Impact of screening and doxycycline prevention on the syphilis epidemic among men who have sex with men in British Columbia: a mathematical modelling study

Background

Men who have sex with men (MSM) in British Columbia (BC) are disproportionately affected by infectious syphilis and HIV. In this study, we developed a co-interaction model and evaluated the impact and effectiveness of possible interventions among different MSM subgroups on the syphilis epidemic.

Methods

We designed a deterministic compartmental model, which stratified MSM by HIV status and HIV pre-exposure prophylaxis (HIV-PrEP) usage into (1) HIV-negative/unaware MSM (HIV-PrEP not recommended, not on HIV-PrEP), (2) HIV-negative/unaware MSM with HIV-PrEP recommended (not on HIV-PrEP), (3) HIV-negative/unaware MSM actively on HIV-PrEP, and (4) MSM diagnosed with HIV. We estimated the effect of scaling up syphilis testing frequency from Status Quo to six-, four-, and three-months, increasing the percentage of MSM using doxycycline prevention (Doxy-P) to 25%, 50%, and 100% of the target level, and a combination of both among subgroups (2)-(4). We also assessed the impact of these interventions on the syphilis incidence rates from 2020 to 2034 in comparison to the Status Quo scenario where no intervention was introduced.

Findings

Under the Status Quo scenario, with the expansion of the HIV-PrEP program to improve syphilis testing, the syphilis incidence rate was estimated to peak at 16.1 [Credible Interval (CI):14.2-17.9] per 1,000 person-years (PYs) in 2023 and decrease to 6.7 (CI:3.8-10.9) per 1,000 PYs by 2034. The syphilis incidence rate in 2034 was estimated at 0.7 (0.3-1.3) per 1,000 PYs if MSM diagnosed with HIV could be tested every four months, and at 1.5 (0.7-3.0) per 1,000 PYs if HIV-negative/unaware MSM actively on HIV-PrEP could be tested every three months. By achieving 100% of the target coverage of Doxy-P, the syphilis incidence rate was estimated at 1.4 (0.5-3.4) if focusing on MSM diagnosed with HIV, and 2.6 (1.2-5.1) per 1,000 PYs if focusing on HIV-negative/unaware MSM actively on HIV-PrEP. Under the combined interventions, the syphilis incidence rate could be as low as 0.0 (0.0-0.1) and 0.8 (0.3-1.8) per 1,000 PYs, respectively.

Interpretation

The HIV-PrEP program in BC plays a crucial role in increasing syphilis testing frequency among high-risk MSM and reducing syphilis transmission among this group. In addition, introducing Doxy-P can be an effective complementary strategy to minimize syphilis incidence, especially among MSM diagnosed with HIV.

Funding

This work was funded by the Canadian Institutes of Health Research.

Using an intersectionality-based approach to evaluate mental health services use among gay, bisexual and other men who have sex with men in Montreal, Toronto and Vancouver

AIMS

To cope with homonegativity-generated stress, gay, bisexual and other men who have sex with men (GBM) use more mental health services (MHS) compared with heterosexual men. Most previous research on MHS among GBM uses data from largely white HIV-negative samples. Using an intersectionality-based approach, we evaluated the concomitant impact of racialization and HIV stigma on MHS use among GBM, through the mediating role of perceived discrimination (PD).

METHODS

We used baseline data from 2371 GBM enrolled in the Engage cohort study, collected between 2017 and 2019, in Montreal, Toronto and Vancouver, using respondent-driven sampling. The exposure was GBM groups: Group 1 (n = 1376): white HIV-negative; Group 2 (n = 327): white living with HIV; Group 3 (n = 577): racialized as non-white HIV-negative; Group 4 (n = 91): racialized as non-white living with HIV. The mediator was interpersonal PD scores measured using the Everyday Discrimination Scale (5-item version). The outcome was MHS use (yes/no) in the prior 6 months. We fit a three-way decomposition of causal mediation effects utilizing the imputation method for natural effect models. We obtained odds ratios (ORs) for pure direct effect (PDE, unmediated effect), pure indirect effect (PIE, mediated effect), mediated interaction effect (MIE, effect due to interaction between the exposure and mediator) and total effect (TE, overall effect). Analyses controlled for age, chronic mental health condition, Canadian citizenship, being cisgender and city of enrolment.

RESULTS

Mean PD scores were highest for racialized HIV-negative GBM (10.3, SD: 5.0) and lowest for white HIV-negative GBM (8.4, SD: 3.9). MHS use was highest in white GBM living with HIV (GBMHIV) (40.4%) and lowest in racialized HIV-negative GBM (26.9%). Compared with white HIV-negative GBM, white GBMHIV had higher TE (OR: 1.71; 95% CI: 1.27, 2.29) and PDE (OR: 1.68; 95% CI: 1.27, 2.24), and racialized HIV-negative GBM had higher PIE (OR: 1.09; 95% CI: 1.02, 1.17). Effects for racialized GBMHIV did not significantly differ from those of white HIV-negative GBM. MIEs across all groups were comparable.

CONCLUSIONS

Higher MHS use was observed among white GBMHIV compared with white HIV-negative GBM. PD positively mediated MHS use only among racialized HIV-negative GBM. MHS may need to take into account the intersecting impact of homonegativity, racism and HIV stigma on the mental health of GBM.

Human Immunodeficiency Virus Treatment Attitudes and Bacterial Sexually Transmitted Infections Among Gay and Bisexual Men

BACKGROUNDS

Positive attitudes toward human immunodeficiency virus (HIV) treatment, such as reduced concern about HIV transmissibility, are associated with sexual behaviors that may increase the risk of bacterial sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (GBM). We examined associations between HIV treatment attitudes and bacterial STI diagnoses among GBM in Canada's three largest cities.

METHODS

We fit a structural equation model between HIV treatment attitudes and bacterial STI diagnoses via sexual behaviors in the Engage study's baseline data. We estimated direct and indirect paths between scores on HIV treatment attitudes and STIs via number of male anal sex partners, condomless anal sex, and oral sex. We conducted sub-analyses with participants stratified by HIV serostatus.

RESULTS

Among 2449 GBM recruited in 2017 to 2019, there was a direct association between HIV treatment attitudes and current STI diagnoses (β = 0.13; 95% CI, 0.07-0.19; P < 0.001). The mediated model revealed a positive total indirect effect through 2 pathways: (1) engaging in condomless anal sex and (2) number of male anal sex partners and condomless anal sex. These 2 indirect pathways remained in the stratified mediation models for both HIV negative GBM and for GBM living with HIV.

CONCLUSIONS

The association between HIV treatment attitudes and diagnosed STIs is mediated through a higher number of male anal sex partners and condomless anal sex. The results highlight the importance of providers educating patients when providing effective STI counseling, testing, and prevention for GBM about how accurate HIV treatment attitudes may inadvertently be associated with the bacterial STI epidemic.

Problematic alcohol use among gay, bisexual, and other men who have sex with men in Canada: the role of proximal stressors and anxiety

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBM) report high rates of problematic alcohol use, anxiety, and depression. This may, in part, be due to stressors related to their sexual identity (i.e., minority stressors). However, few studies have examined both distal and proximal stressors, as well as the specific psychological mechanisms by which these stressors may be related to alcohol use outcomes, in a representative sample of GBM. We explored the relationship between distal and proximal stressors and alcohol use outcomes, as well as the role of anxiety and depression as potential mediators of these relationships.

METHODS

We analyzed the baseline data of 2,449 GBM from Engage, a cohort study of sexually active GBM recruited using respondent-driven sampling (RDS) in Montreal, Toronto, and Vancouver from February 2017 to August 2019. Using structural equation modeling, we examined the associations between distal minority stressors (i.e., experiences of heterosexist harassment, rejection, and discrimination), proximal minority stressors (i.e., internalized homonegativity, concerns about acceptance, concealment, and lack of affirmation), anxiety and depression, and alcohol consumption and alcohol use problems. RDS-adjusted analyses controlled for age, income, sexual orientation, ethnicity, recruitment city, and HIV serostatus.

RESULTS

There were positive direct associations between distal stress and proximal stress, anxiety, and depression, but not alcohol use outcomes. Proximal stress had a positive direct association with anxiety, depression, and alcohol use problems, but not alcohol consumption. Anxiety was positively associated with alcohol consumption and alcohol use problems. Depression was negatively associated with alcohol consumption but not alcohol use problems. Regarding indirect effects, distal stress was associated with alcohol use outcomes via proximal stress and anxiety, but not via depression.

CONCLUSIONS

We found support for a minority stress model as it relates to alcohol use outcomes among GBM. Findings suggest that proximal minority stress and anxiety differentially impact the problematic alcohol use among GBM who experience heterosexist discrimination. Clinical providers should consider incorporating the treatment of proximal minority stressors and anxiety into existing alcohol interventions for GBM.

Ethno-racial variations in mental health symptoms among sexually-active gay, bisexual, and other men who have sex with men in Vancouver, Canada: a longitudinal analysis

BACKGROUND

Minority stress from racism and heterosexism may uniquely interact to impact the mental health of racialized sexual minorities. We examined variations in anxiety and depressive symptoms by reported by ethno-racial identity among gay, bisexual, and other men who have sex with men (gbMSM) in Vancouver, Canada.

