Article

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

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

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/

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Our post-hoc further signifies the importance of PrEP coverage specifically for those who are clinically PrEP eligible and most likely to acquire HIV. Overall, these findings are aligned with previous research among Canadian GBM which found lacking medication insurance and being concerned about the cost of PrEP were associated with PrEP non-use [31]. Vancouver had the greatest PrEP-to-need ratio, indicating that PrEP coverage in Vancouver is highest compared to its needs. ...
Article
Full-text available
Introduction: Accessibility of pre-exposure prophylaxis (PrEP) in Canada remains complex as publicly funded coverage and delivery differs by province. In January 2018, PrEP became publicly funded and free of charge in British Columbia (BC), whereas PrEP coverage in Ontario and Montreal is more limited and may require out-of-pocket costs. We examined differences over time in PrEP uptake and assessed factors associated with PrEP awareness and use. Methods: Gay, bisexual and other men who have sex with men (GBM) were recruited through respondent-driven sampling (RDS) in Toronto, Vancouver and Montreal, Canada, in a prospective biobehavioural cohort study. We applied generalized estimating equations with hierarchical data (RDS chain, participant, visit) to examine temporal trends of PrEP use and correlates of PrEP awareness and use from 2017 to 2020 among self-reported HIV-negative/unknown GBM. Results: Of 2008 self-identified HIV-negative/unknown GBM at baseline, 5093 study visits were completed from February 2017 to March 2020. At baseline, overall PrEP awareness was 88% and overall PrEP use was 22.5%. During our study period, we found PrEP use increased in all cities (all p<0.001): Montreal 14.2% during the first time period to 39.3% during the last time period (p<0.001), Toronto 21.4-31.4% (p<0.001) and Vancouver 21.7-59.5% (p<0.001). Across the study period, more Vancouver GBM used PrEP than Montreal GBM (aOR = 2.05, 95% CI = 1.60-2.63), with no significant difference between Toronto and Montreal GBM (aOR = 0.90, 95% CI = 0.68-1.18). Conclusions: Full free-of-charge public funding for PrEP in BC likely contributed to differences in PrEP awareness and use. Increasing public funding for PrEP will improve accessibility and uptake among GBM most at risk of HIV.
... Baseline data from participants from a larger study of sexual health outcomes among GBQM were used. These GBQM were recruited using respondent-driven sampling (RDS) (Heckathorn, 2011) in Canada's three largest cities (Montreal, Toronto, and Vancouver; see Cox et al., 2021;Hart et al., 2021;Moore et al., 2021). Eligible participants self-identified as cisgender or transgender men who were 16+ years of age and reported having had sex with a male partner in the past 6 months. ...
Article
Full-text available
Among sexual minority men, gay, bisexual, and queer men (GBQM) may experience differences in terms of their sense of belonging to a sexual minority community (community connectedness), outness about their sexual identity, and their experiences of proximal and distal sexuality-based stressors. Although group membership can confer unique benefits to members of marginalized groups, including GBQM, these benefits are likely unequal across the range of identity groups included in this acronym. We analyzed data from 1,827 human immunodeficiency viruses (HIV)-negative cisgender men living in Canada to examine how three different sexual identities, gay, bisexual, and queer, are associated with minority stress, social variables, and outness. Compared with gay and bisexual men, queer men scored lower on measures of identity concealment and internalized homonegativity, were more open about their sexuality in their social networks and reported higher community connectedness. Compared with queer and gay men, bisexual men reported higher rates of identity concealment and internalized homonegativity, were less open about their sexuality and reported less perceived social support and lower community connectedness. Although bisexual men overall also reported less discrimination, bisexual identity moderated the association between distal stress and proximal stress, such that bisexual men who experienced more distal stress were particularly sensitive to its impact and experienced higher proximal stress. Future research with sexual minority men should attend to identity diversity within this group, as minority stressors, social variables, and outness differ between GBQM
... 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. ...
Article
Full-text available
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 ...
Article
Full-text available
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.
