Background: Virologic failure to cabotegravir/rilpivirine with genotypic resistance is rare (1-2%) in clinical trial and cohorts. There remains major interest in how best to manage this clinical situation. While a wide variety of therapeutic regimens have been used, often comprised of complex regimen including protease inhibitors, this has not been studied systematically.

Methods: We describe five patients with virologic failure to cabotegravir/rilpivirine with genotypic resistance who were treated with bictegravir/emtricitabine/tenofovir alafenamide (bictegravir/FTC/TAF).


Results: At our multidisciplinary HIV clinic where we follow over 2200 patients, bimonthly cabotegravir/rilpivirine has been prescribed to approximately 250 individuals. Five patients have experienced virologic failure with genotypic resistance. In the first patient, bictegravir/FTC/TAF was initiated prior to the availability of resistance testing. Despite the presence of mutations associated with integrase inhibitor resistance, this individual experienced virologic suppression. As a result, subsequent patients with confirmed cabotegravir/rilpivirine failure were similarly switched to bictegravir/FTC/TAF. The cohort (aged 24-50 years, three female) had no preexisting rilpivirine or integrase inhibitor resistance-associated mutations (RAMs). All but one adhered fully to cabotegravir/rilpivirine dosing schedules. At failure, all individuals exhibited both integrase and reverse transcriptase RAMs, with mutations in amino acid 148, with or without amino acid 138 in the integrase gene observed in four cases. After a median follow-up of 11 months (range: 6–18 months), all patients remained virologically suppressed on bictegravir/FTC/TAF.

Conclusion: Until the management of cabotegravir/rilpivirine failure can be systematically studied, clinical judgement will guide therapeutic decision. Bictegravir/FTC/TAF may offer a viable option for achieving virologic suppression in this situation.

Title: Using Direct Observed Therapy (DOT) and Client Care Coordination to Improve HIV Outcomes in Hard-to-Reach Populations in Regina, Saskatchewan

Background:
Saskatchewan performs poorly on the care cascade with 77% diagnosed and 65% virally suppressed due to systemic barriers such as poverty, housing instability, and stigma. Direct Observed Therapy (DOT) may improve HIV treatment engagement and retention involving community support workers transiting people living with HIV to clinical HIV services and observe their intake of antiretroviral therapy.

Methods:
In April 2023, AIDS Program South Saskatchewan Inc. (APSS) began a DOT program in Regina for people living with HIV who are treatment non-compliant. The HIV Client Care Coordinator collaborates with Clinical Infectious Disease, Public Health, and peer educators to address barriers (substance use and unstable housing). The HIV worker engages with hard-to-reach populations and takes them to a clinic/pharmacy for ART administration to reduce viral loads. Participants completed the short quality of life and quality of care questionnaires, and case narratives were compiled.

Results:
30 participants accessed DOT with 852 visits between April 2023-December 2024. Participants accessed the program with varying frequencies (daily, twice a week, weekly, or monthly) and moved between these categories as needs changed. 87.1% of participants were Indigenous, highlighting the program's reach within high risk/underserved groups in the region. Over half (56.5%) achieved Undetectable=Untransmittable (U=U) status. Case narratives highlighted impacts, including transitioning clients from unhoused to housed, helping a pregnant participant achieve U=U resulting in an HIV-negative baby.

Conclusions:
The DOT program has shown promising potential in meeting the needs of people living with HIV, especially among high-risk/underserved populations. The flexibility of the program, allowing participants to access services with varying frequencies, along with achieving U = U status in over half of the participants, underscores its effectiveness in enhancing health outcomes and mitigating HIV transmission.

Background: To recruit and educate primary care providers (PCPs) to prescribe antiretrovirals (ARVs), an HIV Continuing Medical Education (HIV CME) program in Saskatchewan was created that offered 8 hours of live virtual education delivered by local HIV specialists and opportunities for in-person HIV Clinical Preceptorships. Participants were offered support to become Designated ARV Prescribers under Saskatchewan’s Drug Plan, ensuring patient access to cost-covered ARVs. New Designated ARV Prescribers were further assigned an Infectious Disease specialist who was available to provide ongoing mentorship. Between 2018 and 2022, 102 PCPs participated in the HIV CME program, with 32 opting to become Designated ARV Prescribers.

Method: An evaluation of the HIV CME program was funded by the University of Saskatchewan Office of the Vice-Dean of Research and conducted in 2024. Ten PCPs who participated in the HIV CME program and became Designated ARV Prescribers were interviewed to assess if the HIV CME program successfully enhanced their HIV clinical practices, including increasing their confidence to prescribe ARVs.

