Targeted HIV Self-Testing Identifies Persons with Undiagnosed HIV and Active Engagement Links them to Care: The GetaKit Study.

Current international HIV testing guidelines recommend that HIV negative persons from HIV priority groups complete repeat screening every 3-6 months; local guidelines in our jurisdiction recommend that such retesting should occur every 3 months. Such an approach allows for timely HIV diagnosis and linkage to care - and aligns with the UNAIDS 95-95-95 targets to have 95% of undiagnosed persons be aware of their HIV status. To meet these aims, new approaches to HIV testing have been developed, including our HIV self-testing initiative, GetaKit.ca, which uses an online screening algorithm to determine eligibility and has built in pathways for re-test reminders, linkage HIV prevention care, and rapid follow-up for positive test results. To understand self-testing frequency in relation to our local recommendations for resting every 3 months, we evaluated data from participants who ordered repeat HIV self-tests through GetaKit.ca. Descriptive analyses were performed on participant characteristics and chi-square tests were performed on aggregated participant risk data. During the study period, 5235 HIV self-tests were distributed to 3627 participants, of whom, 26% ordered more than once and 27% belonged to an HIV priority population. Participants who retested were more likely to have been white, male, and part of an HIV priority population; they were also more likely to have completed prior STI or HIV testing or had a prior STI diagnosis, compared to those who did not. We identified 16 new HIV diagnoses, 2 of which were among repeat testers. Our results suggest that HIV self-testing can be useful to help meet UNAIDS targets to identify undiagnosed infections; however, such efforts are less likely to be successful without adequate linkage to follow-up services, including HIV treatment and prevention care.

Real world outcomes of distributing Lucira Check-It® COVID self-tests in Ontario, Canada: the GetaKit COVID study.

BACKGROUND: In Ontario, Canada we developed and implemented an online screening algorithm for the distribution of HIV self-tests, known as GetaKit. During the COVID pandemic, we adapted the GetaKit algorithm to screen for COVID based on population and infection data and distributed COVID rt-LAMP self-tests (using the Lucira Check-It®) to eligible participants. METHODS: GetaKit/COVID was a prospective observational study that occurred over a 7-month period from September 2021 to April 2022. All potential participants completed an online registration and risk assessment, including demographic information, COVID symptoms and risk factors, and vaccination status. Bivariate comparisons were performed for three outcomes: results reporting status, vaccination status, and COVID diagnosis status. Data were analysed using Chi-Square for categorial covariates and Independent Samples T-Test and Mann-Whitney U test for continuous covariates. Bivariate logistic regression models were applied to examine associations between the covariates and outcomes. RESULTS: During the study period, we distributed 6469 COVID self-tests to 4160 eligible participants; 46% identified as Black, Indigenous or a Person of Colour (BIPOC). Nearly 70% of participants reported their COVID self-test results; 304 of which were positive. Overall, 91% also reported being vaccinated against COVID. Statistical analysis found living with five or fewer people, having tested for COVID previously, and being fully vaccinated were positive factors in results reporting. For COVID vaccination, people from large urban centers, who identified their ethnicity as white, and who reported previous COVID testing were more likely to be fully vaccinated. Finally, being identified as a contact of someone who had tested positive for COVID and the presence of COVID-related symptoms were found to be positive factors in diagnosis. CONCLUSIONS: While most participants who accessed this service were vaccinated against COVID and the majority of diagnoses were identified in participants who had symptoms of, or an exposure to, COVID, our program was able to appropriately link participants to recommended follow-up based on reported risks and results. These findings highlight the utility of online screening algorithms to provide health services, particularly for persons with historical barriers to healthcare access, such as BIPOC or lower-income groups.

The experiences of people who use injection drugs with accessing hepatitis c testing and diagnosis in western countries: A scoping review.

