Kim Engler

Predictors of interest in taking pre-exposure prophylaxis among men who have sex with men who used a rapid HIV-testing site in Montreal (Actuel sur Rue).

The effective use of pre‐exposure prophylaxis (PrEP) as an HIV prevention strategy depends on its uptake by individuals at high risk of infection. Few Canadian data are available on interest in PrEP among men who have sex with men (MSM). This study aimed to identify predictors of interest in PrEP among MSM clients of a rapid HIV‐testing site in Montreals gay village (Actuel sur Rue).

French HIV Experts on Early Antiretroviral Treatment for Prevention Uncertainty and Heterogeneity

Early use of highly active antiretroviral treatment (ART) in people living with HIV for HIV prevention has gained legitimacy but remains controversial. Nineteen French HIV experts with diverse specializations (over half of whom were clinicians) were qualitatively interviewed on their views about ART irrespective of CD4 count of more than 500 cells/mm3 for purposes of HIV prevention, which is not systematically recommended in France. Content analysis identified 2 broad categories: individual considerations (subcategories: patient health and well-being; patient preparedness and choice) and collective considerations (subcategories: HIV transmission risk; impact on the epidemic; cost). Uncertainty surrounded many experts’ considerations, and unity was lacking on key issues (eg, candidacy for early preventive treatment, expected clinical- and population-level effects). An umbrella theme labeled “Weighing the merits of early ART in the face of uncertainties” was identified. Our analyses raise doubts about the current acceptability of widespread implementation of early ART for HIV prevention in France.

Ability of a rapid HIV testing site to attract and test vulnerable populations: a cross-sectional study on Actuel sur Rue:

Quebec’s HIV epidemic persists, particularly among men who have sex with men (MSM) and in Montreal. Increasing access to HIV testing is necessary and community-based rapid testing offers one strategy. This paper examines the clienteles and activities of a rapid HIV testing site in Montreal, the pilot project Actuel sur Rue. Comparative analyses were conducted with 1357 MSM, 147 heterosexual men and 64 women who visited Actuel sur Rue between July 2012 and November 2013 on socio-demographics, health, drug use, sexual practices/infection and HIV testing/prevention. Significant group differences were observed in each category. Actuel sur Rue received 1901 clients, conducted 1417 rapid HIV tests and tested 77 never-tested individuals. Rapid testing produced a high reactive rate (2%). Only 1/28 of those with reactive tests had no previous HIV testing, and 36% had used post-exposure prophylaxis, suggesting missed opportunities for prevention. Findings highlight diverse client vulnerability profiles and the relevance of checkpoints and further prevention efforts.

Minimal interference: A basis for selecting ART for prevention with positives.

Given international interest in “treatment as prevention” (TasP) and the pertinence of optimizing antiretroviral treatment (ART) regimens for TasP, 19 French HIV experts were interviewed on their criteria for ART if used specifically for prevention with HIV-positive persons. Through content analysis of the interview material, nine criteria were identified. The most endorsed criteria, collectively, suggest a choice of treatment based on “minimal interference” where negative impacts of ART are minimized and ease of treatment integration maximized in the lives of people living with HIV/AIDS (PLHIV) for both the short and long term. These criteria were the tolerance, side effects, and/or toxicity profile of ART, simplicity (e.g., of treatment schedule, dosage form) and the individualization of treatment (e.g., adapted to lifestyle). While virologic efficacy (i.e., a durable, undetectable viral load) was also deemed important, several experts specified that it was virtually assured with current treatments. To a much lesser extent, experts endorsed diffusion of ART into the genital compartments, a strong genetic barrier (against resistance), validated treatments (as opposed to new classes of ART), a rapid reduction in HIV viral load, and treatment cost. Pharmacologically, minimal interference calls for further improvements in the tolerance, side effects and toxicity profile of ART and in the simplicity of ART administration. Clinically, it means avoiding a one-size-fits-all approach to ART in TasP and engagement with and of PLHIV in ART selection and side effects management. Strategically, it emphasises keeping the health and quality of life of PLHIV at the forefront of a TasP-oriented public health intervention.

