The cost of anticipating stigma: a longitudinal examination of HIV stigma and health.

Levels of HIV stigma remain high, however there is a limited understanding around how different types of stigma interact to impact health. This study uses data from two time points to examine how enacted and internalized stigma lead to worse health through anticipated stigma as a mediator. We recruited 341 participants in Ontario, Canada to complete the HIV Stigma Index survey at baseline (t1) from September 2018 to August 2019 and follow up (t2) approximately two years later. Mediation models were created with enacted and internalized stigma at t1 as the antecedents, anticipated stigma at t2 as the mediator, and physical health, mental health, and overall health at t2 as the outcomes. Only the model with internalized stigma (t1) as the antecedent had anticipated stigma (t2) as a significant mediator contributing to both decreased mental and overall health. This highlights the need to address internalized stigma and the potential for anticipated stigma interventions to be effective at improving the health and wellbeing of people living with HIV.

Routinized Syphilis Screening Among Men Living With Human Immunodeficiency Virus: A Stepped Wedge Cluster Randomized Controlled Trial.

BACKGROUND: We implemented an opt-out clinic-based intervention pairing syphilis tests with routine human immunodeficiency virus (HIV) viral load testing. The primary objective was to determine the degree to which this intervention increased the detection of early syphilis. METHODS: The Enhanced Syphilis Screening Among HIV-Positive Men (ESSAHM) Trial was a stepped wedge cluster-randomized controlled trial involving 4 urban HIV clinics in Ontario, Canada, from 2015 to 2017. The population was HIV-positive adult males. The intervention was standing orders for syphilis serological testing with viral loads, and control was usual practice. We obtained test results via linkage with the centralized provincial laboratory and defined cases using a standardized clinical worksheet and medical record review. We employed a generalized linear mixed model with a logit link to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the intervention. RESULTS: A total of 3895 men were followed over 7471 person-years. The mean number of syphilis tests increased from 0.53 to 2.02 tests per person per year. There were 217 new diagnoses of syphilis (control, 81; intervention, 136), for which 147 (68%) were cases of early syphilis (control, 61 [75%]; intervention, 86 [63%]). The annualized proportion with newly detected early syphilis increased from 0.009 to 0.032 with implementation of the intervention; the corresponding time-adjusted OR was 1.25 (95% CI, .71-2.20). CONCLUSIONS: The implementation of standing orders for syphilis testing with HIV viral loads was feasible and increased testing, yet produced less-than-expected increases in case detection compared to past uncontrolled pre-post trials. CLINICAL TRIALS REGISTRATION: NCT02019043.

Reporting on patients living with HIV "disengaging from care". Who is actually "lost to follow-up"?

Retention in care remains an important concern for health care providers. However, accurately identifying who is or is not retained in care can be problematic. Not all patients believed to be engaged in care are actually in care, and not all patients believed to be disengaged are truly disengaged. Identifying the status of individuals within populations is important for clinical, administrative and surveillance concerns. As part of the Linkage and Retention in Care Project at St Michael's Hospital in Toronto, Canada, we investigated the status of patients diagnosed with HIV. Detailed investigation determined who was actually Lost-to-Follow-Up (i.e., disengaged from care >12 months) and who had disengaged for known reasons. This approach determined more precisely who was currently followed in care and who was not, and to target efforts to contact and reengage patients more effectively. This study illustrates the importance of accurately monitoring populations enhancing disease management.

Using concept mapping to explore the challenges associated with affording and accessing medications among people living with HIV in Ontario, Canada.

Antiretroviral medications are expensive, and people living with HIV often experience challenges accessing and paying for medication due to various obstacles. We used concept mapping to explore the challenges people living with HIV in Ontario, Canada, face when accessing medication. In brainstorming, 68 participants generated 447 statements in response to the focus prompt "Some people living with HIV have trouble getting and paying for prescription drugs because … ". These were consolidated into 77 statements, which were sorted (n = 30) and rated (n = 32) on importance and commonality. A ten-cluster concept map consisting of individual- and health system-related clusters was generated. Clusters included: (1) Stigma, (2) Medication-Related Issues, (3) Individual Challenges, (4) Basic Needs, (5) Immigration, (6) Coverage, (7) Trillium Drug Program, (8) Access to Services, (9) System-Level Issues and (10) Access to Professional Services. Statements in Coverage and Basic Needs were rated most important and common although there was variability by Ontario residence and drug coverage mechanisms. Strategies to address challenges were generated in Interpretation (n = 25 participants). Given that continuous access to antiretroviral therapy is necessary to fully realize treatment benefits, policies and interventions that address these challenges are needed.

