Pre-exposure prophylaxis (PrEP) is traditionally prescribed by HIV specialist physicians. Given finite specialist resources, there is a need to scale up PrEP delivery by decentralizing services via other healthcare professionals. We aimed to assess the feasibility of delivering PrEP to men who have sex with men (MSM) through primary care physicians and sexual health clinic nurses. We piloted a multi-component, implementation and dissemination research program to increase provision of PrEP through primary care physicians and sexual health clinic nurses in Toronto, Canada. Community-based organizations (CBOs) provided prospective participants with information cards that contained links to an online module on engaging providers in a conversation about PrEP. In our patient-initiated continuing medical education (PICME) strategy, participants saw their family doctors and gave them the card, which also contained a link to a Continuing Medical Education module. In the nurse-led strategy, participants visited one of two participating clinics to obtain PrEP. We administered an optional online questionnaire to patients and providers at baseline and six months. CBOs distributed 3043 cards. At least 339 men accessed the online module and 196 completed baseline questionnaires. Most (55%) intended to visit nurses while 21% intended to consult their physicians. Among 45 men completing follow-up questionnaires at 6 months, 31% reported bringing cards to their physicians and obtaining PrEP through them; sexual health clinics delivered PrEP to 244 patients. Participants who went through the PICME approach reported no changes in relationships with their providers. Nurses showed fidelity to PrEP prescribing guidelines. Nurse-led PrEP and patient-initiated continuing medical education (PICME) for primary care physicians are feasible strategies to increase PrEP uptake. Nurse-led PrEP delivery was preferred by most patients.

BackgroundTo maximize public health impact and cost-effectiveness, HIV pre-exposure prophylaxis (PrEP) must reach individuals at high HIV risk. Referrals for PrEP can be self- or provider-initiated, but there are several challenges to both. We assessed whether HIV risk differed by referral source among gay, bisexual and other men who have sex (gbMSM) screening for an HIV PrEP demonstration project.MethodsPREPARATORY-5 was an open-label PrEP demonstration project enrolling gbMSM at high risk of HIV acquisition in Toronto, Canada. Study eligibility criteria related to high risk was defined as scoring ≥10 on the HIV Incidence Risk Index for MSM (HIRI-MSM) and engaging in at least 1 act of condomless receptive anal sex within the past 6 months. Recruitment was promoted through self-referrals (ads in a sexual networking app and gay newspaper/website) and provider-referrals (10 community-based organizations, CBOs). HIV risk score (HIRI-MSM) and syndemic health burden were measured among gbMSM screened for study participation and compared according to referral source.ResultsBetween October 16 and December 30, 2014, online ads generated 1518 click-throughs and CBOs referred 115 individuals. Overall, 165 men inquired about the trial, of which 86 underwent screening. The majority of screened men were self-referrals (60.5%), scored ≥10 on HIRI-MSM (96.5%), and reported condomless receptive anal sex in the past 6 months (74.2%). Self- and provider-referrals had similarly high HIV risk profiles, with a median (IQR) HIRI-MSM score of 26.0 (19.0–32.5) and 28.5 (20.0–34.0) (p = 0.3), and 75.0% and 73.5% reporting condomless receptive anal sex (p = 0.9), respectively. The overall burden of syndemic health problems was also high, with approximately one-third overall identified as having depressive symptoms (39.5%), alcohol-related problems (39.5%), multiple drug use (31.4%), or sexual compulsivity (31.4%). There were no significant differences in syndemic health problems by referral source.ConclusionsHIV risk and syndemic burden were high among gbMSM presenting for this PrEP demonstration project regardless of referral source. Self-referral may be a useful and efficient strategy for identifying individuals suitable for PrEP use. Online strategies and CBOs working in gay men’s health may play important roles in connecting individuals at high HIV risk to PrEP services.Trial registrationClinicalTrials.gov NCT02149888. Registered May 12th 2014.

A disproportionate burden of HIV infections in Canada occurs among gay, bisexual and other men who have sex with men, who account for 49.7% of prevalent infections and have a 131-fold higher risk of incident HIV than other Canadian men. 1 Preexposure prophylaxis with daily oral tenofovir disoproxil fumarate/emtricitabine therapy is a biomedical HIV prevention approach that has been shown to be safe and efficacious in reducing HIV acquisition in randomized trials. 2-5 As the results of these studies became available, interest increasingly turned to conducting "demonstration projects" or clinical trials addressing implementation outcomes such as adherence and real-world effectiveness. 6-8 However, in surveys we conducted among stakeholders across Canada, 9-13 respondents expressed concerns about the potential for suboptimal adherence, sexually transmitted infections (STIs) and toxic drug effects. Furthermore, there was uncertainty about the acceptability of pre exposure prophylaxis, fuelled in part by reports of slow uptake in other settings. 14,15 To address these concerns and inform broader rollout in Canada, we conducted a pilot demonstration project among gay, bisexual and other men who have sex with men in Toronto. Our primary objective was to assess the acceptability of preexposure prophylaxis at the community and individual levels, by quantifying both the volume of referrals to the study and participants' satisfaction. As secondary outcomes, we also quantified adherence, HIV seroconversion, bacterial STIs and adverse events.

Background Rwanda provides free HIV treatment to all HIV positive person. Adolescents and youth have poorer treatment adherence and experience higher treatment failure than adults. This study aimed at exploring the barriers to adherence among adolescents and youth in two district hospitals in rural Rwanda. Methods Adolescents and youth within the age of 10 to 24 years who have been on HIV treatment for at least one year in the two hospitals and their appointment adherence were identified through electronic medical records. Questionnaires were completed by consented participants or their parents and were used to measure treatment adherence in the previous 30 days and in the previous 3 days. In-depth interviews were also conducted to explore the factors associated with poor adherence and outcomes. Results Among the 139 adolescents enrolled for treatment, 58% had good appointment keeping. Out of the 72 questionnaires completed, 87% reported adhering to at least 95% of treatment in the previous 30 days and 47% reported poor adherence in the previous 3 days. Reported factors causing poor adherence included poverty, stigma, and lack of parents. Conclusion The level of adherence to HIV treatment was low among adolescents and youth in rural Rwanda. Creation of projects that can improve social economic status to Adolescent who are on HIV treatment as well as provision of family care to orphanage HIV adolescent patients would improve their treatment adherence. Disclosure No significant relationships.