High HIV risk and syndemic burden regardless of referral source among MSM screening for a PrEP demonstration project in Toronto, Canada

Abstract

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.

Changes in mental health and drug use among men who have sex with men using daily and event-driven pre-exposure prophylaxis: Results from a prospective demonstration project in Amsterdam, the Netherlands

“…A study using a national sample among 1033 HIV-negative GBMSM in the United States observed a prevalence of depression (as measured by the 20-item Centre for Epidemiological Studies Depression scale) at 26.7%, sexual compulsivity at 13.8%, and polydrug use at 8% [7] . From our study and others, the prevalence of depression among PrEP using GBMSM could be considered comparable to the general U.S. GBMSM population (11–40%), while prevalence of sexual compulsivity (31%), alcohol use disorder (28–40%), and drug use disorder (36–37%) were all higher [ 12 , 13 , 23 ]. Notwithstanding the differences in mental health assessments and demographic composition between studies, the relatively higher prevalence of these disorders emphasizes the importance of addressing mental health in GBMSM who initiate PrEP.…”

“…High levels of drug use among GBMSM PrEP users have been reported previously [ 10 , 12 , 13 ]. In our study, participants reported using most of their drugs 2–4 times a month or less.…”

“…To date, only a handful of studies have addressed mental health and substance use among GBMSM at PrEP initiation, finding high prevalence of drug use, depression and sexual compulsivity [10] , [11] , [12] , [13] ; none of these studies have assessed these outcomes longitudinally.…”

Immediate PrEP after PEP: Results from an Observational Nurse-Led PEP2PrEP Study

“…Other studies have similarly found elevated rates of mood disorders among patients who use PEP and PrEP. 30 - 32 Although no significant correlation was identified between anxiety or depression and PrEP discontinuation, previous studies have identified this relationship. 33 As such, mood disorders may be the reason PrEP is needed (in that sexual practices that can transmit HIV could be the manifestation of depression or anxiety) and might be reason it is not used in an ongoing fashion (in that these illnesses undermine retention in care).…”

Acceptability and tolerability of and adherence to HIV preexposure prophylaxis among Toronto gay and bisexual men: a pilot study

“…We recruited participants through self-referral and provider referral between Oct. 16 and Dec. 30, 2014, as previously described. 17 English-speaking men aged 18 years or more were eligible if they reported having sex with men, tested nonreactive on a fourth-generation HIV test (Architect antigen/antibody combo assay, Abbott Laboratories), had a creatinine clearance rate of 60 mL/min or greater by the Modified Diet in Renal Disease formula, reported condomless receptive anal sex over the preceding 6 months and scored 10 or higher on the HIV Incidence Risk Index for MSM, a recommended cut-off value for identifying candidates for preexposure prophylaxis. 18 Exclusion criteria included symptoms or signs of HIV seroconversion, use of pre-or postexposure prophylaxis within the preceding 3 months, concomitant therapy with nephrotoxic or immunomodulatory drugs, hepatitis B surface antigen positivity, high risk of osteoporosis, enrolment in another HIV prevention trial or perceived inability to adhere to the study protocol.…”