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Doyle CM, Milwid RM, Cox J, Xia Y, Lambert G, Tremblay C, Otis J, Boily MC, Baril JG, Thomas R, Blais AD, Trottier B, Grace D, Moore DM, Mishra S, Maheu-Giroux M. Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): a modelling study of surveillance and survey data. J Int AIDS Soc 2023; 26:e26194. [PMID: 38054579 DOI: 10.1002/jia2.26194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023] Open
Abstract
INTRODUCTION HIV pre-exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population-level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013-2021. METHODS We used an agent-based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID-19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual-level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post-exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free-of-charge), and improving retention. RESULTS Over 2013-2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3-0.6) to 0.2 (90% CrI: 0.1-0.2) per 100 person-years. PrEP coverage among HIV-negative MSM remained low until 2015 (<1%). Afterwards, coverage increased to a maximum of 10% of all HIV-negative MSM, or about 16% of the 62% PrEP-eligible HIV-negative MSM in 2020. Over 2015-2021, PrEP averted an estimated 20% (90% CrI: 11%-30%) of cumulative HIV acquisitions. The hypothetical scenarios modelled showed that, at the same coverage level, prioritizing PrEP to high sexual activity MSM could have averted 30% (90% CrI: 19%-42%) of HIV acquisitions from 2015-2021. Even larger impacts could have resulted from higher coverage. Under the provincial eligibility criteria, reaching 10% coverage among HIV-negative MSM in 2015 and 30% in 2019, like attained in Vancouver, could have averted up to 63% (90% CrI: 54%-70%) of HIV acquisitions from 2015 to 2021. CONCLUSIONS PrEP reduced population-level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition.
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Affiliation(s)
- Carla M Doyle
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
| | - Rachael M Milwid
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
| | - Joseph Cox
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
- Direction Régionale de Santé Publique de Montréal, Montréal, Québec, Canada
- Clinical Outcomes Research and Evaluation, Research Institute - McGill University Health Centre, Montréal, Québec, Canada
| | - Yiqing Xia
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
| | - Gilles Lambert
- Direction Régionale de Santé Publique de Montréal, Montréal, Québec, Canada
| | - Cécile Tremblay
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada
- Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montréal, Québec, Canada
| | - Joanne Otis
- Département de Sexologie, Université du Québec à Montréal, Montréal, Québec, Canada
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Jean-Guy Baril
- Department of Family Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Clinique de médecine urbaine du Quartier Latin, Montréal, Québec, Canada
| | - Réjean Thomas
- Clinique médicale l'Actuel, Montréal, Québec, Canada
| | - Alexandre Dumont Blais
- RÉZO Health and STI prevention for GBQ men, trans people and MSM, Montréal, Québec, Canada
| | - Benoit Trottier
- Clinique de médecine urbaine du Quartier Latin, Montréal, Québec, Canada
| | - Daniel Grace
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - David M Moore
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sharmistha Mishra
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montréal, Québec, Canada
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