Findings: 100% of PCPs interviewed reported the HIV CME program increased their confidence to prescribe ARVs. Notably, 90% indicated they were actively providing care to patients living with HIV and prescribing ARVs. 70% identified that receiving mentorship from an experienced HIV treatment provider and opportunities to participate in a HIV Clinical Preceptorship were key strengths offered by the HIV CME program. These components were regarded as essential for increasing confidence, supporting professional networking, and improving clinical practice, including prescribing ARVs.

Conclusion: Incorporating opportunities for mentorship and HIV Clinical Preceptorships alongside didactic virtual presentations was shown to be essential in building PCPs’ confidence to prescribe ARVs. This finding highlights the importance of integrating applied learning into the design of programs intended to recruit, educate, and support PCPs to confidently provide HIV care.

Introduction: Long-acting injectable cabotegravir/rilpivirine (LAI-CAB/RPV) is an HIV treatment option offering adherence, privacy and psychological advantages, but patient awareness may be limited. We implemented a paper-based checklist to identify patients eligible for LAI-CAB/RPV in an academic hospital-based HIV clinic.

Methods: Between 01/09/2023-31/07/2024, trained staff reviewed the charts of a subset of adults using antiretroviral therapy, and flagged those eligible for LAI-CAB/RPV using a checklist on brightly coloured paper. Eligibility was defined as HIV RNA<20 copies/mL, HIV clade unrelated to A1/A6, and absence of: hepatitis B infection, RPV or INSTI mutations, and contraindicated medications. During clinic visits, a physician and/or pharmacist performed clinical review, discussed eligibility with patients, and documented patient decisions. We quantified the outcomes of this quality improvement initiative and conducted qualitative interviews with physicians and pharmacists to explore its impact on clinical care.

Results: Of 220 charts, 16 (7%) were already on LAI-CAB/RPV, 137 (62%) had available checklists, and 67 (31%) had no checklist available (Figure). Sixteen (12%) reviewed charts were ineligible. Of 121 remaining charts, 66 (55%) had documented discussions, of which 4 (6%) were initiated on LAI-CAB/RPV. Two patients with no checklist also initiated LAI-CAB/RPV. Staff interviews emphasized the opportunistic nature of patient screening, and the importance of addressing patient needs, raising awareness of newer treatment options, and ensuring equitable access. Challenges include clinical workloads and low prioritization of eligibility assessments.

Conclusion: Despite a systematic flagging system, the frequency of LAI-CAB/RPV discussions and drug uptake were modest. Ongoing efforts to engage with patients about newer HIV treatment options are needed.

Background: To support scaling up HIV pre-exposure prophylaxis (PrEP), we conducted a systematic review and meta-analysis of HIV risk tools in predicting HIV infection.

Methods: We searched MEDLINE, Embase, and CINAHL for observational studies (01/01/1998 to 13/05/2024) assessing the diagnostic performance of HIV risk tools. Area under the curve (pAUC) values were pooled using inverse-variance methods, with sensitivity and specificity summarized at common cutoffssss.

Results: Of 3,704 publications, 27 met our criteria. Twelve studies on men who have sex with men (MSM) assessed nine tools, with four extensively validated in predominantly U.S. populations. SexPro exhibited the highest performance (pAUC:0.75), followed by HIRI-MSM (pAUC: 0.69), Menza (pAUC:0.63), and SDET (pAUC:0.66), showing moderate predictive ability. For cisgender women, twelve African studies evaluated six tools, with VOICE being the only repeatedly validated tool (pAUC:0.65 for adults;0.62 for adolescents and youths). There were no tools for cisgender women outside Africa. Among other populations, DHRS demonstrated good discrimination for U.S. adults (pAUC:0.80), ARCH-IDU for people who use drugs in the U.S. (AUC:0.72), HIV Prevalence Risk Score for African populations (AUC: 0.70) and Kahle for African serodiscordant couples (pAUC:0.73). Sensitivity and specificity varied by cutoffs. We identified six domains among tool items: sexual activities, substance use, clinical factors, demographics, reproductive health, and other factors.

Conclusion: Validated tools are useful to identify HIV risk in some populations, but new tools are needed for equitable PrEP access to PrEP, especially for cisgender women outside Africa. Public health programs and clinicians should incorporate local data to improve tool effectiveness.

Background: Amidst shifts to HIV management as a chronic condition and cuts to HIV community programming in Canada, there is little epidemiological data evaluating HIV community-based organizations (CBOs) role in facilitating access to HIV and health care services. This study examined the association between: (1) HIV CBO service use and (2) HIV CBO community participation with health and health services access among women living with HIV.

