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Despite access to healthcare that is similar to the entire population, gay, bisexual, and other men who have sex with men (gbMSM) have worse rates for many pathologies, including sexually transmitted infections (STIs) and HIV, mental health, and substance use. To better understand the barriers to care that occur during healthcare interactions—in an effort to make recommendations to improve these clinical encounters—we engaged in focus groups with three groups of gbMSM. We explored the experiences and concerns of these men regarding healthcare. In total, we interviewed 32 men. Our findings identified that the two most pronounced barriers to delivery of comprehensive and impactful healthcare for gbMSM were (1) wariness and distrust of the healthcare system and fears of neglect and overt discrimination, and (2) a lack of knowledge among healthcare professionals about specific health concerns for MSM. Facilitators as identified by participants were (1) creating safe spaces where MSM are recognized, (2) not only developing but demonstrating an accepting and supportive therapeutic relationship with patients, and (3) attention to issues of disclosure and confidentiality. These findings highlight both ongoing issues in the delivery of healthcare for gbMSM in Canada, and tangible solutions that practitioners can implement immediately to address these problems.

Background We implemented an opt-out clinic-based intervention pairing syphilis tests with routine human immunodeficiency virus (HIV) viral load testing. The primary objective was to determine the degree to which this intervention increased the detection of early syphilis. Methods The Enhanced Syphilis Screening Among HIV-Positive Men (ESSAHM) Trial was a stepped wedge cluster-randomized controlled trial involving 4 urban HIV clinics in Ontario, Canada, from 2015 to 2017. The population was HIV-positive adult males. The intervention was standing orders for syphilis serological testing with viral loads, and control was usual practice. We obtained test results via linkage with the centralized provincial laboratory and defined cases using a standardized clinical worksheet and medical record review. We employed a generalized linear mixed model with a logit link to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the intervention. Results A total of 3895 men were followed over 7471 person-years. The mean number of syphilis tests increased from 0.53 to 2.02 tests per person per year. There were 217 new diagnoses of syphilis (control, 81; intervention, 136), for which 147 (68%) were cases of early syphilis (control, 61 [75%]; intervention, 86 [63%]). The annualized proportion with newly detected early syphilis increased from 0.009 to 0.032 with implementation of the intervention; the corresponding time-adjusted OR was 1.25 (95% CI, .71–2.20). Conclusions The implementation of standing orders for syphilis testing with HIV viral loads was feasible and increased testing, yet produced less-than-expected increases in case detection compared to past uncontrolled pre–post trials. Clinical Trials Registration NCT02019043.

High rates of cigarette smoking is the leading contributor to the increasing risk of cardiovascular disease (CVD) among people living with HIV (PLH). Relapse rates among PLH who quit smoking are high among those receiving standard care, which may be due to several unique social and psychological challenges PLH face when they attempt to quit smoking. The purpose of the current study was to examine change in relevant psychological factors in a subgroup of participants (n = 14) who remained smoke-free at 6-months follow-up in an HIV-tailored smoking cessation counselling program (N = 50). We examined self-reported depressive symptoms, attachment style and self-efficacy across 5 time points (baseline, quite date, 4, 12 and 24 weeks). At study baseline, mean depression scores fell above the clinical cut off of 16 (M = 16.31; SD = 13.53) on the Centre for Epidemiological Studies - Depression (CES-D) scale and fell below the clinical cut off at 24 weeks post quit date (M = 13.36; SD = 10.62). Results of multi-level modeling indicated a significant linear reduction in depressive symptoms and a significant linear improvement in self-efficacy to refrain from smoking across study visits. These results suggest that positive change in mood and self-efficacy may be helpful for PLH who remain smoke-free during a quit attempt.

Canadian Blood Services introduced new eligibility criteria that allows some sexually active gay, bisexual, and other men who have sex with men (gbMSM) to donate source plasma, marking a significant change from time-based deferral criteria. We aimed to identify potential barriers and enablers to implementing the new criteria from the perspective of donor center staff.We conducted Theoretical Domains Framework-informed interviews with staff from two source plasma donation centers in Canada.We completed 28 interviews between June 2020 and April 2021. Three themes representing eight domains captured key tensions. Valuing inclusive eligibility criteria: staff support inclusive criteria; many were concerned the new criteria remained discriminatory. Investing in positive donor experiences: staff wished to foster positive donor experiences; however, they worried gbMSM donors would express anger and disappointment regarding the new criteria, staff would experience unease over using stigmatizing criteria and convey nonverbal cues of discomfort, and recurring plasma donors may behave inappropriately. Supporting education, training, and transparency of eligibility criteria: participants believed providing in-person training (i.e., to explain criteria rationale, address discomfort, practice responding to donor questions) and ensuring donors and the public were well-informed of the upcoming changes would improve implementation.Participant views emphasize the importance of supporting staff through training and transparent communication to optimize the delivery of world-class equitable care for a new cohort of donors who have previously been excluded from plasma donation. Findings inform which staff supports to consider to improve implementation as policies continue to shift internationally.

