Background: In 01/2024, the International Anal Neoplasia Society released new guidelines recommending anal precancer screening in high-risk populations, including men who have sex with men (MSM) and transgender women living with HIV starting at age 35, and all others living with HIV starting at age 45. We estimated the proportions undergoing anal screening in 2023 as a baseline for monitoring the future implementation of this guideline.

Methods: We analysed data from the Ontario HIV Treatment Network Cohort Study, a multi-site clinical HIV cohort. During interviews in 2023, respondents were asked about anal screening modalities in the past 12 months: (1) an anal Pap test (for precancer); and (2) a digital anal rectal exam (DARE, for early-stage cancer). We estimated the proportions reporting anal screening and examined correlates using multiple logistic regression.

Results: Among the 2,238 interviewed, 18% were aged 35-44 and 72% were aged 45 and older. Among the 1720 respondents who were assigned male sex at birth, 24 identified as transgender women or genderqueer, and 1692 as cisgender men. We observed statistically-significant (p<0.05) differences in screening by guideline-defined cancer risk category and age (Table). Screening also varied by region but not by race, viral load suppression, CD4 cell count, tobacco smoking, or history of AIDS.

Conclusion: Limitations include voluntary participation and self-report. A minority reported screening. It was more often reported by MSM/transgender women and among older respondents, but least by cisgender women and heterosexual men. Ideally, post-guideline implementation will incorporate strategies to facilitate the scale-up of equitable screening.

Background: Neurosyphilis (NS) is a severe complication of syphilis that may be more common among people living with HIV (PLWH). While a lumbar puncture (LP) is clearly indicated in people with syphilis and neurologic symptoms, criteria for performing an LP in neurologically asymptomatic PLWH and syphilis remain unclear. We evaluated the diagnostic accuracy of serum rapid plasma reagin (RPR) titre (≥1:32) and peripheral CD4 count (≤350cells/mm³) for identifying asymptomatic neurosyphilis (ANS) in PLWH.

Methods: We searched Medline and EMBASE databases (1983–June 2024) for observational studies involving adults (aged≥18 years) living with HIV and confirmed syphilis, reporting data on the relationship between serum RPR or peripheral CD4 count and the diagnosis of ANS. The definition of ANS was a positive cerebrospinal fluid (CSF) VDRL or CSF white blood cell (WBC) count >10 cells/mm3, but was varied in sensitivity analyses. Diagnostic accuracy measures were pooled using bivariate random effects models.

Results: Of 4,758 abstracts screened, 67 underwent full-text article review, of which 15 (published between 1992-2022) met eligibility criteria. Studies came from North America (n=5), Europe (n=4), Asia (n=3), and South America (n=3), with a median sample size of 65 (IQR:30-110). Most studies were cross-sectional (n=9), and diagnostic reference standards varied across studies. Four studies focused on neurologically asymptomatic patients and reported a pooled NS prevalence of 26% (95%CI:15%-42%). Pooled sensitivity for serum RPR≥1:32 was 63% (95%CI=21%-92%), and specificity 56% (95%CI=16%-90%). Pooled sensitivity for CD4 count ≤350 cells/mm3 was 74% (95%CI:58%-85%), and specificity of 41% (95%CI:23%-63%). Having either RPR≥1:32 or CD4≤350 showed a pooled sensitivity of 89% (95%CI:28%-99%) and specificity of 36% (95%CI:8%-79%).

Conclusion: Serum RPR≥1:32 and CD4 count≤350 have moderate sensitivity for ruling out ANS in asymptomatic PLWH with syphilis co-infection. These findings may guide clinicians in determining which PLWH with syphilis can safely forego an LP.

Self-harm and suicidal ideation are major concerns for people with HIV (PWH), often stemming from stigma and mental health challenges. The AI-powered MARVIN chatbot supports HIV self-management across Canada by providing knowledge and assisting with medication adherence. To help MARVIN manage high-risk messages on stigma and mental health, we developed a preventive intervention module for extreme user intentions.

Following the CO-START framework (i.e., providing Context, Objective, Style, Tone, Audience, and Response format), we prompt-tuned ChatGPT to identify 3 types of message intent: self-harm, insult, and non-extreme (i.e., any other intent). To test its performance, we compiled three public hate speech databases from an online catalog (hatespeechdata.com) and combined them with MARVIN-user conversations and a synthetic dataset (N=1000 for each class). We computed precision, recall, and F1 Score for each class, as well as overall accuracy. After integrating ChatGPT into MARVIN, three PWH, two engineers, and a doctor, participated in a two-hour test by performing 14 conversational scenarios and completing a two-item questionnaire on conversation clarity and user satisfaction.

