Introduction: In Canada, rates of new HIV diagnoses have remained relatively unchanged, despite the availability of various HIV prevention options. To address this issue locally, in Ottawa, we launched Canada’s first nurse-led HIV prevention service (PrEP-RN), involving active-offer PrEP referrals and initiations to HIV priority populations.

Methods: PrEP-RN launched in 2018 as pilot within the sexual health clinic in Ottawa. The study uses a two-pronged approach to care: (1) active-offer PrEP referrals by nurses to patients with high-risk HIV indicators and (2) PrEP delivery by nurses. Referrals were offered at the time of STI follow-up, screening, or treatment. Patients who accepted, were offered a referral to the PrEP-RN clinic or other PrEP service. Clinical care, including testing, STI/creatinine monitoring, and follow-up was completed by nurses under medical directives from nurse practitioners.

Results: From August/2018-October/2022, nurses made ~2500 offers for PrEP. Of these offers, 41% of patients accepted a PrEP referral and 44% declined. Offers for PrEP referral and rates of clinical service access within PrEP-RN were highest among gbtMSM; however, a subset of cis-and-trans-women from HIV priority groups also accessed care through PrEP-RN. The implementation of PrEP-RN coincided with a sustained decrease in HIV diagnosis rates in Ottawa (data to 2021). This change was most notable among gbtMSM, where beginning, in 2019, the number of new HIV diagnoses in this group decreased by 82% (from 22 cases to <5).

Conclusions: Findings from the PrEP-RN study show high uptake of PrEP, particularly among gbMSM, when offered by nurses. Using a collaborative approach to identify persons at-risk for HIV and offer supports/connection to PrEP, the PrEP-RN referral process could yield similar reductions in HIV rates in other cities throughout Canada.

Background: In Ontario, groups eligible for publicly funded vaccines include men who have sex with men (MSM) for hepatitis A virus (HAV); MSM, people who inject drugs, and those with multiple sex partners/sexually transmitted infections for hepatitis B virus (HBV); and MSM aged ≤26 years for human papillomavirus (HPV). We explored immunity to/vaccination against these viruses among individuals entering the Ontario PrEP Cohort Study (ON-PrEP).

Methods: ON-PrEP is a prospective cohort of HIV-negative PrEP users from 10 clinics across Ontario. Through deterministic linkage, we used Public Health Ontario Laboratory (PHOL) data from the five years prior to study enrolment to quantify those with serologic evidence of immunity against HAV (IgG reactive) and/or HBV (HBsAb>10). Study personnel determined HPV vaccination status (3 doses=complete, 1-2=partial, 0=unvaccinated) by chart review at baseline. We descriptively analyzed evidence of immunity and vaccination status by study site.

Results: Of the 527 eligible participants, 357 (67.7%) were white, 456 (86.5%) identified as male, and 421 (79.9%) as gay with a mean age of 43.0 (SD=11.1). Serology data for HAV were available for 276 (52.4%) participants with 190 (68.8%) displaying evidence of immunity. Serology data for HBV were available for 302 (57.3%) participants with 198 (65.6%) displaying evidence of immunity. Across study sites, the median proportions of participants with documented immunity towards HAV and HBV were 69.4% (Q1=64.3%, Q3=79.8%) and 68.1% (Q1=58.8%, Q3=76.7%), respectively. Of the 125 (26.5%) participants with HPV vaccination data, 49 (39.2%) completed the vaccine series, 26 (20.8%) received a partial series, and 50 (40.0%) were unvaccinated. All 14 (2.7%) participants that were eligible for publicly funded HPV vaccination (aged ≤26) had unknown vaccine status.

Conclusion: Preliminary findings suggest that a sizeable proportion of Ontario PrEP users warrant HAV, HBV, and/or HPV vaccination. PrEP presents an opportunity for improved vaccination against these common infections.

BACKGROUND: Syphilis has been proposed as a clinical indication for HIV PrEP in women, based on the two agents’ biological interactions and shared transmission modes. We explored how often women had a new HIV diagnosis after being diagnosed with syphilis in Ontario.
METHODS: Using health card numbers, first/last names, and dates of birth for deterministic linkage, we extracted HIV serology data on females with positive syphilis tests from PHOL records between April/2010-March/2022. Since women may also enter HIV care based on anonymous HIV testing, we further linked HIV viral load data. We report aggregate numbers of women with new laboratory evidence of HIV infection after their first positive syphilis result.
RESULTS: Among 8151 women with positive syphilis tests during the study period, 6726 (82.5%) had linkable HIV serology tests, and 135 (1.7%) ever tested positive. With further linkage to viral load data, the number of women who ever had laboratory evidence of HIV infection increased to 186 (2.3%; see Table). However, when restricting to women whose first positive HIV test or HIV viral load occurred after their first positive syphilis test, this number decreased to 39 (0.5%). The average number of days between the positive syphilis test and the first laboratory evidence of HIV was 735 days.
CONCLUSION: Although it is clinically appropriate to offer HIV PrEP to women with syphilis, Ontario surveillance data suggest that the absolute number of HIV infections that could be averted in this way seems limited. Other strategies for prioritizing women for PrEP warrant study.

