Background: The COVID-19 pandemic has shifted healthcare services to telephone/virtual platforms, limited service capacity, and deferred some care. For those living with HIV, COVID-19 has disrupted the provision of essential care, especially for those experiencing syndemics like mental health disorders. Our aim was to capture the impact of COVID-19 on care experiences for people living with HIV.

Methods: The Ontario HIV Treatment Network Cohort Study is a community-driven, longitudinal, clinic-based cohort of over 9,000 people living with HIV in Ontario, Canada, with annual interviewer-administered questionnaires at 13 sites. In May 2020, we implemented a virtually-administered 35-item COVID-19 questionnaire module to assess the impact of COVID-19 on people living with HIV.

Results: Results from 1,166 responses collected between May and December 2020 include 276 women and 880 men (median age: 52 years, 61% white, 22% black). Amongst men, 748 (85%) identified as men who have sex with men. Approximately 44% (n=507) of respondents remotely accessed primary care with 86% (n=437) reporting being ‘very’ or ‘somewhat’ satisfied, and 38% (n=437) remotely accessed HIV-specific care (n=373, 85% satisfied). Alarmingly, of the 292 people accessing mental health care, 161 (55%) reported having had care interrupted. Additionally, 37% (n=435) of participants deferred at least one type of care, with 24% of those (n=106) being ‘extremely’ or ‘quite a bit’ concerned about the impact on their long-term health.

Discussion: Despite healthcare systems transitioning to remote care during COVID-19, more than a third of people living with HIV report deferring care and fear that it may impact their long-term health. However, where remote options are available, respondents report high levels of service satisfaction. Continued isolation, service modification, and reduced access may have lasting negative health consequences for people living with HIV. This research highlights the need for flexible care models that support equitable access.

Background: Physical and social isolation due to the COVID-19 pandemic may be triggers for substance use and mental health issues among people living with HIV. We examined whether loneliness due to the pandemic was associated with increased depression and hazardous alcohol use among participants of the OCS.

Methods: The OCS is a cohort of people receiving HIV care at 13 clinics across Ontario. Clinical data is collected through chart abstraction and linkage with the Public Health Ontario Laboratory database. Participants also complete an annual interviewer-administered questionnaire that includes Alcohol use (AUDIT-C) and depression (PHQ-9). Since May 2020, additional COVID-19 related items included experiences of physical isolation and loneliness. We used logistic regression to examine the relationship between loneliness, alcohol use, and depression.

Results: Sample included 640 participants (median age: 45 years) and most were male (75%), Gay/Lesbian/Bisexual/Queer (66%), White (60%), and born in Canada (62%). Compared to the pre-pandemic period, prevalence of depression (26% vs. 28%, p=0.216) and hazardous alcohol use (37% vs 38%, p=0.448) remained stable. Nearly half (48%) reported increased loneliness during the pandemic and those who felt increased loneliness had significantly (p<0.01) higher prevalence of current depression (36% vs. 16%) and hazardous alcohol use (34% vs. 23%) than those who did not experience increased loneliness. In multivariable analyses, increased loneliness was associated with increased risk of depression (aPR: 1.96, 95% CI: 1.43-2.68) but not with hazardous alcohol use (aPR: 1.08, 95% CI: 0.87-1.35) after controlling for pre-pandemic depression and hazardous alcohol use, physical health, and demographic variables.

Discussion: Our results suggest that, although the overall prevalence of depression remained stable, OCS participants who felt increased loneliness during the pandemic were at higher risk of depression. Interventions that address mental health among those at risk of social isolation may improve the mental health of people living with HIV.

Background: Cancer is an important comorbidity among people living with HIV (PLWH). We estimated cancer burden among people with HIV in Ontario.

