Background: Childhood protective service (CPS) out-of-home care, including foster care and group homes, is associated with poorer health outcomes. Knowledge gaps exist regarding prevalence and outcomes of out-of-home care among women with HIV. We examined if childhood CPS out-of-home care was associated with HIV outcome trajectories among women with HIV in Canada.

Methods: We conducted a longitudinal study with women with HIV in Ontario, British Columbia and Quebec. At three timepoints across five years, we examined CD4 counts (<200, 200-500, >500 cells/mm3), current anti-retroviral therapy (ART) use, and detectable/undetectable viral load (VL) (<50 copies/mL). We used latent class growth analysis to identify trajectories of these outcomes and assessed if childhood CPS out-of-home care (foster/group home) was associated with class membership.

Findings: Nearly one-fifth (n=272,19%) of participants (n=1422, mean age: 42.8) reported childhood out-of-home care. We identified four trajectories of CD4 counts: consistently high (35%), consistently low (8%), consistently medium (15%), and U-shaped (42%). Best fitting models for ART use and VL both included two trajectories with intercept, slope, and quadratic terms. Most participants (89%) were in categories that used ART and had a consistently undetectable VL. Individuals with a history of CPS out-of-home care were two to three times more likely to be in the ‘consistently low’ CD4 count class relative to any other class (βs=0.75–1.16, ps=0.002–0.02) and twice as likely to have a consistently detectable VL (β=0.72, p=0.02); there were no differences in ART use over time.

Discussion: Women with HIV disproportionately experience childhood CPS out-of-home care, with rates 14-fold higher than the national prevalence (1.3%), signaling the urgent need for HIV preventive strategies with CPS-involved youth. Women with HIV with CPS involvement had worse HIV outcome trajectories (low CD4, detectable VL). Better understanding pathways from CPS-involvement to clinical outcomes can inform tailored HIV care for women with HIV.

Background: Access to sexual and reproductive health (SRH) services is critical for cisgender and transgender women living with HIV (WLWH), who have historically faced substantial stigma within the healthcare system. HIV providers can be a critical point of referral and provision. Our study therefore examined prevalence and correlates of being comfortable discussing SRH with participants’ primary HIV provider.

Methods: Data were drawn from a longitudinal community-based open cohort (SHAWNA) of cis and trans WLWH aged 14 and older. The associations between social-structural factors and two outcomes (‘being comfortable discussing sexual health[SH]’ and ‘being comfortable discussing reproductive health[RH]’) were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals[95%CIs] are reported.

Results: Our study included 314 participants, 1392 observations over 4.5 years of follow-up. Overall, 77.1% felt comfortable discussing SH while 64.7% were comfortable discussing RH with their primary HIV provider at baseline. In multivariable analysis, being comfortable discussing SH was inversely associated with: sexual minority identity (AOR:0.59, 95%CI:0.37-0.94), gender minority identity (AOR:0.52, 95%CI:0.29-0.95) and enacted HIV stigma (AOR:0.55, 95%CI:0.31-0.97) and positively associated with accessing women-centred services (Oak Tree Clinic)(AOR:4.25, 95%CI:2.20-8.23). Being comfortable discussing RH was inversely associated with: sexual minority identity (AOR:0.56, 95%CI:0.40-0.79), gender minority identity (AOR:0.45, 95%CI:0.25-0.81) and being born in Canada (AOR:0.29, 95%CI:0.15-0.56) and positively associated with accessing women-centred services (AOR:1.81, 95%CI:1.29-2.53) and a history of pregnancy (AOR:2.25, 95%CI:1.47-3.44).

Conclusions: Our findings suggest that there is an unmet need for safe SRH care and practice among WLWH, and in particular, for WLWH who identify as members of sexual and gender minority communities and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental, gender-affirming spaces for discussions on SRH to occur; this can be facilitated through awareness, women-centred and trauma-informed approaches.

Background: Clinical guidelines recommend at least annual and quarterly sexually transmitted infection (STI) testing among sexually active men who have sex with men (MSM), including those on HIV PrEP or in HIV care. We built consensus around interventions to improve local STI testing services for MSM in Toronto using a web-based “e-Delphi” process.
Methods: We recruited Experts for a Community Panel (MSM who sought/underwent STI testing in the preceding 18 months, conducted 09/2019-11/2019) and a Provider Panel (offered STI testing to MSM in the past 12 months, conducted 02/2020-05/2020). Experts prioritized 6-8 potential interventions, generated from a literature review, on a 7-point Likert scale over 3 survey rounds. Consensus was defined as ≥60% within a ±1 response point. Summaries of panel responses were given in successive rounds.
Results: Among Community Experts, 43/51 (84%) completed all rounds; 19% HIV-positive, 37% HIV-negative on PrEP, 42% HIV-negative not on PrEP. The highest-rated interventions were Client Reminders, Routine and Express testing, citing convenient testing while also maintaining a relationship with their provider (Table 1). Priorities did not differ by HIV status or PrEP use. Among Provider Experts, 37/48 (77%) completed all rounds; 59% were physicians. Highest-rated interventions were Online-based, Express and Nurse-led testing, citing streamlined processes and decreasing the need to see a provider (Table 1).
Discussion: Both panels were enthusiastic about innovations that make STI testing more efficient. However, Community Experts preferred convenient interventions that involved their provider while Provider Experts favoured interventions that prioritized patient independence and reduced patient-provider time

Introduction: People living with HIV (PLHIV) are at a higher risk of suicide, despite advances in antiretroviral therapy (ART) in recent years. Healthcare utilization trends help identify underlying healthcare interaction patterns for those at risk of suicide. We hypothesized that PLHIV who died by suicide interact with healthcare systems less than PLHIV who died by all other causes between 1998 and 2012 in British Columbia (BC).