With one-shot prompting, MARVIN-ChatGPT attained 97.00% & 94.80% for recall, 99.59% & 93.86% for precision and 98.28% & 94.33% for F1 Score on self-harm and insult intent, respectively. The overall accuracy reached 95.57%. This hybrid model then successfully generated appropriate responses containing 1) emergency Canadian contact information for self-harm intents; 2) messages guiding users to use stigma-free expressions for insult messages; and 3) a response reviewed by a medical expert for non-extreme intents. All testers found the responses to be clear and concise and were satisfied with the overall experience. However, one participant PWH suggested including links to additional resources.

Testing this anti-stigma/suicidal ideation module within MARVIN demonstrated its ability to detect extreme intents and deliver concise responses, highlighting AI-driven chatbots' potential in fostering stigma-free self-management and mental health support across Canada.

Background: Pharmacists are conveniently positioned to offer accessible testing for sexually transmitted and bloodborne infections (STBBI). The APPROACH 2.0 study aimed to evaluate the implementation of human immunodeficiency virus (HIV), hepatitis C (HCV) and syphilis screening by pharmacists in Newfoundland and Labrador, Nova Scotia, and Alberta.

Methods: Pharmacists in 34 pharmacies across urban and rural communities offered point-of-care (HIV, HCV) and dried blood spot (HIV, HCV, syphilis) testing. Pharmacists collected blood samples, administered testing, and provided pre- and post-test counselling. Participants with reactive results were offered laboratory requisitions for confirmatory testing and linkage to care. Participant questionnaires collected demographic and risk behaviour data and testing experience feedback.

Results: From December 1, 2022, to April 3, 2024, 1,424 tests were performed for 399 participants. Participants had a median age of 33 years. Most lived in urban settings (88%) and 33% reported not having a primary care provider. Sexual intercourse without a condom (81%) and having multiple sexual partners (54%) were commonly reported risk factors.

Participants were tested for HIV (97%), HCV (87%), and syphilis (68%). Notably, 35%, 43%, and 62% were first-time testers for each infection, respectively. Twenty-five participants had reactive screening test results (1 HIV, 11 HCV, and 13 syphilis). Confirmatory lab-based test results available for 16 participants indicated 4 current HCV and 2 current syphilis infections.

Most participants felt comfortable being tested by a pharmacist (97%), STBBI screening should always be available in pharmacies (91%), found pharmacies accessible (95%) and did not experience stigma/discrimination (91%). Some participants stated they would not have been screened (15%) or were uncertain if they would have been tested elsewhere (32%) if pharmacist-led testing was unavailable.

Conclusions: STBBI screening by pharmacists was accessible, acceptable, and successful at reaching first-time testers and identifying new infections. These findings support the broader scale-up of pharmacist-led testing.

Introduction: Ovarian function is critical to women’s health given the protective effects of ovarian sex hormones. We previously reported that women living with HIV in British Columbia (BC) were more likely to experience prolonged amenorrhea, defined as ≥12 months without menses unrelated to pregnancy/lactation/contraception/surgery/menopause. Low ovarian hormone levels have been associated with accelerated liver fibrosis. Thus, abnormal ovarian function (early menopause onset or history of prolonged amenorrhea) may place women at risk for liver disease. We therefore examined the potential association between a history of abnormal ovarian function and liver disease, in women living with and without HIV.

Methods: We included all women ≥16y participating in two BC cohorts, CARMA and BCC3, with available data to assess liver disease fibrosis-4 (FIB4) index. History of abnormal ovarian function was defined as either a history of prolonged amenorrhea (described above), premature ovarian insufficiency (biochemically confirmed menopause <40y), or early menopause (<45y). FIB-4 variable was modelled through multivariable linear regression analyses adjusted for covariates/confounders and segregated according to hepatitis C (HCV) seropositivity to allow inclusion of opioid use in the models, as opioids can induce amenorrhea.

Results: Participant characteristics and multivariable results are shown in Table 1. Increased FIB-4 was significantly associated with living with HIV but not with a history of abnormal ovarian function in both HCV seropositive/seronegative women.

Conclusions: In this analysis, history of abnormal ovarian function showed no association with liver fibrosis. However, living with HIV amplified liver fibrosis independently of older age, alcohol and opioid use.

Background: One-third of syphilis cases in British Columbia (BC), are classified as latent syphilis of unknown duration (LSUD), which are treated with longer treatment duration. Treponema pallidum (TP) polymerase chain reaction (PCR) is typically reserved for lesions, though can confirm early infection if reactive from mucocutaneous sites in asymptomatic individuals. This study examines the role of TP-PCR in restaging LSUD to early latent syphilis.

