Reach of GetCheckedOnline among gay, bisexual, transgender and queer men and Two-Spirit people and correlates of use 5 years after program launch in British Columbia, Canada.

OBJECTIVES: Understanding who uses internet-based sexually transmitted and blood-borne infection (STBBI) services can inform programme implementation, particularly among those most impacted by STBBIs, including gender and sexual minority (GSM) men. GetCheckedOnline, an internet-based STBBI testing service in British Columbia, Canada, launched in 2014. Our objectives were to assess reach, identify factors associated with use of GetCheckedOnline 5 years into implementation and describe reasons for using and not using GetCheckedOnline among GSM men. METHODS: The Sex Now 2019 Survey was an online, cross-sectional survey of GSM men in Canada administered from November 2019 to February 2020. Participants were asked a subset of questions related to use of GetCheckedOnline. Multivariable binary logistic regression modelling was used to estimate associations between correlates and use of GetCheckedOnline. RESULTS: Of 431 British Columbia (BC) participants aware of GetCheckedOnline, 27.6% had tested using the service. Lower odds of having used GetCheckedOnline were found among participants with non-white race/ethnicity (adjusted OR (aOR)=0.41 (95% CI 0.21 to 0.74)) and those living with HIV (aOR=0.23 (95% CI 0.05 to 0.76)). Those who usually tested at a walk-in clinic, relative to a sexual health clinic, had greater odds of using GetCheckedOnline (aOR=3.91 (95% CI 1.36 to 11.61)). The most commonly reported reason for using and not using GetCheckedOnline was convenience (78%) and only accessing the website to see how the service worked (48%), respectively. CONCLUSION: Over a quarter of GSM men in BC aware of GetCheckedOnline had used it. Findings demonstrate the importance of social/structural factors related to use of GetCheckedOnline. Service promotion strategies could highlight its convenience and privacy benefits to enhance uptake.

"To do so in a patient-centred way is not particularly lucrative": The effects of neoliberal health care on PrEP implementation and delivery.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention used by HIV-negative people to prevent HIV acquisition. Despite increased use of PrEP worldwide, several barriers to PrEP implementation have resulted in insufficient uptake, inadequate adherence, and frequent discontinuation. Our objective was to interrogate the social, political, and economic conditions shaping PrEP implementation and delivery among gay, bisexual, queer and other men who have sex with men (GBQM) in Ontario, Canada. METHODS: Six focus groups and three interviews with 20 stakeholders in Ontario (e.g., healthcare professionals, clinicians, community-based organization staff, and government staff) were conducted between July and October 2021. Participants were asked about the personal, workplace, and structural factors shaping PrEP delivery strategies for GBQM. Transcripts were analyzed using reflexive thematic analysis informed by the political economy of PrEP and employed a critique of neoliberalism. RESULTS: Participants critiqued the problematic arrangements of the current healthcare system in Canada. Neoliberal governmentality and policies have resulted in inequitable PrEP care by establishing funding structures prioritizing profit and requiring patients and providers to function as individual entrepreneurs. Consequently, healthcare disparities are compounded for marginalized peoples who lack the resources and capacity to navigate existing healthcare systems. Participants identified several pathways to improve the implementation of PrEP, including greater institutional and governmental supports for PrEP and healthcare, leveraging communities and collaboration, and moving beyond risk-based health frameworks. CONCLUSION: Socio-political-economic changes reflecting post-neoliberal principles are needed to overcome existing barriers to PrEP care, and sexual and reproductive healthcare more broadly.

Using an intersectionality-based approach to evaluate mental health services use among gay, bisexual and other men who have sex with men in Montreal, Toronto and Vancouver.

