Grant: Team Grant: HIV Implementation Science - Component 2

Gay, bisexual and other men who have sex with men (MSM) account for over half of new HIV infections in Canada each year. Pre-exposure prophylaxis (PrEP) is an effective, safe and acceptable HIV prevention option among MSM, and holds great promise for reversing the course of the epidemic. However, for PrEP to achieve its full public health potential, two challenges must be overcome. First, PrEP must be targeted to those at highest HIV risk. Evidence suggests that having certain bacterial sexually transmitted infections or scoring highly on a validated risk index are particularly strong predictors of subsequent HIV. Since public health units routinely generate these data through daily activities, personnel could readily build such PrEP targeting strategies onto existing healthcare encounters. Second, more providers are needed within the healthcare system to deliver PrEP at scale. Engaging primary care providers, sexual health clinics nurses and PrEP-specific clinics in PrEP delivery may relieve the bottleneck of having too few specialists. Our experienced, multidisciplinary team in British Columbia and Ontario will implement and study the scale-up of these targeting and delivery strategies. Public health units and PrEP delivery sites in 5 cities will routinize a cascade of steps including identifying MSM with these criteria, offering PrEP services, linking patients to care, and ultimately initiating and retaining them on PrEP over time. Our research team will document how well the cascade is operationalized, tabulate healthcare costs, analyze qualitative and quantitative data on barriers and facilitators, and provide ongoing feedback to program implementers to inform how they modify programs. By synthesizing findings in mathematical models of HIV transmission we will determine the optimal strategies for targeting and delivering PrEP to MSM that maximize infections averted for the least additional cost, across a range of social, health systems and epidemic contexts.