An exploration of the fertility desires and intentions of men living with HIV in Ontario, Canada.

Planning families is an important issue within the HIV community. The primary objective of this study was to explore the fertility desires and intentions of men living with HIV (MLWH). A cross-sectional survey containing 77 questions in 10 domains was developed, validated and administered to MLWH. The sample was stratified by sexual orientation, ethnicity, and city of residence. Logistic regression analyses were conducted to determine sociodemographic correlates of intention to have children. 276 men were recruited, of whom 118 (43%) identified as heterosexual and 158 (57%) as gay, bisexual, two-spirit or queer (GBTQ). 133 (45%) men wished and 120 (44%) actually intended to become a parent. Significantly more heterosexual men desired fatherhood (63% vs 37%, p < .0001) and intended to have children in the future (57% vs. 34%, p < .0001). Among all men, significant predictors of intention to have children were age ≤40, heterosexual orientation, African/Caribbean/Black ethnicity, living in Toronto, higher household income, and being partnered with an HIV-negative individual. When stratified by sexual orientation, younger age remained a significant correlate for both groups. A significant proportion of heterosexual and GBTQ MLWH desire and intend to become a parent. Health care providers and policy makers must support these individuals in their reproductive parenting needs.

The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile.

The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33-49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of "safer opioid supply" programs and impacts of COVID-19.

Late cognitive outcomes among allogeneic stem cell transplant survivors: follow-up data from a 6-year longitudinal study.

CONTEXT: Survivors of allogeneic hematopoietic stem cell transplantation (alloHCT) may experience cognitive impairment over time post-treatment, but early identification of these individuals is limited. OBJECTIVES: We previously reported a prospective evaluation of cognitive functioning over the first 6 months of alloHCT. Here, we report an extension of this study, with specific aims to (1) evaluate the trajectory of cognitive outcomes over the first 6 years post-alloHCT, and (2) determine the extent to which late cognitive impairment is predicted by earlier impairment. METHODS: Participants completed objective and subjective cognitive measures before alloHCT, and at 100 days, 6 months, and 6 years post-alloHCT. Outcome trajectories were determined using linear mixed effects models. Relationships between early and late cognitive impairment were assessed using logistic regression and receiver operator curves. RESULTS: This analysis is based on longitudinal data from 59 participants, of whom 20 provided data at 6-year follow-up. Longitudinal models revealed an overall stability of cognitive outcomes over time, except for psychomotor efficiency/processing speed performance, which significantly improved (p = .049). However, poor learning/memory and cognitive complaints were persistently observed. At 6 years, 40% of relapse-free survivors met the impairment criteria. Impairment at 100 days was associated with impairment 6 years (OR = 20.00, p = .028) and demonstrated good accuracy in classifying those who were impaired and not impaired at 6 years (AUC = .79; 95% CI = .56-1.00). CONCLUSION: Poor cognitive outcomes among long-term alloHCT survivors are associated with cognitive functioning during the early post-treatment period. Early identification of survivors likely to experience poor cognitive outcomes may be possible, enabling timely intervention to mitigate long-term negative impacts.

Impact of experienced HIV stigma on health is mediated by internalized stigma and depression: results from the people living with HIV stigma index in Ontario.

BACKGROUND: Experiences of HIV stigma remain prevalent across Canada, causing significant stress and negatively affecting the health and wellbeing of people living with HIV. While studies have consistently demonstrated that stigma negatively impacts health, there has been limited research on the mechanisms behind these effects. This study aims to identify which dimensions of stigma have significant relationships with self-rated health and examine the mechanisms by which those types of stigma impact self-rated health. METHODS: We recruited 724 participants to complete the People Living with HIV Stigma Index in Ontario, designed by people living with HIV to measure nuanced changes in stigma and discrimination. The present study utilizes data from externally validated measures of stigma and health risks that were included in the survey. First, we conducted multiple regression analyses to examine which variables had a significant impact on self-rated health. Results from the multiple regression guided the mediation analysis. A parallel mediation model was created with enacted stigma as the antecedent, internalized stigma and depression as the mediators, and self-rated health as the outcome. RESULTS: In the multiple regression analysis, internalized stigma (coefficient = -0.20, p < 0.01) and depression (coefficient = -0.07, p < 0.01) were both significant and independent predictors of health. Mediation analyses demonstrated that the relationship between enacted stigma and self-rated health is mediated in parallel by both internalized stigma [coefficient = -0.08, se = 0.03, 95% CI (-0.14, -0.02)] and depression [coefficient = -0.16, se = 0.03, 95% CI (-0.22, -0.11)]. CONCLUSIONS: We developed a mediation model to explain how HIV-related stigma negatively impacts health. We found that that enacted stigma, or experiences of prejudice or discrimination, can lead to internalized stigma, or internalization of negative thoughts regarding one's HIV status and/or increased depressive symptoms which then may lead to worse overall health. Highlighting the importance of internalized stigma and depression has the potential to shape the development of targeted intervention strategies aimed at reducing the burden of stigma and improving the health and wellbeing of people living with HIV.