METHODS

We recruited gbMSM aged ≥ 16 years from February 2012 to February 2015 using respondent-driven sampling (RDS). Participants completed computer assisted self-interviews (CASI) at enrollment and every 6 months until February 2017. We examined factors associated with moderate/severe anxiety and depression scores (> 10) on the Hospital Anxiety and Depression Scale (HADS) and differences in key explanatory variables including sociodemographic, psychosocial, and substance use factors. We used multivariable mixed effects models to assess whether moderate/severe scores were associated with ethno-racial identity across all visits.

RESULTS

After RDS-adjustment, of 774 participants, 79.9% of participants identified as gay. 68.6% identified as white, 9.2% as Asian, 9.8% as Indigenous, 7.3% as Latin American, and 5.1% as other ethno-racial identities. Participants contributed a median of 6 follow-up visits (Q1-Q3: 4-7). In the multivariable analysis, Asian participants had decreased odds of moderate/severe anxiety scores compared to white participants (aOR = 0.39; 95% CI: 0.18-0.86), and Latin American participants had decreased odds of moderate/severe depression scores compared to both white (aOR = 0.17; 95% CI: 0.08-0.36) and Asian (aOR = 0.07; 95% CI: 0.02-0.20) participants.

CONCLUSION

Asian and Latino gbMSM reported decreased mental health symptoms compared to white participants. Asian and Latino gbMSM in Vancouver appear to manage multiple minority stressors without adversely affecting their mental health.

Depressive Symptoms, the Impact on ART Continuation, and Factors Associated with Symptom Improvement Among a Cohort of People Living with HIV in British Columbia, Canada

Depressive symptoms among people living with HIV (PLWH) are associated with poorer overall health outcomes. We characterized depressive symptoms and improvements in symptomology among PLWH (≥ 19 years old) in British Columbia (BC), Canada. We also examined associations between depressive symptomology and antiretroviral therapy (ART) treatment interruptions. Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10), within a longitudinal cohort study with three surveys administered 18-months apart. We used multivariable logistic regression to model factors associated with improvements in depressive symptoms (CES-D-10 scores from ≥ 10 to < 10). Of the 566 participants eligible for analysis 273 (48.2%) had CES-D scores indicating significant depressive symptoms (score ≥ 10) at enrollment. Improvements in symptoms at first follow-up were associated with greater HIV self-care on the Continuity of Care Scale (adjusted odds ratio: 1.17; 95% CI 1.03-1.32), and not having a previously reported mental health disorder diagnosis (aOR 2.86; 95% CI 1.01-8.13). Those reporting current cocaine use (aOR 0.33; 95% CI 0.12-0.91) and having a high school education, vs. less than, (aOR 0.25; 95% CI 0.08-0.82) had lower odds of improvement in depressive symptomatology. CES-D scores ≥ 10 were not significantly associated with ART treatment interruptions during follow-up (aOR: 1.08; 95% CI:0.65-1.8). Supporting greater self-care and consideration of mental health management strategies in relation to HIV may be useful in promoting the wellbeing of PLWH who experience depressive symptoms.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities

BACKGROUND

We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time.

METHODS

We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable.

RESULTS

We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29).

CONCLUSIONS

Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

It's all about connection: Determinants of social support and the influence on HIV treatment interruptions among people living with HIV in British Columbia, Canada

BACKGROUND

Social support has previously been found to be associated with improved health outcomes of individuals managing chronic illnesses, including amongst people living with HIV (PLWH). For women and people who use injection drugs who continue to experience treatment disparities in comparison to other PLWH, social support may have potential in facilitating better treatment engagement and retention. In this analysis, we examined determinants of social support as measured by the Medical Outcomes Study - Social Support Survey (MOS-SSS) scale, and quantified the relationship between MOS-SSS and HIV treatment interruptions (TIs) among PLWH in British Columbia, Canada.

METHODS

Between January 2016 and September 2018, we used purposive sampling to enroll PLWH, 19 years of age or older living in British Columbia into the STOP HIV/AIDS Program Evaluation study. Participants completed a baseline survey at enrolment which included the MOS-SSS scale, where higher MOS-SSS scores indicated greater social support. Multivariable linear regression modeled the association between key explanatory variables and MOS-SSS scores, whereas multivariable logistic regression modeled the association between MOS-SSS scores and experiencing TIs while controlling for confounders.

RESULTS

Among 644 PLWH, we found that having a history of injection drug use more than 12 months ago but not within the last 12 months, self-identifying as Indigenous, and sexual activity in the last 12 months were positively associated with MOS-SSS, while being single, divorced, or dating (vs. married), experiences of lifetime violence, and diagnosis of a mental health disorder were inversely associated. In a separate multivariable model adjusted for gender, ethnicity, recent homelessness, sexual activity in the last 12 months, and recent injection drug use, we found that higher MOS-SSS scores, indicating more social support, were associated with a lower likelihood of HIV treatment interruptions (adjusted odds ratio: 0.90 per 10-unit increase, 95% confidence interval: 0.83, 0.99).

CONCLUSIONS

Social support may be an important protective factor in ensuring HIV treatment continuity among PLWH. Future research should examine effective means to build social support among communities that have potential to promote increased treatment engagement.

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

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.

Examining the secondary impacts of the COVID-19 pandemic on syndemic production and PrEP use among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada

BACKGROUND

The secondary impacts of the COVID-19 pandemic may disproportionately affect gay, bisexual, and other men who have sex with men (GBM), particularly related to HIV prevention and treatment outcomes. We applied syndemic theory to examine PrEP disruptions during the during the height of the COVID-19 pandemic in Vancouver, Canada.

METHODS

Sexually-active GBM, aged 16 + years, were enrolled through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview every six months and data were linked to the BC PrEP Program (program responsible for publicly funded PrEP in the province) to directly measure PrEP disruptions. The analysis period for this study was from March 2018-April 2021. We used univariable generalized linear mixed models to examine (1) six-month trends for syndemic conditions: the prevalence of moderate/severe depressive or anxiety symptoms, polysubstance use, harmful alcohol consumption, intimate partner violence, and (2) six-month trends for PrEP interruptions among HIV-negative/unknown GBM. We also applied 3-level mixed-effects logistic regression with RDS clustering to examine whether syndemic factors were associated with PrEP interruptions.

RESULTS

Our study included 766 participants, with 593 participants who had at least one follow-up visit. The proportion of respondents with abnormal depressive symptoms increased over the study period (OR = 1.35; 95%CI = 1.17, 1.56), but we found decreased prevalence for polysubstance use (OR = 0.89; 95%CI = 0.82, 0.97) and binge drinking (OR = 0.74; 95%CI = 0.67, 0.81). We also found an increase in PrEP interruptions (OR = 2.33; 95%CI = 1.85, 2.94). GBM with moderate/severe depressive symptoms had higher odds (aOR = 4.80; 95%CI = 1.43, 16.16) of PrEP interruptions, while GBM with experiences of IPV had lower odds (aOR = 0.38; 95%CI = 0.15, 0.95) of PrEP interruptions. GBM who met clinical eligibility for PrEP had lower odds of experiencing PrEP interruptions (aOR = 0.25; 95%CI = 0.11, 0.60).

CONCLUSION

There were increasing PrEP interruptions since March 2020. However, those most at risk for HIV were less likely to have interruptions. Additional mental health services and targeted follow-up for PrEP continuation may help to mitigate the impacts of the COVID-19 pandemic on GBM.

Unpacking racism during COVID-19: narratives from racialized Canadian gay, bisexual, and queer men

OBJECTIVE

Epidemics impact individuals unevenly across race, gender, and sexuality. In addition to being more vulnerable to COVID-19 infection, evidence suggests racialized gender and sexual minorities experienced disproportionate levels of discrimination and stigma during the COVID-19 epidemic. Drawing on Critical Race Theory (CRT), we examined the experiences of gay, bisexual, queer, and other men who have sex with men (GBQM) of colour facing discrimination during COVID-19.

DESIGN

Engage-COVID-19 is a mixed methods study examining the impact of COVID-19 on GBQM living in Vancouver, Toronto, and Montréal, Canada. We conducted two rounds of qualitative interviews (November 2020 to February 2021, and June to October 2021) with 93 GBQM to explore the evolving impact of COVID-19 on their lives. Transcripts were coded using inductive thematic analysis. Data analysis was conducted using Nvivo software.

RESULTS

Fifty-nine participants identified as Black, Indigenous, and/or a Person of Colour (BIPOC). These GBQM of colour described multiple experiences of discrimination during COVID-19. Although participants did not report experiences of discrimination based on their sexual identity during COVID-19, we found that experiences of racism affected how they were treated within their sexual networks. Experiences of racism were most often reported by East Asian and Black GBQM. These participants faced racism in public and online spaces, primarily in the form of verbal harassment. Several participants were also harassed because they wore face masks. Verbal abuse against GBQM of colour was largely prompted by racist discourses related to COVID-19.

CONCLUSION

Racism remains a pernicious threat to the well-being of GBQM of colour. CRT highlights the importance of assessing how sexualized and gendered discourses about race shape the experiences of GBQM of colour navigating multiple epidemics like COVID-19 and HIV. These pervasive discourses unevenly affect racial and sexual minorities across multiple epidemics, and negatively impact health outcomes for these populations.

Vaccine Effectiveness Against 12-Month Incident and Persistent Anal Human Papillomavirus Infection Among Gay, Bisexual, and Other Men Who Have Sex With Men

BACKGROUND

Real-world evidence of human papillomavirus (HPV) vaccine effectiveness (VE) against longitudinal outcomes is lacking among gay, bisexual, and other men who have sex with men (GBM). We compared 12-month incidence and persistence of anal HPV infection between vaccinated and unvaccinated GBM.

