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Using cross-sectional survey data (Engage, 2017–2018) from 1,137 men who have sex with men, ≥16 years old, in Montreal, we compared observed human immunodeficiency virus (HIV) seroconcordance in previous-6-months' sexual partnerships with what would have been observed by chance if zero individuals serosorted. Of 5 recent partnerships where both individuals were HIV-negative, we compared observed concordance in preexposure prophylaxis (PrEP) use with the counterfactual if zero individuals selected partners based on PrEP use. We estimated the concordance by chance using a balancing-partnerships approach assuming proportionate mixing. HIV-positive respondents had a higher proportion of HIV-positive partners (66.4%, 95% confidence interval (CI): 64.0, 68.6) than by chance (23.9%, 95% CI: 23.1, 24.7). HIV-negative respondents (both on and not on PrEP) had higher proportions of HIV-negative partners (82.9% (95% CI: 81.1, 84.7) and 90.7% (95% CI: 89.6, 91.7), respectively) compared with by chance (76.1%, 95% CI: 75.3, 76.9); however, those on PrEP had a higher proportion of HIV-positive partners than those not on PrEP (17.1% (95% CI: 15.3, 18.9) vs. 9.3% (95% CI: 8.3, 10.4). Those on PrEP also had a higher proportion of partners on PrEP among their HIV-negative partners (50.6%, 95% CI: 42.5, 58.8) than by chance (28.5%, 95% CI: 27.5, 29.4). The relationship between PrEP and sexual-mixing patterns demonstrated by less population-level serosorting among those on PrEP and PrEP-matching warrants consideration during PrEP roll-out. [ABSTRACT FROM AUTHOR]

Background: The HIV cascade is an important framework for assessing systems of care, but population-based assessment is lacking for most jurisdictions worldwide. We measured cascade indicators over time in a population-based cohort of diagnosed people living with HIV (PLWH) in Ontario, Canada. Methods: We created a retrospective cohort of diagnosed PLWH using a centralized laboratory database with HIV diagnostic and viral load (VL) test records linked at the individual-level. Individuals enter the cohort with record of a nominal HIV-positive diagnostic test or VL test, and remain unless administratively lost to follow-up (LTFU, >2 consecutive years with no VL test and no VL test in later years). We calculated the annual percent of diagnosed PLWH (cohort individuals not LTFU) between 2000 and 2015 who were in care (≥1 VL test), on ART (as documented on VL test requisition) or virally suppressed (<200 copies/ml). We also calculated time from diagnosis to linkage to care and viral suppression among individuals newly diagnosed with HIV. Analyses were stratified by sex and age. Upper/lower bounds were calculated using alternative indicator definitions. Results: The number of diagnosed PLWH increased from 8,859 (8,859–11,389) in 2000 to 16,110 (16,110–17,423) in 2015. Over this 16-year period, the percent of diagnosed PLWH who were: in care increased from 81% (63–81%) to 87% (81–87%), on ART increased from 55% (34–60%) to 81% (70–82%) and virally suppressed increased from 41% (23–46%) to 80% (67–81%). Between 2000 and 2014, the percent of newly diagnosed individuals who linked to care within three months of diagnosis or achieved viral suppression within six months of diagnosis increased from 67% to 82% and from 22% to 42%, respectively. Estimates were generally lower for females and younger individuals. Discussion: HIV cascade indicators among diagnosed PLWH in Ontario improved between 2000 and 2015, but gaps still remain—particularly for younger individuals. [ABSTRACT FROM AUTHOR]

Cervical cancer caused by oncogenic types of the human papillomavirus (HPV) is of concern among HIV-positive women due to impairment of immune responses required to control HPV infection. Our objectives were to describe patterns of cervical cancer screening using Pap cytology testing among HIV-positive women in Ontario, Canada from 2008 to 2013 and to identify factors associated with adequate screening. We conducted a retrospective, population-based cohort study among screen-eligible HIV-positive women using provincial administrative health data. We estimated annual proportions tested and reported these with 95% confidence intervals (CI). Next, using person-years as the unit of analysis, we identified factors associated with annual Pap testing using log-binomial regression. A total of 2271 women were followed over 10,697 person-years. In 2008, 34.0% (95%CI 31.1-37.0%) had a Pap test. By 2013, the proportion of HIV-positive women tested was 25.9% (95%CI 23.6-28.2%). Women who were most likely to undergo testing were younger, were immigrants from countries with generalized HIV epidemics, lived in the highest income neighbourhoods, had a female primary care physician, had two or more encounters per year with an infectious disease or internal medicine specialist, and had greater comorbidity. Nearly three in four HIV-positive women were under-screened despite all having universal insurance for medically-necessary services. Annual Pap testing decreased following the 2011-2013 release of new guidelines for a lengthened screen interval for average risk women and a billing disincentive. Clinic-based intervention such as physician alerts or reminders may be needed to improve screening coverage among HIV-positive women. [ABSTRACT FROM AUTHOR]

Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients’ median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues. [ABSTRACT FROM PUBLISHER]

Background: Detection of human papillomavirus (HPV) DNA in genital samples may not always represent true infections but may be depositions from infected sexual partners. We examined whether sexual risk factors and a biomarker (Y chromosome DNA) were associated with genital HPV partner concordance and estimated the fraction of HPV detections potentially attributable to partner deposition.Methods: The HITCH study enrolled young women attending a university or college in Montréal, Canada, and their male partners, from 2005 to 2010. We tested baseline genital samples for Y chromosome DNA and HPV DNA using polymerase chain reaction.Results: Type-specific HPV concordance was 42.4% in partnerships where at least one partner was HPV DNA positive. Y chromosome DNA predicted type-specific HPV concordance in univariate analyses, but in multivariable models the independent predictors of concordance were days since last vaginal sex (26.5% higher concordance 0-1 vs 8-14 days after last vaginal sex) and condom use (22.6% higher concordance in never vs always users). We estimated that 14.1% (95% confidence interval [CI], 6.3-21.9%) of HPV DNA detections in genital samples were attributable to vaginal sex in the past week.Conclusions: A substantial proportion of HPV DNA detections may be depositions due to recent unprotected vaginal sex. [ABSTRACT FROM AUTHOR]

Background: The risk of anal cancer due to high-risk human papillomavirus (HR-HPV) is higher in women living with human immunodeficiency virus (HIV) than in the general population. We present findings of cervical and anal HPV and cytologic tests at baseline in the EVVA cohort study and HPV persistence data 6 months after baseline.Methods: Semiannual visits included questionnaires, chart reviews, cervical/anal cytologic and cervical/anal HPV testing for 2 years. Genotyping for 36 HPV genotypes was performed using the Roche Linear Array HPV genotyping test.Results: A total of 151 women living with HIV were recruited. At baseline, 75% had anal HPV, 51% had anal HR-HPV, 50% had cervical HPV, and 29% had cervical HR-HPV. Anal HPV-16 and HPV-51 were more frequent in women born in Canada (31% and 29%, respectively, compared with ≤16% for other women). Most anal HR-HPV types detected at 6 months (57%-93%) were persistent from baseline. Findings of anal cytologic tests were abnormal for 37% of women.Conclusions: Anal HPV is highly prevalent in women living with HIV, and type distribution varies by place of birth. High-resolution anoscopy was indicated in more than one third of results. As anal cancer is potentially preventable, these important findings need to be considered when selecting the best approach for anal cancer screening programs. [ABSTRACT FROM AUTHOR]

Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests. For participants interviewed in 2009, we used three-category multinomial logistic regression to identify predictors of retention in 2010-2012, defined as (1) continuous care (=2 viral loads =90 days in all years; reference category); (2) discontinuous care (only 1 viral load/year in =1 year); and (3) a gap in care (=1 year in 2010-2012 with no viral load). In total, 1838 participants were included. In 2010-2012, 71.7% had continuous care, 20.9% had discontinuous care, and 7.5% had a gap in care. Discontinuous care in 2009 was predictive (p < .0001) of future retention. SDH associated with discontinuous care were Indigenous ethnicity, being born in Canada, being employed, reporting hazardous drinking, and non-injection drug use. Being a heterosexual male was associated with having a gap in care, and being single and younger were associated with discontinuous care and a gap in care. Various SDH were associated with retention. Care discontinuity was highly predictive of future gaps. Targeted strategic interventions that better engage those at risk of suboptimal retention merit exploration. [ABSTRACT FROM AUTHOR]

In Ontario, Canada, the number of heterosexual men living with HIV has increased over time, yet they remain an understudied population. The study objective was to describe the sociodemographic and clinical characteristics of this population, using data from a multisite clinical cohort of patients receiving HIV care. Sociodemographic and clinical characteristics of men interviewed between 2010 and 2012 were compared according to their self-identified sexual orientation, followed by multivariable linear and logistic regression to assess the association of sexual orientation with CD4 cell count, viral load, hepatitis C co-infection, self-rated health, and mental health concerns after adjustment for covariates. A total of 552 men identified as heterosexual, 2,023 as gay, and 171 as bisexual. Compared to gay and bisexual men, heterosexual men were more likely to have been born outside of Canada (34.8%); more likely to report African, Caribbean, or Black ethnicity (26.4%) or Indigenous ethnicity (13.6%); and more likely to have low socioeconomic status (59.5% earning less than $20,000 per year), and/or a history of injection drug use (31.7%). Relative to gay men, heterosexual men had 5.19 times the odds of co-infection with hepatitis C virus regardless of injection drug use history (95% confidence interval = 3.87-6.96), and 40% lower odds of rating their health as excellent or good (95% confidence interval = 0.50-0.84). HIV-positive heterosexual men in Ontario constituted a socially marginalized group characterized by a high prevalence of injection drug use history and hepatitis C co-infection. [ABSTRACT FROM AUTHOR]