AIMS: To cope with homonegativity-generated stress, gay, bisexual and other men who have sex with men (GBM) use more mental health services (MHS) compared with heterosexual men. Most previous research on MHS among GBM uses data from largely white HIV-negative samples. Using an intersectionality-based approach, we evaluated the concomitant impact of racialization and HIV stigma on MHS use among GBM, through the mediating role of perceived discrimination (PD). METHODS: We used baseline data from 2371 GBM enrolled in the Engage cohort study, collected between 2017 and 2019, in Montreal, Toronto and Vancouver, using respondent-driven sampling. The exposure was GBM groups: Group 1 (n = 1376): white HIV-negative; Group 2 (n = 327): white living with HIV; Group 3 (n = 577): racialized as non-white HIV-negative; Group 4 (n = 91): racialized as non-white living with HIV. The mediator was interpersonal PD scores measured using the Everyday Discrimination Scale (5-item version). The outcome was MHS use (yes/no) in the prior 6 months. We fit a three-way decomposition of causal mediation effects utilizing the imputation method for natural effect models. We obtained odds ratios (ORs) for pure direct effect (PDE, unmediated effect), pure indirect effect (PIE, mediated effect), mediated interaction effect (MIE, effect due to interaction between the exposure and mediator) and total effect (TE, overall effect). Analyses controlled for age, chronic mental health condition, Canadian citizenship, being cisgender and city of enrolment. RESULTS: Mean PD scores were highest for racialized HIV-negative GBM (10.3, SD: 5.0) and lowest for white HIV-negative GBM (8.4, SD: 3.9). MHS use was highest in white GBM living with HIV (GBMHIV) (40.4%) and lowest in racialized HIV-negative GBM (26.9%). Compared with white HIV-negative GBM, white GBMHIV had higher TE (OR: 1.71; 95% CI: 1.27, 2.29) and PDE (OR: 1.68; 95% CI: 1.27, 2.24), and racialized HIV-negative GBM had higher PIE (OR: 1.09; 95% CI: 1.02, 1.17). Effects for racialized GBMHIV did not significantly differ from those of white HIV-negative GBM. MIEs across all groups were comparable. CONCLUSIONS: Higher MHS use was observed among white GBMHIV compared with white HIV-negative GBM. PD positively mediated MHS use only among racialized HIV-negative GBM. MHS may need to take into account the intersecting impact of homonegativity, racism and HIV stigma on the mental health of GBM.

Human Immunodeficiency Virus Treatment Attitudes and Bacterial Sexually Transmitted Infections Among Gay and Bisexual Men.

BACKGROUNDS: Positive attitudes toward human immunodeficiency virus (HIV) treatment, such as reduced concern about HIV transmissibility, are associated with sexual behaviors that may increase the risk of bacterial sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (GBM). We examined associations between HIV treatment attitudes and bacterial STI diagnoses among GBM in Canada's three largest cities. METHODS: We fit a structural equation model between HIV treatment attitudes and bacterial STI diagnoses via sexual behaviors in the Engage study's baseline data. We estimated direct and indirect paths between scores on HIV treatment attitudes and STIs via number of male anal sex partners, condomless anal sex, and oral sex. We conducted sub-analyses with participants stratified by HIV serostatus. RESULTS: Among 2449 GBM recruited in 2017 to 2019, there was a direct association between HIV treatment attitudes and current STI diagnoses (ß = 0.13; 95% CI, 0.07-0.19; P < 0.001). The mediated model revealed a positive total indirect effect through 2 pathways: (1) engaging in condomless anal sex and (2) number of male anal sex partners and condomless anal sex. These 2 indirect pathways remained in the stratified mediation models for both HIV negative GBM and for GBM living with HIV. CONCLUSIONS: The association between HIV treatment attitudes and diagnosed STIs is mediated through a higher number of male anal sex partners and condomless anal sex. The results highlight the importance of providers educating patients when providing effective STI counseling, testing, and prevention for GBM about how accurate HIV treatment attitudes may inadvertently be associated with the bacterial STI epidemic.

Problematic alcohol use among gay, bisexual, and other men who have sex with men in Canada: the role of proximal stressors and anxiety.