Background Blood donation policy in Canada for gay, bisexual and other men who have had sex with men (gbMSM) has changed progressively in the last decade from indefinite deferral to 3-month deferral from last male-to-male sex. Driven by safety data and overseen by the national regulator, more inclusive policies continue to redress the disparity in donation for gbMSM. At the same time, the need for source plasma to prepare fractionated blood products is growing worldwide. The collection and processing of source plasma ensures greater safety compared to whole blood donation with respect to transfusion-transmitted infection. This greater safety offers an opportunity to evolve policies for gbMSM from time-based to behaviour-based deferral using revised eligibility criteria. However, changing policies does not in itself necessarily guarantee that gbMSM will donate or that staff in donor clinics are ready to support them to do so. In anticipation of a move to behaviour-based donation screening for gbMSM in Canada, we aim to assess the acceptability of and perceived barriers and enablers to source plasma donation using revised screening criteria for gbMSM among key stakeholders to inform policy implementation strategies. Methods This mixed-methods feasibility study will involve gbMSM and donor centre staff to understand modifiable barriers to implementing more inclusive eligibility criteria. Key informant interviews and surveys will be rooted in the Theoretical Domains Framework to identify modifiable factors associated with source plasma donation motives in gbMSM and training needs in donation centre staff. We will use an integrated knowledge translation approach involving a partnership between researchers, the national blood operator and gbMSM, situating knowledge users as key research team members to ensure their perspectives inform all aspects of the research. Discussion Our integrated knowledge translation approach will provide a more comprehensive and collaborative understanding of blood operator and gbMSM needs while accelerating the implementation of study findings. Given the historical backdrop of the decades of exclusion of sexually active gbMSM from blood donation, this study has the potential not only to inform a process and policy for gbMSM to donate source plasma, a blood product, but also offers opportunities for new relationships between these knowledge users.

With potential to improve patient outcomes, quality of care and cost-effectiveness, clinical research activity in community hospitals has recently begun to increase. Recognizing that establishing or strengthening a clinical research program in this setting is an important, complex and challenging undertaking, this article introduces many of the resources, best practices and success stories that community hospitals can draw upon to develop and incentivize clinical researchers, operationalize the clinical research enterprise and make clinical research impactful.

Background Human IL-32 is a polyfunctional cytokine that was initially reported to inhibit HIV-1 infection. However, recent data suggest that IL-32 may enhance HIV-1 replication by activating the HIV-1 primary targets, CD4 T-cells. Indeed, IL-32 is expressed in multiple isoforms, some of which are proinflammatory, whereas others are anti-inflammatory. Setting and methods Here, we aimed to determine the relative expression of IL-32 isoforms and to test their inflammatory nature and potential to induce HIV-1 production in latently infected cells from virologically suppressed HIV-infected individuals. IL-32 and other cytokines were quantified from plasma and supernatant of CD4 T-cells by ELISA. Transcripts of IL-32 isoforms were quantified by qRT-PCR in peripheral blood mononuclear cells. The impact of recombinant human IL-32 isoforms on HIV-1 transcription was assessed in CD4 T-cells from HIV-1cART individuals by qRT-PCR. Results All IL-32 isoforms were significantly upregulated in HIV-1cART compared to HIV individuals with IL-32β representing the dominantly expressed isoform, mainly in T-cells and NK-cells. At the functional level, although IL-32γ induced typical proinflammatory cytokines (IL-6 and IFN-γ) in TCR-activated CD4 T-cells, IL-32α showed an anti-inflammatory profile by inducing IL-10 but not IL-6 or IFN-γ. However, IL-32β showed a dual phenotype by inducing both pro- and anti-inflammatory cytokines. Interestingly, consistent with its highly pro-inflammatory nature, IL-32γ, but not IL-32α or IL-32β, induced HIV-1 production in latently infected CD4 T-cells isolated from combined antiretroviral therapy-treated individuals. Conclusions Our data report on the differential expression of IL-32 isoforms and highlight the potential role of IL-32, particularly the γ isoform, in fueling persistent inflammation and transcription of viral reservoir in HIV-1 infection.

