A Systematic Review of Oral Pre-exposure Prophylaxis HIV Adherence Interventions.

ABSTRACT: Clinical trials of pre-exposure prophylaxis (PrEP) to prevent HIV infection have established its efficacy as upwards of 99%. Despite this, the effectiveness of this medication has been shown to be diminished by individual factors, such as medication adherence. We completed a systematic review to identify and describe interventions to improve oral PrEP adherence. Overall, 16 articles were located. Two of the articles reported on results from the same trial and were collapsed for analysis, bringing the total to 15 studies. Twelve unique PrEP adherence interventions were tested, with the most common intervention being the use of mobile phone technology, which was used in 7 (46%) of the studies. Ten (67%) studies found that medication adherence improved when participants received an intervention to support adherence. Adherence intervention strategies effectively improved PrEP adherence. Further research into PrEP adherence interventions is warranted, particularly among diverse groups.

Targeted HIV Self-Testing Identifies Persons with Undiagnosed HIV and Active Engagement Links them to Care: The GetaKit Study.

Current international HIV testing guidelines recommend that HIV negative persons from HIV priority groups complete repeat screening every 3-6 months; local guidelines in our jurisdiction recommend that such retesting should occur every 3 months. Such an approach allows for timely HIV diagnosis and linkage to care - and aligns with the UNAIDS 95-95-95 targets to have 95% of undiagnosed persons be aware of their HIV status. To meet these aims, new approaches to HIV testing have been developed, including our HIV self-testing initiative, GetaKit.ca, which uses an online screening algorithm to determine eligibility and has built in pathways for re-test reminders, linkage HIV prevention care, and rapid follow-up for positive test results. To understand self-testing frequency in relation to our local recommendations for resting every 3 months, we evaluated data from participants who ordered repeat HIV self-tests through GetaKit.ca. Descriptive analyses were performed on participant characteristics and chi-square tests were performed on aggregated participant risk data. During the study period, 5235 HIV self-tests were distributed to 3627 participants, of whom, 26% ordered more than once and 27% belonged to an HIV priority population. Participants who retested were more likely to have been white, male, and part of an HIV priority population; they were also more likely to have completed prior STI or HIV testing or had a prior STI diagnosis, compared to those who did not. We identified 16 new HIV diagnoses, 2 of which were among repeat testers. Our results suggest that HIV self-testing can be useful to help meet UNAIDS targets to identify undiagnosed infections; however, such efforts are less likely to be successful without adequate linkage to follow-up services, including HIV treatment and prevention care.

Safer opioid supply: qualitative program evaluation.

BACKGROUND: As the overdose crisis in Canada continues to escalate in severity, novel interventions and programs are required. Safer Supply programs offer pharmaceutical-grade medication to people who use drugs to replace and decrease harms related to the toxic illicit drug supply. Given the paucity of research surrounding these programs, we sought to better understand the experience of being part of a Safer Supply program from the perspective of current participants. METHODS: We completed semi-structured interviews and surveys with Safer Supply participants in Ottawa, Canada. Interviews were audio-recorded, transcribed, and analyzed thematically. Descriptive statistics were used to report survey data. RESULTS: Participants most commonly discussed Safer Supply benefits. This included programs offering a sense of community, connection, hope for the future, and increased autonomy. Participants also described program concerns, such as restrictive protocols, inadequate drugs, and diversion. CONCLUSIONS: Our research demonstrated that participants found Safer Supply to be effective and impactful for their substance use goals. While participants did discuss concerns about the program, overall, we found that this is an important harm reduction-based program for people who use drugs in the midst of the overdose crisis.

Delivering COVID self-tests through GetaKit.ca: Creating testing access during a pandemic.

OBJECTIVES: To determine the real-world outcomes associated with using the GetaKit.ca website to distribute COVID self-tests to persons with risk factors, with a focus on facilitating testing for persons who are Black, Indigenous, or of Colour (BIPOC). METHODS: GetaKit was an open cohort observational study to distribute free self-tests, starting with HIV self-testings and then adding the Lucira Check-It® COVID self-test. Participants would register on our website and complete a risk assessment, which would calculate their need for each type of testing. RESULTS: Focusing on the COVID self-tests, from September to December 2021 (with targeted outreach in winter 2022), we distributed 6474 COVID self-tests to 3653 persons through 4161 unique orders, of which 47% came from BIPOC participants. Compared to white participants, BIPOC participants were more likely to have been a contact of COVID but less likely to be vaccinated. As well, 69% of results were reported back via the GetaKit.ca website, with 5.3% of these being positive. The positivity rate for our 3653 participants was 9.6%. CONCLUSIONS: Delivering COVID self-tests via our website provided tests to BIPOC communities and yielded positivity rates that matched local COVID testing centres. This highlights the utility of such systems for delivering testing during future pandemics.

