Prevalence, Trends, and Correlates of HIV Pre-Exposure Prophylaxis (PrEP) Use During Sexual Events by Sexual Minority Men in Montreal, Toronto, and Vancouver Lachowsky NJ1, Cui Z2, Bacani N2, Armstrong HL2,3, Olarewaju G2, Messier-Peet M4, Apelian H4, Rodrigues R5, Noor S5, Skakoon-Sparling S5, Moore DM2,3, Jollimore J6, Lambert G4, Cox J7, Grace D8, Hart TA5,8, and the Engage team 1. University of Victoria; 2. BC Centre for Excellence in HIV/AIDS; 3. University of British Columbia; 4. Direction Régionale de Santé Publique de Montréal; 5. Ryerson University; 6. Community Based Research Centre Society; 7. McGill University; 8. University of Toronto

Conflict of Interest Disclosures In the past 2 years I have been an employee of: University of Victoria In the past 2 years I have been a consultant for: None In the past 2 years I have held investments in the following pharmaceutical organizations, medical devices companies or communications firms: None In the past 2 years I have been a member of the Scientific advisory board for: None In the past 2 years I have been a speaker for: None In the past 2 years I have received research support (grants) from: Canadian Blood Services, Canadian Foundation for AIDS Research, CIHR, CIHR HIV Clinical Trials Network, Gilead Science Canada, Island Health, Mitacs, Michael Smith Foundation for Health Research, Public Health Agency of Canada, University of Victoria, Vancouver Foundation In the past 2 years I have received honoraria from: Saskatchewan Health Research Foundation, Michael Smith Foundation for Health Research I agree to disclose approved and non-approved indications for medications in this presentation: YES I agree to use generic names of medications in this presentation: YES There are relationships to disclose: YES (see above)

Background Since Health Canada approval in 2016,1 PrEP awareness and use has increased markedly2 PrEP access varies across Canada: Indigenous people with status: free access via non-insured health benefits British Columbia: free access via BC-CfE within provincial clinical guidelines Ontario: free if <25, over 65, or ODSP/Ontario Works income-contingent access to coverage via provincial drug plan (Trillium) Quebec : co-pay via provincial health plan (RAMQ) up to $83.33/month Private health insurance plans Tan et al. CMAJ 2017 Mosley et al. AIDS Behav 2018

Background (continued) Sexual event-level analyses can provide granular evidence of the impact of HIV PrEP-use on the sexual behaviour of gay, bisexual, and other men who have sex with men (gbMSM).3 “One with many” design We examined the prevalence, trends and correlates of sexual event-level HIV PrEP-use among urban gbMSM Cite good for first point here too 3. Lachowsky et al. (2016) STDs

What is Engage? Mixed-method biobehavioural cohort study Initiated in 2014 in Toronto, Montreal, and Vancouver Focused on the health of gbMSM (inclusive of trans men): Eligible if sexually active (past six months) and aged ≥16 years Computer-assisted surveys & biomedical testing Uses respondent-driven sampling (RDS) Social network-based chain recruitment

Methods “Partner Matrix” asks questions on their last sexual encounter with up to their five most recent partners in the last 6 months Outcome: Participant and/or partner PrEP use Data from all visits between Feb 2017 – Feb 2019 (2 years) RDS-II weights applied to all analyses Multivariable logistics regression to evaluate temporal trends (6-monthly) and factors associated with event-level PrEP use General estimating equations accounted for individual as main clustering level using an exchange correlation structure City and visit number were controlled for in the models CODE proc genmod data = sex_prep_mdl; class PART_ID SEX_EL_PREP_USE city &vars/param=ref ref=first; model SEX_EL_PREP_USE = visit_num city &vars/dist=binomial link=logit type3; repeated subject = PART_ID/type = exch; weight wt; run;

Results: Study Sample 2198 participants 3486 study visits 11474 sexual events 3277 events with PrEP use (28.6%) Sample size by city (% of overall): Montreal: n=1179 (53.6%) Toronto: n=422 (19.2%) Vancouver: n=597 (27.2%) Descriptive statistics: 90.4% cisgender 75.6% gay-identified 63.9% Canadian/European-identified 63.9% earned <$30,000/year 43.2% aged <30 years 44.1% have a current romantic partner 23.7% completed high school or less education 15.6% identified as living with HIV 9.2% reported recent PrEP use (individual-level) Average of 3.3 events per visit 40 visits did not have any sexual events 1201 events had a missing outcome

Event-Level PrEP Use: Trends by HIV Status HIV- trend P<0.001 Difference by HIV Status: P=0.2143 Overall trend P<0.001 PLHIV trend P=0.318

Event-Level PrEP Use: Trends by City trend P<0.001 trend P<0.001 Difference by City: P=0.0422 trend P=0.062

Event-Level PrEP Use: Multivariable Correlates AOR 95% CI Relationship With Partner (ref: current romantic partner) Transactional sex (money, goods, or drugs) 2.82 (1.53-5.22) One-time hookup 3.39 (2.42-4.73) Other (e.g. friends, casual) 3.22 (2.42-4.28) Recent Place (ref: my/their home) Bathhouse 0.66 (0.46-0.94) Sexual Activity (separate variables) Received oral sex (ref: did not) 0.79 (0.64-0.97) Condom used as bottom (ref: did not) 0.60 (0.46-0.78) Condom used as top (ref: did not) 0.40 (0.28-0.59) Gave rim job (ref: did not) 1.22 (1.01-1.47) Participant Substance Use (separate variables) Alcohol, 5+ drinks (ref: not used) 0.67 (0.50-0.90) Crystal methamphetamine (ref: not used) 0.65 (0.44-0.94) Poppers (ref: not used) 1.71 (1.33-2.20) Model controls for: City Age Income Ethnicity Sexual identity Education Relationship status HIV status

Discussion Event-level PrEP-use increased over time and varied by city Vancouver’s marked increase a result of provincial PrEP coverage? Contextual factors should inform future health promotion PrEP-reported events more common with non-romantic partners, notably during transactional sex PrEP-reported events less likely to involve substances associated with condom non-use (e.g. binge drinking, crystal meth) Less PrEP-reported events at bathhouses due to non-verbal conversations?

Strengths & Limitations Novel approach to use sexual events as analytic unit Greater causal evidence (temporal association) Distribution of study visits vary by city Limited follow-up visits Outcome was self-reported PrEP use for participant or partner Either or both could have reported PrEP use Self-reported by participant (future research should explore dyadic data) How accurate are self-reports of PrEP use?

Conclusions PrEP use is reported in one third to half of all sexual events in Canada’s largest urban centres Access to PrEP is an important individual and community issue Need to consider equity in PrEP implementation Key factors include both social determinants and contextual partner- level and event-level Future research can examine issue with more granularity PrEP use by participant and by partner Addition or substitution of other prevention practices e.g. condoms + lube, strategic positioning

Community & Public Health Partners Acknowledgements Community & Public Health Partners

Acknowledgements Academic Partners

Acknowledgements Funders