Objective: PrEP-using GBM may be more likely to engage in sexual behaviors associated with bacterial STI transmission. We assessed the associations between PrEP use, condomless anal sex (CAS), number of sex partners (NSP), oral sex (OS), and odds of acquiring a subsequent bacterial STI among GBM living in Canada.

Methods: Among 2,008 HIV-negative/unknown-status GBM from the baseline sample of the Engage Cohort Study (recruited 2/2017-8/2019), we fit a structural mediation model to estimate pathways between PrEP use at baseline, and sexual behaviors and bacterial STI diagnoses (gonorrhea, chlamydia and syphilis) observed at 1-year follow-up.

Results: Among baseline participants, 17.0% used PrEP within the last 6 months and 6.8% were diagnosed with a bacterial STI at 1-year follow-up. The direct association between PrEP use at baseline and STI diagnosis at 1-year follow-up (see Figure) was mediated by CAS, β=0.09, 95%CI [0.03, 0.17], p=.02, and the number of sexual partners β=0.08, 95%CI [0.03, 0.13], p=.001. That is, those who were on PrEP at baseline were, 1 year later, more likely to report CAS and a greater number of sexual partners (1-yr later), which accounted for the increase in STI diagnosis in the 1-year follow-up.

Conclusion: PrEP use at baseline was indirectly associated with future bacterial STIs among GBM via both an increased number of sex partners and increased engagement in CAS. Behavioural and biomedical interventions, including consistent STI screening as per PrEP care and potential bacterial STI prophylaxis, are needed to reduce PrEP-using GBM’s risk of bacterial STIs.

To increase PrEP adoption, primary care providers (PCPs) need to have adequate PrEP knowledge, skills and motivation. To acquire the necessary skills to practice PrEP, PCPs also need a supportive learning environment. By conducting 13 semi-structured interviews and thematic analysis, we explored the learning climate experienced by clinic managers and PCPs around HIV PrEP and identified recommendations to improve PrEP learning and adoption in Southeastern Ontario (SEO), a mixed urban-rural setting. Results revealed that participants mainly obtained PrEP knowledge through online resources (CATIE, ontarioprep.ca) and published Canadian guidelines. Most PCPs learned PrEP out of their own initiative with no institutional support. All participants emphasized the importance of continued PrEP education and noted that PrEP educational resources could be improved by 1) the teaching of counselling skills and how to initiate a PrEP conversation, and 2) emphasis on PrEP medication safety as fear and concerns about using PrEP medications remain high. Participants preferred strategies for future delivery of PrEP training that include 1) the provision of incentives; 2) the use of mixed delivery methods (online, in person, expert visits), 3) access to PrEP consultants to discuss complex cases; 4) access to clinical decision support, such as algorithms. We anticipate that this project will generate new insights for increasing PrEP adoption among PCPs who have not yet adopted PrEP and foster the development of a support system to assist those PCP who are struggling to practice PrEP in their clinical environments

BACKGROUND: HIV preventive services are often concentrated in downtown urban settings. We hypothesized that wait times are longer in less densely populated areas.

METHODS: The PRIMP survey collected cross-sectional data on sociodemographic and PrEP access in Toronto, Vancouver, Ottawa, Hamilton and Victoria between JUL/2019-AUG/2020; among gay, bisexual and other men who have sex with men aged > 19. We analyzed wait times for the first PrEP prescription from the moment the person decided to start PrEP, by area of residence. We used the first three digits of participants’ postal codes together with 2016 census data to calculate population density (inhabitants/Km2) for each geographic code. We calculated and mapped the median waiting time (days) for each quartile of population density. We stratified the analyses by former and current PrEP users. Kruskall-Wallis tests were used to test for differences between wait time and population density quartiles.

RESULTS: Areas with longer wait time were generally outside city cores (See Figure). Among current PrEP users, the median wait times (Q1-Q3) for quartiles 1 (less densely populated) to 4 (more densely populated) were: 23 (8-60), n=76; 14 (7-30), n=81; 15 (7-30), n=86; and 10 (5-30), n=85, respectively (p=0.026). Among former PrEP users, the median wait times (Q1-Q3) for quartiles 1-4 were: 14 (7-15), n=38; 10 (7-15), n=33; 13 (7-20), n=38; and 10 (10-15), n=19, respectively (p=0.793).

CONCLUSION: Geographic accessibility may impact PrEP usage. PrEP availability could be improved by considering distribution of providers, ensuring providers are culturally-affirming, and providing online/telemedicine access options.