Nurse-led safer opioid supply and HIV pre-exposure prophylaxis: a novel pilot project.

Introduction: HIV pre-exposure prophylaxis (PrEP) is an effective intervention for preventing HIV infections yet is largely unknown to and underutilized among people who use drugs. Methods: To better provide services to this group, we present a prospective, single-group interventional study involving the creation of a partnership between a safer opioid supply program and an HIV PrEP program, both of which were nurse-led. Results: Overall, HIV PrEP was offered to 42 individuals within the safer opioid supply program, resulting in 55% (n = 23) acceptance. Almost half of the group that accepted PrEP identified as female, and nearly all participants were homeless and did not have a primary care provider. While it was challenging to obtain routine PrEP follow-up labs per guideline recommendations due to poor venous access, most participants were able to successfully stay on PrEP and maintained good medication adherence. There were no PrEP discontinuations due to renal impairment and no participants tested positive for HIV. Conclusion: This novel integration of programs appeared to be a highly effective way to expand access to HIV prevention among people who use drugs. Given the historical and current mistreatment of people who use drugs within the healthcare system, rapport and trust were essential to the uptake of HIV PrEP services. Further, the importance of infectious disease screening among people who use drugs is underscored, and built-in program flexibility and low barrier access is essential.

Understanding the Perspectives of Women Who Use Intravenous Drugs and are Experiencing Homelessness in an Urban Centre in Canada: An Analysis of Ethnographic Data.

Injection drug use has long been a topic of investigation, whether through a health or criminal justice lens. Whilst these bodies of literature offer important perspectives, missing from the extant literature is evidence, particularly involving women who use drugs, and more specifically evidence about the health beliefs of these women. To address this knowledge gap, we undertook an ethnographic study of homeless women in downtown Ottawa who inject drugs. This included interviews, observations, and artifact analyses. In this paper, we report on these ethnographic data to show the context and nature of the subjective lives of women who use injection drugs and their beliefs and perspectives on health. We use these data to make recommendations for nursing and healthcare practice moving forward.

HIV self-testing in Ottawa, Canada used by persons at risk for HIV: The GetaKit study.

BACKGROUND: The Public Health Agency of Canada estimates that about 87% of persons living with human immunodeficiency virus (HIV) in Canada have been diagnosed, which is well below the Joint United Nations Programme on HIV/AIDS target to have 95% of HIV-positive persons diagnosed. Research has shown that HIV self-testing may help increase such diagnoses, especially among the populations who are most affected by HIV. The objective of the study was to determine the uptake and diagnosis outcomes associated with free HIV self-testing. METHODS: We developed the first online mailout free HIV self-testing program in Canada and implemented it in Ottawa. This project ran through the website, www.GetaKit.ca. We intended to recruit 150-400 participants over a 6-12-month period, estimating that this number would yield between 0-1 positive test results (expected positivity rate of 0.08%). RESULTS: Between July 20, 2020 and April 1, 2021, 1,268 people accessed the GetaKit website and verified their eligibility. In total, 600 persons were eligible and 405 ordered an HIV kit. Of those who ordered a kit, 399 completed a baseline survey. Overall, 71% of these participants were members of HIV priority groups. For test results, 228 persons reported test results, with one being positive, for a positivity rate of 0.24% overall and 0.44% of reported results. These rates exceed that normally observed in Ottawa. CONCLUSION: Self-testing of HIV can be effectively delivered through a website. Such an intervention will also be used by persons with undiagnosed infections and appears to do so at a rate higher than that observed by other means of testing. Self-testing of HIV may therefore help Canada achieve the United Nations 95-95-95 targets.

Injectable opioid agonist treatment: An evolutionary concept analysis.