Methods: PLHIV in the Comparative Outcomes and Service Utilization Trends (COAST) study with a recorded death and at least 90-days of follow-up were included. Using healthcare utilization codes identified within BC administrative datasets, we used bivariable and multivariable logistic regression models to examine associations between healthcare utilization and death by suicide (vs. death by other causes). Analyses controlled for age at death, sex, health authority, neighbourhood socioeconomic status, and time period of death.

Results: Among 2363 individuals who met the inclusion criteria, 71 PLHIV died by suicide with significantly lower healthcare counts with a median of 4 (Quartile 1st-3rd(Q1-Q3):2-11), compared to 2292 PLHIV who died of other causes with a median of 13 (Q1-Q3:5-25). Adjusting for potential confounders, the logistic models found death by suicide was associated with lower total number of healthcare codes billed (odds ratio(OR):0.95, 95%CI:0.93,0.98), lower number of codes other than mental health and self-harm (OR:0.94, 95%CI:0.91,0.96), but higher number of codes related to self-harm (OR:1.07, 95%CI:1.01,1.14). Mental health code counts, however, were not significantly associated with suicide death (OR:1.00, 95%CI:0.96,1.04).

Conclusions: Our study results suggest that PLHIV who die by suicide engage with the healthcare system less when compared to those who die of other causes, despite there being no differences in the presentation of mental health codes. Given clear indications for risk of self-harm, these analyses highlight potential missed opportunities for suicide prevention among PLHIV on ART in BC.

Background: Globally, trans women living with HIV are known to experience inequitable HIV care access. The main objective of this study was to characterize HIV care among trans women living with HIV in Canada and identify factors that may influence HIV care access.

Methods: Sociodemographics, clinical factors, and laboratory values were collected from charts of trans women aged ≥16 years across 7 family medicine, endocrinology, and/or HIV clinics in Montreal and Toronto. Data were analyzed for 92 trans women living with HIV. The prevalence of each HIV care outcome (ever accessed HIV specialist care, ever ART use, current ART use, and current viral load suppression [<200 copies/ml]) were reported overall and compared across subgroups using chi-square tests.

Results: Of eligible participants, 48.5% had ever accessed HIV specialist care, 97.2% ever used ART, 93.5% currently used ART, and 93.8% had suppressed viral load. A higher proportion of those never diagnosed with a mental health condition (72.7% vs. 47.2%; p=0.041) and those who had seen an endocrinologist (45.0% vs. 28.6%; p=0.030) had accessed HIV specialist care. A higher proportion of those born outside of Canada ever used ART (100.0% vs. 86.7%; p=0.020). A higher proportion of participants of color ever used ART (100.0% vs. 83.3%; p=0.006) and currently use ART (100.0% vs. 76.9%; p=0.012). A higher proportion of those with no documented injection drug use (IDU) (96.7% vs. 66.7%; p=0.017) and those with documented planned or completed gender-affirming surgery (100.0% vs. 90.6%; p=0.043) were currently virally suppressed.

Conclusions: This clinical sample of trans women living with HIV in Toronto and Montreal had optimal estimates for HIV care engagement. Findings of this analysis can be leveraged to identify target populations (e.g., trans women with a history of IDU) and specific strategies (e.g., increasing access to gender-affirming care) to increase engagement in HIV care.

Background
Although the effectiveness of antiretrovirals (ARVs) is unquestionable, the high cost of new drugs puts considerable economic pressure. Generic drugs play a central role in the sustainability of healthcare systems. This study modelled the utilization of both generic and brand ARV products in a publicly funded HIV treatment program to improve understanding of the market share of prescribed ARVs, and generic drug penetration.

Methods
We included longitudinal ARV utilization data from participants of the publicly funded HIV Drug Treatment Program in British Columbia (BC). Participants received ARVs between the fiscal years 2014/2015 and 2019/2020. We modelled usage of 20 brand and generic ARVs. The outcome was the proportion of participants who received each drug per fiscal period. The outcome was modeled assuming a beta distribution.

Results
The number of unique participants increased from 6520 in the first period of 2014/2015 to 7421 in the last period of 2019/2020 (14% increase). From 2014/15 to 2018/19, utilization of most ARVs declined with the exception of BIC/FTC/TAF, DRV/COB, DTG, DTG/ABC/3TC, EVG/COB/FTC/TAF, EVG/COB/FTC/TDF, and FTC/TAF. In 2019/2020, integrase inhibitors had 49% of the market share, and in the next two years, this is estimated to increase to 61%. Several generic products were marketed in 2017/2018, and the proportion of the market share of generics increased from 16% in 2017/2018 to 68% in 2019/2020, with ABC/3TC and FTC/TDF holding the majority of the generic market. However, current trends suggest that the utilization of generic products will decrease by 33% by 2021/2022.

Conclusions
There has been a significant shift in ARV usage in BC. Consistent with evolving guidelines, we have seen a marked shift towards the use of integrase inhibitors-based regimens, which now dominates the market share in BC. We have also seen a recent declining penetration of generic ARVs, yielding a high economic impact.