Article
In March 2020, in response to the COVID‐19 pandemic, Canadian provincial governments instituted a variety of public health measures that included social distancing and isolation, which may have had unintended consequeses. According to the Loneliness and Sexual Risk Model, gay, bisexual, and other men who have sex with men (GBM) often cope with loneliness through risky sexual behaviors. Previous studies have demonstrated that COVID‐19 measures such as social distancing and isolation led to increases in loneliness; thus, these measures may also have led to elevated sexual risk‐taking among some GBM. Participants were recruited from an ongoing cohort study on GBM health and well‐being, and were included in the current analysis if they had completed relevant study questions ( n = 1134). GBM who reported lower levels of social support pre‐COVID‐19, were younger, and lived alone each reported greater loneliness during the first year of COVID‐19. Although feelings of loneliness did not predict sexual risk‐taking within the first year of COVID‐19, loneliness did predict greater sexual risk‐taking 6 months later. Additionally, younger GBM and those living alone were more likely to engage in sexual risk‐taking at both COVID‐19 data collection points. These findings offer some support of the Loneliness and Sexual Risk Model; however, it is possible that the unique circumstances of the COVID‐19 pandemic resulted in a temporary suspension of this association, as many GBM took steps to protect themselves and partners in the context of COVID‐19.
Article
There are many reasons why individuals engage in prosocial behavior; communal sexual altruism is based on the notion that some practice safer sex in the interest of promoting the well‐being of their community/in‐group. Given that definitions of what constitutes “safer sex” have changed with advances in human immunodeficiency virus (HIV) prevention, we investigated the importance of communal sexual altruism (herein “altruism”) among urban gay, bisexual, and other sexual minority men (GBM) in the contemporary context. Using a sample of 2449 GBM we examined the association of both safer‐sex‐related attitudes (e.g., HIV treatment optimism–skepticism) and behaviors (e.g., condomless anal sex [CAS]) with altruism scores. Higher altruism scores were associated with a lower likelihood of CAS and a greater frequency of discussing HIV status with new partners. These findings demonstrate that many GBM are motivated to engage in several kinds of behaviors that improve the well‐being of their in‐group (i.e., the GBM community).
Article
Full-text available
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.
Article
Full-text available
There are limited data on population-level mixing patterns by HIV status or pre-exposure prophylaxis (PrEP) use. Using cross-sectional survey data (Engage, 2017-2018) of 1137 men who have sex with men ≥16 year-old in Montreal, we compared observed seroconcordance in the past-6-month sexual partnerships to what would have been observed by chance if zero individuals serosort. Of 5 recent partnerships where both individuals were HIV-negative, we compared observed concordance in PrEP use to the counterfactual if zero individuals selected partners based on PrEP use. We estimated the concordance by chance using a balancing-partnerships approach assuming proportionate-mixing. HIV-positive respondents had a higher proportion of HIV-positive partners (66.4% (95% confidence interval: 64.0%-68.6%)) than by chance (23.9%(23.1%-24.7%)). HIV-negative respondents (both on and not on PrEP) had higher proportions of HIV-negative partners (82.9%(81.1%-84.7%), and 90.7%(89.6%-91.7%), respectively) compared with by chance (76.1%(75.3%-76.9%)); but those on PrEP had a higher proportion of HIV-positive partners than those not on PrEP (17.1%(15.3%-18.9%) vs. 9.3%(8.3%-10.4%)). Those on PrEP also had a higher proportion of partners on PrEP among their HIV-negative partners (50.6%(42.5%-58.8%)) than by chance (28.5%(27.5%-29.4%)). The relationship between PrEP and sexual-mixing patterns demonstrated by less population-level serosorting among those on PrEP and PrEP-matching warrants consideration during PrEP roll-out.
Article
Full-text available
Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among at-risk populations. The 2015 CDC report estimates that about 1.2 million people in the US have indications for PrEP. However, only 49,158 or 4% of the targeted population are currently using PrEP. Efforts to optimize uptake of PrEP may be facilitated by the development of a comprehensive theoretical framework which can be used to understand reasons for poor uptake and to develop interventions to maximize PrEP uptake and adherence. This article reviews research on correlates of PrEP uptake and presents findings organized within an Information-Motivation-Behavioral Skills (IMB) model framework. In the context of PrEP uptake, the IMB model asserts that to the extent that at-risk groups are well-informed about PrEP, motivated to act on their knowledge, and have necessary behavioral skills to seek out and initiate PrEP regimen, they will successfully overcome obstacles to initiate and adhere to PrEP. The article proposes an adaptation the IMB model for PrEP uptake, provides empirical support for the adapted IMB model extracted from related research, and discusses its application in PrEP uptake interventions.