METHODS

We recruited GBM aged 16-30 years in Montreal, Toronto, and Vancouver, Canada, from 2017 to 2019. Participants were followed over a median of 12 months (interquartile range, 12-13 months). Participants self-reported HPV vaccination and self-collected anal specimens for HPV DNA testing. We calculated prevalence ratios (PR) for 12-month cumulative incidence and persistence with ≥1 quadrivalent vaccine type (HPV 6/11/16/18) between vaccinated (≥1 dose at baseline) and unvaccinated participants using a propensity score-weighted, modified Poisson regression.

RESULTS

Among 248 participants, 109 (44.0%) were vaccinated at baseline, of whom 62.6% received 3 doses. PRs for HPV 6/11/16/18 were 0.56 (95% confidence interval [CI], .24-1.31) for cumulative incidence and 0.53 (95% CI, .25-1.14) for persistence. PRs were 0.23 (95% CI, .05-1.03) and 0.08 (95% CI, .01-.59) for incidence and persistence, respectively, among participants who received their first dose at age ≤23 years and 0.15 (95% CI, .03-.68) and 0.12 (95% CI, .03-.54) among participants who were sexually active for ≤5 years before vaccination.

CONCLUSIONS

Findings support national recommendations for HPV vaccination at younger ages or soon after sexual debut.

Examining differential success in recruitment using respondent driven sampling (RDS) in a multi-site study of gay, bisexual and other men who have sex with men

BACKGROUND

The Engage Study is a longitudinal biobehavioral cohort study of gay, bisexual and other men who have sex with men (GBM) in Toronto, Montreal, and Vancouver. Baseline data (2,449 participants) were collected from February 2017 - August 2019 using respondent-driven sampling (RDS). Recruitment in Montreal required fewer seeds, had a much shorter recruitment period, and recruited the largest sample.

METHODS

To better understand why RDS recruitment was more successful in Montreal compared to other sites, we conducted an analysis to examine RDS recruitment characteristics for GBM in each of the three study sites, explore demographic characteristics and measures of homophily, that is, the tendency of individuals to recruit other study participants who are like themselves, and compared motivations for study participation.

RESULTS

Montreal had the greatest proportion of participants over the age of 45 (29.1% in Montreal, 24.6% in Vancouver, and 21.0% in Toronto) and the highest homophily for this age group, but homophily was high across the three cities. Montreal also reported the lowest percentage of participants with an annual income greater or equal to $60,000 (7.9% in Montreal, 13.1% in Vancouver and 10.6% in Toronto), but homophily was similar across all three cities. The majority of participants indicated interest in sexual health and HIV as the main reason for participating (36.1% in Montreal, 34.7% in Vancouver, and 29.8% in Toronto). Financial interest as the main reason for participation was low (12.7% in Montreal, 10.6% in Vancouver, and 5.7% in Toronto).

CONCLUSION

Taken together, although we found some differences in study demographic characteristics and homophily scores, we were unable to fully explain the different recruitment success based on the data available. Our study underlines the fact that success of RDS implementation may vary by unknown factors, and that researchers should be proactive and flexible to account for variability.

Exploring Primary Healthcare Experiences and Interest in Mobile Technology Engagement Amongst an Urban Population Experiencing Barriers to Care

Mobile phone-based engagement approaches provide potential platforms for improving access to primary healthcare (PHC) services for underserved populations. We held two focus groups (February 2020) with residents (n = 25) from a low-income urban neighbourhood (downtown Vancouver, Canada), to assess recent healthcare experiences and elicit interest in mobile phone-based healthcare engagement for underserved residents. Note-based analysis, guided by interpretative description, was used to explore emerging themes. Engagement in PHC was complicated by multiple, intersecting personal-level and socio-structural factors, and experiences of stigma and discrimination from care providers. Perceived inadequacy of PHC services and pervasive discrimination reported by participants indicate a significant and ongoing need to improve client-provider relationships to address unmet health needs. Mobile phone-based engagement was endorsed, highlighting phone ownership and client-provider text-messaging, facilitated by non-clinical staff such as peers, as helpful to strengthening retention and facilitating care team connection. Concerns raised included reliability, cost, and technology and language accessibility.

The relevance of communal altruism for sexual minority men in contemporary contexts

There are many reasons why individuals engage in prosocial behavior; communal sexual altruism is based on the notion that some practice safer sex in the interest of promoting the well-being of their community/in-group. Given that definitions of what constitutes "safer sex" have changed with advances in human immunodeficiency virus (HIV) prevention, we investigated the importance of communal sexual altruism (herein "altruism") among urban gay, bisexual, and other sexual minority men (GBM) in the contemporary context. Using a sample of 2449 GBM we examined the association of both safer-sex-related attitudes (e.g., HIV treatment optimism-skepticism) and behaviors (e.g., condomless anal sex [CAS]) with altruism scores. Higher altruism scores were associated with a lower likelihood of CAS and a greater frequency of discussing HIV status with new partners. These findings demonstrate that many GBM are motivated to engage in several kinds of behaviors that improve the well-being of their in-group (i.e., the GBM community).

Factors associated with improvements in symptoms of anxiety and depression among gay, bisexual and other men who have sex with men (gbMSM) in Vancouver, Canada: A prospective cohort study

BACKGROUND

Depression and anxiety are commonly experienced among gay, bisexual and other men-who-have-sex-with-men (gbMSM). We explored factors associated with improvements in mental health symptoms among gbMSM with abnormal depression and anxiety scores over a period of four years, in Vancouver, Canada.

METHODS

Sexually active gbMSM ≥16 years of age were recruited using respondent-driven sampling from February 2012 to February 2015. Participants completed a computer-assisted questionnaire which included the Hospital Anxiety and Depression Scale (HADS), and psychometric scales to measure loneliness, self-esteem and social connectedness, every 6 months until July 2019. Generalized linear mixed models were used to assess factors associated with normal/borderline HADS scores (<11) following a previous abnormal score (≥11) for each of anxiety and depression subscales.

RESULTS

We recruited 694 participants, of whom 580 had at least one follow-up visit. Across all visits, 43.6 % of participants ever had abnormal anxiety scores and 16.2 % ever had abnormal depression scores. Among those with abnormal anxiety scores, 34.9 % of follow-up visits demonstrated reductions in anxiety scores. Among those with abnormal depression scores 51.0 % of follow-up visits demonstrated reductions in depression scores. Reductions in anxiety scores were associated with increased self-esteem, decreased loneliness and the number of gbMSM seen/spoken to in the previous month. Reductions in depression scores were associated with increased self-esteem, decreased loneliness and having a regular partner.

CONCLUSION

Improvements in mental health symptoms were frequently observed. Social connectedness was related with improved anxiety and depression symptoms. Interventions to improve social connectedness may help to improve mental health for gbMSM.

Examining the impacts of a syphilis awareness campaign among gay, bisexual, and other men who have sex with men (gbMSM) in British Columbia, Canada

OBJECTIVES

Syphilis rates have increased in BC and disproportionately affect gay, bisexual, and other men who have sex with men (gbMSM). A social marketing campaign (Syphistory) ran from January to September 2017 with the primary goal of increasing syphilis knowledge and a secondary goal of increasing syphilis screening among gbMSM in BC.

METHODS

We used pre- and post-campaign surveys to assess changes in syphilis knowledge from a convenience sample of clients attending STI clinics using one-sided t-tests. We used online Piwik metrics to examine the campaign reach, and provincial testing data to examine trends in syphilis screening. We used data from the Engage Study to examine factors associated with campaign awareness and associations with syphilis testing.

RESULTS

Of the 2155 visitors to the Syphistory website with known geography, 79.4% were from BC. Moreover, STI clinic participants who saw the campaign demonstrated a greater knowledge of syphilis (9.7/12, 80.8%) than those who did not see the campaign (mean 8.9/12, 74%) (p < 0.001). Provincial syphilis testing rates were 8764 and 9749 in the 12 months before and after the campaign; however, we did not find an overall trend in testing before versus after the campaign (p = 0.147). Among Engage participants, 12.7% reported seeing the campaign and we found an association between campaign exposure and recent syphilis testing (aOR = 2.73; 95% CI = 1.51, 4.93).

CONCLUSION

gbMSM who saw the campaign were more likely to report being tested for syphilis in the previous 6 months. STI clinic attendees who reported seeing the campaign also had higher syphilis knowledge compared to those who did not.

Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver

This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.

Examining Associations Between Resilience and PrEP Use Among HIV-negative GBM in Toronto, Montreal and Vancouver

This study evaluated the association between resilience and PrEP use among a population-based sample of Canadian gay, bisexual, and other men who have sex with men (GBM). Sexually active GBM aged ≥ 16 years old were recruited via respondent-driven sampling (RDS) in Toronto, Montreal, and Vancouver from 02/2017 to 07/2019. We conducted a pooled cross-sectional analysis of HIV-negative/unknown GBM who met clinical eligibility for PrEP. We performed multivariable RDS-II-weighted logistic regression to assess the association between scores on the Connor-Davidson Resilience-2 Scale and PrEP. Mediation analyses with weighted logistic and linear regression were used to assess whether the relationship between minority stressors and PrEP use was mediated by resilience. Of 1167 PrEP-eligible GBM, 317 (27%) indicated they took PrEP in the past six months. Our multivariable model found higher resilience scores were associated with greater odds of PrEP use in the past six months (aOR = 1.13, 95%CI = 1.00, 1.28). We found that resilience reduced the effect of the association between heterosexist discrimination and PrEP use. Resilience also mediated the relationship between internalized homonegativity and PrEP use and mediated the effect of the association between LGBI acceptance concern and PrEP use. Overall, PrEP-eligible GBM with higher resilience scores had a greater odds of PrEP use in the past six months. We also found mixed results for the mediating role of resilience between minority stress and PrEP use. These findings underline the continued importance of strength-based factors in HIV prevention.