Understanding the sexual activities and partnerships of women living with human immunodeficiency virus (HIV) remains important to promote healthy sexuality and to reduce the transmission of HIV and other sexually transmitted infections. We described sexual behaviors of women living with HIV enrolled in an ongoing study in Ontario, Canada. Data were available from 582 women who self-completed a sexual behavior questionnaire between 2010 and 2012. Nearly half (46.1%) of women reported a sexual partner in the preceding three months; women less likely to be sexually active were older, Black/African, separated, divorced, widowed, single, and unemployed. Most sexually active women had one partner (76.4%), a regular partner (75.9%), male (96.2%) partner(s), and partners who were HIV-negative or unknown HIV status (75.2%). Women were more likely to use a condom with HIV-negative/status unknown partners (81.3%) than with HIV-positive partners (58.6%;p = .008). Only 8.0% of sexually active women reported condomless sex with a discordant HIV-negative/status unknown partner when their viral load was detectable. Overall, most women living with HIV were sexually inactive or engaged in sexual activities that were low risk for HIV transmission. [ABSTRACT FROM PUBLISHER]

Background: Atazanavir/ritonavir and darunavir/ritonavir are common protease inhibitor-based regimens for treating patients with HIV. Studies comparing these drugs in clinical practice are lacking.Methods: We conducted a retrospective cohort study of antiretroviral naïve participants in the Canadian Observational Cohort (CANOC) collaboration initiating atazanavir/ritonavir- or darunavir/ritonavir-based treatment. We used separate Fine and Gray competing risk regression models to compare times to regimen failure (composite of virologic failure or discontinuation for any reason). Additional endpoints included virologic failure, discontinuation due to virologic failure, discontinuation for other reasons, and virologic suppression.Results: We studied 222 patients treated with darunavir/ritonavir and 1791 patients treated with atazanavir/ritonavir. Following multivariable adjustment, there was no difference between darunavir/ritonavir and atazanavir-ritonavir in the risk of regimen failure (adjusted hazard ratio 0.76, 95% CI 0.56 to 1.03) Darunavir/ritonavir-treated patients were at lower risk of virologic failure relative to atazanavir/ritonavir treated patients (aHR 0.50, 95% CI 0.28 to 0.91), findings driven largely by high rates of virologic failure among atazanavir/ritonavir-treated patients in the province of British Columbia. Of 108 discontinuations due to virologic failure, all occurred in patients starting atazanavir/ritonavir. There was no difference between regimens in time to discontinuation for reasons other than virologic failure (aHR 0.93; 95% CI 0.65 to 1.33) or virologic suppression (aHR 0.99, 95% CI 0.82 to 1.21).Conclusions: The risk of regimen failure was similar between patients treated with darunavir/ritonavir and atazanavir/ritonavir. Although darunavir/ritonavir was associated with a lower risk of virologic failure relative to atazanavir/ritonavir, this difference varied substantially by Canadian province and likely reflects regional variation in prescribing practices and patient characteristics. [ABSTRACT FROM AUTHOR]

Background: Combination antiretroviral therapy (cART) has reduced mortality from AIDS-related illnesses and chronic comorbidities have become prevalent among HIV-infected patients. We examined the association between hepatitis C virus (HCV) co-infection and chronic kidney disease (CKD) among patients initiating modern antiretroviral therapy.Methods: Data were obtained from the Canadian HIV Observational Cohort for individuals initiating cART from 2000 to 2012. Incident CKD was defined as two consecutive serum creatinine-based estimated glomerular filtration (eGFR) measurements <60 mL/min/1.73m2 obtained ≥3 months apart. CKD incidence rates after cART initiation were compared between HCV co-infected and HIV mono-infected patients. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox regression.Results: We included 2595 HIV-infected patients with eGFR >60 mL/min/1.73m2 at cART initiation, of which 19% were HCV co-infected. One hundred and fifty patients developed CKD during 10,903 person-years of follow-up (PYFU). The CKD incidence rate was higher among co-infected than HIV mono-infected patients (26.0 per 1000 PYFU vs. 10.7 per 1000 PYFU). After adjusting for demographics, virologic parameters and traditional CKD risk factors, HCV co-infection was associated with a significantly shorter time to incident CKD (HR 1.97; 95% CI: 1.33, 2.90). Additional factors associated with incident CKD were female sex, increasing age after 40 years, lower baseline eGFR below 100 mL/min/1.73m2, increasing HIV viral load and cumulative exposure to tenofovir and lopinavir.Conclusions: HCV co-infection was associated with an increased risk of incident CKD among HIV-infected patients initiating cART. HCV-HIV co-infected patients should be monitored for kidney disease and may benefit from available HCV treatments. [ABSTRACT FROM AUTHOR]