Article
Full-text available
Pre-exposure prophylaxis (PrEP) remains an under-utilized HIV prevention tool among men who have sex with men (MSM). To more comprehensively elucidate barriers and facilitators to PrEP use among US MSM, we conducted a systematic review of peer-reviewed published articles and content analysis of online posts about PrEP. We searched peer-reviewed databases (Medline, Web of Science, Google Scholar) using MESH headings and keywords about PrEP and/or HIV prevention from 2005 to 2015. We included original studies among MSM in the US that reported on barriers, facilitators, or other factors related to PrEP use. We also searched online posts and associated comments (news articles, opinion pieces, blogs and other social media posts) in diverse venues (Facebook, Slate Outward, Huffington Post Gay Voices, Queerty, and My PrEP Experience blog) to identify posts about PrEP. We used content analysis to identify themes and compare potential differences between the peer-reviewed literature and online posts. We identified 25 peer-reviewed articles and 28 online posts meeting inclusion criteria. We identified 48 unique barriers and 46 facilitators to using PrEP. These 94 themes fit into six overarching categories: (1) access (n = 14), (2) attitudes/beliefs (n = 24), (3) attributes of PrEP (n = 13), (4) behaviors (n = 11), (5) sociodemographic characteristics (n = 8), and (6) social network (n = 6). In all categories, analysis of online posts resulted in identification of a greater number of unique themes. Thirty-eight themes were identified in the online posts that were not identified in the peer-reviewed literature. We identified barriers and facilitators to PrEP in online posts that were not identified in a systematic review of the peer-reviewed literature. By incorporating data both from a systematic review of peer-reviewed articles and from online posts, we have identified salient and novel information about barriers to and facilitators of PrEP use. Traditional research approaches may not comprehensively capture current factors important for designing and implementing PrEP related interventions.
Article
Full-text available
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
Full-text available
We sought to determine preferences for oral versus long-acting injectable (LAI) PrEP among gay and bisexual men (GBM). We surveyed a national U.S. sample of 1071 GBM about forms of PrEP. LAI PrEP was found to be acceptable among 43.2 % of men when injected monthly compared with 53.6 % of men when injected every 3 months. When asked to choose between forms of PrEP, 46.0 % preferred LAI, 14.3 % oral, 21.7 % whichever was most effective, 10.1 % had no preference, and 7.8 % would not take PrEP. There were no differences in PrEP preferences by race/ethnicity, income, region of residence, or relationship status. Those unwilling to take PrEP were significantly older than those who preferred LAI PrEP and those who would take either. Those who preferred the most effective form were younger, had less education, and reported more recent club drug use. Those who reported condomless anal sex and those who thought they were good PrEP candidates were more willing to take PrEP. Long-term health and side effects were of the greatest concern for both LAI and oral PrEP. The availability of LAI PrEP has the potential to increase uptake among GBM. The results of ongoing clinical trials of LAI PrEP will need to demonstrate similar or greater efficacy as daily Truvada for uptake to be maximized.
Article
Full-text available
Men who have sex with men (MSM) in the Americas require targeted, combination HIV prevention approaches. We solicited client and provider perspectives on emerging prevention interventions including HIV pre-exposure prophylaxis (PrEP) and HIV self-tests through focus groups and in-depth interviews with 130 MSM and 41 providers across four sites: New York, San Francisco, Lima, and Rio de Janeiro. Among the MSM participants, we identified three prevention typologies: non-condom users, inconsistent condom users, and consistent condom users. Northern and Southern MSM differed in the variety of harm reduction strategies utilized: where U.S. MSM relied on condom use as well as disclosure and seroadaptive behaviors for prevention, condom use without disclosure or serostatus discussions was the norm in South America. Interest in new prevention technologies was shaped by the social context. U.S. MSM preferences differed by typology, such that non-condom users were interested in taking PrEP and using home HIV tests. MSM in Brazil, regardless of typology, were interested in exploring new prevention options. MSM in Peru demonstrated moderate interest but were less comfortable with adopting new strategies. MSM and providers' opinions differed substantially with respect to new prevention options. Across sites, most providers were reticent to engage with new prevention options, though some NGO-based providers were more supportive of exploring new prevention tools. Both clients and providers will need to be engaged in developing integrated prevention strategies for MSM.