Background Implementation of anal cancer screening requires the procedure to be acceptable to the target population. Our objective was to assess the beliefs of men living with HIV regarding anal cancer screening and identify factors associated with their willingness to participate in screening. Methods We developed a cross-sectional questionnaire using the Theory of Planned Behavior to examine beliefs regarding prevention of human papillomavirus (HPV)-related diseases, administered to men living with HIV in 2016–2017 in a multi-site HIV clinical cohort. Correspondence analysis was used to examine the interrelationships between men’s beliefs and willingness to undergo anal cancer screening. We used multivariable proportional odds models to identify factors associated with increasing willingness. Results were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Among 1677 male participants, the vast majority (90%) would be willing to undergo screening by “anal Pap test”; willingness clustered with positive beliefs (e.g. confident they can get screened; disagree that they will feel pain) in the correspondence analysis. Higher self-perceived risk for anal cancer and positive beliefs regarding screening were associated with higher willingness to be screened. Gay, bisexual and other men who have sex with men had higher willingness (aOR = 1.62; 95% CI: 1.15, 2.29) than heterosexual men. Racialized men reported lower willingness (aOR = 0.68; 95% CI: 0.54, 0.89) than white men. Conclusions Men generally had positive beliefs and were willing to undergo screening, though there were differences by sexual orientation and racial identity. Tailored community-led initiatives could focus on men’s understanding of their risk and expectations of anal cancer screening to facilitate participation.

This study aimed to evaluate markers of systemic as well as imaging markers of inflammation in the ascending aorta, bone marrow, and spleen measured by 18F-FDG PET/CT, in HIV+ patients at baseline and following therapy with rosuvastatin. Of the 35 HIV+ patients enrolled, 17 were randomized to treatment with 10 mg/day rosuvastatin and 18 to usual care for 6 months. An HIV− control cohort was selected for baseline comparison of serum inflammatory markers and monocyte markers of inflammation. 18F-FDG-PET/CT imaging of bone marrow, spleen, and thoracic aorta was performed in the HIV+ cohort at baseline and 6 months. While CD14++CD16− and CCR2 expressions were reduced, serum levels of IL-7, IL-8, and MCP-1 were elevated in the HIV+ population compared to the controls. There was a significant drop in FDG uptake in the bone marrow (TBRmax), spleen (SUVmax) and thoracic aortic (TBRmax) in the statin-treated group compared to the control group (bone marrow: − 10.3 ± 16.9% versus 5.0 ± 18.9%, p = .0262; spleen: − 9.8 ± 20.3% versus 11.3 ± 28.8%, p = .0497; thoracic aorta: − 19.1 ± 24.2% versus 4.3 ± 15.4%, p = .003). HIV+ patients had significantly markers of systemic inflammation including monocyte activation. Treatment with low-dose rosuvastatin in the HIV+ cohort significantly reduced bone marrow, spleen and thoracic aortic FDG uptake.

Background Syphilis infections have been on the rise, affecting men living with HIV in urban centres disproportionately. Since individuals in HIV care undergo routine blood testing, HIV clinics provide practical opportunities to conduct regular and frequent syphilis testing. Following the implementation of a routine syphilis testing intervention in HIV outpatient clinics, we conducted a qualitative process evaluation of patient experiences to measure patient acceptability, barriers to implementation, and facilitators of successful uptake. Methods Upon completion of the trial, which took place at four HIV outpatient clinics in Toronto and Ottawa, Canada, we recruited male patients attending these clinics from November 2017 to April 2018. Interviews were conducted on-site and were audio-recorded and transcribed verbatim. All participants provided written informed consent. Interview data were analyzed using grounded theory, assessing qualitative modulators of effective uptake of routinised syphilis testing. Results A total of 21 male patients were interviewed. Overall, interviewees found the clinical intervention acceptable, endorsing the practice of routinising syphilis testing alongside regular viral load bloodwork. Some men preferred, based on their self-assessment of syphilis risk, to opt out of testing; we considered this as a potential barrier to uptake of population-wide routinised syphilis testing. Interviewees also identified multiple facilitators of successful uptake, including the de-stigmatising of STI testing as a consequence of the universal nature of routinised testing. Participants recommended a routinised syphilis screening intervention to give patients peace of mind surrounding their sexual health. Participants identified HIV care clinics as comfortable and efficient locations to offer testing. Conclusions Overall, most men were in support of implementing routinised syphilis testing as part of standard HIV care. From the patient perspective, HIV care clinics are convenient places to be tested for syphilis, and the routine approach was viewed to have a de-stigmatisng effect on syphilis testing. Trial registration ClinicalTrials.gov NCT02019043; registered December 23, 2013.

HIV pre-exposure prophylaxis (PrEP) is an increasingly important part of the HIV prevention armamentarium. Issues with PrEP, however, include access. We propose that one way to surmount this issue would be to have nurses provide PrEP. Although clinical guidelines exist for PrEP, they are overwhelmingly not targeted to nonprescriber clinicians. In this article, we overview current U.S. and Canadian PrEP guidelines and provide explicit guidance about how nurses can provide PrEP, including the clinical pathways and medical directives we use in our clinic. We call nurse-led provision of PrEP, PrEP-RN (Pre-Exposure Prophylaxis–Registered Nurse) and feel it may be an important step forward in HIV prevention.