Self-reported Human Papillomavirus Vaccination and Vaccine Effectiveness Among Men Who Have Sex with Men: A Quantitative Bias Analysis

BACKGROUND

Self-report of human papillomavirus (HPV) vaccination has ~80-90% sensitivity and ~75-85% specificity. We measured the effect of nondifferential exposure misclassification associated with self-reported vaccination on vaccine effectiveness (VE) estimates.

METHODS

Between 2017-2019, we recruited sexually active gay, bisexual, and other men who have sex with men aged 16-30 years in Canada. VE was derived as 1-prevalence ratio × 100% for prevalent anal HPV infection comparing vaccinated (≥1 dose) to unvaccinated men using a multivariable modified Poisson regression. We conducted a multidimensional and probabilistic quantitative bias analysis to correct VE estimates.

RESULTS

Bias-corrected VE estimates were relatively stable across sensitivity values but differed from the uncorrected estimate at lower values of specificity. The median adjusted VE was 27% (2.5-97.5th simulation interval = -5-49%) in the uncorrected analysis, increasing to 39% (2.5-97.5th simulation interval = 2-65%) in the bias-corrected analysis.

CONCLUSION

A large proportion of participants erroneously reporting HPV vaccination would be required to meaningfully change VE estimates.

Treatment interruptions and community connectedness among gbMSM living with HIV in Metro Vancouver, Canada

HIV treatment interruptions are a major public health concern that demonstrate a lack of engagement in care and is detrimental to the health of people living with HIV. Community connectedness have demonstrated a protective effect for psychosocial health but are not well understood for HIV treatment outcomes. We explored associations between community connectedness and treatment interruptions among gay, bisexual and other men who have sex with men (gbMSM) living with HIV in Vancouver, British Columbia. We analyzed survey data from the Momentum Health Study and identified treatment interruptions through data linkages with the provincial HIV Drug Treatment Program as episodes lasting more than 60 days beyond an expected antiretroviral therapy refill date from February 2012 to July 2019. We built a mixed-effects logistic regression model, adjusting for confounders. Of 213 gbMSM living with HIV, 54 experienced treatment interruption (25.4%) over a median five-year follow-up. Multivariable results found the number gbMSM who spoken to in the past month (aOR = 0.995; 95% CI = 0.991, 1.000 (per 100-unit increase)) and attending a gay community meeting more than once per month (aOR = 0.32; 95% CI = 0.11, 0.89) were associated with lower odds of treatment interruptions. These results highlight the importance of social connections in facilitating effective HIV care.

Crystal methamphetamine use and bacterial sexually transmitted infections (STIs) among gay, bisexual and other sexual minority men in Canada

OBJECTIVE

While crystal methamphetamine use by gay, bisexual, and other men who have sex with men (GBM) is associated with increased risk for sexually transmitted infection (STI) transmission, less is understood about the causal pathways between crystal methamphetamine use and STIs. We examined whether the association between greater crystal methamphetamine risk and prevalent bacterial STI diagnosis among GBM was mediated by two types of attitudinal variables: attitudes toward condoms, and sexual escape motives, defined as the use of substances to escape self-awareness during sex, and by sexual behaviors.

METHODS

We used computer-assisted self-interview questionnaires from 2449 sexually active GBM (18% living with HIV; median age = 33, interquartile range, 27-45) recruited via respondent-driven sampling in Vancouver, Toronto, and Montreal, Canada. Using the baseline data from the Engage cohort study, we fit a series of structural mediation models of the associations between greater crystal methamphetamine risk and bacterial STI (syphilis, gonorrhea, and chlamydia) diagnosis. We estimated indirect paths from greater crystal methamphetamine risk, attitudes toward condoms, sexual escape motives, and sexual risk behaviors, adjusting for self-reported demographic variables.

RESULTS

In the mediated model, the direct association between greater crystal methamphetamine risk and bacterial STI diagnosis was non-significant; however, five indirect paths were significant. Greater crystal methamphetamine risk was associated with bacterial STIs via condom use attitudes and escape motives, which in turn were associated with number of male anal sex partners, condomless anal sex, and oral sex.

DISCUSSION

Public health and counselling interventions for GBM who use crystal methamphetamine and who are at higher risk for STIs should target evidence-based causal paths that consider sexual attitudes and sexual practices.

HIV incidence and related risks among gay, bisexual, and other men who have sex with men in Montreal, Toronto, and Vancouver: Informing blood donor selection criteria in Canada

BACKGROUND

An individualized behavior-based selection approach has potential to allow for a more equitable blood donor eligibility process. We collected biological and behavioral data from urban gay, bisexual, and other men who have sex with men (GBM) to inform the use of this approach in Canada.

STUDY DESIGN AND METHODS

Engage is a closed prospective cohort of sexually active GBM, aged 16+ years, recruited via respondent-driven-sampling (RDS) in Montreal, Toronto, and Vancouver, Canada. Participants completed a questionnaire on behaviors (past 6 months) and tested for HIV and sexually transmitted and blood-borne infections at each visit. Rate ratios for HIV infection and predictive values for blood donation eligibility criteria were estimated by RDS-adjusted Poisson regression.

RESULTS

Data on 2008 (study visits 2017-02 to 2021-08) HIV-negative participants were used. The HIV incidence rate for the three cities was 0.4|100 person-years [95%CI:0.3, 0.6]. HIV seroconversion was associated with age <30 years: adjusted rate ratio (aRR) 9.1 [95%CI:3.2, 26.2], 6-10 and >10 anal sex partners versus 1-6 aRR: 5.3 [2.1,13.5] and 8.4 [3.4, 20.9], and use of crystal methamphetamine during sex: 4.2 [1.5, 11.6]. Applying the combined selection criteria: drug injection, ≥2 anal sex partners, and a new anal sex partner, detected all participants who seroconverted (100% sensitivity, 100% negative predictive value), and would defer 63% of study participants from donating.

CONCLUSION

Using three screening questions regarding drug injection and sexual behaviors in the past 6 months would correctly identify potential GBM donors at high risk of having recently contracted HIV. Doing so would reduce the proportion of deferred sexually active GBM by one-third.

Examining provincial PrEP coverage and characterizing PrEP awareness and use among gay, bisexual and other men who have sex with men in Vancouver, Toronto and Montreal, 2017-2020

INTRODUCTION

Accessibility of pre-exposure prophylaxis (PrEP) in Canada remains complex as publicly funded coverage and delivery differs by province. In January 2018, PrEP became publicly funded and free of charge in British Columbia (BC), whereas PrEP coverage in Ontario and Montreal is more limited and may require out-of-pocket costs. We examined differences over time in PrEP uptake and assessed factors associated with PrEP awareness and use.

METHODS

Gay, bisexual and other men who have sex with men (GBM) were recruited through respondent-driven sampling (RDS) in Toronto, Vancouver and Montreal, Canada, in a prospective biobehavioural cohort study. We applied generalized estimating equations with hierarchical data (RDS chain, participant, visit) to examine temporal trends of PrEP use and correlates of PrEP awareness and use from 2017 to 2020 among self-reported HIV-negative/unknown GBM.

RESULTS

Of 2008 self-identified HIV-negative/unknown GBM at baseline, 5093 study visits were completed from February 2017 to March 2020. At baseline, overall PrEP awareness was 88% and overall PrEP use was 22.5%. During our study period, we found PrEP use increased in all cities (all p<0.001): Montreal 14.2% during the first time period to 39.3% during the last time period (p<0.001), Toronto 21.4-31.4% (p<0.001) and Vancouver 21.7-59.5% (p<0.001). Across the study period, more Vancouver GBM used PrEP than Montreal GBM (aOR = 2.05, 95% CI = 1.60-2.63), with no significant difference between Toronto and Montreal GBM (aOR = 0.90, 95% CI = 0.68-1.18).

CONCLUSIONS

Full free-of-charge public funding for PrEP in BC likely contributed to differences in PrEP awareness and use. Increasing public funding for PrEP will improve accessibility and uptake among GBM most at risk of HIV.

Virological suppression among gay, bisexual, and other men who have sex with men living with HIV in Vancouver, Canada: A longitudinal cohort study from 2012-2017

INTRODUCTION

In 2010, British Columbia (BC) implemented HIV Treatment as Prevention (TasP) as policy. We examined trends in virologic suppression and determinants of significant viremia among a prospective biobehavioural cohort of men who have sex with men (gbMSM) in Vancouver from 2012-2017.

METHODS

Respondent-driven sampling was used to recruit sexually active gbMSM (≥16 years) who completed biannual study visits with a computer-assisted self-interview and clinical CD4 and viral load (VL) testing. We linked participant data with the BC HIV Drug Treatment Program to obtain antiretroviral dispensing and VL data. We conducted a trend analysis of VL suppression using univariable generalized estimating equation (GEE) multi-level modelling and multivariable GEE to identify factors associated with episodes of VL ≥200 copies/mL.

