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: Introduction: HIV pre‐exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population‐level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013–2021. Methods: We used an agent‐based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID‐19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual‐level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post‐exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free‐of‐charge), and improving retention. Results: Over 2013–2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3–0.6) to 0.2 (90% CrI: 0.1–0.2) per 100 person‐years. PrEP coverage among HIV‐negative MSM remained low until 2015 ( Conclusions: PrEP reduced population‐level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition., INTRODUCTION After over 20 years under study [1–3] and 10 years of availability [4], oral pre‐exposure prophylaxis (PrEP) has proven highly efficacious for preventing HIV acquisition across transmission routes. Rigorous [...]

: Introduction: Long‐acting injectable cabotegravir (CAB‐LA) demonstrated superiority to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre‐exposure prophylaxis (PrEP) in the HPTN 083/084 trials. We compared the potential impact of expanding PrEP coverage by offering CAB‐LA to men who have sex with men (MSM) in Atlanta (US), Montreal (Canada) and the Netherlands, settings with different HIV epidemics. Methods: Three risk‐stratified HIV transmission models were independently parameterized and calibrated to local data. In Atlanta, Montreal and the Netherlands, the models, respectively, estimated mean TDF/FTC coverage starting at 29%, 7% and 4% in 2022, and projected HIV incidence per 100 person‐years (PY), respectively, decreasing from 2.06 to 1.62, 0.08 to 0.03 and 0.07 to 0.001 by 2042. Expansion of PrEP coverage was simulated by recruiting new CAB‐LA users and by switching different proportions of TDF/FTC users to CAB‐LA. Population effectiveness and efficiency of PrEP expansions were evaluated over 20 years in comparison to baseline scenarios with TDF/FTC only. Results: Increasing PrEP coverage by 11 percentage points (pp) from 29% to 40% by 2032 was expected to avert a median 36% of new HIV acquisitions in Atlanta. Substantially larger increases (by 33 or 26 pp) in PrEP coverage (to 40% or 30%) were needed to achieve comparable reductions in Montreal and the Netherlands, respectively. A median 17 additional PYs on PrEP were needed to prevent one acquisition in Atlanta with 40% PrEP coverage, compared to 1000+ in Montreal and 4000+ in the Netherlands. Reaching 50% PrEP coverage by 2032 by recruiting CAB‐LA users among PrEP‐eligible MSM could avert >45% of new HIV acquisitions in all settings. Achieving targeted coverage 5 years earlier increased the impact by 5–10 pp. In the Atlanta model, PrEP expansions achieving 40% and 50% coverage reduced differences in PrEP access between PrEP‐indicated White and Black MSM from 23 to 9 pp and 4 pp, respectively. Conclusions: Achieving high PrEP coverage by offering CAB‐LA can impact the HIV epidemic substantially if rolled out without delays. These PrEP expansions may be efficient in settings with high HIV incidence (like Atlanta) but not in settings with low HIV incidence (like Montreal and the Netherlands)., INTRODUCTION Two clinical studies (HPTN 083 and HPTN 084) have shown that long‐acting injectable cabotegravir (CAB‐LA) pre‐exposure prophylaxis (PrEP) given every 8 weeks is highly efficacious at preventing HIV among [...]

: Introduction: Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second‐highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back‐calculation model synthesizing surveillance data. Methods: We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self‐reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975–2020 by modelling a cubic M‐spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID‐19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses. Results: HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33–227) and 266 (95% CrI: 103–508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0–14) and 6 (95% CrI: 1–26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to Conclusions: HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage—and the 2013 introduction of pre‐exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID‐19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these., INTRODUCTION We have the biomedical tools to eliminate HIV [1]. Yet, transmission continues to occur in Canada. In fact, HIV diagnoses have recently stabilized at counts near those observed in [...]