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and under-studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

Nurse-led PrEP-RN clinic: a prospective cohort study exploring task-Shifting HIV prevention to public health nurses.

OBJECTIVE: To report the results of a nurse-led pre-exposure prophylaxis (PrEP) delivery service. DESIGN: This was a prospective cohort study conducted from 5 August 2018 to 4 March 2020. It involved manual chart review to collect data. Variables were described using frequencies and percentages and analysed using χ2 testing. Those significant in bivariate analysis were retained and entered into a binary multiple logistic regression. Hierarchical modelling was used, and only significant factors were retained. SETTING: This study occurred in an urban public health unit and community-based sexually transmitted infection (STI) clinic in Ottawa, Canada. PARTICIPANTS: Of all persons who were diagnosed with a bacterial STI in Ottawa and everyone who presented to our STI clinic during the study period, there were 347 patients who met our high-risk criteria for PrEP; these criteria included patients who newly presented with any of the following: HIV contacts, diagnosed with a bacterial STI or single use of HIV PEP. Further, eligibility could be determined based on clinical judgement. Patients who met the foregoing criteria were appropriate for PrEP-RN, while lower-risk patients were referred to elsewhere. Of the 347 patients who met our high-risk criteria, 47% accepted and 53% declined. Of those who accepted, 80% selected PrEP-registered nurse (RN). PRIMARY AND SECONDARY OUTCOME MEASURES: Uptake, acceptance, engagement and attrition factors of participants who obtained PrEP through PrEP-RN. FINDINGS: 69% of participants who were eligible attended their intake PrEP-RN visit. 66% were retained in care. Half of participants continued PrEP and half were lost to follow-up. We found no significant differences in the uptake, acceptance, engagement and attrition factors of participants who accessed PrEP-RN regarding reason for referral, age, ethnicity, sexual orientation, annual income, education attainted, insurance status, if they have a primary care provider, presence or absence of depression or anxiety and evidence of newly acquired STI during the study period. CONCLUSIONS: Nurse-led PrEP is an appropriate strategy for PrEP delivery.

Harm Reduction Services in Ottawa: The Culture of Drug Use.

Between January 2016 and June 2019, there were over 13,900 apparent opioid-related deaths in Canada, solidifying the need for appropriate and effective services for people who use drugs (PWUD). Within government initiatives and policies, PWUD are often inappropriately considered a homogeneous group of individuals, with implementation of services nationally often being guided by these governmental bodies without meaningful consultation and collaboration with PWUD. However, recent harm reduction research and best practice guidelines have emphasized the importance of tailoring services to local drug scenes. Despite this, very little research on the cultural norms of PWUD exists in the literature. In an attempt to explore the local culture of drug use in Ottawa, a literature review ultimately uncovered very few articles on this topic. However, by expanding the search beyond Ottawa and using a social determinants of health framework, the factors of culture, income and social status, physical environment, and access to services were revealed as unique experiences for PWUD. Further, through four in-depth interviews with current harm reduction providers in Ottawa, the themes of (1) uncertainty and concerns surrounding the overdose crisis; (2) lack of flexibility in resources and access issues; and (3) diversity in the culture of drug use in Ottawa were explored. Recommendations surrounding partnering with PWUD, policy changes, and a safer supply were subsequently discussed. These findings helped to validate the reality of the unique drug-use culture in Ottawa, and the requirement for harm reduction services to be adapted to the local needs of PWUD.

Active-Offer Nurse-Led PrEP (PrEP-RN) Referrals: Analysis of Uptake Rates and Reasons for Declining.

While pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, its uptake is limited. To address barriers, we piloted a nurse-led PrEP clinic in an STI clinic and had public health nurses refer patients during STI follow-up. We recorded the number of PrEP offers and declines and clinic uptake. We conducted a thematic analysis of patients' responses from nursing notes written at the time patients declined PrEP. From August 6, 2018 to August 5, 2019, nurses offered a PrEP referral to 261 patients who met our criteria; only 47.5% accepted. Qualitative analysis identified four themes: (1) perceptions of risk, (2) lack of interest, (3) inability to manage, and (4) concerns about PrEP. Our patients did not feel sufficiently at-risk for HIV to use PrEP and maintained that PrEP was for a reckless "other". This analysis sheds light on how assumptions about risk affect PrEP uptake, particularly among those at-risk for HIV.