Methods: We conducted a population-based retrospective cohort study of PLWH (≥18 years) using health administrative data assessing incident cancers from 01/01/1997 to 31/12/2018. Cancers were categorized as AIDS-defining cancers (ADC), infection-related non-ADC (NADC) and infection-unrelated NADC. We used direct standardization (2011 Canadian population as reference) to calculate age-standardized incidence with 95% confidence intervals (CI) and the counting method to calculate 2-, 5-, and 10-year limited duration prevalence.

Results: Among 17,675 individuals (78% males) followed for 179,485 person-years (PY), 1127 first primary incident cancers were diagnosed (531 [47%] infection-unrelated NADC, 267 [24%] infection-related NADC and 329 [29%] ADC). Cancer incidence declined from 1087/100,000 PY (95% CI 646, 1714) in the early cART era (1997-2000) to 757/100,000 PY (659, 866) in 2016-2018. Infection-unrelated NADC incidence ranged between 499/100,000 PY (196, 1045) in 1997-2000 and 489/100,000 PY (409, 580) in 2016-2018. Infection-related NADC incidence declined from 200/100,000 PY (43, 573) to 168/100,000 PY (124, 221) between 1997-2000 and 2016-2018. Similarly, ADC incidence decreased from 387/100,000 PY (185, 712) in 1997-2000 to 101/100,000 PY (70, 142) in 2016-2018. When stratified by sex, cancer incidence among females surpassed cancer incidence in males in 2016-2018 (aIR females: 859/100,000 PY [638, 1132] vs. aIR males: 705/100,000 PY [597, 826]). Among 14,896 people alive at the end of follow-up, 1.1% (n=165), 3.1% (n=463) and 5.5% (n=824) had a cancer diagnosis in the past 2, 5 and 10 years, respectively.

Conclusions: This is the first study of the overall cancer burden among PLWH in Ontario. Although infection-related NADC and ADC incidence declined, infection-unrelated NADC incidence remained high throughout the study period. These findings can locally inform cancer prevention and care service planning.

Background: Transient elastography (TE) with controlled attenuation parameter (CAP) is a feasible and accurate tool to assess both non-alcoholic fatty liver disease (NAFLD) and associated liver fibrosis in people with HIV (PWH). However, it is not widely accessible. Serum liver biomarkers, including FIB-4, APRI and hepatic steatosis index (HSI), can be used for large scale studies and in limited resource settings. Concordance between TE with CAP and serum biomarkers in PWH is not known, particularly across the spectrum of body mass index (BMI).
Methods: HIV mono-infected patients from three prospective cohorts (LIVEHIV in Montreal, LHIVPA in Palermo, MHMC in Modena) underwent TE with CAP and serum liver biomarkers. NAFLD was defined as CAP ≥285 dB/m. A HSI threshold <30 defined absence of NAFLD. Multivariable logistic regression was used to identify predictors of discordance between serum fibrosis biomarkers and TE, defined as FIB-4<1.3 with TE>7.1, and as APRI<0.5 with TE>7.1.
Results: 1510 PWH were included. Discordance between HSI<30 and CAP>285 for NAFLD was rare (1% in normoweight PWH, no discordance in overweight and obese PWH). For FIB-4 and APRI compared to TE, most of the discordance was observed in obese patients. Of note, over 5% of PWH defined as cirrhotic by TE>13 were missed by both FIB-4<1.3 and APRI<0.5. After adjusting for sex, CD4 cell count and time since HIV diagnosis, BMI was an independent predictor of discordance for both FIB-4<1.30 with TE>7.1 (OR 1.13, 95% CI: 1.08-1.19) and APRI<0.5 with TE>7.1 (OR 1.13, 95% CI 1.08-1.17). In obese patients, the combination of HSI<30 and APRI<0.5 or HSI<30 and FIB-4<1.3 had 100% negative predictive value to exclude presence of liver cirrhosis by TE.
Conclusions: Obese PWH have less concordance between serum fibrosis biomarkers and TE to diagnose significant fibrosis. The combination of multiple serum biomarkers should be considered in obese PWH.

