Background: Socio-demographic factors are associated with comorbidity burden and other aging outcomes. Here, we investigate the relationship between psychological distress, resilience, social support, and comorbidity burden among women living with HIV (WLWH) and HIV-negative controls in the BCC3 Study.

Methods: BCC3 is a community-based cohort study of healthy aging enrolling WLWH and controls ≥16y. Kessler Psychological Distress Scale (K6), Resilience Scale (RS-14), and the 4-item Medical Outcome Study Social Support Survey (MOS-SSS) were used to assess psychological distress, resilience, and social support, respectively. Thirty-seven physical and thirteen mental diagnoses by a healthcare provider were self-reported. Mann-Whitney and Kruskal-Wallis test, and Spearman’s correlation were used.

Results: In unadjusted analyses, WLWH had more physical diagnoses than controls; mental diagnoses were similar (Table 1). In WLWH and controls, having higher social support was associated with lower number of physical (rho=-0.2, p=0.01 and rho=-0.3, p<0.0001) and mental (rho=-0.3, p<0.01 and rho=-0.4, p<0.0001) diagnoses. In both groups, having lower psychological distress and higher resilience was associated with fewer mental diagnoses. For physical diagnoses, a weak relationship with psychological distress among WLWH was detected (Table 1).

Conclusions: These results suggest that for both WLWH and controls, having social support is protective for physical and mental comorbidities while low psychological distress and high resilience may be particularly protective for mental diagnoses, less for physical diagnoses. Our data highlight the importance of considering and addressing psychological distress, resilience, and social support in the prevention and management of comorbidities to promote healthy aging in women with and without HIV.

Background: Syphilis is a curable sexually transmitted infection that disproportionately affects men who have sex with men living with HIV. Opt-out syphilis screening with routine HIV viral load tests has been shown to be moderately effective at increasing detection of syphilis, especially early-stage infections. We examined the cost-effectiveness of pairing syphilis tests with routine HIV viral load testing versus physician-initiated syphilis testing (usual care) from the perspective of the health care system (regional Ministry of Health).
Methods: We used patient-level data from the Enhanced Syphilis Screening Among HIV-Positive Men (ESSAHM) step-wedged randomized trial conducted across four urban clinics in Ontario, Canada, between 2015 to 2017. The study population comprised of adult men diagnosed with HIV and receiving care. The total cost of syphilis screening and frequency of tests were extracted from the trial and adjusted to 2020 Canadian Dollars. We used a net benefit regression (NBR) framework, employing a generalized linear mixed model to estimate the incremental net benefit of the intervention adjusting for fixed and random effects. The clinical outcomes were: (i) detection of new untreated cases of syphilis; (ii) detection of new untreated early-stage syphilis. We then derived cost-effectiveness acceptability curves across willingness to pay (WTP) thresholds.
Results: Among the 3024 patients enrolled, there were 7583 screening tests, 5598 confirmatory tests conducted over the trial period. In total, 217 cases of syphilis and 147 early-stage syphilis were detected. The average additional cost of implementing the intervention was CAD $6825/clinic compared to cost of usual care. The intervention was cost-effective with a probability of 58% at a WTP of CAD $6000 for each additional detection of early syphilis.
Interpretation: Upscaling implementation of routinized syphilis screening with HIV viral load may be a cost-effective intervention and aim toward improving efficiency and value in health care for men with HIV co-infection.

Background: Adolescent girls and young women (AGYW) account for disproportionate numbers of HIV infections in sub-Saharan Africa. This study estimated the prevalence of HIV infection and related vulnerabilities among AGYW under 25 living in post-conflict Northern Uganda.

Methods: The ‘Cango Lyec’ Project is an open cohort involving conflict-affected populations in mid-Northern Uganda. Between December 2020 and March 2023 a total of 888 consenting AGYW aged 13-24 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioral characteristics. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression modeling was used to assess the independent effect of factors associated with HIV prevalence.

Results: HIV prevalence was 2.7% (1.1% among 13-14, 1.7% among 15-19, and 5.0% among 20-24). Six (25.0%) out of 24 HIV cases were not sexually active. Among sexually active AGYW (N=424), HIV prevalence was 4.2% (2.2% among 15-19, and 5.2% among 20-24). Among the 24 HIV+, 50% had detectable viral loads. The prevalence of probable PTSD was 2.7% (95%CI: 1.7-4.0) overall, and 4.1% (95%CI: 2.4-6.3) among sexually active AGYW. The mean resilience score was only 60.5 (95%CI: 59.8-61.2). After adjusting for age and district in multivariable logistic regression: AGYW who had a first partner at least 10 years older were 3.68 times more likely to have HIV (95%CI: 1.00-13.61; p=0.051). AGYW who lost a parent (OR: 4.00; 95%CI: 1.54-10.00; p=0.005), had syphilis (OR: 11.93; 95%CI: 3.18-44.81; p<0.001), ever attempted suicide (OR: 5.86; 95%CI: 1.88-18.31; p=0.002), or never vaccinated for HPV (OR: 7.14; 95%CI: 0.88-50.00; p=0.065), were associated with an increased risk of HIV.