RESULTS

Of 774 participants, 223 were living with HIV at baseline and 16 were diagnosed during follow-up (n = 239). We observed a significant trend towards reduced levels of unsuppressed VL (>200 copies/mL) from 22% (07/2012-12/2012) to 12% (07/2016-12/2016) (OR:0.87; 95%CI:0.83-0.91 for each 6-month period). Among those with at least one follow-up visit, (n = 178, median follow-up = 3.2 years, median age = 46.9 years), younger age (aOR:0.97; 95%CI:0.94-0.99, per year), ecstasy use (aOR:1.69; 95%CI:1.13-2.53), crystal methamphetamine use (aOR:1.71; 95%CI:1.18-2.48), seeking sex via websites (aOR:1.46; 95%CI:1.01-2.12), and lower HIV treatment optimism (aOR:0.94; 95%CI:0.90-0.97) were associated with episodes of elevated viremia.

CONCLUSIONS

During a period when TasP policy was actively promoted, we observed a significant trend towards reduced levels of unsuppressed VL. Continued efforts should promote HIV treatment optimism and engagement, especially among younger gbMSM and those who use ecstasy and crystal methamphetamine.

Phenotypic predictors of pathogenic variants in probands with hypertrophic cardiomyopathy

Introduction

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy (CM) and a leading cause of sudden cardiac death (SCD). With growing access to genetic testing, and incorporation of genetics in diagnosis and personalized management, it is critical to better understand the phenotypic predictors of pathogenic or likely pathogenic (P/LP) variants. This has implications for family screening, as well as resource planning.

Aims

To identify the phenotypic predictors of genotype positivity in HCM patients (pts).

Methods

In this retrospective single center study, 213 pts, who had undergone comprehensive HCM testing were assessed. Thirteen pts were excluded (6 – SCD, 7 – significant, non-HCM gene).

Demographic information was obtained from clinic data and each patient's LVH pattern was then classified as sigmoid, concentric, reverse or apical based on trans-thoracic echocardiogram (TTE). Pathogenicity of variants was classified according to the American College of Medical Genetics (ACMG) criteria.

Results

A total of 200 pts were included in the analysis, of which 167 had TTE undertaken in the study center, allowing for further detailed phenotype analysis. In the 200 pts, the mean age was 53.85 (SD 14.04) with 151 (75.5%) being male, 66 pts (17.5%) had an underlying diagnosis of hypertension (HTN) with an average of 1 anti-hypertensive agent (58.7%), 30 pts had a family history of SCD (17.5%), 41 pts (24.6%) had underlying atrial fibrillation, 53 pts had a history of ventricular arrhythmia (26.5%), 61 pts had an implantable defibrillator (31.8%), 3 pts had an aborted cardiac arrest (1.5%), 7 (3.5%) pts had septal myo-mectomy and 4 (1%) pts required a cardiac transplant.

A core HCM panel (17 genes) was performed in 192 pts, 6 pts had extended HCM (69 genes) and 2 pts had global CM panel (109 genes), with a yield, of LP/P in 58 (30.2%), 3 (50%) and 1 (50%) within each respective panel. No gene, including likely benign (LB) and benign (B), was identified in 98 pts (49%). MYBPC3 and MYH7 were the most frequently identified variants and 50% of pts carried a risk factor in the FHOD3 gene (Graph 1).

Sub-analysis of 167 pts with TTE showed the concentric pattern of LVH was most frequent at 31.5% (53 pts) followed by reverse, apical and sigmoid patterns. A LP/P Variant was identified in 7 (13.2%), 37 (88.1%), 4 (10.5%), 1 (2.9%) accordingly (Table 1). Younger pts, females, family history of SCD and non-HTN pts were more likely to have a LP/P variant identified. Mean IVSd, did not predict a LP/P variant identification, however low normal LVIDd and reverse LVH pattern did (p value &lt;0.001).

Conclusion

In our study assessing phenotype predictors of LP/P HCM genetic finding, younger pts, females, family history of SCD, normotensive and reverse LVH pattern on TTE positively correlated with LP/P variant identification. This study has implications for supporting better phenotype-based genetic counselling and resource usage for HCM pts.

Funding Acknowledgement

Type of funding sources: None.

Use of Gay Chatlines and Online Dating Platforms as Potential Mediators or Moderators in the Relationship Between Loneliness, Self-Rated Attractiveness and Human Immunodeficiency Virus Acquisition Risk Among Gay, Bisexual, and Other Men Who Have Sex With Men in Vancouver, Canada

BACKGROUND

Gay, bisexual, and other men who have sex with men (gbMSM) remain disproportionately affected by human immunodeficiency virus (HIV). Interaction between psychosocial factors likely plays a role in HIV acquisition risk. We aimed to analyze the association of loneliness and self-rated attractiveness with HIV acquisition risk, and determine whether these associations were mediated by gay telephone chatlines or online dating platforms.

METHODS

This cross-sectional study included HIV-negative gbMSM 16 years or older enrolled into the Momentum Health Study from February 2012 to February 2015. Loneliness, self-rated attractiveness (exposures) and use of gay chatlines or online dating platforms (mediators) were assessed through self-interviews. Human immunodeficiency virus acquisition risk (outcome) was assessed by the HIV Incidence Risk Index. Weighted logistic regression modeled the association and moderation effect between exposures and outcome. Mediation models estimated 3-way direct effect among exposures, mediators, and outcome.

RESULTS

Of 542 gbMSM, those who were lonely (adjusted odds ratio [aOR], 1.54; 95% confidence intervals [CI], 1.04-2.28) and attractive (aOR, 1.69; 95% CI, 1.04-2.76) had increased odds for HIV acquisition risk. Our moderation analysis demonstrated a heightened joint effect among lonely and attractive participants (aOR, 1.70; 95% CI, 1.08-2.65). Use of gay telephone chatlines or online dating platforms mediated 30.5% of the association between loneliness and HIV acquisition risk, but did not mediate attractiveness and HIV acquisition risk.

CONCLUSIONS

Our findings suggest that the provision of interventions focusing on mental health support and safer sex practices through gay telephone chatlines or online dating platforms is promising to help alleviate the HIV burden among gbMSM.

Hosts as Gatekeepers for North American Gay and Bisexual Men's Private Group Sex Parties

Gay and bisexual men's (GBM) group sex parties are considered HIV risk environments due to their association with concurrent sexual partners, condomless anal sex, and polysubstance use. The possibility of group sex party hosts acting as gatekeepers to minimize risks has been suggested, but remains understudied. We analyzed qualitative data from 20 in-depth interviews with North American GBM who recently attended private group sex parties to determine if hosts' actions constitute harm reduction strategies. Results showed hosts acting as gatekeepers before parties by establishing and disseminating themes and rules, screening applicants, and selecting guests. During parties hosts enforced rules and rejected uninvited guests. By their actions, hosts established a more controlled environment compared to public sex-on-premises bathhouses, and facilitated boundary play, the paradoxical behavior of simultaneously desiring risk and safety, previously noted for GBM circuit parties. Results suggest initiating education programs focusing on private group sex party hosts as gatekeepers.

Prevalence and incidence of hepatitis C infection amongst men who have sex with men in a population-based pre-exposure prophylaxis program in British Columbia, Canada

BACKGROUND

Men who have sex with men (MSM) are at risk for sexually-transmitted hepatitis C (HCV). Evidence for HCV infection in the context of pre-exposure prophylaxis (PrEP) use in North America is limited. We sought to characterize baseline HCV prevalence and incidence in MSM receiving PrEP in British Columbia (BC), Canada.

METHODS

We followed individuals in the BC PrEP program from January 2018 to August 2019. We evaluated baseline prevalence and incident seroconversions (newly positive HCV antibody). A multivariable logistic regression model was performed in MSM for factors associated with HCV prevalence at enrollment, including reported prior sexually transmitted infection (STI), HIV Incidence Risk Index for MSM score, PrEP use because of a partner living with HIV, and location of residence.

RESULTS

The median age of the cohort was 33 years, 98.3% male, with 3058 person years (PY) of follow-up. Baseline HCV prevalence was 0.82% (31/3907 MSM enrollees) and HCV incidence (n = 3) was 0.15 per 100 PY (95% confidence interval [CI] 0.03-0.45). In multivariable analysis, initiating PrEP because of a partner living with HIV (adjusted odds ratio [aOR] 5.02; 95% CI 1.87-13.47) and prior STI (aOR 2.34; 95% CI 1.04-5.24) were associated with positive HCV status.

CONCLUSIONS

Baseline HCV prevalence and incidence was low amongst MSM in a population-based PrEP program in BC, Canada. HCV was associated with bridging from populations living with HIV and evidence of a reported prior STI as a PrEP indicator condition amongst MSM. PrEP initiation may be an opportunity for linkage to HCV screening and treatment.

Evaluation of a Public Health Referral System to Re-Engage Individuals Living With HIV Who Have Interrupted Antiretroviral Therapy in British Columbia, Canada

BACKGROUND

In 2016, the British Columbia HIV/AIDS Drug Treatment Program modified its prescriber alert system for antiretroviral therapy (ART) interruptions to include referrals to regional public health nursing teams for direct outreach support for those who remain off treatment for 4 months or longer. We evaluated clinically relevant outcomes of this Re-Engagement and Engagement in Treatment for Antiretroviral Interrupted and Naïve populations (RETAIN) initiative, in comparison to previous time-periods.