Article
Full-text available
Respondent-driven sampling (RDS) is a new data collection methodology used to estimate characteristics of hard-to-reach groups, such as the HIV prevalence in drug users. Many national public health systems and international organizations rely on RDS data. However, RDS reporting quality and available reporting guidelines are inadequate. We carried out a systematic review of RDS studies and present Strengthening the Reporting of Observational Studies in Epidemiology for RDS Studies (STROBE-RDS), a checklist of essential items to present in RDS publications, justified by an explanation and elaboration document. We searched the MEDLINE (1970-2013), EMBASE (1974-2013), and Global Health (1910-2013) databases to assess the number and geographical distribution of published RDS studies. STROBE-RDS was developed based on STROBE guidelines, following Guidance for Developers of Health Research Reporting Guidelines. RDS has been used in over 460 studies from 69 countries, including the USA (151 studies), China (70), and India (32). STROBE-RDS includes modifications to 12 of the 22 items on the STROBE checklist. The two key areas that required modification concerned the selection of participants and statistical analysis of the sample. STROBE-RDS seeks to enhance the transparency and utility of research using RDS. If widely adopted, STROBE-RDS should improve global infectious diseases public health decision making. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.
Article
Full-text available
We evaluated the relationship among syndemic conditions (defined as a cluster of interconnected psychosocial health conditions), sexual behaviours and self-reported HIV infection in a global sample of men who have sex with men (MSM). We used generalised estimating equations logistic regression models with robust SEs to assess the relationships among cumulative number of syndemic conditions-including depression, substance use, violence, sexual stigma and homelessness-and unprotected anal intercourse (UAI) and HIV infection, while accounting for clustering within-country in a global cross-sectional survey of 3934 MSM across 151 countries. We observed parallel, significant dose-response associations between the number of syndemic conditions and UAI, as well as number of syndemic conditions and HIV infection. Compared with participants without syndemics, the adjusted OR (aOR) for UAI among those with 1, 2 and 3 or more syndemic conditions were 1.44 (Bonferroni-adjusted 95% CI 1.23 to 1.68), 1.89 (1.51 to 2.36) and 2.03 (1.43 to 2.89), respectively. Compared with participants without syndemics, the aOR for HIV infection among those with 1, 2 and 3 or more syndemic conditions were 1.67 (1.24 to 2.26), 2.02 (1.44 to 2.85) and 2.35 (1.31 to 4.21), respectively. This analysis provides evidence of intertwining syndemics that may operate synergistically to increase HIV risk among MSM globally. To curb HIV effectively and advance the health of MSM, multiple conditions must be addressed concurrently using multi-level approaches that target both individual and structural risk factors.
Article
Full-text available
Introduction. Men who have sex with men (MSM) are disproportionately impacted by HIV globally. Easily accessible combination HIV prevention strategies, tailored to the needs of MSM, are needed to effectively address the AIDS pandemic. Methods and Materials. We conducted a cross-sectional study among MSM () from 145 countries from April to August 2012. Using multivariable random effects models, we examined factors associated with acceptability of preexposure prophylaxis (PrEP) and access to condoms, lubricants, HIV testing, and HIV treatment. Results. Condoms and lubricants were accessible to 35% and 22% of all respondents, respectively. HIV testing was accessible to 35% of HIV-negative respondents. Forty-three percent of all HIV-positive respondents reported that antiretroviral therapy was easily accessible. Homophobia, outness, and service provider stigma were significantly associated with reduced access to services. Conversely, community engagement, connection to gay community, and comfort with service providers were associated with increased access. PrEP acceptability was associated with lower PrEP-related stigma, less knowledge about PrEP, less outness, higher service provider stigma, and having experienced violence for being MSM. Conclusions. Ensuring HIV service access among MSM will be critical in maximizing the potential effectiveness of combination approaches, especially given the interdependence of both basic and newer interventions like PrEP. Barriers and facilitators of HIV service access for MSM should be better understood and addressed.
Article
Full-text available
Background Access is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services. Methods A synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework. Results Here, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage. Conclusions This paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.
Article
Full-text available
In 2010, the iPrEx trial demonstrated that oral antiretroviral pre-exposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk men who have sex with men (MSM). The impact of iPrEx on PrEP knowledge and actual use among at-risk MSM is unknown. Online surveys were conducted to assess PrEP awareness, interest and experience among at-risk MSM before and after iPrEx, and to determine demographic and behavioral factors associated with these measures. Cross-sectional, national, internet-based surveys were administered to U.S. based members of the most popular American MSM social networking site 2 months before (n = 398) and 1 month after (n = 4 558) publication of iPrEx results. Comparisons were made between these samples with regards to PrEP knowledge, interest, and experience. Data were collected on demographics, sexual risk, and experience with post-exposure prophylaxis (PEP). Regression analyses were performed to identify factors associated with PrEP awareness, interest, and experience post-iPrEx. Most participants were white, educated, and indicated high-risk sexual behaviors. Awareness of PrEP was limited pre- and post-iPrEx (13% vs. 19%), whereas interest levels after being provided with a description of PrEP remained high (76% vs. 79%). PrEP use remained uncommon (0.7% vs. 0.9%). PrEP use was associated with PEP awareness (OR 7.46; CI 1.52-36.6) and PEP experience (OR 34.2; CI 13.3-88.4). PrEP interest was associated with older age (OR 1.01; CI 1.00-1.02), unprotected anal intercourse with ≥1 male partner in the prior 3 months (OR 1.40; CI 1.10-1.77), and perceiving oneself at increased risk for HIV acquisition (OR 1.20; CI 1.13-1.27). Among MSM engaged in online networking, awareness of PrEP was limited 1 month after the iPrEx data were released. Utilization was low, although some MSM who reported high-risk behaviors were interested in using PrEP. Studies are needed to understand barriers to PrEP utilization by at-risk MSM.