BACKGROUND: Gay, bisexual, and other men who have sex with men (GBM) report high rates of problematic alcohol use, anxiety, and depression. This may, in part, be due to stressors related to their sexual identity (i.e., minority stressors). However, few studies have examined both distal and proximal stressors, as well as the specific psychological mechanisms by which these stressors may be related to alcohol use outcomes, in a representative sample of GBM. We explored the relationship between distal and proximal stressors and alcohol use outcomes, as well as the role of anxiety and depression as potential mediators of these relationships. METHODS: We analyzed the baseline data of 2,449 GBM from Engage, a cohort study of sexually active GBM recruited using respondent-driven sampling (RDS) in Montreal, Toronto, and Vancouver from February 2017 to August 2019. Using structural equation modeling, we examined the associations between distal minority stressors (i.e., experiences of heterosexist harassment, rejection, and discrimination), proximal minority stressors (i.e., internalized homonegativity, concerns about acceptance, concealment, and lack of affirmation), anxiety and depression, and alcohol consumption and alcohol use problems. RDS-adjusted analyses controlled for age, income, sexual orientation, ethnicity, recruitment city, and HIV serostatus. RESULTS: There were positive direct associations between distal stress and proximal stress, anxiety, and depression, but not alcohol use outcomes. Proximal stress had a positive direct association with anxiety, depression, and alcohol use problems, but not alcohol consumption. Anxiety was positively associated with alcohol consumption and alcohol use problems. Depression was negatively associated with alcohol consumption but not alcohol use problems. Regarding indirect effects, distal stress was associated with alcohol use outcomes via proximal stress and anxiety, but not via depression. CONCLUSIONS: We found support for a minority stress model as it relates to alcohol use outcomes among GBM. Findings suggest that proximal minority stress and anxiety differentially impact the problematic alcohol use among GBM who experience heterosexist discrimination. Clinical providers should consider incorporating the treatment of proximal minority stressors and anxiety into existing alcohol interventions for GBM.

Ethno-racial variations in mental health symptoms among sexually-active gay, bisexual, and other men who have sex with men in Vancouver, Canada: a longitudinal analysis.

BACKGROUND: Minority stress from racism and heterosexism may uniquely interact to impact the mental health of racialized sexual minorities. We examined variations in anxiety and depressive symptoms by reported by ethno-racial identity among gay, bisexual, and other men who have sex with men (gbMSM) in Vancouver, Canada. METHODS: We recruited gbMSM aged ≥ 16 years from February 2012 to February 2015 using respondent-driven sampling (RDS). Participants completed computer assisted self-interviews (CASI) at enrollment and every 6 months until February 2017. We examined factors associated with moderate/severe anxiety and depression scores (> 10) on the Hospital Anxiety and Depression Scale (HADS) and differences in key explanatory variables including sociodemographic, psychosocial, and substance use factors. We used multivariable mixed effects models to assess whether moderate/severe scores were associated with ethno-racial identity across all visits. RESULTS: After RDS-adjustment, of 774 participants, 79.9% of participants identified as gay. 68.6% identified as white, 9.2% as Asian, 9.8% as Indigenous, 7.3% as Latin American, and 5.1% as other ethno-racial identities. Participants contributed a median of 6 follow-up visits (Q1-Q3: 4-7). In the multivariable analysis, Asian participants had decreased odds of moderate/severe anxiety scores compared to white participants (aOR = 0.39; 95% CI: 0.18-0.86), and Latin American participants had decreased odds of moderate/severe depression scores compared to both white (aOR = 0.17; 95% CI: 0.08-0.36) and Asian (aOR = 0.07; 95% CI: 0.02-0.20) participants. CONCLUSION: Asian and Latino gbMSM reported decreased mental health symptoms compared to white participants. Asian and Latino gbMSM in Vancouver appear to manage multiple minority stressors without adversely affecting their mental health.

'It's not as good as the face-to-face contact': A sociomaterialist analysis of the use of virtual care among Canadian gay, bisexual and queer men during the COVID-19 pandemic.

The COVID-19 pandemic led to the widespread adoption of virtual care-the use of communication technologies to receive health care at home. We explored the differential impacts of the rapid transition to virtual care during the COVID-19 pandemic on health-care access and delivery for gay, bisexual and queer men (GBQM), a population that disproportionately experiences sexual and mental health disparities in Canada. Adopting a sociomaterial theoretical perspective, we analysed 93 semi-structured interviews with GBQM (n = 93) in Montreal, Toronto and Vancouver, Canada, conducted between November 2020 and February 2021 (n = 42) and June-October 2021 (n = 51). We focused on explicating how the dynamic relations of humans and non-humans in everyday virtual care practices have opened or foreclosed different care capacities for GBQM. Our analysis revealed that the rapid expansion and implementation of virtual care during the COVID-19 pandemic enacted disruptions and challenges while providing benefits to health-care access among some GBQM. Further, virtual care required participants to change their sociomaterial practices to receive health care effectively, including learning new ways of communicating with providers. Our sociomaterial analysis provides a framework that helps identify what works and what needs to be improved when delivering virtual care to meet the health needs of GBQM and other diverse populations.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities.

