Cohort profile: l’Actuel Pre-Exposure Prophylaxis (PrEP) Cohort study in Montreal, Canada

Abstract

PurposeThel’Actuel PrEP Cohortwas established to monitor the uptake, effectiveness, safety and changes in sexual risk behaviours among individuals receiving pre-exposure prophylaxis (PrEP) for the prevention of HIV. This prospective dynamic cohort is based at Clinique médicale l’Actuel, a large sexual health clinic located in Montreal, Canada.ParticipantsSince the cohort inception in January of 2013 through June 2018, 2156 individuals consulted for PrEP as participants in the l’Actuel PrEP Cohort. Median age was 35 years (IQR: 29–44 years) and the majority (96%) were men who have sex with men. Among 1551 individuals who initiated PrEP care, the median duration of follow-up was 9.2 months (IQR: 3.7–19.6), with substantial variation based on year of cohort entry. Thel’Actuel PrEP Cohortcontains both daily and intermittent ‘on-demand’ PrEP users and has the largest reported population of intermittent PrEP users (n=406) in North America.Findings to dateNo incident HIV infections have occurred among individuals using PrEP over 1637 person-years of follow-up. However, retention in PrEP care is essential as three individuals who discontinued PrEP subsequently acquired HIV, translating to an HIV incidence of 3.9 cases per 100 person-years (95% CI: 1.3 to 12.1). Among a sample of participants with 1 year of follow-up before and after PrEP initiation (n=109), a moderate increase in sexually transmitted infections was observed following PrEP start.Future plansThel’Actuel PrEP Cohortcontinues to grow with new participants starting PrEP monthly and extended follow-up for existing users. The cohort data will be used for ongoing monitoring of PrEP and for population-level modelling of the impact of PrEP on HIV incidence in Montreal.

Missed opportunities to prevent HIV infections among pre‐exposure prophylaxis users: a population‐based mixed methods study, San Francisco, United States

“…Among the seven individuals who stopped PrEP and subsequently developed HIV, factors impacting continued PrEP use included substance use, mental health and housing concerns; difficulty accessing PrEP due to cost, insurance and the need for medical and laboratory visits; difficulty weighing PrEP’s benefit versus one’s self‐perceived HIV risk; and entering a primary partnership. HIV incidence after stopping PrEP was similar to that in a Boston LGBT primary care clinic [11 but lower than that seen in a Los Angeles LGBT primary care clinic [10 and Montreal sexual health clinic [12] potentially due to our study being performed among a general primary care population. A strength of this analysis is that we were able to rigorously ascertain HIV diagnoses by leveraging the SFDPH/CDC’s enhanced HIV surveillance system.…”

“…Despite many individuals stopping PrEP due to low self‐perception of risk, prior studies have also shown relatively large numbers of HIV infections after PrEP discontinuation [10‐12]. In a prior analysis, we found that African‐Americans, transgender women and younger participants were more likely to discontinue PrEP in our system, in spite of disproportionate HIV incidence in these groups [16].…”

“…Pre‐exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy when taken during periods of HIV risk [1,2]. Although PrEP persistence (sustained PrEP use over time) was high among PrEP users in clinical trials and early demonstration projects [2‐4], it has been variable among later PrEP adopters and in real‐world evaluations, with 15 to 62% of users discontinuing PrEP by six months [5‐14]. Prevention‐effective adherence is a concept which describes the importance of using PrEP during periods of HIV risk, as compared to antiretroviral therapy, for which lifelong adherence is required [15].…”

Exploring nurse‐led HIV Pre‐Exposure Prophylaxis in a community health care clinic

“…Currently, only daily use of PrEP is recommended in Canada. However, 'on demand' PrEP (intermittent PrEP, taken at the time of sexual activity) is more readily accepted and used in some jurisdictions (Greenwald et al, 2019;Molina et al, 2017).…”

“…Currently, only daily use of PrEP is recommended in Canada. However, ‘on demand’ PrEP (intermittent PrEP, taken at the time of sexual activity) is more readily accepted and used in some jurisdictions (Greenwald et al., 2019; Molina et al., 2017). In the context of public health, patients often enter the BC PrEP program through a visit with a nurse in consult with, or directly through a licensed physician or nurse practitioner.…”