METHODS

We analyzed ART interruptions triggering alerts in pre-RETAIN (July 2013-April 2016) and post-RETAIN periods (May 2016-October 2017) with follow-up continuing until October 2018. We compared the proportions of those who restarted ART and achieved viral suppression in pre-RETAIN and post-RETAIN periods and the time to ART restart using generalized estimating equations. Cox proportional hazards modelling was used to examine associations with time-to-ART-restart.

RESULTS

A total of 1805 individuals experienced ART interruptions triggering 3219 alerts; 2050 in pre-RETAIN and 1169 in post-RETAIN periods. Participants were predominantly men (74%) and had a median duration of ART of 5 years. Among persons who remained interrupted >4 months after an ART interruption alert was sent, the median time from interruption to ART re-initiation declined from 8.7 months to 7.4 months (P < 0.001) from pre-to post-RETAIN periods. Interruptions in the post-RETAIN era were associated with an increased hazard of restarting ART (adjusted hazard ratio 1.51; 95% CI: 1.34 to 1.69).

CONCLUSIONS

Public health referrals shortened the length of ART interruptions after alerts sent to prescribers had not resulted in re-engagement. Similar programs should be considered in other jurisdictions.

Analysis of Athletes Who Did Not Return to Play After Open Latarjet

Background:

The Latarjet procedure is indicated in patients with risk factors for postoperative recurrence, including collision and competitive athletes. However, the factors that prevent athletes from being able return to play (RTP) after the open Latarjet procedure are still unclear and have not been fully elucidated in the literature.

Purpose:

To evaluate patient-reported outcomes and psychological and psychosocial factors associated with athletes who did not RTP after the open Latarjet procedure compared with patients who did RTP.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a retrospective review of athletes who underwent the open Latarjet procedure and subsequently did not RTP after a minimum of 12 months. These patients were pair matched in a 2:1 ratio for age, sex, sport, and level of preoperative play with a control group who returned to play. Patients were evaluated for their psychological readiness to return to sport using the Shoulder Instability–Return to Sport after Injury (SIRSI); other measures included the visual analog scale (VAS) for pain and Subjective Shoulder Value (SSV). Multivariate regression models were used to evaluate factors affecting RTP.

Results:

Included were 35 patients in the no-RTP group and 70 patients in the RTP group. In the no-RTP group, 7 patients (20%) passed the SIRSI benchmark of 56, with a mean overall score of 41.5 ± 21.9; in the RTP group, 57 patients (81.4%) passed the SIRSI benchmark, with a mean overall score of 74.5 ± 19.8 (P < .0001 for both). Patients in the RTP group had better SSV (88.0 vs 75.7; P <.0001) and VAS pain (1.7 vs 2.9; P = .0046) scores. Of the athletes who did not return, 18 felt persistent pain/apprehension and 17 felt that it was a natural end to their career or that their lifestyle had changed. Multiple logistic regression revealed that thoughts of having to go through surgery and rehabilitation again was significantly associated with lower RTP (P < .05).

Conclusion:

Patients who did not RTP after open Latarjet exhibited poor psychological readiness to RTP and worse pain VAS and SSV scores compared with patients who did RTP.

Anal Human Papillomavirus Prevalence Among Vaccinated and Unvaccinated Gay, Bisexual, and Other Men Who Have Sex With Men in Canada

BACKGROUND

Starting in 2015, human papillomavirus (HPV) vaccine has been publicly funded for gay, bisexual, and other men who have sex with men (GBM) 26 years or younger in Canada.

METHODS

Self-identified GBM who reported having sex with another man within the past 6 months were enrolled using respondent-driven sampling (RDS) between February 2017 and August 2019 in Montreal, Toronto, and Vancouver, Canada. Men aged 16 to 30 years self-collected anal specimens for HPV-DNA testing. Prevalence was estimated using RDS-II weights. We compared the prevalence of quadrivalent (HPV-6/11/16/18) and 9-valent (HPV-6/11/16/18/31/33/45/52/58) vaccine types between GBM who self-reported HPV vaccination (≥1 dose) and those reporting no vaccination using a modified Poisson regression for binary outcomes.

RESULTS

Among 645 GBM who provided a valid anal specimen (median age, 26 years; 5.9% HIV positive), 40.3% reported receiving ≥1 dose of HPV vaccine, of whom 61.8% received 3 doses. One-quarter were infected with ≥1 quadrivalent type (crude, 25.7%; RDS weighted, 24.4%). After adjustment for potential confounders, vaccinated GBM had a 27% lower anal prevalence of quadrivalent types compared with unvaccinated GBM (adjusted prevalence ratio [aPR], 0.73; 95% confidence interval [CI], 0.54-1.00). Lower prevalence ratios were found among vaccinated participants who were vaccinated >2 years before enrollment (aPR, 0.47; 95% CI, 0.25-0.86) or received their first vaccine dose at age ≤23 years (aPR, 0.64; 95% CI, 0.42-0.99). Point estimates were similar for ≥2 or 3 doses and 9-valent types.

CONCLUSIONS

Human papillomavirus vaccination was associated with a lower anal prevalence of vaccine-preventable HPV types among young, sexually active GBM. Findings will help inform shared decision making around HPV vaccination for GBM and their healthcare providers.

Social support and HIV prevention behaviors among urban HIV-negative gay, bisexual, and other men who have sex with men

OBJECTIVE

Supportive social relationships can have direct positive effects on health and mitigate the negative impact of stressors. This study investigated the main effect of perceived social support on STI/HIV risk and prevention behaviors. The buffering effect of perceived social support on the impact of proximal minority stressors, like internalized homonegativity, was also examined on one risk behavior specifically, condomless anal sex (CAS) without HIV preexposure prophylaxis (PrEP) use.

METHOD

HIV-negative gay, bisexual, and other men who have sex with men (GBM) were recruited using respondent driven sampling from three major Canadian urban centers (n = 1,409). GBM completed measures of perceived social support, proximal minority stress, and engagement in STI/HIV risk and prevention behaviors.

RESULTS

Higher perceived social support was positively associated with a several health behaviors, including recent STI and HIV testing, discussing HIV status with prospective partners, the use of behavioral HIV-risk reduction strategies during sexual encounters, and a lower likelihood of engaging in CAS without PrEP. There was evidence of moderation as well. Among GBM with higher perceived social support, internalized homonegativity was no longer associated with increased odds of engaging in CAS without PrEP.

CONCLUSIONS

The results of the current study advance social support theory to GBM in the context of biomedical prevention, showing both evidence of both direct associations and buffering effects on STI/HIV risk and prevention behaviors. This highlights the importance of promoting social support seeking in interventions aimed at improving GBM health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A review of outcomes after operative fixation of clavicular fractures over a 10-year period—a single tertiary trauma unit experience

Background

Early definitive fixation of clavicular fractures is rising in popularity when compared with conservative management. Despite this, the relative risk of subsequent hardware removal or revision surgery is relatively undocumented in the literature. The aim of this study was to review all clavicle fractures treated operatively in a single tertiary referral trauma unit and determine the true incidence of hardware removal and revision rates among this cohort.

Methods

A retrospective electronic review was performed in a single tertiary trauma unit for all open reduction internal fixation of clavicle fractures over 10 years (2010-2019 inclusive). All patients were cross referenced for hardware removal during the same period. Patients identified as having undergone ORIF clavicle were reviewed via the National Integrated Medical Imaging System to identify the fracture pattern, fixation method, radiographic nonunion, or radiographic malunion. Age, gender, time from injury to fixation, and time from insertion to removal of hardware where relevant were also collected.

Results

Over the 10-year period from 2010 to 2019, 352 patients underwent ORIF of clavicular fractures. After application of inclusion and exclusion criteria, 346 patients (76% male and 24% female) were analyzed with a mean age of 34.46 years old (95% confidence interval [33.02-35.91]). In total, 54 (15.6%) patients underwent removal of hardware. When fracture type and fixation method were accounted for, only 11% of plate fixations for mid-shaft fractures (n = 29) were removed, whereas 76% of clavicular hook plates for distal fractures (n = 25) underwent removal (P < .001). No distal clavicle fractures treated with locking plates underwent removal (n = 23). Women were almost 3 times more likely to undergo removal of hardware than men (28.6% vs. 11.5%, P < .001). Seven patients (2%) underwent revision ORIF in the 10-year period for nonunion (n = 3), malunion (n = 2), and failure of fixation (n = 2). The mean follow-up time was 1 year (366 days) for those who underwent subsequent surgery and 5.7 years (2087 days) for those who did not.

Conclusion

Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision. Women are more likely to request plate removal. Distal locking plates are a safe alternative to hook plates for distal one-third clavicle fractures with lower reoperation rates. Newer techniques are emerging for the management of distal fractures such as tight rope fixation and locking plates which also appear to be successful.