Article
Full-text available
Health literacy is a relatively new concept in health promotion. It is a composite term to describe a range of outcomes to health education and communication activities. From this perspective, health education is directed towards improving health literacy. This paper identifies the failings of past educational programs to address social and economic determinants of health, and traces the subsequent reduction in the role of health education in contemporary health promotion. These perceived failings may have led to significant underestimation of the potential role of health education in addressing the social determinants of health. A ‘health outcome model’ is presented. This model highlights health literacy as a key outcome from health education. Examination of the concept of health literacy identifies distinctions between functional health literacy, interactive health literacy and critical health literacy. Through this analysis, improving health literacy meant more than transmitting information, and developing skills to be able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, it is argued that improved health literacy is critical to empowerment. The implications for the content and method of contemporary health education and communication are then considered. Emphasis is given to more personal forms of communication, and community-based educational outreach, as well as the political content of health education, focussed on better equipping people to overcome structural barriers to health.
Article
Full-text available
Rates of HIV antibody testing remain at approximately 45% of the general population. To more effectively design interventions to increase testing, comprehensive information is needed to understand the barriers to HIV testing. A measure of barriers to HIV testing was developed using the major barriers identified in the literature on barriers to health care utilization (Melnyk, 1988), and tested with a diverse group of individuals at high risk for HIV, including heterosexuals, men who have sex with men, injected drug users, and sex workers. An exploratory factor analysis indicated that the factor structure was replicated over 2 years of data collection. Three factors--Structural Barriers, Fatalism/Confidentiality Concerns, and Fear--emerged for both years. The reliabilities ranged from .75 to .87, indicating moderate to high internal consistency.
Article
Full-text available
Conventional systematic review techniques have limitations when the aim of a review is to construct a critical analysis of a complex body of literature. This article offers a reflexive account of an attempt to conduct an interpretive review of the literature on access to healthcare by vulnerable groups in the UK METHODS: This project involved the development and use of the method of Critical Interpretive Synthesis (CIS). This approach is sensitised to the processes of conventional systematic review methodology and draws on recent advances in methods for interpretive synthesis. Many analyses of equity of access have rested on measures of utilisation of health services, but these are problematic both methodologically and conceptually. A more useful means of understanding access is offered by the synthetic construct of candidacy. Candidacy describes how people's eligibility for healthcare is determined between themselves and health services. It is a continually negotiated property of individuals, subject to multiple influences arising both from people and their social contexts and from macro-level influences on allocation of resources and configuration of services. Health services are continually constituting and seeking to define the appropriate objects of medical attention and intervention, while at the same time people are engaged in constituting and defining what they understand to be the appropriate objects of medical attention and intervention. Access represents a dynamic interplay between these simultaneous, iterative and mutually reinforcing processes. By attending to how vulnerabilities arise in relation to candidacy, the phenomenon of access can be better understood, and more appropriate recommendations made for policy, practice and future research. By innovating with existing methods for interpretive synthesis, it was possible to produce not only new methods for conducting what we have termed critical interpretive synthesis, but also a new theoretical conceptualisation of access to healthcare. This theoretical account of access is distinct from models already extant in the literature, and is the result of combining diverse constructs and evidence into a coherent whole. Both the method and the model should be evaluated in other contexts.