Explaining the appeal for immigrant men who have sex with men of a community-based rapid HIV-testing site in Montreal (Actuel sur Rue)

Immigrant men who have sex with men (MSM) are vulnerable to HIV. In the last decade, several rapid HIV-testing facilities targeting MSM have been established around the world and seem popular among immigrants. This study analyzes factors contributing to immigrant MSMs use of Actuel sur Rue (AsR), a community-based rapid HIV-testing site in Montreals gay village, where 31% of clients are immigrants. From October 2013 to January 2014, AsR staff compiled a list of new clients born outside of Canada. With their consent, 40 immigrant MSM were reached among these new clients for a 15-minute phone survey entailing open-ended and multiple-choice questions. The survey sought immigrant MSMs reasons for visiting AsR; satisfaction with service and staff; and open comments. An inductive thematic analysis was conducted with the qualitative data, and descriptive statistics were produced with the quantitative data. The qualitative findings indicate that the main reasons for seeking an HIV test were a recent risk, routine testing, or being in a new relationship. Clients chose AsR mainly because it is easily accessible, service is fast or they heard about it from a friend. The quantitative findings indicate that rates of satisfaction were high (over 90% were satisfied about all aspects except for openings hours) and more than 80% felt comfortable while receiving services at AsR. Nevertheless, this studys findings have implications for improving services. They stress the importance of offering rapid yet comprehensive service and of taking into account immigrant MSMs concerns for confidentiality.

Explaining the Presence of “Heterosexual” Female Clients of a Rapid HIV Testing Site Located in the Gay Village of Montreal, Quebec

Background: Increasing access and uptake of HIV testing among at-risk women is needed. Examining women’s motives for visiting a community-based rapid HIV testing site (Actuel sur Rue–AsR) oriented to men who have sex with men (MSM) could offer suggestions. Objective: To compare the “heterosexual” female and male clients of AsR, located in Montreal’s (Canada) gay village, to better understand the women’s particular HIV prevention and sexual health service needs. Methods: This cross-sectional pilot study analyzed questionnaire data provided by AsR clients and staff (nurse and community agent teams) between July 2012 and November 2013. Women and men reporting only opposite-sex partners were compared with chi-square, Fisher’s exact, and Kruskal-Wallis tests, as appropriate, on sociodemographics, HIV-related behaviors, motives for visiting AsR, and health service provision. Results: AsR received 1901 clients. Among these, 55 women and 147 men reported only opposite-sex partners. Women were significantly younger. Significantly greater proportions of women visited AsR because no appointment was necessary (67% vs 48%), sought testing for condom failure (18% vs 5%), and had no regular doctor (44% vs 27%). Both groups mainly chose AsR for the rapid test results (80% and 77%), visited it to receive the rapid HIV test (71% and 76%), and sought testing due to unprotected vaginal sex (44% and 43%). Similar proportions saw the nurse (91% and 89%), received the rapid HIV test (44% and 35%), and were linked to a medical clinic (49% and 52%), especially, to receive complete sexually transmitted infection testing (50% and 44%). Conclusions: The results of this innovative study highlight the draw of rapid HIV testing for “heterosexual” users of a site mainly targeting MSM. They also suggest that further research is warranted into the importance for this group of women clients of drop-in and linkage services, particularly given their possible lesser access to regular care.

HIV experts on the decision to use early ART for prevention in France: are we there yet?

The finding that successful antiretroviral therapy (ART) can almost eliminate the risk of heterosexual HIV transmission is the scientific breakthrough of 2011 according to Science Magazine. This potential of ART has generated novel approaches to prevention including “Test and Treat” (T&T). Our qualitative study, drawing on the perspectives of French HIV experts, aims to better understand if, and how, a T&T approach might be applied in France and to generally learn more about concerns raised by prevention with early ART.