Factors associated with transactional sex among a cohort of gay, bisexual, and other men who have sex with men in Vancouver, Canada

Background Gay, bisexual, and other men who have sex with men (GBM) who engage in transactional sex (sex in exchange for drugs, money, or goods) experience increased risk of sexually transmitted infections (STI), including HIV. This study explored additional psychosocial and health-related factors associated with transactional sex among GBM. Methods Respondent-driven sampling was used to recruit GBM in Vancouver, Canada, from 2012 to 2015, with follow up every 6months until July2019. We examined factors associated with transactional sex using multivariable three-level mixed-effects modelling. Results Among 698 GBM, 22.1% reported ever receiving drugs, money, or goods for sex. Transactional sex was more likely to be reported by GBM who were younger (<30years) and who had lower incomes, less education, and insecure housing. GBM reporting transactional sex were more likely to report substance use (i.e. crystal methamphetamine, poppers, GHB, and non-steroid injection drugs) and higher risk sexual behaviours (i.e. more sex partners, sex party attendance, and condomless anal sex with serodifferent or unknown HIV status partners); however, they were no more likely to be living with HIV or to report a recent bacterial STI diagnosis. GBM who reported higher loneliness, anxiety, and cognitive escape were also more likely to report transactional sex. Conclusions More than one-fifth of GBM in Vancouver reported transactional sex and those who did were more likely to also experience psychosocial stressors, increased substance use, and higher risk sexual behaviours. Programs which consider the interconnections of personal, social, and structural challenges faced by GBM engaging in transactional sex are necessary to support improved mental, physical, and sexual health for these men.

Chronic Hepatitis B Infection Among Preexposure Prophylaxis Users Enrolled in a Population-Based Program in British Columbia, Canada

Initiation of human immunodeficiency virus preexposure prophylaxis (PrEP) medications will also treat hepatitis B infection (HBV). The prevalence of chronic HBV was 0.86% (n=41/4760) among enrollees in a provincial PrEP program in British Columbia, Canada. Overall, 46.3% lacked follow-up HBV DNA monitoring, underscoring the need for HBV-related education for PrEP prescribers.

Variations in Sexual Behaviors by Use of Specific Substances Among Vancouver Gay, Bisexual, and Other Men Who Have Sex with Men: An Event-Level Analysis

Event-level studies measure substance use and sexual behaviors happening during a specific sexual encounter, ensuring that both variables are temporally paired. This study explored the event-level associations between a range of sexual behaviors (masturbation, anal sex, oral sex, rimming, fisting, sex toys, and group sex) and five sexualized substances (poppers, methamphetamine, GHB, ecstasy/MDMA, and ketamine) used during 11,582 sexual events reported by 762 gay, bisexual, and other men who have sex with men (GBMSM) in Vancouver, Canada. Data were obtained from a prospective cohort of GBMSM who self-reported their behaviors via computer-based questionnaires on their last sexual encounter with up to five of their most recent partners in the past six months. These clustered data were analyzed with multivariable generalized linear mixed models. Participants reported popper use in 16.1% of sexual encounters, methamphetamine in 8.6%, gamma-hydroxybutyrate (GHB) in 4.1%, ecstasy/3,4-methylenedioxymethamphetamine (MDMA) in 3.3%, and ketamine in 1.5%. Condomless receptive anal sex (25.0% of events) was associated with increased odds of using poppers, methamphetamine, GHB, and ecstasy/MDMA. Group sex (13.1% of events) and sharing sex toys (2.0% of events) were more likely with the use of all five substances. Receiving money/drugs/goods in exchange for sex (2.5% of events) was associated with increased odds of poppers, methamphetamine, GHB, and ecstasy/MDMA use. GBMSM living with HIV (29.9% of participants) had higher odds of using poppers, methamphetamine, and GHB, but lower odds of using ecstasy/MDMA. In conclusion, these event-level results suggest public health strategies are needed to address the possible negative impacts of sexualized substance use among GBMSM.

Prevalence of HIV and sexually transmitted and blood-borne infections, and related preventive and risk behaviours, among gay, bisexual and other men who have sex with men in Montreal, Toronto and Vancouver: results from the Engage Study

Objectives

The last Canadian biobehavioural surveillance study of HIV and other sexually transmitted and blood-borne infections (STBBI) among gay, bisexual and other men who have sex with men (GBM) was conducted in 2010. We designed a study to measure STBBI prevalence among GBM in metropolitan Montreal, Toronto and Vancouver and to document related preventive and risk behaviours.

Methods

The Engage Cohort Study used respondent-driven sampling (RDS) to recruit GBM who reported sex with another man in the past 6 months. At baseline, we examined recruitment characteristics of the samples, and the RDS-II-adjusted distributions of socio-demographics, laboratory-confirmed HIV and other STBBI prevalence, and related behaviours, with a focus on univariate differences among cities.

Results

A total of 2449 GBM were recruited from February 2017 to August 2019. HIV prevalence was lower in Montreal (14.2%) than in Toronto (22.2%) or Vancouver (20.4%). History of syphilis infection was similar across cities (14–16%). Vancouver had more HIV-negative/unknown participants who reported never being HIV tested (18.6%) than Toronto (12.9%) or Montreal (11.5%). Both Montreal (74.9%) and Vancouver (78.8%) had higher proportions of men who tested for another STBBI in the past 6 months than Toronto (67.4%). Vancouver had a higher proportion of men who used pre-exposure prophylaxis (PrEP) in the past 6 months (18.9%) than Toronto (11.1%) or Montreal (9.6%).

Conclusion

The three largest cities of Canada differed in HIV prevalence, STBBI testing and PrEP use among GBM. Our findings also suggest the need for scale-up of both PrEP and STI testing among GBM in Canada.

Durability of non-nucleotide reverse transcriptase inhibitor-based first-line ART regimens after 7 years of treatment in rural Uganda: A prospective cohort study

Most antiretroviral therapy (ART) programs in resource-limited settings have historically used non-nucleotide reverse transcriptase inhibitor (NNRTI)-based regimens with limited access to routine viral load (VL) testing. We examined the long-term success of these regimens in rural Uganda among participants with 1 measured suppressed VL.We conducted a prospective cohort study of participants who had been on NNRTI-based first-line regimens for ≥4 years and had a VL <1000 copies/mL at enrollment in Jinja, Uganda. We collected clinical and behavioral data every 6 months and measured VL again after 3 years. We quantified factors associated with virologic failure (VF) (VL ≥ 1000 copies/mL) using Wilcoxon Rank Sum, chi-square, and Fisher's Exact Tests.We enrolled 503 participants; 75.9% were female, the median age was 45 years, and the median duration of time on ART was 6.8 years (IQR = 6.0-7.6 years). Sixty-nine percent of participants were receiving nevirapine, lamivudine, and zidovudine regimens; 22.5% were receiving efavirenz, lamivudine, and zidovudine; and 8.6% were receiving other regimens. Of the 479 with complete follow-up data, 12 (2.5%) had VL ≥ 1000 copies/mL. VF was inversely associated with reporting never missing pills (41.7% of VFs vs 72.8% non-VFs, P = .034). There were differences in distribution of the previous ART regimens (P = .005), but no clear associations with specific regimens. There was no association between having a VL of 50 to 999 copies/mL at enrollment and later VF (P = .160).Incidence of VF among individuals receiving ART for nearly 7 years was very low in the subsequent 3 years. NNRTI-based regimens appear to be very durable among those with good initial adherence.

Use of HIV pre-exposure prophylaxis among urban Canadian gay, bisexual and other men who have sex with men: a cross-sectional analysis of the Engage cohort study

BACKGROUND

In Canada, gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by HIV. Our objective was to describe access to HIV pre-exposure prophylaxis (PrEP) and identify factors associated with not using PrEP among self-reported HIV-negative or HIV-unknown GBM.

METHODS

This was a cross-sectional analysis of the Engage study cohort. Between 2017 and 2019, sexually active GBM aged 16 years or more in Montréal, Toronto and Vancouver were recruited via respondent-driven sampling (RDS). Participation included testing for HIV and sexually transmitted and blood-borne infections, and completion of a questionnaire. We examined PrEP access using a health care services model and fit RDS-adjusted logistic regressions to determine correlates of not using PrEP among those for whom PrEP was clinically recommended and who were aware of the intervention.

RESULTS

A total of 2449 GBM were recruited, of whom 2008 were HIV-negative or HIV-unknown; 1159 (511 in Montréal, 247 in Toronto and 401 in Vancouver) met clinical recommendations for PrEP. Of the 1159, 1100 were aware of PrEP (RDS-adjusted proportion: Montréal 84.6%, Toronto 94.2%, Vancouver 92.7%), 678 had felt the need for PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 39.2%, Toronto 56.1%, Vancouver 49.0%), 406 had tried to access PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 20.6%, Toronto 33.2%, Vancouver 29.6%) and 319 had used PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 14.5%, Toronto 21.6%, Vancouver 21.8%). Not using PrEP was associated with several factors, including not feeling at high enough risk, viewing PrEP as not completely effective, not having a primary care provider and lacking medication insurance.

INTERPRETATION

Although half of GBM met clinical recommendations for PrEP, less than a quarter of them reported use. Despite high levels of awareness, a programmatic response that addresses PrEP-related perceptions and health care system barriers is needed to scale up PrEP access among GBM in Canada.

Characteristics of the HIV cascade of care and unsuppressed viral load among gay, bisexual and other men who have sex with men living with HIV across Canada's three largest cities

INTRODUCTION

Treatment as prevention strategies have been variously applied across provinces in Canada. We estimated HIV care cascade indicators and correlates of unsuppressed viral load (VL) among gay, bisexual and other men who have sex with men (GBM) recruited in Vancouver, Toronto and Montreal.