BACKGROUND: We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time. METHODS: We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable. RESULTS: We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29). CONCLUSIONS: Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

Migration and health study: a socio-ecological analysis of sexual health among migrants in Manitoba, Canada.

BACKGROUND: To develop effective public health policies, programs, and services tailored to the unique sexual health needs of migrant populations, it is essential to understand the myriad socio-ecological factors that influence their sexual health. This qualitative community-based participatory study aimed to explore factors influencing migrants' sexual health at different socio-ecological levels in a Canadian setting. METHODS: Participants (n = 34) from African, Caribbean, Black; Latin American; South Asian; Middle Eastern, as well as East and Southeast Asian communities were recruited across Manitoba using printed flyers, community organizations, and social media. Individual interviews, conducted in English, French, Mandarin, Cantonese, Tagalog, Arabic, Swahili, and Tigrinya languages, explored questions relating to sexual health and experiences with service providers. Data were analyzed using reflexive thematic analysis and socio-ecological systems theory. RESULTS: The study uncovered a range of individual, interpersonal, institutional, and socio-structural factors that affect the sexual health of migrants in Manitoba. Individual factors such as sexual health knowledge and testing practices, interpersonal factors like the type of sexual partnerships, institutional factors such as sexual health information needs, language, and service access barriers, and structural-level factors like gender norms and HIV stigma exerted a significant influence on the sexual health practices of study respondents. Sexual health awareness was influenced by various factors including length of time in Canada and involvement in community-based services. Study respondents identified issues related to access to HIV testing and sexual health information, as well as language barriers, racism in healthcare, and HIV stigma. Gender and social norms played a significant role in discouraging communication about sex and safer sex practices. CONCLUSIONS: The study highlights the complex interplay of factors that influence the sexual health of migrants, and the need for targeted sexual health awareness campaigns and provision of sexual health information in languages spoken by migrants. Public health interventions focused on improving the sexual health outcomes for migrants should consider the socio-ecological elements identified in this study. These findings can inform public health campaigns to increase access to services and address sexual health inequities among migrant communities in Canada.

Conformity to Masculinity Norms and Mental Health Outcomes Among Gay, Bisexual, Trans, Two-Spirit, and Queer Men and Non-Binary Individuals.

Homophobia and biphobia negatively impact the mental health of gay, bisexual, trans, Two-Spirit, and queer men and non-binary individuals (GBT2Q) and sexual and gender minority men, but little is known about the impact of gender-related oppression. The current study examines the impact of pressure to conform to masculine norms in Canada-based GBT2Q individuals. Specifically, the associations between (a) gender expression and pressure to be masculine and (b) pressure to be masculine and depression, anxiety, and self-rated mental health were investigated. Drawing from an online national cross-sectional survey of 8,977 GBT2Q individuals and sexual and gender minority men living in Canada aged 15 years or older, 56.4% (n = 5,067) of respondents reported experiencing pressure to conform to masculine norms. Respondents were more likely to report masculine pressure if they were younger than 30 years, described their gender expression as fluid, identified their sexuality as queer, were an ethnoracial minority, and were trans. Pressure to be masculine was associated with increased odds of depression, anxiety, and reporting poor or fair mental health. The current study provides evidence of the detrimental impact of pressure to conform to masculine norms on the mental health of gay, bisexual, trans, Two-Spirit, and queer men and non-binary peoples.

Examining the secondary impacts of the COVID-19 pandemic on syndemic production and PrEP use among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada.