In the modern antiretroviral (ARV) era, there is limited knowledge about the prevalence and risk factors for HIV patient-reported gastrointestinal (GI) symptoms (diarrhoea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, and weight loss/wasting) and distress. We prospectively analysed data (2007–2014) on distressing GI symptoms from the Ontario HIV Treatment Network Cohort Study, which follows people attending HIV clinics. Using generalized estimating equations with a logit link, we estimated the associations of psychosocial, demographic, behavioural, and clinical factors with each GI symptoms compared to asymptomatic and non-bothersome symptoms. Among 1532 included participants, 80.4% were male, mean age was 45 years, and 64.6% reported being men who have sex with men. Most were Caucasian (56.3%), a median time since HIV diagnosis of 9.8 years (interquartile range (IQR): 4.1–16.9), and 83.1% were on ARV. More than two-thirds (68.7% (95% confidence intervals (CI): 63.1% to 69.2%)) reported one or more symptoms with a median of 1.2 (IQR: 0–1.7). The proportion remained stable over time since HIV diagnosis and ARV initiation. Risk factors varied for multivariable models. A strong association with Centre for Epidemiologic Studies Depression scale scores of ≥23 was found for all symptoms. Adjusted odds ratios (95% CI) were 1.72 (1.39–2.12), 2.95 (2.33–3.72), 2.20 (1.81–2.68), 4.97 (3.99–6.19), and 2.98 (2.52–3.82) for diarrhoea, nausea/vomiting, bloating, loss of appetite, and weight loss, respectively. With the exception of bloating, odds were significantly lower for those on ARV containing integrase inhibitors and greater for patients reporting current cannabis use. GI symptoms in the modern ARV era are highly prevalent and may arise as a common pathway of distress in response to psychosocial vulnerabilities, regardless of the stage of diagnosis. These findings support the need for integrated approaches to address psychological and physical distress in HIV disease. [ABSTRACT FROM AUTHOR]

Background: Recent birth cohorts vaccinated against human papillomavirus (HPV) may be protected against up to 4 genotypes (HPV-6, -11, -16, and -18). If natural competition exists between these and other HPV types, then the prevalence of other types may increase after vaccination.Methods: Cohort information from 3 studies was used to compare acquisition and clearance of 30 different HPV types (individually and grouped by species), according to infection status with vaccine-targeted types at baseline and the time of the index infection, respectively. Hazard ratios (HRs) were adjusted for predictors of multiple-type infection.Results: Among 3200 females across all studies, 857 were infected with HPV at baseline, and 994 acquired new infections during follow-up. Females infected with HPV-16 were at higher risk of acquiring other α-9 HPV types (HR, 1.9; 95% confidence interval [CI], 1.2-3.0) but at similar risk of clearing existing α-9 HPV infections (HR, 0.9; 95% CI, .7-1.3). Females infected with vaccine-targeted types were generally at higher risk of acquiring additional types (HRs, > 1.0) and at equal risk of clearing existing infections. Accounting for multiple comparisons, none of the HRs of < 1.0 or >1.0 were statistically significant in our analyses of acquisition or clearance.Conclusions: Vaccine-targeted HPV types do not appear to compete with other types, suggesting that HPV type replacement is unlikely to occur. [ABSTRACT FROM AUTHOR]

ObjectivesPeople with human immunodeficiency virus (HIV) are living longer lives and like many other patients, need a health system better adapted for the management of complex chronic conditions. A key element of system transformation is measuring and reporting on system performance indicators relevant to the different stakeholders. Our objective was to produce a performance measurement framework for assessing the quality of comprehensive community-based primary healthcare for people with HIV.MethodsSemi-structured interviews were performed with HIV providers, advocates, and policy-makers to obtain input on a draft performance framework, constructed using existing HIV-specific indicators, as well as the use of performance data in improving care for people with HIV.ResultsStakeholders were overwhelmingly supportive of the framework’s comprehensiveness. Many noted the absence of indicators addressing social determinants of health and had mixed opinions on the importance of indicators addressing access to after-hours care and the frequency of routine screening for behavioural risk factors. The draft framework was modified to reflect stakeholder input, triangulated against expert opinion and recently released HIV care guidelines, and finalized at 79 indicators. The resources and infrastructure to collect and use performance data will have to be improved for performance measurement to contribute to improving care for people with HIV.ConclusionsThis framework presents a comprehensive though not exhaustive tool to support performance measurement and improvement in the care for people with HIV. However, advances in data collection and use across the system will be needed to support performance measurement driving quality improvement. [ABSTRACT FROM AUTHOR]