Background and purpose The rates of many sexually transmitted infections (STIs) have increased in recent years. Many health care professionals miss these potential diagnoses in clinical practice. Methods Two case studies are presented, one an adult female with dysuria; the other an adult male with a rash. Appropriate differential diagnoses and relevant history, examination, and investigation details are discussed. Conclusions Not all dysuria signifies a urinary tract infection. Although most rashes are not syphilis or HIV, it is important to rule out these etiologies for rashes in adults without a previous history of similar dermatologic conditions. Implications for practice Due to increased rates of many STI and HIV, it is important for nurse practitioners who work in primary care to consider these infections in patients who present with dysuria and rashes. Similarly, nurse practitioners who work in STI clinic settings should consider non-STI diagnoses in their work. In both cases, a perspective that includes both STI and non-STI etiologies is essential.

Pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP) are part of combination HIV prevention strategies that include behavioural interventions such as condoms and risk-reduction counselling. A 25-member panel was convened to develop Canadian guidelines for PrEP and nPEP, with the full guidelines recently published in the Canadian Medical Association Journal (CMAJ). This article provides a discussion beyond the guideline, highlighting areas of particular interest to infectious disease (ID) specialists and discusses the possible role of ID specialists as access to both PrEP and nPEP become more widely available across the country.

HIV pre-exposure prophylaxis (PrEP) is effective at preventing sexual acquisition of HIV, and failures in clinical trials are largely attributable to medication nonadherence. We report here a case of infection with a fully susceptible strain of HIV in an individual adherent to PrEP as demonstrated by pharmacy records and intracellular tenofovir diphosphate levels. At diagnosis, the viral load was 90 copies/mL precluding initial genotype testing due to low copy number. While PrEP failure is rare, this case underscores the importance of regular HIV testing for patient on PrEP and prompts discussion regarding the approach to treatment following failure where an initial genotype is not yet available or not possible due to low viral load. Few other case reports of PrEP failure exist in the literature and approaches to treatment varied widely. We suggest the initial viral copy number may guide next steps and discuss the risks and benefits of stopping PrEP, escalating therapy with integrase inhibitors or boosted protease inhibitors, or switching to non-nucleoside antiretroviral treatment regimens.

Early warning of infection is critical to reduce the risk of deterioration and mortality, especially in neutropenic patients following hematopoietic stem cell transplantation (HCT). Given that heart rate variability (HRV) is a sensitive and early marker for infection, and that serum inflammatory biomarkers can have high specificity for infection, we hypothesized their combination may be useful for accurate early warning of infection. In this study, we developed and evaluated a composite predictive model using continuous HRV with daily serum biomarker measurements to provide risk stratification of future deterioration in HCT recipients. A total of 116 ambulatory outpatients about to undergo HCT consented to collection of prospective demographic, clinical (daily vital signs), HRV (continuous electrocardiography [ECG] monitoring, laboratory [daily serum samples frozen at -80 °C]), and infection outcome variables (defined as the time of escalation of antibiotics), all from 24 hours pre-HCT to the onset of infection or 14 days post-HCT. Indications for antibiotic escalation were adjudicated as "true infection" or not by 2 blinded HCT clinicians. A composite time series of 8 HRV metrics was created for each patient, and the probability of deterioration within the next 72 hours was estimated using logistic regression modeling of composite HRV and serum biomarkers using a rule-based naïve Bayes model if the HRV-based probability exceeded a median threshold. Thirty-five patients (30%) withdrew within24 hours owing to intolerability of ECG monitoring, leaving 81 patients, of whom 48 (59%) had antibiotic escalation adjudicated as true infection. The combined HRV and biomarker (TNF-α, IL-6, and IL-7) predictive model began increasing at ~48 hours on average before the diagnosis of infection, could distinguish between high risk of impending infection (90% incidence of subsequent infection within 72 hours), average risk (~50%), and low risk (10%), with an area under the receiver operating characteristic curve of 0.87. However, given that prophylactic predictive ECG monitoring and daily serum collection proved challenging for many patients, further refinement in measurement is necessary for further study.