Methods: A retrospective cohort study was conducted on all BC’s LSUD cases with TP-PCR results from 06/2022-05/2024, focusing on cases restaged to early latent. Demographic, clinical and laboratory data were analysed using descriptive statistics. Logistic regression was used to identify predictors associated with restaging. One key predictor is the enzyme immunoassay (EIA) index, a marker of infection stage (i.e. index >45, established infection; index ≤45, recent infection).

Results: Of 1282 LSUD cases, 179 (14.0%) had a TP-PCR performed; 48 (26.8%) were TP-PCR positive and restaged to early latent. Compared to non-restaged individuals (Table 1), restaged individuals were significantly more likely to have an RPR >1:32, and EIA index ≤45, both of which are consistent with early infection. All 29 (100%) restaged cases with 12-month follow-up serology demonstrated an appropriate treatment response (i.e. 4-fold decrease in RPR titre).

Conclusion: In this study, a quarter of LSUD cases were restaged to early latent syphilis due to a positive TP-PCR. These findings support using TP-PCR in LSUD cases, to more accurately stage syphilis. This approach could shorten treatment duration, prevent antibiotic overuse, and enable targeted public health management.

Background: Doxycycline pre-exposure prophylaxis (doxyPrEP) has shown potential in preventing bacterial sexually transmitted infections (STI) in gay, bisexual, and other men who have sex with men (GBM). However, its impact on the microbiome is unclear. This study assessed rectal microbiome changes over 48 weeks in participants on HIV PrEP enrolled in a doxyPrEP trial.

Methods: The Dual Daily HIV and STI PrEP (DuDHS) study is an open-label, randomized pilot trial comparing immediate versus deferred doxycycline (100 mg daily) in HIV-negative GBM and transgender women on tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV PrEP. Fifty-two participants with recent syphilis diagnoses were recruited in Vancouver, Canada. Participants received 48 weeks of TDF/FTC and were randomized to immediate (starting doxycycline at baseline) or deferred (starting at week 24) arms. Rectal swabs were collected at baseline, week 24, and week 48 for microbiome analysis via 16S rRNA sequencing. Microbiome changes were evaluated using Wilcoxon signed rank and Mann-Whitney U tests, with p-values adjusted for multiple comparisons.

Results: Among 311 operational taxonomic units (OTUs), the most prevalent taxa were Finegoldia, Prevotella, Corynebacterium, and Streptococcus. At baseline, no significant differences in alpha diversity (Shannon’s H mean: immediate 2.58, deferred 2.60; p=0.91), beta diversity (Bray-Curtis) or taxa composition were observed between groups. A slight decrease in alpha diversity at the order, class, and phylum levels occurred at week 48 in the immediate arm (mean: 0.84 vs. 0.66 at Phylum, p<0.05), but not in the deferred arm. Fusobacterium abundance decreased slightly in both arms, though this did not pass multiple hypothesis testing. Beta diversity remained similar between groups at weeks 24 and 48 (p>0.05).

Conclusion: This study is the first to assess microbiome changes from doxyPrEP, showing minimal impact over 12 months. Further research is needed to explore doxycycline’s effects on microbiome function and antimicrobial resistance.

Background: Rates of HIV and syphilis in Saskatchewan are among the highest in Canada, with HIV rates at 19.4 per 100,000 people, more than three times the national rate, and rates of infectious syphilis at 186.6 per 100,000, over five times the national average. To help address this, a community-centered HIV and syphilis point-of-care test (POCT) study was implemented across 29 sites in February 2023, with opportunities for immediate treatment of newly diagnosed individuals.
Methods: The study offered a choice between three POCT options: HIV and syphilis combined; HIV alone; and syphilis alone. The MedMira Reveal® TP POCT was used for participants who selected syphilis alone upon consent. A key objective of this study was to evaluate the field performance of the Reveal® TP POCT when compared to standard serum-based testing for syphilis.
Results: From a total of 1759 participants as of November 2024, with overall seropositivity of 16.6% for syphilis and 3.4% for HIV, 348 completed Reveal® TP POCT and syphilis serology. Results are presented in the table below. For TP EIA and RPR reactives, the positive percent agreement between Reveal® TP and syphilis serology was 84.7% (39/46 excluding the 2 invalids) but dropped to 53.6% (15/28) when RPR was negative. Of the 271 participants who were non-reactive for syphilis serology, the negative percent agreement was 98.9% (264/267). Conclusions: The Reveal® TP test is a reliable and effective device for community-centered POCT programs taking syphilis testing out into communities most in need, providing opportunities for immediate treatment and connection to care.