BACKGROUND: The secondary impacts of the COVID-19 pandemic may disproportionately affect gay, bisexual, and other men who have sex with men (GBM), particularly related to HIV prevention and treatment outcomes. We applied syndemic theory to examine PrEP disruptions during the during the height of the COVID-19 pandemic in Vancouver, Canada. METHODS: Sexually-active GBM, aged 16 + years, were enrolled through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview every six months and data were linked to the BC PrEP Program (program responsible for publicly funded PrEP in the province) to directly measure PrEP disruptions. The analysis period for this study was from March 2018-April 2021. We used univariable generalized linear mixed models to examine (1) six-month trends for syndemic conditions: the prevalence of moderate/severe depressive or anxiety symptoms, polysubstance use, harmful alcohol consumption, intimate partner violence, and (2) six-month trends for PrEP interruptions among HIV-negative/unknown GBM. We also applied 3-level mixed-effects logistic regression with RDS clustering to examine whether syndemic factors were associated with PrEP interruptions. RESULTS: Our study included 766 participants, with 593 participants who had at least one follow-up visit. The proportion of respondents with abnormal depressive symptoms increased over the study period (OR = 1.35; 95%CI = 1.17, 1.56), but we found decreased prevalence for polysubstance use (OR = 0.89; 95%CI = 0.82, 0.97) and binge drinking (OR = 0.74; 95%CI = 0.67, 0.81). We also found an increase in PrEP interruptions (OR = 2.33; 95%CI = 1.85, 2.94). GBM with moderate/severe depressive symptoms had higher odds (aOR = 4.80; 95%CI = 1.43, 16.16) of PrEP interruptions, while GBM with experiences of IPV had lower odds (aOR = 0.38; 95%CI = 0.15, 0.95) of PrEP interruptions. GBM who met clinical eligibility for PrEP had lower odds of experiencing PrEP interruptions (aOR = 0.25; 95%CI = 0.11, 0.60). CONCLUSION: There were increasing PrEP interruptions since March 2020. However, those most at risk for HIV were less likely to have interruptions. Additional mental health services and targeted follow-up for PrEP continuation may help to mitigate the impacts of the COVID-19 pandemic on GBM.

Unpacking racism during COVID-19: narratives from racialized Canadian gay, bisexual, and queer men.

OBJECTIVE: Epidemics impact individuals unevenly across race, gender, and sexuality. In addition to being more vulnerable to COVID-19 infection, evidence suggests racialized gender and sexual minorities experienced disproportionate levels of discrimination and stigma during the COVID-19 epidemic. Drawing on Critical Race Theory (CRT), we examined the experiences of gay, bisexual, queer, and other men who have sex with men (GBQM) of colour facing discrimination during COVID-19. DESIGN: Engage-COVID-19 is a mixed methods study examining the impact of COVID-19 on GBQM living in Vancouver, Toronto, and Montréal, Canada. We conducted two rounds of qualitative interviews (November 2020 to February 2021, and June to October 2021) with 93 GBQM to explore the evolving impact of COVID-19 on their lives. Transcripts were coded using inductive thematic analysis. Data analysis was conducted using Nvivo software. RESULTS: Fifty-nine participants identified as Black, Indigenous, and/or a Person of Colour (BIPOC). These GBQM of colour described multiple experiences of discrimination during COVID-19. Although participants did not report experiences of discrimination based on their sexual identity during COVID-19, we found that experiences of racism affected how they were treated within their sexual networks. Experiences of racism were most often reported by East Asian and Black GBQM. These participants faced racism in public and online spaces, primarily in the form of verbal harassment. Several participants were also harassed because they wore face masks. Verbal abuse against GBQM of colour was largely prompted by racist discourses related to COVID-19. CONCLUSION: Racism remains a pernicious threat to the well-being of GBQM of colour. CRT highlights the importance of assessing how sexualized and gendered discourses about race shape the experiences of GBQM of colour navigating multiple epidemics like COVID-19 and HIV. These pervasive discourses unevenly affect racial and sexual minorities across multiple epidemics, and negatively impact health outcomes for these populations.

Correlates of hazardous alcohol drinking among trans and non-binary people in Canada: A community-based cross-sectional study.

PURPOSE: Transgender and non-binary people (TGNB) have a higher rate of heavy episodic drinking than cisgender people; however, extant knowledge about predictors of hazardous alcohol drinking (HAD) among different TGNB groups is limited. This study examined predictors of HAD in a national sample of TGNB people in Canada. METHODS: Logistic regression models were fit to examine the effects of 1) minority stressors and 2) stress-buffering factors on the likelihood of HAD, stratified by gender, among 2324 TGNB individuals from the Trans PULSE Canada survey, a cross-sectional survey conducted in 2019 among trans and non-binary people aged 14+ in Canada. RESULTS: Almost 17% of participants reported past-year HAD. Lifetime day-to-day and lifetime major discrimination were associated with higher odds of HAD in the full sample [(AOR=1.37, 95% CI: 1.30, 1.44) and (AOR=1.69, 95% CI: 1.55, 1.86) respectively], and across all gender groups. Social support was associated with lower odds of HAD in trans men, non-binary people assigned female at birth (NB-AFAB), and non-binary people assigned male at birth (NB-AMAB) groups, but with higher odds of HAD in the trans women group. Misgendering was associated with lower odds of HAD in trans men and NB-AFAB, but higher odds of HAD in trans women and NB-AMAB. Mixed effects of gender distress, gender positivity, and gender-affirming medical care were also reported across groups. CONCLUSION: The study provided a more detailed understanding of the predictors of HAD across four TGNB groups. Public health interventions should focus on structural discrimination and social support for TGNB people.