Conclusion: The ongoing legacies of war, especially gender violence, are contributing to HIV vulnerability among AGYW in Northern Uganda. Wholistic approaches integrating HIV prevention with culturally-safe mental health initiatives are urgently required in Northern Uganda.

Background: Childhood abuse elevates risks for long-term mental health challenges. Knowledge gaps remain regarding the mechanisms of association, particularly among women with HIV. Informed by the ‘chain of risk’ life course approach, we examined pathways from childhood abuse to mental health among women with HIV in Canada.

Methods: This five-year longitudinal study with women with HIV in Ontario, British Columbia and Quebec collected data on history of childhood abuse (sexual, physical, verbal) and poverty (income, food insecurity, housing insecurity) at time 1 (T1), substance use and past 3-month (recent) violence at time 2 (T2), and mental health challenges (MHC) (depression, PTSD, mental functioning) at time 3 (T3). We conducted path analysis to examine direct and indirect effects from childhood abuse to adulthood MHC via poverty, substance use, and violence.

Findings: Most (68%) participants with reported data (n=1,315) had experienced ≥1 type of childhood abuse. Childhood abuse was directly associated with adult poverty (β=0.17, p<0.001), violence (β=0.16, p=0.005), substance use (β=0.18, p<0.001), and MHC (β=0.13, p=0.01). Additionally, poverty was associated with later substance use (β = 0.27, p < 0.001), violence (β= -0.15, p=0.02), and MHC (β=0.32, p<0.001), and violence (β=0.30, p<0.001) but not substance use (β=-0.05, p=0.70) was associated with later MHC. The total standardized effect of history of childhood abuse on T3 MHC was 0.27 (p<0.001), half of which was direct (β=0.13, p = 0.01) and the other half indirect (β=0.13, p<0.001). Poverty (β=0.06, p=0.003) and violence (β=0.05, p=0.02) accounted for 43% and 35% of total indirect effects, respectively.

Discussion: Over two-thirds of women with HIV experienced childhood abuse, double the women’s national prevalence (31%). Consequences of this trauma are numerous, including effects on adulthood mental health directly and indirectly via poverty, violence, and substance use. Findings emphasize the need for violence and trauma-aware care across the HIV cascade.

Background: Life expectancy of people with HIV (PWH) has increased considerably in the last decades. We used data from the Comparative Outcomes And Service Utilization Trends (COAST) study to examine trends in life expectancy between 1996-2020 among men and women living with HIV in BC.

Methods: COAST is a comparative cohort study, including data on all PWH and a 10% general population sample in BC, linking clinical and demographic data from the BC Centre for Excellence in HIV/AIDS with administrative health data from Population Data BC. We calculated life expectancy for PWH at ages 20, 40, and 60 using life tables stratified by sex and calendar period.

Results: At total of 12,710 men (81.4%) and 2,889 women (18.4%) with HIV were included. Median nadir CD4 counts of men and women were 160 (Q1-Q3, 50-310) and 150 (Q1-Q3,43-290) cells/mm³, respectively, and 85% of men and 77% of women were ever on antiretroviral therapy. Life expectancy at ages 20, 40 and 60 increased over time in all strata, but remained lower among women (see table). The sex-gap in life expectancy at ages 20 and 40 increased over time. This gap was not as discernible at age 60.

Conclusion: While life expectancy in men and women with HIV in BC has increased considerably over time, women’s life expectancy remains lower than men’s, suggesting most deaths among women occur at a younger age. Planned analyses include exploring social determinants of mortality that may contribute to the observed differences in life expectancy.

OBJECTIVE: Although antiretroviral therapy (ART) should be initiated as soon as possible after HIV diagnosis to reduce viral load, delays are often encountered in clinical practice, contributing to virus transmission. The objective of this study was to assess, from a Canadian perspective, the potential epidemiological and economic impact of rapid ART initiation with bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) compared to current initiation in Canadian clinical practice.

METHODS: A dynamic transmission model was adapted to the Canadian setting, over a 20-year time horizon, to estimate the cumulative HIV infection incidence and potential cost savings, based on the number of HIV infections prevented. Three key subgroups were considered: men who have sex with men (MSM), heterosexual males and females, and people who inject drugs (PWID). The impact of rapid treatment initiation with B/F/TAF (7 days as a target) was compared to current clinical practice (45 days). The lifetime direct health care cost of HIV was applied to the number of infected patients to estimate the economic burden of the two scenarios. Productivity costs were added in a scenario analysis.

