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

James Wilton, Syed W Noor, Alexandre Schnubb, James Lawless, Trevor A Hart, Troy Grennan, Shawn Fowler, John Maxwell, Darrell H S Tan, James Wilton, Syed W Noor, Alexandre Schnubb, James Lawless, Trevor A Hart, Troy Grennan, Shawn Fowler, John Maxwell, Darrell H S Tan

Abstract

Background: To 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.

Methods: PREPARATORY-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.

Results: Between 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.

Conclusions: HIV 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 registration: ClinicalTrials.gov NCT02149888 . Registered May 12th 2014.

Keywords: Gay men and other men who have sex with men; HIV risk; PrEP; Screening; Syndemics.

Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Research Ethics Boards of St. Michael’s Hospital, Ryerson University, and the University of Toronto. Informed consent was obtained prior to the collection of study data.

Consent for publication

Not applicable.

Competing interests

DHST has received honoraria from Merck, Abbvie, Gilead and Viiv Healthcare for developing educational lectures; investigator-driven grants from Gilead and Viiv Healthcare; and clinical trial contracts from Gilead and GSK. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Recruitment and referral pathway to the PREPARATORY-5 demonstration project. Participants could be referred through either self or provider-referred pathways. Specific information on referral source only collected for screened participants. Number of uniquely numbered referrals cards distributed by CBOs to clients used to quantify CBO referrals. CBO = community-based organization
Fig. 2
Fig. 2
Reasons for wanting to participate in PREPARATORY-5 by referral source. Participants could provide multiple reasons for study participation. Participants were defined as self- or provider-referred based on their primary reported referral pathway, such that some self-referred participants still reported “provider suggestion” among their reasons for wanting to join the study. P values calculated using chi-squared analyses

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