Examining differential success in recruitment using respondent driven sampling (RDS) in a multi-site study of gay, bisexual and other men who have sex with men.

BACKGROUND: The Engage Study is a longitudinal biobehavioral cohort study of gay, bisexual and other men who have sex with men (GBM) in Toronto, Montreal, and Vancouver. Baseline data (2,449 participants) were collected from February 2017 - August 2019 using respondent-driven sampling (RDS). Recruitment in Montreal required fewer seeds, had a much shorter recruitment period, and recruited the largest sample. METHODS: To better understand why RDS recruitment was more successful in Montreal compared to other sites, we conducted an analysis to examine RDS recruitment characteristics for GBM in each of the three study sites, explore demographic characteristics and measures of homophily, that is, the tendency of individuals to recruit other study participants who are like themselves, and compared motivations for study participation. RESULTS: Montreal had the greatest proportion of participants over the age of 45 (29.1% in Montreal, 24.6% in Vancouver, and 21.0% in Toronto) and the highest homophily for this age group, but homophily was high across the three cities. Montreal also reported the lowest percentage of participants with an annual income greater or equal to $60,000 (7.9% in Montreal, 13.1% in Vancouver and 10.6% in Toronto), but homophily was similar across all three cities. The majority of participants indicated interest in sexual health and HIV as the main reason for participating (36.1% in Montreal, 34.7% in Vancouver, and 29.8% in Toronto). Financial interest as the main reason for participation was low (12.7% in Montreal, 10.6% in Vancouver, and 5.7% in Toronto). CONCLUSION: Taken together, although we found some differences in study demographic characteristics and homophily scores, we were unable to fully explain the different recruitment success based on the data available. Our study underlines the fact that success of RDS implementation may vary by unknown factors, and that researchers should be proactive and flexible to account for variability.

Reasons for not using pre-exposure prophylaxis for HIV and strategies that may facilitate uptake in Ontario and British Columbia among gay, bisexual and other men who have sex with men: a cross-sectional survey.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV is underutilized. We aimed to identify barriers to use of PrEP and strategies that may facilitate its uptake. METHODS: Gay, bisexual and other men who have sex with men, aged 19 years or older and living in Ontario and British Columbia, Canada, completed a cross-sectional survey in 2019-2020. Participants who met Canadian PrEP guideline criteria and were not already using PrEP identified relevant barriers and which strategies would make them more likely to start PrEP. We described the barriers and strategies separately for Ontario and BC. RESULTS: Of 1527 survey responses, 260 respondents who never used PrEP and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about adverse effects (42%). In BC, the most common reasons were concern about adverse effects (41%) and not feeling at high enough risk (36%). In Ontario, preferred strategies were short waiting time (63%), the health care provider informing about their HIV risk being higher than perceived (62%), and a written step-by-step guide (60%). In BC, strategies were short waiting time (68%), people speaking publicly about PrEP (68%), and the health care provider counselling about their HIV risk being higher than perceived (64%), adverse effects of PrEP (65%) and how well PrEP works (62%). INTERPRETATION: Concern about adverse effects and not self-identifying as having high risk for HIV were common barriers, and shorter waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability, whereas in BC, strategies involving health care providers were valued.

Disjuncture between self-perceived and clinically assessed risk of HIV among gay, bisexual, and other men who have sex with men in Ontario and British Columbia, Canada.