An observed, prospective field study to evaluate the performance and acceptance of a blood-based HIV self-test in Canada.

BACKGROUND: Self testing for HIV is a targeted intervention with the potential to increase the access, uptake and frequency of HIV testing and more effectively reach the undiagnosed, especially in priority populations. The objectives of this study were to (1) evaluate the INSTI HIV self-test performance compared with laboratory reference testing, (2) document if intended users can perform the steps to use the HIV self-test device, and (3) document if intended users can successfully interpret contrived positive, negative, and invalid results. Study was intended to be submitted to Health Canada for review for regulatory approval purposes. METHODS: The study used a cross-sectional design and recruited consenting adults who were representative of intended users of HIV self-testing from four community sites across Ontario, Québec, and Manitoba between August 2019 and March 2020. The results of the observed HIV self-test were compared with results of the Abbott Architect HIV Ag/Ab Combo test. Usability outcomes for critical (e.g., lancing finger, blood droplet into bottle, shaking bottle four times) and noncritical self-test procedure steps were also determined. RESULTS: Overall, 77% (n = 522) of participants were between 18 and 45 years of age, 61% (n = 410) were male, 71% (n = 480) had some college or more education, and 45% (n = 307) were employed; identity for race and ethnicity: Caucasian (44%; n = 296), African, Caribbean or Black (17%; n = 113), Indigenous [First Nations, Métis or Inuit] (14%; n = 95), Asian (16%; n = 106), Latin American (7%; n = 46). Primary performance analysis on 678 completed HIV self-tests revealed a positive percent agreement of 100% (5/5, 95% CI: 43.6-97.0%) and a negative percent agreement of 99.5% (614/617, 95% CI: 98.6-99.8%) with the comparator method. The overall percent agreement of results interpretation between participant and observer was 93.5% (n = 633). For the 708 participants who took part in the usability study, the average success rate for steps determined to be "critical" for successful completion of the test was 92.4%. 97% (n = 670) of participants found the instructions easy to follow, and 95% (n = 655) of participants indicated that they would use the test again. Of the 404 participants who interpreted the strong positive, weak positive, negative, and invalid contrived results, successful interpretation ranged from 90.6% (for weak positive, n = 366) to 99.3% (for negative, n = 401). CONCLUSIONS: The addition of a regulatory-approved self-test into the Canadian HIV testing landscape could significantly increase HIV testing rates. Having a blood-based HIV self-test approved in Canada can offer an accurate, acceptable, and simple alternative to facility-based HIV testing, particularly when impacted by Coronavirus pandemic restrictions.

Stigma, Coping, and Alcohol Use Severity Among People Living With HIV: A Prospective Analysis of Bidirectional and Mediated Associations.

Background: HIV-related stigma is associated with health consequences among people living with HIV, including increased risk for alcohol problems. Theory suggests that maladaptive coping may mediate the relationship between HIV-related stigma and alcohol outcomes, and these variables may be bidirectionally associated over time. However, no studies have examined the temporal relationships among these variables in people living with HIV. Purpose: This study examined prospective bidirectional and mediated associations among HIV-related stigma, maladaptive coping, and alcohol use severity in patients enrolled in the Ontario HIV Treatment Network Cohort study. Method: Patients receiving care for HIV (N = 1,520) at one of several clinics completed self-report measures annually. Data were analyzed in a four-wave, cross-lagged panel model. Results: Greater HIV-related stigma at each wave consistently predicted increased maladaptive coping 1 year later. Similarly, maladaptive coping consistently predicted greater subsequent HIV-related stigma. Further, we observed some evidence that maladaptive coping mediated the prospective associations between HIV-related stigma and alcohol use severity in both directions (i.e., stigma to subsequent alcohol use severity and vice versa) although these associations were not observed across all waves. Conclusion: Results suggest that HIV-related stigma and maladaptive coping are bidirectionally associated with one another over time. This study also provides some evidence that coping may be a relevant mediator of these associations, although findings were less consistent for mediated pathways. Future research should examine whether interventions addressing stigma and coping among people living with HIV may help to minimize health risks such as hazardous drinking.

Elevated Mortality and Associated Social Determinants of Health in a Community-Based Sample of People Living with HIV in Ontario, Canada: Findings from the Positive Spaces, Healthy Places (PSHP) Study.