Article
Full-text available
The Centers for Disease Control and Prevention, in collaboration with 25 state and local health departments, began the National HIV Behavioral Surveillance System (NHBS) in 2003. The system focuses on people at risk for HIV infection and surveys the three populations at highest risk for HIV in the United States: men who have sex with men, injecting drug users, and high-risk heterosexuals. The project collects information from these three populations during rotating 12-month cycles. Methods for recruiting participants vary for each at-risk population, but NHBS uses a standardized protocol and core questionnaire for each cycle. Participating health departments tailor their questionnaire to collect information about specific prevention programs offered in their geographic area and to address local data needs. Data collected from NHBS will be used to describe trends in key behavioral risk indicators and evaluate current HIV prevention programs. This information in turn can be used to identify gaps in prevention services and target new prevention activities with the goal of reducing new HIV infections in the United States.
Article
The appropriate use of pre-exposure prophylaxis (PrEP) by men who have sex with men (MSM) can be highly effective at reducing HIV transmission. Our review examined prevalence estimates, sexual behaviors, and medication adherence among MSM PrEP users in high-income countries. Articles published between January 2008 and December 2018 were identified through Medline, Web of Science, CINAHL, and CENTRAL. The search identified 643 publications, of which 52 were included in the final synthesis. We found that PrEP initiation was not consistently associated with significant changes in sexual behavior, but some users may have risk compensated. A minority of MSM used PrEP, and they had high levels of adherence. PrEP-related stigma, side effects, and psychosocial factors lead to nonadherence. A daily routine, pill boxes, alarms/texts, and education can promote adherence. Further research is required to examine PrEP impact on sexual behavior and factors that influence adherence in high-risk MSM subpopulations.
Article
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.
Article
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
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).
Article
This paper describes the AACTG Adherence Instruments, which are comprised of two self-report questionnaires for use in clinical trials conducted by the Adult AIDS Clinical Trials Group (AACTG). The questionnaires were administered to 75 patients at ten AACTG sites in the USA. All patients were taking combination antiretroviral therapy (ART), including at least one protease inhibitor. Eleven per cent of patients reported missing at least one dose the day before the interview, and 17% reported missing at least one dose during the two days prior. The most common reasons for missing medications included 'simply forgot' (66%) and a number of factors often associated with improved health, including being busy (53%), away from home (57%) and changes in routine (51%). Less adherent patients reported lower adherence self-efficacy (p = 0.006) and were less sure of the link between non-adherence and the development of drug resistance (p = 0.009). They were also more likely to consume alcohol, to be employed outside the home for pay and to have enrolled in clinical trials to gain access to drugs (all p < 0.05). Twenty-two per cent of patients taking drugs requiring special instructions were unaware of these instructions. Each questionnaire took approximately ten minutes to complete. Responses to the questionnaires were favourable. These questionnaires have been included in six AACTG clinical trials to date and have been widely disseminated to investigators both in the USA and abroad.
  • N Haddad
Haddad N. HIV Surveillance report, 2018, CCDR 45(12) [Internet]. aem. 2019 [cited 2020 Feb 28].
Trends in HIV Diagnoses by Age and Ethnicity Among Men Who Have Sex with Men (MSM) in British Columbia
  • H Lee
  • S Colyer
  • H L Armstrong
  • J Cox
Lee H, Colyer S, Armstrong HL, Cox J. Trends in HIV Diagnoses by Age and Ethnicity Among Men Who Have Sex with Men (MSM) in British Columbia, Ontario, and Quebec: 2006-2015. In Vancouver, BC; [cited 2020 Jul 27]. Available from: https://www.cahr-acrv.ca/wp-content/uploads/2018/04/CAHR2018-Abstract-Book-with-Errata.pdf
Census in Brief: Same-sex couples in Canada in 2016
  • Canada Government
  • Sc
Government of Canada SC. Census in Brief: Same-sex couples in Canada in 2016 [Internet]. 2017 [cited 2020 Feb 28]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016007/98-200-x2016007-eng.cfm
PrEP Era: A Latent Class Analysis
PrEP Era: A Latent Class Analysis. AIDS Behav [Internet]. 2020 Jul 9 [cited 2020 Jul 27];
Centre for Communicable Diseases and Infection Control
  • Ont Ottawa
Ottawa, Ont.: Centre for Communicable Diseases and Infection Control; 2012 [cited 2020 May 27]. Available from: https://www.deslibris.ca/ID/232461
RDS: Respondent-Driven Sampling, Version 0.9-0
  • Mark S Handcock
  • Ian E Fellows
  • Krista J Gile
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)
  • G Lambert
  • J Cox
  • Y Miangotar
  • Argus
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
  • E Conway
  • A Hastings
  • 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
  • Sc
Government of Canada SC. Canadian Community Health Survey -Annual Component (CCHS) [Internet]. 2019 [cited 2020 Dec 18]. Available from: https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226