HIV prevention interventions cost-effectively, busy care providers need validated, rapid, risk screening tools for identifying persons at highest risk of incident infection. To develop and validate an index, we included behavioral and HIV test data from initially HIV-uninfected men who have sex with men who reported no injection drug use during semiannual interviews in the VaxGen VAX004 study and Project Explore HIV prevention trials. Using generalized estimating equations and logistic regression analyses, we identified significant predictors of incident HIV infection, then weighted and summed their regression coefficients to create a risk index score. The final logistic regression model included age, and the following behaviors reported during the past 6 months: total number of male sex partners, total number of HIV-positive male sex partners, number of times the participant had unprotected receptive anal sex with a male partner of any HIV status, number of times the participant had insertive anal sex with an HIV-positive male partner, whether the participant reported using poppers, and whether they reported using amphetamines. The area under the receiver operating characteristic curve was 0.74, possible scores on index range from 0 to 47 and a score ≥10 had as sensitivity of 84% and a specificity of 45%, levels appropriate for a screening tool. We developed an easily administered and scored 7-item screening index with a cutoff that is predictive of HIV seroconversion in 2 large prospective cohorts of US men who have sex with men. The index can be used to prioritize patients for intensive HIV prevention efforts (eg, preexposure prophylaxis).
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Trends in HIV Diagnoses by Age and Ethnicity Among Men Who Have Sex with Men (MSM) in British Columbia
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RDS: Respondent-Driven Sampling, Version 0.9-0
  • Mark S Handcock
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Mark S. Handcock, Ian E. Fellows, Krista J. Gile (2012) RDS: Respondent-Driven Sampling, Version 0.9-0. Project home page at http://hpmrg.org, URL https://CRAN.R-project.org/package=RDS.
A survey on HIV, viral hepatitis and sexually transmitted infections (STI) as well as associated risk behaviours among Quebec men who have sex with men (MSM)
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Lambert G, Cox J, Miangotar Y. ARGUS 2008-2009: A survey on HIV, viral hepatitis and sexually transmitted infections (STI) as well as associated risk behaviours among Quebec men who have sex with men (MSM). Quebec: Direction de santé publique de l'Agence de la santé et des services sociaux de Montréal, Institut national de santé publique du Québec and the Public Health Agency of Canada. 2011.
Is 'Candidacy' a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis
  • M Mackenzie
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  • M Munro
  • O' Donnell
Mackenzie M, Conway E, Hastings A, Munro M, O'Donnell C. Is 'Candidacy' a Useful Concept for Understanding Journeys through Public Services? A Critical Interpretive Literature Synthesis. Soc Policy Adm. 2013;47(7):806-25.
Canadian Community Health Survey -Annual Component (CCHS)
  • Canada Government
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