Expanding the reach of pre-exposure prophylaxis services in suburban and rural Ontario: an implementation science evaluation of a public health-led model.

backgroundDespite the proven efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV, disparities among service delivery prevail in Canada, particularly among suburban and rural regions. This study evaluates the reach and effectiveness of a mixed-service delivery PrEP clinic embedded within a public health unit, located in Southeastern Ontario.

methodsThe PrEP clinic possesses an interdisciplinary team that delivers in-person and remote services. In consultation with PrEP clinic staff, we used the RE-AIM Framework to describe client characteristics (reach) and evaluate implementation effectiveness across the continuum of care, leveraging client electronic medical records.

resultsBetween 2018 and 2024, 141 clients engaged in PrEP services, the majority of whom were cisgender men (97.2%) with a median age of 37 years. Of those assessed, 70% (n = 98) initiated PrEP. Initiation was more likely among clients living outside the catchment area (RR = 1.35, 95% CI: 1.11-1.64), those with a history of hepatitis B (RR = 1.45, 95% CI: 1.30-1.62), and those reporting a history of having an HIV-positive partner (RR = 1.33, 95% CI: 1.18-1.49). The median duration of engagement was 8 months (IQR: 3-21 months), with no new HIV diagnoses reported. Overall, 54.1% of clients disengaged (n = 53), with the highest rates occurring within the first 3 months and after 12 months. Common reasons for disengagement included transferring care (24.5%), moving (18.9%), and changes in sexual activity (16.98%).

conclusionThis evaluation demonstrates that mixed-service public-health led PrEP delivery models can effectively engage clients in suburban and rural settings. Findings support the scalability of flexible, public health led approaches to expanding equitable access to PrEP in Canada.