Methods: Data were drawn from the Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment (SHAWNA) Project, a longitudinal community-based study with women living with HIV in Metro Vancouver (September/2014-February/2025). Bivariate and multivariable logistic regression with generalized estimating equations were used to examine associations between HIV CBO service use (‘used the services of HIV CBOs’) and HIV CBO community participation (‘volunteered/worked/participated in HIV CBOs’), both measured in the last six months, with multiple outcomes reflecting health and health services access. Adjusted odds ratios (aOR) and 95% confidence intervals were reported. Missing data from covariates was addressed using multiple imputation.

Results: The study sample for the first and second outcome included 269 participants (1425 observations, 2019-2023) and 270 participants (1438 observations, 2019-2023), respectively. In multivariable analysis, HIV CBO service use was associated with higher odds of being on antiretroviral therapy (ART) (aOR:1.83[1.17-2.85]) and being able to access health services when needed (aOR:2.07[1.32-3.26]). With a sample of 216 participants (835 observations, 2020-2023) for the third outcome, HIV CBO community participation was associated with higher odds of being satisfied with social support to take ART (aOR:1.62[1.08-2.44])

Discussion: Findings underscore the critically important role of HIV CBOs in supporting health and health services access among women. Increasing HIV CBO funding for operational costs and tailored programming that supports health and health services access (i.e. peer navigation, community collectivization, referrals to resources) among women living with HIV is urgently recommended.

Introduction: HIV-PrEP and doxy-PrEP/PEP are important prevention interventions for HIV and bacterial sexually transmitted infections. We sought to determine knowledge, use and interest in HIV-PrEP and doxy-PrEP/PEP, and how stigma/discrimination impacted these.
Methods: Our community-based cross-sectional survey recruited in all provinces in 19 cities at 43 events (e.g., Two-Spirit powwows, Pride festivals) between June-September 2024. Eligibility criteria included all Two-Spirit people, gay/bisexual/queer men (inclusive of trans men), and nonbinary people (herein 2S/GBTQ+). Participants were aged 15+, lived in Canada, and self-completed our questionnaire in English, French or Spanish. Data analyses determined prevalence of HIV-PrEP and doxy-PrEP/PEP indicators, including cross-tabulations with past-year avoidance of health due to stigma/discrimination.
Results: Of 4,881 eligible participants, the majority identified as gay (52%) and men (62%), 47% were aged <30, 28% identified as trans, and 36% identified as non-white. 11% were Indigenous, of whom 64% were Two-Spirit. 4% self-reported as living with HIV. Before our survey, 20% of participants did not know about HIV-PrEP. By HIV-PrEP status, 17% were current users, 7% former users, and 75% naïve/never used. Of those not currently using HIV-PrEP, 24% were interested and 38% were unsure. HIV-PrEP use was associated with avoiding healthcare services due to stigma/discrimination, which was reported by 10% of current users, 16% of former users, and 27% of PrEP-naïve participants. Before our survey, 54% of participant did not know about doxy-PrEP/PEP. Doxy-PrEP/PEP was used by 11% of participants; among non-users, 30% were interested and 33% were unsure. Doxy-PrEP/PEP knowledge was less common (35%) among those who avoided healthcare services due to stigma/discrimination compared with those who did not (47%).
Discussion: Among our sample of 2S/GBTQ+, 17% currently used HIV-PrEP and 11% had used doxy-PrEP/PEP. A meaningful proportion of 2S/GBTQ+ were interested in using HIV-PrEP and doxy-PrEP/PEP. Stigma/discrimination in healthcare shaped HIV-PrEP and doxy-PrEP/PEP among 2S/GBTQ+people.

Background: HIV treatment guidelines highlight the importance of incorporating patient preferences in selection antiretroviral therapy (ARV); however, tools for this do not exist.
Objective: To develop a decision aid to support shared decision making among treatment naïve people living with HIV.
Methods: As part of a quality improvement initiative, the decision aid was developed based on International Patient Decision Aids Standards criteria and consisted of the following steps: 1) Literature Review, 2) Draft Decision Aid, 3) Stakeholder Feedback Meeting.
Results:
The literature review found 5 observational studies that provided data on shared-decision making factors related to ARV selection.
The draft decision aid is depicted in Figure 1 and is organized into 3 sections: 1) Introduction, 2) Prescriber-Patient Eligibility Factors (What Medications Will Work For Me?), and 3) Patient Factors (What Is Most Important To Me?).
The stakeholder feedback meeting was attended by 28 health-care providers or students (n=15 in person, n=13 online) with the majority working directly with HIV patients from Saskatoon or Regina, Saskatchewan based locations. The feedback is summarized in Table 1.
Conclusion: The decision aid is a tool that could be implemented to support shared decision making for initial ARV selection in people living with HIV.