We examined social determinants of health associated with all-cause mortality among 602 people living with HIV/AIDS in Ontario, Canada. Mortality status was verified at 1-, 3-, and 5-year follow-up visits with information obtained from proxies (family members, partners, and friends), obituaries, and local AIDS memorial lists. Of the 454 people for whom mortality information was available, 53 individuals died yielding a crude mortality rate of 22.3 deaths per 1000 person-years, a rate substantially higher than the rate in the general population (6.8 per 1000 population). Experiencing both homelessness and incarceration independently predicted high risk of mortality among men who have sex with men (MSM) while suboptimal self-rated general health at previous visit predicted higher greater risk of mortality in both MSM and women and heterosexual men. Homelessness and incarceration may contribute to HIV disease progression and mortality. Intensive case management that increases retention in care and facilitates linkage to housing services may help to reduce excess deaths among people with HIV.

Assessing Timely Presentation to Care Among People Diagnosed with HIV During Hospital Admission: A Population-Based Study in Ontario, Canada.

Timely presentation to care for people newly diagnosed with HIV is critical to optimize health outcomes and reduce onward HIV transmission. Studies describing presentation to care following diagnosis during a hospital admission are lacking. We sought to assess the timeliness of presentation to care and to identify factors associated with delayed presentation. We conducted a population-level study using health administrative databases. Participants were all individuals older than 16 and newly diagnosed with HIV during hospital admission in Ontario, Canada, between April 1, 2007 and March 31, 2015. We used modified Poisson regression models to derive relative risk ratios for the association between sociodemographic and clinical variables and the presentation to out-patient HIV care by 90 days following hospital discharge. Among 372 patients who received a primary HIV diagnosis in hospital, 83.6% presented to care by 90 days. Following multivariable analysis, we did not find associations between patient sociodemographic or clinical characteristics and presentation to care by 90 days. In a secondary analysis of 483 patients diagnosed during hospitalization but for whom HIV was not recorded as the principal reason for admission, 73.1% presented to care by 90 days. Following multivariable adjustment, we found immigrants from countries with generalized HIV epidemics (RR 1.265, 95% CI 1.133-1.413) were more likely to present to care, whereas timely presentation was less likely for people with a mental health diagnosis (RR 0.817, 95% CI 0.742-0.898) and women (RR 0.748, 95% CI 0.559-1.001). Future work should evaluate mechanisms to facilitate presentation to care among these populations.

High retention in HIV care at a tertiary care centre in Toronto, Canada.

Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients' median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues.

Prevalence and predictors of food insecurity among people living with HIV affiliated with AIDS service organizations in Ontario, Canada.

Up to half of people living with HIV in resource-rich settings experience moderate to severe food insecurity. Food insecurity, in turn, has been linked to adverse health outcomes including poor antiretroviral adherence, poor HIV viral suppression, frailty, and mortality. We estimated the prevalence of food insecurity among 649 adults living with HIV and recruited from community-based AIDS service organizations in Ontario, Canada. Food security was assessed using the Canadian Household Food Security module. We used logistic regression modeling to identify demographic, socioeconomic, and psychosocial factors independently associated with food insecurity. Almost three-fourths of participants (70.3%) were food insecure and a third (31%) reported experiencing hunger. The prevalence of food insecurity in this sample is approximately six times higher than that of the general population. Factors independently associated with food insecurity were: having dependent children at home, residing in large urban areas, low annual household income (<$40,000), difficulty meeting housing-related expenses, cigarette smoking, harmful drug use, and depression. Broad, multisector interventions that address income, housing affordability, substance use and mental health issues are needed and could offset future public health expenditures.

Challenges with access to healthcare from the perspective of patients living with HIV: a scoping review & framework synthesis.

Accessing healthcare can be difficult but the barriers multiply for people living with HIV (PLHIV). To improve access and the health of PLHIV, we must consider their perspectives and use them to inform standard practice. A better understanding of the current literature related to healthcare access from the perspective of PLHIV, can help to identify evidence gaps and highlight research priorities and opportunities. To identify relevant peer-reviewed publications, search strategies were employed. Electronic and grey literature databases were explored. Articles were screened based on their title and abstract and those that met the screening criteria, were reviewed in full. Data analysis was conducted using a collaborative approach that included knowledge user consultation. Initial concepts were extracted, summarized and through framework synthesis, developed into emerging and final themes. From 20,678 articles, 326 articles met the initial screening criteria and 64 were reviewed in full. The final themes identified, in order of most to least frequent were: Acceptability, Availability, Accessibility, Affordability, Other Barriers, Communication, Satisfaction, Accommodation, Preferences and Equity in Access. The most frequently discussed concepts related to negative interactions with staff, followed by long wait times, limited household resources or inability to pay fees, and fear of one's serostatus being disclosed. Knowledge users were in agreement with the categorization of initial concepts and final themes; however, some gaps in the literature were identified. Specific changes are critical to improving access to healthcare for PLHIV. These include improving availability by ensuring staff and healthcare professionals have proper training, cultivating acceptability and reducing stigma through improving HIV awareness, increasing accessibility through increased HIV information for PLHIV and improved dissemination of this information to increase patient knowledge and health awareness. Finally, ensuring proper protocols are implemented and followed to guarantee patient confidentiality and overall satisfaction with healthcare services are recommended.