HIV-Positive Patients’ Perceptions of Antiretroviral Therapy Adherence in Relation to Subjective Time: Imprinting, Domino Effects, and Future Shadowing:

Antiretroviral treatment adherence barriers are major concerns in HIV care. They are multiple and change over time. Considering temporality in patients’ perceptions of adherence barriers could improve adherence management. We explored how temporality manifests itself in patients’ perceptions of adherence barriers. We conducted 2 semi-structured focus groups on adherence barriers with 12 adults with HIV which were analyzed with grounded theory. A third focus group served to validate the results obtained. Three temporal categories were manifest in HIV-positive patients’ perceptions of barriers: (1) imprinting (events with lasting impacts on patients), (2) domino effects (chain of life events), and (3) future shadowing (apprehension about long-term adherence). An overarching theme, weathering (gradual erosion of abilities to adhere), traversed these categories. These temporalities explain how similar barriers may be perceived differently by patients. They could be useful to providers for adapting their interventions and improving understanding of patients’ subjective experience of adherence.

Decision-making about motherhood among women living with HIV in Canada: a negotiation of multidimensional risks

Abstract Little research in Canada has examined the perspectives of women living with HIV on decision-making across the stages of motherhood. In 2004–2005, semi-structured interviews were conducted with 42 African, Caucasian and Haitian HIV-positive women recruited in Montreal. All were or wished to be biological mothers. Transcripts underwent thematic analysis organised by three culturally informed models of motherhood described by the participants, which influenced decision-making and perceived risks. For women who saw motherhood as ‘self-fulfilment and completeness’, vertical HIV transmission was a primary concern. It threatened their identity as a ‘good mother’, which also meant adhering to antiretrovirals. For women who viewed motherhood as a ‘social realisation’ (all African or Haitian), fears of compromised fertility dominated. Not becoming pregnant threatened their social status and presumed health within their community. Antiretrovirals were abandoned after delivery, fearing they would reveal their HIV status. For women endorsing a ‘personal growth’ model of motherhood (all Caucasian), threats to personal health were paramount. Pregnancy meant purifying body and soul. Antiretrovirals, seen as pollutants, were stopped after delivery. These findings can inform current research and sensitise health providers to the complex biological, psychological, social and spiritual risks that HIV-positive women negotiate in motherhood-related decision-making, towards more patient-centred care.

Barriers to antiretroviral therapy adherence in developed countries: a qualitative synthesis to develop a conceptual framework for a new patient-reported outcome measure

ABSTRACT Suboptimal adherence to antiretroviral therapy (ART) remains common. Patient-centered tools are needed to comprehensively assess adherence barriers in HIV clinical practice. Thus, we conducted a research synthesis to produce a conceptual framework for a new patient-reported outcome measure (PRO) for use in routine HIV care in Canada and France. A PRO’s conceptual framework graphically represents the concepts to be measured and the potential relationships between them. Towards ensuring the framework’s relevance to the target populations’ concerns, qualitative studies with HIV-positive adults on barriers to ART adherence in developed countries were synthesized with thematic analysis, attending to the cross-study prevalence and interrelationships of barrier themes. In March 2016, searches within Medline, PsychINFO, and Embase produced 5,284 records. Two reviewers determined the final sample (n = 41). Analysis generated three levels of ART adherence barrier themes. Twenty Level 2 themes and their component subthemes (Level 3) were organized into 6 higher-order themes (Level 1): Cognitive and emotional aspects (100% of studies contributing content -prevalence), Lifestyle factors (95%), Social and material context (95%), Characteristics of ART (90%), Health experience and state (73%), and Healthcare services and system (66%). As to interrelationships, study authors articulated relationships between all higher-order themes (Level 3). Linkages between Level 2 barrier themes showed great variability, from 21% to 95%. Overall, this synthesis contributes an exceptionally detailed conceptual framework and report of ART adherence barriers, applicable to a wide range of PLHIV. It suggests that a key to understanding many barriers is through their interconnections. It also identifies gaps in barrier research. Concerning the new PRO’s development, comprehensiveness will need to be weighed against other concerns (e.g., respondent burden) and the provision of barrier-specific guidance for clinically addressing its scores seems essential.