BACKGROUND: Self-perceived and clinically assessed HIV risk do not always align. We compared self-perceived and clinically assessed risk of HIV and the reasons for self-perceived low risk of HIV among gay, bisexual, and other men who have sex with men (GBM) from large urban centers in Ontario and British Columbia, Canada. METHODS: Never PrEP users recruited from sexual health clinics or online, completed a cross-sectional survey between July/2019 and August/2020. We contrasted self-perceived HIV risk against criteria from the Canadian PrEP guidelines and participants were categorized as concordant or discordant. We used content analysis to categorize participants' free-text explanations for perceived low HIV risk. These were compared with answers to quantitative responses about condomless sex acts and number of partners. RESULTS: Of 315 GBM who self-perceived low risk of HIV, 146 (46%) were considered at high risk according to the guidelines. Participants with discordant assessment were younger, had less years of formal education, were more often in an open relationship and were more likely to self-identify as gay. Reasons for self-perceived low HIV risk in the discordant group were condom use (27%), being in a committed relationship/having one main partner (15%), having no or infrequent anal sex (12%) and having few partners (10%). CONCLUSIONS: There is a disjuncture between self-perceived and clinically assessed risk of HIV. Some GBM may underestimate their HIV risk and clinical criteria may overestimate risk. Bridging these gaps requires efforts to increase HIV risk awareness in the community, and refinement of clinical assessments based on individualized discussions between the provider and the user.

Injectable Pre-Exposure Prophylaxis for HIV Prevention: Perspectives on the Benefits and Barriers from Gay, Bisexual, and Queer Men and Health System Stakeholders in Ontario, Canada.

One hope surrounding long-acting HIV pre-exposure prophylaxis (PrEP) is reaching new users who could most benefit, as well as improving the experiences of oral PrEP users who may desire to switch modalities. Gay, bisexual, queer, and other men who have sex with men (GBQM) continue to make up over half of new HIV diagnoses in Canada, and oral PrEP uptake has plateaued among this population. Approval of injectable PrEP is anticipated, but there is a paucity of research to inform health promotion and implementation. Between June and October 2021, we conducted 22 in-depth interviews with GBQM oral PrEP users and non-PrEP users living in Ontario, Canada. We also conducted small focus groups or individual interviews with 20 key stakeholders (health care providers, public health officials, community-based organization staff). Interviews were audio recorded, transcribed verbatim, and analyzed in NVivo using thematic analysis. Only about one-third of GBQM had heard of injectable PrEP. Many PrEP users perceived greater convenience, adherence, and confidentiality with injectable PrEP. Some PrEP users did not anticipate switching because of needle discomfort or feeling more "in control" with oral PrEP. None of the non-PrEP users said that injectable PrEP would make them start PrEP. Injectable PrEP may offer additional convenience for GBQM; however, it did not appear to affect participants' PrEP decision-making significantly. Stakeholders noted that injectable PrEP may improve access, support adherence, and benefit marginalized groups. Some clinicians expressed concerns about the time/personnel required to make injectable PrEP available. System-level challenges in implementing injectable PrEP, including cost, must also be addressed.

Comparison of the burden of self-reported bacterial sexually transmitted infections among men having sex with men across 68 countries on four continents.

BACKGROUND: Men who have sex with men (MSM) are in general more vulnerable to sexually transmitted infections (STIs) than the heterosexual men population. However, surveillance data on STI diagnoses lack comparability across countries due to differential identification of MSM, diagnostic standards and methods, and screening guidelines for asymptomatic infections. METHODS: We compared self-reported overall diagnostic rates for syphilis, gonorrhea, and chlamydia infections, and diagnostic rates for infections that were classified to be symptomatic in the previous 12 months from two online surveys. They had a shared methodology, were conducted in 68 countries across four continents between October 2017 and May 2018 and had 202,013 participants. RESULTS: Using multivariable multilevel regression analysis, we identified age, settlement size, number of sexual partners, condom use for anal intercourse, testing frequency, sampling rectal mucosa for extragenital testing, HIV diagnosis, and pre-exposure prophylaxis use as individual-level explanatory variables. The national proportions of respondents screened and diagnosed who notified some or all of their sexual partners were used as country-level explanatory variables. Combined, these factors helped to explain differences in self-reported diagnosis rates between countries. The following differences were not explained by the above factors: self-reported syphilis diagnoses were higher in Latin America compared with Europe, Canada, Israel, Lebanon, and the Philippines (aORs 2.30 - 3.71 for symptomatic syphilis compared to Central-West Europe); self-reported gonorrhea diagnoses were lower in Eastern Europe and in Latin America compared with all other regions (aORs 0.17-0.55 and 0.34 - 0.62 for symptomatic gonorrhea compared to Central-West Europe); and self-reported chlamydia diagnoses were lower in Central East and Southeast Europe, South and Central America, and the Philippines (aORs 0.25 - 0.39 for symptomatic chlamydia for Latin American subregions compared to Central West Europe). CONCLUSIONS: Possible reasons for differences in self-reported STI diagnosis prevalence likely include different background prevalence for syphilis and syndromic management without proper diagnosis, and different diagnostic approaches for gonorrhea and chlamydia.