METHODS

Sexually active GBM, aged ≥16 years, were recruited through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview and tests for HIV and other sexually transmitted infections (STIs). We conducted bivariate analyses comparing RDS-adjusted proportions across cities. We used multivariable logistic regression to examine factors associated with having a measured VL ≥ 200 copies/mL with data pooled from all three cities.

RESULTS

We recruited 1179 participants in Montreal, 517 in Toronto and 753 in Vancouver. The RDS-adjusted HIV prevalence was 14.2% (95% CI 11.1 to 17.2) in Montreal, 22.1% (95% CI 12.4 to 31.8) in Toronto and 20.4% (95% CI 14.5 to 26.3) in Vancouver (p < 0.001). Of participants with confirmed HIV infection, 3.3% were previously undiagnosed in Montreal, 3.2% undiagnosed in Toronto and 0.2% in Vancouver (p = 0.154). In Montreal, 87.6% of GBM living with HIV were receiving antiretroviral therapy (ART) and 10.6% had an unsuppressed VL; in Toronto, 82.6% were receiving ART and 4.0% were unsuppressed; in Vancouver, 88.5% were receiving ART and 2.6 % were unsuppressed (p < 0.001 and 0.009 respectively). Multivariable modelling demonstrated that participants in Vancouver (adjusted odds ratio [AOR]=0.23; 95% CI 0.06 to 0.82), but not Toronto (AOR = 0.27; 95% CI 0.07 to 1.03), had lower odds of unsuppressed VL, compared to Montreal, as did older participants (AOR 0.93 per year; 95% CI 0.89 to 0.97), those at high-risk for hazardous drinking (AOR = 0.19; 95% CI 0.05 to 0.70), those with a primary care provider (AOR = 0.11; 95% CI 0.02 to 0.57), and those ever diagnosed with other STIs (AOR = 0.12; 95% CI 0.04 to 0.32).

CONCLUSIONS

GBM living in Montreal, Toronto and Vancouver are highly engaged in HIV testing and treatment and all three cities have largely achieved the 90-90-90 targets for GBM. Nevertheless, we identified disparities which can be used to identify GBM who may require additional interventions, in particular younger men and those who are without a regular primary care provider.

Longitudinal Event-Level Sexual Risk and Substance Use among Gay, Bisexual, and Other Men Who Have Sex with Men

(1) Background: Condomless anal sex and substance use are associated with STI risk among gay, bisexual, and other men who have sex with men (gbMSM). Our first study objective was to describe event-level sexual risk and substance use trends among gbMSM. Our second study objective was to describe substances associated with event-level sexual risk. (2) Methods: Data come from the Momentum Health Study in Vancouver, British Columbia and participants were recruited from 2012-2015, with follow-up until 2018. Stratified by self-reported HIV status, we used generalized estimating equations to assess trends of sexual event-level substance use and assessed interactions between substance use and time period on event-level higher risk sex defined as condomless anal sex with an HIV serodifferent or unknown status partner. (3) Results: Event-level higher risk anal sex increased across the study period among HIV-negative/unknown (baseline prevalence: 13% vs. study end prevalence: 29%) and HIV-positive gbMSM (baseline prevalence: 16% vs. study end prevalence: 38%). Among HIV-negative/unknown gbMSM, event-level erectile drug use increased, while alcohol use decreased over the study period. Overall, interactions between substance use and time on higher risk anal sex were not statistically significant, regardless of serostatus. However, we found a number of time-specific significant interactions for erectile drugs, poppers, Gamma-hydroxybutyrate (GHB), crystal methamphetamine and ecstasy/MDMA use among HIV-negative/unknown gbMSM. (4) Conclusion: Significant differences in substance use trends and associated risks exist and are varied among gbMSM by serostatus. These findings provide a more comprehensive understanding of the effects of event-level substance use on sexual risk through longitudinal follow-up of nearly six years.

Gender disparities operate in opposite directions for hospitalizations and mortality among individuals receiving long-term ART in rural Uganda

OBJECTIVES

We conducted an analysis to determine if differences in health-seeking behaviour can explain gender disparities in mortality among long-term survivors receiving antiretroviral therapy (ART) in rural Uganda.

METHODS

From June 2012 to January 2014, we enrolled patients receiving a first-line ART regimen for at least 4 years without previous viral load (VL) testing in Jinja, Uganda. We measured HIV VL at study entry. We switched participants to second-line therapy, if VL was ≥ 1000 copies/mL on two measurements, and followed participants for 3 years. We collected clinical and behavioural data at enrolment and every 6 months after that. We used Poisson regression to examine factors associated with hospitalizations and Cox proportional hazards modelling to assess mortality to September 2016.

RESULTS

We enrolled 616 participants (75.3% female), with a median age of 44 years and a median duration of ART use of 6 years. Of these, 113 (18.3%) had VLs ≥ 1000 copies/mL. Hospitalizations occurred in 101 participants (7% of men vs. 20% of women; P < 0.001). A total of 22 (3.6%) deaths occurred, 9% of men vs. 2% of women (P < 0.001). Multivariate modelling revealed that mortality was associated with age [adjusted hazard ratio (AHR) = 1.07 per year increase; 95% confidence interval (CI): 1.01-1.13], male gender (AHR = 2.57; 95% CI 1.06-6.23) and time-updated CD4 counts (AHR = 0.67 per 100 cell increment; 95% CI: 0.52-0.88). Virological failure was not associated with mortality (P = 0.762).

CONCLUSION

Female patients receiving ART in rural Uganda were three times more likely to be hospitalized than men, but male mortality was nearly four times higher. Facilitating care for acute medical problems may help to improve survival among male ART patients.

Combination HIV Prevention Strategies Among Montreal Gay, Bisexual, and Other Men Who Have Sex with Men in the PrEP Era: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) became publicly available in Quebec for gay, bisexual and other men who have sex with men (GBM) in 2013. We used baseline data from Engage, a cohort of GBM recruited by respondent-driven sampling, to examine patterns of combination HIV prevention use among Montreal GBM since PrEP became available. Latent class analysis, stratified by HIV status, was used to categorize GBM by self-reported use of biomedical and behavioural prevention strategies. Correlates of resulting classes were identified using multinomial logistic regression. Among HIV-negative/unknown GBM (n = 968), we identified four classes: low use of prevention (32%), condoms (40%), seroadaptive behaviour (21%), and biomedical (including PrEP; 7%). Those using prevention (condoms, seroadaptive behaviour, and biomedical) had a higher number of anal sex partners and were more likely to report a recent sexually transmitted infection diagnosis. GBM using biomedical prevention also had a higher level of formal education. Among GBM living with HIV (n = 200), we identified three classes: mainly antiretroviral treatment (ART) with viral suppression (53%), ART with viral suppression and condoms (19%), and ART with viral suppression and seroadaptive behaviour (18%). Again, the number of anal sex partners was higher among those using condoms and seroadaptive behaviours. Our findings show antiretroviral-based prevention, either alone or in combination with other strategies, is clearly a component of the HIV prevention landscape for GBM in Montreal. Nevertheless, PrEP uptake remains low, and there is a need to promote its availability more widely.

High Sensitivity Protein Gel Electrophoresis Label Compatible with Mass-Spectrometry

Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) is a widely utilized technique for macromolecule and protein analysis. While multiple methods exist to visualize the separated protein bands on gels, one of most popular methods of staining the proteins is with Coomassie dye. A more recent approach is to use Bio-Rad stain-free technology for visualizing protein bands with UV light and achieve similar or greater sensitivity than that of Coomassie dye. Here, we developed a method to further amplify the sensitivity of stain-free gels using carboxyfluorescein succinimidyl ester (CFSE) staining. We compared our novel method using foetal bovine serum samples with Coomassie dye, standard stain-free gels, and silver staining. Our results show that while silver staining remains a gold-standard method in terms of sensitivity; CFSE staining of samples prior to use with stain-free gels results in a 10–100-fold increase in sensitivity over Coomassie staining and the standard stain-free method. Our method offers a sensitivity similar to that of silver staining which is compatible with downstream mass spectrometry, and therefore more advantageous for further retrieval and analysis of macromolecules in bands.

Current practices in the management of anterior glenohumeral instability in rugby union players

BACKGROUND

Rugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices.

METHODS

A survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test.

RESULTS

Ninety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p < 0.05), but not recurrent dislocation (p > 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p < 0.05), but not following conservative treatment or the Latarjet procedure (p > 0.05).

CONCLUSIONS

There remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety.

LEVEL OF EVIDENCE

Level 4 (case series).

Managing a National Intrathecal Pump Service During the COVID-19 Pandemic

Objective

The healthcare and social disruption caused by the COVID-19 pandemic could pose significant risk to patients with intrathecal pump (ITP) who may miss refill or replacement appointments. In some cases, this could be life-threatening. We designed and piloted a novel refill protocol to assess its efficacy and safety.

Materials and Methods

Screening of our ITP database for patients most at risk of harm was conducted. These patients were risk-assessed for COVID-19 infection and were enrolled in a protocol to optimize the safety and efficiency of their pump replacement or refill.

Results

Of note, 31 of 51 database patients were deemed to be high risk of ITP failure during the pandemic. Thirty patients were successfully refilled with only one patient refusing to leave their house for refill. There were no significant adverse outcomes.

Conclusion

Our protocol offers a safe and efficient pathway for ITP management during a pandemic.