Introduction: Cardiovascular disease (CVD) is a major source of morbidity and mortality in HIV+ patients, which is thought to be in part due to a state of persistent systemic inflammation that results in accelerated atherosclerosis. Hypothesis: We hypothesized that inflammation, as measured by 18F-fluorodeoxyglucose (18F-FDG) uptake measured by 18F-FDG positron emission tomography/computed tomography (18F-FDG-PET/CT) in the bone marrow, spleen and thoracic aorta would improve in HIV+ patients following therapy with rosuvastatin compared to HIV+ patients not receiving a statin. Methods: HIV+ patients with a moderate Framingham risk score were enrolled in the study and randomized to treatment with rosuvastatin or usual treatment for 6 months. Patients were matched for age, sex, smoking status, Framingham risk score, duration of anti-retroviral therapy (ART) and type of ART. Fasting blood was collected and 18F-FDG-PET/CT imaging of bone marrow, spleen, and thoracic aorta was performed at baseline and 6 months. Results: Thirty-five HIV+ patients were enrolled in the study; 17 were randomized to treatment with rosuvastatin and 18 were randomized to the control group. There was a significant drop in the 18F-FDG bone marrow, spleen and thoracic aortic uptake in the statin-treated group compared to the control group (bone marrow: -10.3±16.9% versus 5.0±18.9%, p=0.0262; spleen: -9.8±20.3% versus 11.3±28.8%, p=0.0497; thoracic aorta: -8.6±24.5% versus 12.6±29.5%, p=0.0343). 18F-FDG changes over the study period are shown in Figure 1. Conclusions: The present study observed a significant decrease in 18F-FDG-PET uptake in the bone marrow, spleen, and thoracic aorta following treatment with rosuvastatin for 6 months in HIV+ patients. These data suggest a wide-range anti-inflammatory effect of rosuvastatin in HIV+ individuals with well-controlled infection on ART, ultimately resulting in decreased inflammatory activity in the arterial walls of these patients.

Background Methamphetamine use and harms are rising rapidly. Management of patients with methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU) is challenging, with no clearly established best approach; both psychosocial and pharmacologic interventions have been described. Furthermore, given the diversity of individuals that use methamphetamines, there is a need to assess evidence for treatments for subgroups including youths; gay, bisexual, and other men who have sex with men; individuals with mental health comorbidities; and individuals in correction services. Establishing awareness of the messages regarding treatment from recent clinical practice guidelines (CPG) in the field is also of value. The first study objective will be to establish a greater understanding of the methods, populations, and findings of controlled studies for psychosocial and pharmacologic treatments for MUD and PMU. Investigation of this information can help establish the potential for advanced syntheses of the evidence (such as network meta-analysis) to compare therapies for this condition and to identify gaps related to key populations where more primary research is needed. Summarizing the recommendations regarding treatment of MUD/PMU from recent CPGs and systematic reviews will be an important secondary objective. Methods A scoping review will be performed. Using the OVID platform, MEDLINE, Embase, PsycINFO, and relevant Cochrane databases from EBM Reviews will be searched (from databases’ inception onwards). Eligibility criteria will include individuals described as having MUD or PMU, with designs of interest including randomized trials, non-randomized trials, and controlled cohort studies with three or more months of follow-up; systematic reviews and CPGs will also be sought. Two reviewers (with support from automation tools) will independently screen all citations, full-text articles, and chart data. Different approaches to handling and summarizing the data will be implemented for each type of study design. Tables and graphics will be used to map evidence sources and identify evidence gaps. Discussion This research will enhance awareness of evidence addressing the effects of psychosocial and pharmacologic interventions for MUD/PMU overall and in sub-populations, both in terms of recent CPGs/reviews and primary studies; inspection of the latter will also help establish the feasibility of future syntheses to compare treatments, such as network meta-analysis. Systematic review protocol registration Open Science Framework (https://osf.io/9wy8p)

Syphilis has increased in recent years, causing difficulties for clinicians and public health practitioners alike. While one issue with the current management of syphilis is that it has both a myriad of presentations and complicated laboratory results, another issue relates to the current case definitions used to define and track syphilis in public health surveillance. One item that is missing is a "probable" case definition, which could help capture the number of likely cases of syphilis that were appropriately treated clinically, but which failed to reach public health case definition based on serologic markers. This approach could produce a more accurate picture of the breadth of syphilis transmission in North America and help better appreciate the groups most affected by syphilis change. We put forward and argue this position herein.