Background: People living with HIV and/or HCV who use drugs are at greater risk of acquiring serious infections (e.g., endocarditis, viral infections). Parenteral antibiotic therapy (PAT) delivered through peripherally inserted central catheters (PICCs) is best practice to treat bacterial infections. However, health care providers (HCPs) are often concerned about the risk of PICCs being ‘abused’ and limit their use with people who use drugs (PWUD). This presentation reports on the use of PICCs from HCPs and PWUDs perspectives.

Methods: This study draws on n=50 interviews conducted in Toronto and Ottawa; we recruited 24 PWUDs with self-reported HIV and/or HCV infection, history of substance use, hospital admission in the past five years; and, 26 HCPs (physician, nurse, social worker etc.) with experience with this patient group. Participants completed semi-structured, audio-recorded interviews (10-60min). Thematic analysis was conducted.

Results: Stigma and lack of trust between most PWUD and their HCPs influenced if, how, and when PICCs were used. Most HCPs were reluctant to prescribe PICCs fearing use by patients to inject drugs that had not been prescribed. Concerns about the health and liability risks led some to withhold PICCs even when clinically indicated, and/or to closely monitor patients with PICCs. Contrary to HCPs fears, most PWUD reported never injecting into a PICC but were heavily surveilled and threatened when given one. A participant who had injected into their PICC described it as a way to avoid infections. A minority of HCPs educated their patients about how to safely manage their PICC (including when injecting), and some managed opioid needs as part of PAT.

Conclusions: This study suggests the need to challenge how drug user related stigma may influence clinical decisions and implement patient centred/harm reduction approaches to improve therapeutic relationships and outcomes for people living with HIV and/or HCV who use drugs.

BICSTaR Canada (GS-CA-380-4574/NCT03580668) is an ongoing, observational cohort study evaluating the effectiveness, safety and tolerability of B/F/TAF in antiretroviral treatment‐naïve (TN) or treatment‐experienced (TE) adults living in Canada with HIV. This analysis includes HIV‐1 RNA (missing=excluded analysis), drug‐related (DR) adverse events (AEs), weight changes and treatment persistence in participants who completed a 12M visit.

170 persons (10 TN and 160 TE) were included in the analysis. Most were male (88%), white (72%) and 52% were ≥50 years old. Baseline comorbidities were very prevalent (90%), including neuropsychiatric disorders (38%), hyperlipidemia (27%), and hypertension (24%). Amongst TE persons, 68%/23%/11% switched from INSTI/NNRTI/PI regimens to B/F/TAF, respectively; 46% switched from TDF-containing regimens. 19 participants (12%; 2 TN and 17 TE) had baseline primary resistance (7% NRTI [6 M184V/I, 1 K65R] and 6% NNRTI [7 K103N/S] mutations). Of those with data at 12M (n=154), 9/9 (100%) TN and 140/145 (97%) TE had HIV-1 RNA <50 copies/ml, with no emergent resistance. Median CD4+ cell counts (cells/µl) increased in TN (392 to 699) and were stable in TE (586 to 583) from baseline to 12M. Persistence with B/F/TAF was 93%; 1 TN and 11 TE discontinued (5 due to AEs, 5 participant/investigator decision, 1 death, 1 lack of efficacy). No discontinuations occurred due to renal/bone/hepatic AEs and no serious DRAEs were recorded. DRAEs occurred in 12 TE participants (7%), with weight increase (n=4) and psychiatric disorders (abnormal dreams [n=1], anxiety [n=1] and major depression [n=1]) being most common. Median (Q1, Q3) weight change was +1.6 kg (0.5, 4.7) for TN (n=7) and +0.7 kg (−1.3, 2.7) for TE (n=117), with modest BMI changes (TN: +0.6 kg/m² [0.1, 1.4]; TE: +0.2 kg/m² [−0.5, 0.8]).

B/F/TAF was highly effective and well-tolerated through one-year in this real-world Canadian cohort, consisting largely of older adults with HIV and multiple comorbidities.