Unmet basic needs negatively affect health-related quality of life in people aging with HIV: results from the Positive Spaces, Healthy Places study.

BACKGROUND: Basic needs (e.g., food security and stable housing) are important determinants of health and well-being, yet their impact on health-related quality of life (HRQoL) in the context of HIV and aging has not been systematically investigated. METHODS: Multiple linear regression models examined the relationship between unmet basic needs, and physical and mental HRQoL by age strata (20-34, 35-49 and 50+) in a cross-sectional sample of 496 people living with HIV in Ontario, Canada. RESULTS: An overwhelming majority of participants (87%) reported unmet needs related to food, clothing or housing. The prevalence of unmet basic needs in the two older groups appeared to be lower than among younger participants, but the difference did not reach statistical significance. The presence of unmet basic needs predicted substantially lower mean physical health and mental health summary scores in the two oldest groups. Notably, age moderated the influence of unmet basic needs on HRQoL. CONCLUSIONS: The availability and accessibility of food security, appropriate clothing and stable housing for people living with HIV who are aging need to become a higher priority for program planners and decision makers.

"I'm Just Forgetting and I Don't Know Why": Exploring How People Living With HIV-Associated Neurocognitive Disorder View, Manage, and Obtain Support for Their Cognitive Difficulties.

HIV-associated neurocognitive disorder (HAND) is common, but the lived experience of HAND is not well-understood. In this descriptive qualitative study, we explored how adults with HAND view, manage, and obtain support for cognitive difficulties. We interviewed 25 participants (20% female; median age = 51 years) who were diagnosed with HAND using neuropsychological assessment and a clinical interview. Semistructured interviews, co-developed with community members living with HIV, focused on how cognitive difficulties manifested and progressed, impacted well-being, and were discussed with others. We analyzed interview transcripts using a team-based, thematic approach. Participants described concentration, memory, and multitasking difficulties that fluctuated over time, as well as potential risk factors, management strategies, and psychosocial consequences. They reported they seldom discussed cognitive impairment with health care professionals, and that receiving a HAND diagnosis was validating, informative, yet somewhat disconcerting. Conversations between health care professionals and people living with HIV about HAND may provide opportunities for education, assessment, and support.

Serosorting and recreational drug use are risk factors for diagnosis of genital infection with chlamydia and gonorrhoea among HIV-positive men who have sex with men: results from a clinical cohort in Ontario, Canada.

OBJECTIVES: Rates of chlamydia and gonorrhoea have been rising in urban centres in Canada, particularly among HIV-positive men who have sex with men (MSM). Our objective was to identify behavioural risk factors for diagnosis with chlamydia and gonorrhoea in this population, with a focus on the HIV status of sexual partners. METHODS: The OHTN Cohort Study follows people in HIV care across Ontario. We restricted the analysis to 1997 MSM who completed questionnaires in 2010-2013 at one of seven clinics that submit all chlamydia and gonorrhoea tests to the provincial public health laboratory; we obtained test results via record linkage. We estimated cumulative incidences using Kaplan-Meier methods and identified risk factors for diagnosis of a composite outcome (chlamydia or gonorrhoea infection) using Cox regression. RESULTS: At follow-up, there were 74 new chlamydia/gonorrhoea diagnoses with a 12-month cumulative incidence of 1.7% (95% CI 1.1% to 2.2%). Risk factors for chlamydia/gonorrhoea diagnosis were: 5+ HIV-positive partners (HR=3.3, 95% CI 1.4 to 7.8; reference=none) and recreational drug use (HR=2.2, 95% CI 1.2 to 3.9). CONCLUSIONS: Heightened risks with recreational drug use and multiple HIV-positive partners suggest that chlamydia/gonorrhoea may have achieved high prevalence in certain sexual networks among HIV-positive MSM. Interventions to promote safer sex and timely testing among MSM are needed.