IntroductionContinuous antiretroviral therapy (ART) suppresses HIV plasma viral load (pVL) to very low levels, which allows for some immune recovery. Discontinuation of ART leads to pVL rebound from reservoirs of persistence and latency, and progressive immunodeficiency. One promising but controversial strategy targeting CD4+ T lymphocytes with a monoclonal antibody (mAb) against α4β7 integrin has shown promise through sustained virological remission of pVL (SVR) in SIV239-infected rhesus macaques. We propose to assess the safety and tolerability of vedolizumab, a licensed humanised mAb against human α4β7 integrin, in healthy HIV-infected adults on ART. This study will also assess, by analytical treatment interruption (ATI), whether vedolizumab treatment can induce SVR beyond ART and vedolizumab treatment.Methods and analysisThe HIV-ART-vedolizumab-ATI (HAVARTI) trial is a single-arm, dose-ranging pilot trial in healthy HIV-positive adult volunteers receiving ART. Twelve consenting persons will be enrolled in sequential groups of 4 to each serial dosing vedolizumab regimen (300 mg, 150 mg, 75 mg). The primary outcomes are: (1) to assess the safety and tolerability of seven serial infusions of vedolizumab at each of three doses; (2) to identify the immunovirological measures, including pVL and T-cell kinetics, that characterise HIV/ART cases before, during, after vedolizumab treatment and ATI; and (3) to seek SVR of pVL after ATI. Secondary outcomes will include immune reconstitution and pVL suppression as well as immune reconstitution and long-term safety following re-initiation of ART in the absence of SVR.Ethics and disseminationThe study protocol was approved by the Ottawa Health Science Network-REB and by the Health Canada Therapeutic Products Directorate. A Data Safety Monitor will review safety information at regular intervals. The final manuscript will be submitted to an open access journal within a year of study completion.Trial registration numberClinicalTrials.gov NCT03147859; https://clinicaltrials.gov/ct2/show/NCT03147859

Background Current data on cardiac surgical practices for people living with human immunodeficiency virus (HIV) are lacking. We hypothesized that cardiac surgeons would consider people living with HIV as candidates for the full scope of cardiac surgery including heart transplant for these patients. Methods We conducted a prospective survey of 155 cardiac surgeons across Canada to evaluate their current clinical perceptions regarding cardiac surgery in people living with HIV. Specifically, we evaluated their assessment of eligibility towards a wide scope of cardiac surgeries by using representative clinical scenarios. Results A total of 63 (40.6%) surgeon responses were completed. The majority of surgeons agreed that a 50-year-old male with HIV and no other comorbidities, who was on combination antiretroviral therapy for 5 years with an undetectable viral load since starting therapy and a CD4 count >350 cells/ul, would be a candidate for valve replacement (73%), valve repair surgery (74.6%), or CABG (coronary artery bypass graft; 79.4%). Few surgeons believed that this patient would be eligible for cardiac transplantation (7.9%) or could be a cardiac transplant donor (1.6%). There was clinical equipoise over the eligibility for ventricular assist device surgery. Conclusions A majority of cardiac surgeons would perform CABG or valve surgery on patients with controlled HIV, but most consider HIV status as a prohibitive risk factor for cardiac transplantation. While this may represent an opportunity for continuing medical education for cardiac surgeons, it also highlights the need for contemporary, high quality evidence in this patient population.

We trialed a nurse-led HIV postexposure prophylaxis (PEP) program in two sexually transmitted infection clinics in Ottawa, Canada. From September 5, 2013 to September 4, 2015, 112 persons sought PEP: 103 were male, of whom 84 were men who have sex with men (MSM). Seventy-two patients (59 MSM) initiated PEP; 11 were diagnosed with HIV: 6 diagnoses occurred during initial assessment (all MSM; 1 also shared injection equipment); 5 MSM were diagnosed with HIV within 1 year of seeking PEP. This level of positivity indicated that, when access is facilitated, individuals at high risk of HIV seek PEP. However, the 8.5% of MSM who seroconverted within a year of taking PEP demonstrated that this group remained at risk and needed additional prevention services. Delivery of PEP should include provision of medication, as well as an opportunity to address individual-level HIV risk strategies and population-level syndemic conditions that contribute to ongoing HIV transmission among MSM.

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score = 67.2, SD = 14.2 versus 65.0, SD = 14.9, p = 0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR = 0.276, 95%CI = 0.103-0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.

With the emergence of daily oral tenofovir disoproxil fumarate and emtricitabine-based pre-exposure prophylaxis (PrEP) use in Canada, questions have emerged concerning the impacts of this HIV prevention tool on gay men's social and sexual lives. We conducted small focus groups and individual qualitative interviews with 16 gay men in Toronto who were part of the ‘first wave’ of Canadian PrEP users. Participants were on PrEP for at least one year as part of a demonstration project (November 2014–June 2016). These participants accessed PrEP before regulatory approval by Health Canada in February 2016. The mean age of participants was 37.6 years (SD 11.02); 94% completed secondary education, and 69% were white. Sex-stigma emerged as a complex theme in men's accounts of PrEP use across three overlapping domains: (1) PrEP-related stigma, including discussions of concealment and stigma from friends, family, and sexual partners, (2) PrEP as a perceived tool for combating HIV-related stigma, where some men said that they no longer discussed HIV status with sexual partners, and (3) PrEP as illuminating structural stigma, where it was attributed to unmasking stigma related to sex and sexuality. For some participants, PrEP has allowed for liberating sex and a self-described return to normalcy—normal, exciting, pleasurable sex that was no longer reliant on condom use. Paradoxically, some men said that PrEP use both led them to experience stigmatizing reactions within their social and sexual networks, while also helping to remove stigma, shame, and fear related to HIV, sexuality, and sex with gay men living with HIV.