RESULTS: Over the 20-year projection period, rapid B/F/TAF initiation is expected to prevent 415 HIV infections, resulting in savings of $139M to the Canadian healthcare system. Nearly half of new HIV infections avoided (42%) were from the MSM, while 33% were from heterosexuals and 25% from PWID. When considering productivity costs, potential savings increased to $510M. Varying the time to ART initiation by ±7 days in current clinical practice results in savings ranging from $115M to $162M over the 20-year projection period.

CONCLUSION: These results suggest that rapid ART initiation with B/F/TAF in newly diagnosed patients with HIV is a high-value strategy for the Canadian healthcare system to prevent future HIV infections and thus, to reduce related costs of care.

Introduction: Case-finding algorithms can be applied to administrative healthcare records to identify people with various diseases, including people living with HIV (PLWH). When supplementing an existing registry, near-perfect specificity helps reduce the impact of algorithm-identified false positive cases. We evaluated the performance of algorithms applied to healthcare records to supplement an HIV registry in British Columbia (BC), Canada.

Methods: The BC-CfE’s Drug Treatment Program provides free HIV medications to medically-eligible persons in BC, and resembles a registry of most PLWH in BC. To identify PLWH absent from this registry, we applied algorithms based on HIV-related diagnostic codes to physician and hospitalizations records. We evaluated 159 algorithms in a validation sub-sample of 6,696 persons with positive HIV tests (of whom 2,482 had a prior negative test) from the STOP HIV/AIDS data linkage (1996-2017). Algorithms were also evaluated based on sensitivity and specificity, as well as the impact on the estimated number of PLWH in BC as of March 2017 (i.e., algorithm-identified PLWH added to the BC-CfE registry).

Results: In the validation sub-sample, median age at HIV-positive test was 37 years, 79.2% were men, and 49.5% resided in Vancouver Coastal Health Authority. For all algorithms, specificity exceeded 96% and sensitivity ranged from 10% to 96%. When supplementing a pre-existing HIV registry, we recommend an algorithm with 99.87% (95% CI: 99.72%, 100.00%) specificity and 79.11% (95% CI: 78.06%, 80.15%) sensitivity, requiring five HIV-related physician encounters or two HIV-related hospitalizations within a 12-month period, or one hospitalization with HIV listed as the most responsible diagnosis. Upon adding PLWH identified by this highly-specific algorithm to the registry, 8,532 PLWH were present in BC as of March 2017, of which 283 (3.3%) were algorithm-identified.

Discussion: This study highlighted the value of applying case-finding algorithms to administrative healthcare records to further identify PLWH in BC.

Background:
Suboptimal retention in opioid agonist treatment (OAT) has been linked to varied factors including inflexible treatment programs and inadequate dosing. COVID-19 spurred innovation in OAT delivery, including via expansion of telemedicine services. We therefore developed a unique program delivering high-quality telecare for people with opioid use disorder (PWOUD) within a community-based harm reduction setting.

Description:
Procedures were co-constructed by the Centre hospitalier de l’Université de Montréal’s Addiction medicine service (CHUM-A) and CACTUS Montréal, a longstanding community-based harm reduction organization. CACTUS workers promoted the program, facilitated eligibility screening, established private on-site telemedicine connections to CHUM-A, and offered holistic ongoing follow-up. CHUM-A offered individualized OAT, often combined with short-acting opioids to reduce withdrawal/illicit consumption, and other health services as needed. Effectiveness was assessed via longitudinal chart review (April 2020–March 2022) and semi-structured interviews with 20 participants.

Results:
71 patients were enrolled during the assessment period. Most reported past-month opioid injection (95%), did not have a family doctor (72%), and had previously received OAT (73%). Over half were unstably housed and one-third reported recent overdose. 12-month retention in OAT was high (80%), with many participants ultimately transferred to the CHUM-A outpatient clinic (51%) or primary care (14%). Five people commenced HIV treatment, 24 were treated for HCV, and 26 transitioned to stable housing. Qualitative data suggest the trusted community setting, strong therapeutic relationships, and expanded medication options were pivotal to success. Technology afforded an efficient structure for patient-centered collaborative care, but participants also shed light on the limitations of telemedicine and the need to integrate additional partners.

Conclusion:
Our community-based telemedicine program provides an alternative treatment pathway for PWOUD disengaged from mainstream services and an efficient means to bridge the health and community sectors. Working collaboratively around the patient, partners leveraged their strengths to support patient retention and catalyze new service trajectories.