Gay, bisexual, and queer men's confidence in the Undetectable equals Untransmittable HIV prevention message: longitudinal qualitative analysis of the sexual decision-making of pre-exposure prophylaxis users over time.

BACKGROUND: Our objective was to understand what gay, bisexual, and queer men (GBQM) who had experience using pre-exposure prophylaxis (PrEP) thought about the 'Undetectable equals Untransmittable' (U=U) message and how it informed their sexual decision-making over time. METHODS: We conducted annual longitudinal qualitative interviews (2020-22) with 17 current or former PrEP users as part of a mixed-methods implementation science study examining barriers and facilitators to PrEP awareness, access, and adherence. Over 3years, 47 interviews were conducted with GBQM in Ontario, Canada. Interviews were transcribed verbatim and coded in NVivo following reflexive thematic analysis. RESULTS: Participants' sexual health decision-making was informed by their confidence in biomedical HIV prevention and the person taking medication (i.e. themselves using PrEP versus a real/imagined person living with HIV (PLHIV)). Longitudinal narratives of U=U clustered around four overarching themes: (1) U=U confidence (i.e. increasing trust in U=U irrespective of their PrEP use); (2) PrEP confidence (i.e. accounts of self-reliance and PrEP as sufficient HIV protection); (3) combination confidence (i.e. trusting U=U and PrEP as a package); and (4) partner confidence (i.e. potential 'distrust' of U=U due to uncertainties about partners' medication adherence). Overall, men described increased sex with PLHIV over time, including some participants who, during earlier interviews, said they would 'never be comfortable' with serodifferent sexual partners. CONCLUSIONS: GBQM's use of PrEP shaped how they thought about U=U and sex with PLHIV. Although many GBQM embraced treatment as prevention/U=U as significant to their sexual lives, longitudinal analysis revealed its varied and uneven adoption across participants and time.

Acceptability of an existing online sexually transmitted and blood-borne infection testing model among gay, bisexual and other men who have sex with men in Ontario, Canada.

Objectives: Gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by sexually transmitted and blood-borne infections (STBBI) due to stigma and other factors such as structural barriers, which delay STBBI testing in this population. Understanding acceptability of online testing is useful in expanding access in this population, thus we examined barriers to clinic-based testing, acceptability of a potential online testing model, and factors associated with acceptability among GBM living in Ontario. Methods: Sex Now 2019 was a community-based, online, bilingual survey of GBM aged ≥15. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated using modified Poisson regression with robust variances. Multivariable modelling was conducted using the Hosmer-Lemeshow-Sturdivant approach. Results: Among 1369 participants, many delayed STBBI testing due to being too busy (31%) or inconvenient clinic hours (29%). Acceptability for online testing was high (80%), with saving time (67%) as the most common benefit, and privacy concerns the most common drawback (38%). Statistically significant predictors of acceptability for online testing were younger age (PR = 0.993; 95%CI: 0.991-0.996); a greater number of different sexual behaviours associated with STBBI transmission (PR = 1.031; 95%CI: 1.018-1.044); identifying as an Indigenous immigrant (PR = 1.427; 95%CI: 1.276-1.596) or immigrant of colour (PR = 1.158; 95%CI: 1.086-1.235) compared with white non-immigrants; and currently using HIV pre-exposure prophylaxis (PrEP) compared to not currently using PrEP (PR = 0.894; 95%CI: 0.828-0.965). Conclusions: Acceptability of online testing was high among GBM in Ontario. Implementing online STBBI testing may expand access for certain subpopulations of GBM facing barriers to current in-person testing.