Background HIV Pre-exposure prophylaxis (PrEP) is an underutilized intervention to prevent HIV infection in Canada. Known barriers to PrEP uptake include lack of awareness, low HIV risk perception, side effects, PrEP not being publicly funded (which is the case in Ontario) and stigma. We aimed to identify barriers to PrEP use and actions that may facilitate PrEP uptake in Ontario and British Columbia. Methods Gay, bisexual and other men who have sex with men 19 years or older living in Ontario and British Columbia, Canada, answered a survey between July 2019 and August 2020. Participants who met Canadian PrEP guideline criteria for PrEP and not already using PrEP indicated which barriers were relevant to them and which actions would make them more likely to start PrEP. We used descriptive statistics and tested differences between Ontario and British Columbia using Chi-square tests for proportions and t-tests or Wilcoxon rank-sum tests for continuous variables. Results Of 1527 survey responses, 260 (184 in Ontario and 76 in British Columbia) who were never PrEP users and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about side effects (42%). In British Columbia, the most common reasons were concern about side effects (41%) and not feeling at high enough risk (36%). In Ontario, the actions that would most likely encourage the respondent to start PrEP were short waiting time (63%), the healthcare provider informing about their HIV risk being higher than perceived (62%) and a written step-by-step guide (60%). In British Columbia, the actions that would most likely encourage the respondent to start PrEP were short waiting time (68%), people speaking publicly about PrEP (68%) and their healthcare provider counselling about: their HIV risk being higher than perceived (64%), side effects of PrEP (64%) and about how PrEP works (62%). Table. Top reasons for not using PrEP and top actions that might influence the decision to start PrEP stratified by province. (n= 184 in Ontario, n= 76 in British Columbia). Conclusion Concern about side effects and not feeling at high enough risk were common barriers. Short waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability. In British Columbia, actions involving healthcare providers were valued. Disclosures Kevin Woodward, MD FRCPC, Gilead (Independent Contractor) Darrell Tan, MD PhD, Abbvie (Grant/Research Support)Gilead (Grant/Research Support)GlaxoSmithKline (Scientific Research Study Investigator)ViiV Healthcare (Grant/Research Support)

Background Frequent syphilis screening allows for early detection and treatment and decreased transmission. We conducted a clinic-based intervention incorporating opt-out syphilis testing into routine HIV viral loads. The primary objective was to determine the degree to which the intervention increased the detection rate of early syphilis. Methods The Enhanced Syphilis Screening in HIV-positive Men (ESSAHM) Trial was a stepped wedge cluster-randomized controlled trial in 4 urban HIV clinics in Ontario, Canada from 01/02/2015 to 31/07/2017 (ClinicalTrials.gov: NCT02019043). Population: adult males. Intervention (I): standing orders for syphilis serological testing with HIV viral loads. Control (C): maintenance of current, provider-initiated syphilis testing practice. Outcome: new diagnoses of early infectious syphilis. We obtained syphilis serologies via linkage with the centralized provincial laboratory and defined early syphilis cases using a standardized clinical worksheet and medical chart review. The trial was powered (≥80%) to detect a ≥75% increase in case detection rate, assuming 3 tests per patient per year. We employed a generalized linear mixed-effect model to estimate time- and age-adjusted rate ratios (aRR) comparing intervention to control periods. Results 3,893 men were followed over 7,468 person-years (PY), and had a mean of 2 viral load tests per year. The mean number of syphilis tests per person per year increased from 0.65 in control to 1.44 in intervention periods. There were 217 new diagnoses of syphilis in total (C: 81; I: 136), for which 147 were cases of early syphilis (C:61; I:86). The detection rate increased from 1.51 per 100PY in control to 2.50 per 100PY in intervention periods, with a corresponding aRR = 1.28 (95%CI 0.73, 2.24; p = 0.40). Conclusion The implementation of standing orders for syphilis serological testing with HIV viral loads resulted in a modest but statistically non-significant increase in detection of new cases of early infectious syphilis. Disclosure No significant relationships.

