Characteristics of the HIV cascade of care and unsuppressed viral load among gay, bisexual and other men who have sex with men living with HIV across Canada's three largest cities

Introduction: Treatment as prevention strategies have been variously applied across provinces in Canada. We estimated HIV care cascade indicators and correlates of unsuppressed viral load (VL) among gay, bisexual and other men who have sex with men (GBM) recruited in Vancouver, Toronto and Montreal.

Methods: Sexually active GBM, aged ≥16 years, were recruited through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview and tests for HIV and other sexually transmitted infections (STIs). We conducted bivariate analyses comparing RDS-adjusted proportions across cities. We used multivariable logistic regression to examine factors associated with having a measured VL ≥ 200 copies/mL with data pooled from all three cities.

Results: We recruited 1179 participants in Montreal, 517 in Toronto and 753 in Vancouver. The RDS-adjusted HIV prevalence was 14.2% (95% CI 11.1 to 17.2) in Montreal, 22.1% (95% CI 12.4 to 31.8) in Toronto and 20.4% (95% CI 14.5 to 26.3) in Vancouver (p < 0.001). Of participants with confirmed HIV infection, 3.3% were previously undiagnosed in Montreal, 3.2% undiagnosed in Toronto and 0.2% in Vancouver (p = 0.154). In Montreal, 87.6% of GBM living with HIV were receiving antiretroviral therapy (ART) and 10.6% had an unsuppressed VL; in Toronto, 82.6% were receiving ART and 4.0% were unsuppressed; in Vancouver, 88.5% were receiving ART and 2.6 % were unsuppressed (p < 0.001 and 0.009 respectively). Multivariable modelling demonstrated that participants in Vancouver (adjusted odds ratio [AOR]=0.23; 95% CI 0.06 to 0.82), but not Toronto (AOR = 0.27; 95% CI 0.07 to 1.03), had lower odds of unsuppressed VL, compared to Montreal, as did older participants (AOR 0.93 per year; 95% CI 0.89 to 0.97), those at high-risk for hazardous drinking (AOR = 0.19; 95% CI 0.05 to 0.70), those with a primary care provider (AOR = 0.11; 95% CI 0.02 to 0.57), and those ever diagnosed with other STIs (AOR = 0.12; 95% CI 0.04 to 0.32).

Conclusions: GBM living in Montreal, Toronto and Vancouver are highly engaged in HIV testing and treatment and all three cities have largely achieved the 90-90-90 targets for GBM. Nevertheless, we identified disparities which can be used to identify GBM who may require additional interventions, in particular younger men and those who are without a regular primary care provider.