Background Anal cancer caused by oncogenic, high-risk (HR) human papillomavirus (HPV) is emerging as a leading cause of non-HIV-related death in HIV-positive MSM. Anal cancer rates in HIV-positive MSM are up to 100-times higher than the general population. There are no universally-accepted guidelines for anal cancer screening, even in high risk populations, due to a paucity of evidence to support its effectiveness. We assessed the acceptance rate to invitations for anal cancer screening, and describe preliminary pathology results. Methods The HPV-SAVE Study is an ongoing Canadian study on screening and treatment of anal cancers and pre-cancers in HIV-positive MSM. Participants were invited to have anal cytology and HPV testing in their physician’s office. Those with abnormalities were referred for high resolution anoscopy (HRA) and anal biopsies. Cytology was graded as per the Bethesda classification, and histology was described per the Lower Anogenital Squamous Terminology (LAST) nomenclature. Results Out of 2241 invitations as of 01/2019, 617 men (27.5%) agreed to be screened. Cytology results from 518 satisfactory Pap tests were: 246 negative (47.5%), 62 LSIL (12.0%), 9 LSIL-H (1.7%), 14 HSIL (2.7%), 174 ASCUS (33.6%), and 13 ASC-H (2.5%). In 116 participants referred for HRA, 247 biopsies were done, yielding HSIL in 62 (53.4%) unique individuals, and one invasive carcinoma. In a sample of 127 participants, 111 (87.4%) had any HPV type, 82 (64.6%) had multiple HPV types, 78 (61.4%) had at least one high-risk HPV type, and 39 (30.7%) had HPV-16. Conclusion MSM living with HIV had moderate acceptance of anal cancer screening invitations, with over half of screened men having abnormal cytology. A majority of those undergoing HRA had high-grade histology diagnosed, and most participants had HPV anal canal infection, with nearly two-thirds having anal canal infection with HR-HPV. These early results highlight the enormous HPV burden in this high-risk population. Disclosure No significant relationships.

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.

Men living with human immunodeficiency virus (HIV) are internationally recognized as a priority population for human papillomavirus (HPV) vaccination. Our objective was to explore HPV vaccine uptake among men living with HIV in Ontario, Canada, and investigate differences between vaccinated and unvaccinated men. We used data from a cross-sectional questionnaire administered between 2016 and 2017 among men living with HIV and participating in the Ontario HIV Treatment Network Cohort Study. We calculated the proportion vaccinated against HPV, described vaccination experiences, and HPV vaccine knowledge, and calculated differences in characteristics between vaccinated and unvaccinated men. Among 1651 men (mean age = 51 years, 72% identified as gay), 7% were vaccinated (95% confidence interval[CI] 5.5–7.9%); 85% received their first dose at a primary care or HIV clinic. Among unvaccinated men, 40% were unaware of the HPV vaccine, 65% reported low perceived risk for HPV, and 8% discussed HPV vaccination with a physician. Compared to unvaccinated men, vaccinated men were younger, most identified as gay, had a higher education/income, reported a higher number of recent sex partners, and had a history of bacterial sexually transmitted infections (STIs), HPV, anogenital warts, and/or anal cancer. Our findings reveal that few men living with HIV were vaccinated against HPV. This may be influenced by low HPV awareness, prohibitive cost, and lack of physician recommendation. Several men reporting lower socio-economic status, older men, and heterosexual, bisexual, and other men who have sex with men were missed for vaccination. Primary care and HIV clinics may be ideal locations to increase uptake.

Human papillomavirus (HPV)-associated anal cancer is orders of magnitude higher among men living with HIV than the general male population. Our objective was to examine factors associated with HPV awareness and self-perceived risk for HPV-associated anal cancer among men living with HIV, which may influence uptake of cancer prevention strategies. A cross-sectional questionnaire on HPV was administered from 2016 to 2017 to 1677 men in a multisite, HIV clinical cohort in Ontario, Canada. We used logistic regression and proportional odds models to identify factors associated with being familiar with HPV and increasing self-perceived risk for anal cancer, respectively. We used correspondence analysis to examine associations of specific HPV-related knowledge with self-perceived risk. Only 52% were familiar with HPV, and 72% felt they had no or low risk for anal cancer. Familiarity with HPV was more common among men who have sex with men than heterosexual men (58% vs. 21%). Older men were less likely to be familiar with HPV (adjusted odds ratio [aOR] per 10 years = 0.77; 95% confidence interval [CI]: 0.69, 0.85). Familiarity with HPV was associated with increasing self-perceived risk (aOR = 2.39; 95% CI: 1.87, 3.04). After accounting for differences in HPV awareness and sexual orientation, racialized men had lower self-perceived risk (aOR = 0.68; 95% CI: 0.52, 0.88). In the correspondence analysis, risk-focused HPV-related knowledge (e.g., knowing smoking increases risk) was associated with highest risk perception. Efforts are needed to improve HPV-related health literacy in this population. Our findings suggest specific HPV-related knowledge may differentially influence self-perceived risk for anal cancer.