BACKGROUND: The purpose of this scoping review was to summarize the literature that reported on the experiences of people who use injection drugs' access to hepatitis C testing and diagnosis in Western countries. METHODS: The initial search was conducted in 2020 and an updated review was completed in 2022. Seven electronic databases were searched using a peer-reviewed search strategy and included: full-text, peer-reviewed studies with people who inject(ed) drugs, hepatitis C testing or diagnosis, conducted in Western countries. Excluded were studies published prior to 2014 and intervention studies. Two-step screening was conducted in duplicate. Conventional content analysis was used. RESULTS: Six studies were found from the search. The studies were published between 2014 and 2021 in Australia, United Kingdom, and United States. A total of 19 participant characteristics were extracted to contextualize their experiences, demonstrating a lack of demographic data. Four themes were found: Awareness and Knowledge, Stigma, Healthcare Service, and Psychological Responses. There were 58 occurrences of client quotes where participants described their experiences, 29 occurrences of quotes describing client-identified barriers, and 14 occurrences of quotes describing client-identified facilitators. CONCLUSION: A scoping review was conducted to present the experiences, barriers, and facilitators of people who use injection drugs to hepatitis C testing. The lack of demographic data and connection to client quotes further exacerbates the inequities among the population by overlooking their intragroup identities. Understanding their experiences of accessing hepatitis C testing and collecting demographic data will help advance health policies and interventions targeting people who use injection drugs.

Lefebvre's production of space: Implications for nursing.

In this paper, we argue that nurses need to be aware of how the production of space in specific contexts - including health care systems and research institutions - perpetuates marginalized populations' state of social otherness. Lefebvre's idea regarding spatial triad is mobilized in this paper, as it pertains to two-spirited, lesbian, gay, bisexual, trans and queer populations (2SLGBTQ*). We believe that nurses can create counter-spaces within health care systems and research institutions that challenge normative discourses. Lefebvre's work provides us the necessary tools to understand how various places or environments produce identities. In understanding Lefebvre's principles, we believe that nurses can play an essential role in creating counter-spaces, thereby instigating counter-institutional practices, for those who experience otherness.

First-time testers in the GetaKit study: conceptualizing new paths to care for gbMSM.

When analyzing the data for Ontario, Canada, HIV rates continue to be highest among gay, bisexual and other men who have sex with men (gbMSM). Since HIV diagnosis is a key component of HIV care, self-testing has provided options for allowing this population to access care, resulting in a significant number of first-time testers. Between 1 April 2021 and 31 January 2022, 882 gbMSM participants ordered an HIV self-test through GetaKit. Of these, 270 participants reported that they had never undergone HIV testing previously. Our data showed that first-time testers were generally younger, members of BIPOC (Black, Indigenous and people of color) communities and they reported more invalid test results than those who had tested previously. This suggests that HIV self-testing may be a more successful and appealing component of the HIV prevention armamentarium for this population, but one that is not without its shortcomings as an entry to care.

Safer opioid supply: qualitative program evaluation.

BACKGROUND: As the overdose crisis in Canada continues to escalate in severity, novel interventions and programs are required. Safer Supply programs offer pharmaceutical-grade medication to people who use drugs to replace and decrease harms related to the toxic illicit drug supply. Given the paucity of research surrounding these programs, we sought to better understand the experience of being part of a Safer Supply program from the perspective of current participants. METHODS: We completed semi-structured interviews and surveys with Safer Supply participants in Ottawa, Canada. Interviews were audio-recorded, transcribed, and analyzed thematically. Descriptive statistics were used to report survey data. RESULTS: Participants most commonly discussed Safer Supply benefits. This included programs offering a sense of community, connection, hope for the future, and increased autonomy. Participants also described program concerns, such as restrictive protocols, inadequate drugs, and diversion. CONCLUSIONS: Our research demonstrated that participants found Safer Supply to be effective and impactful for their substance use goals. While participants did discuss concerns about the program, overall, we found that this is an important harm reduction-based program for people who use drugs in the midst of the overdose crisis.

HIV self-testing enabled access to testing for Black persons: The GetaKit study.

In Ontario, new HIV diagnoses continue to affect gay, bisexual, and other men who have sex with men (gbMSM) and persons of African, Caribbean, or Black (ACB) ethnicities. Because treatment and suppressed viral loads flow from diagnosis, testing is key. We sought to determine the outcomes of online ordering and mail-out of free at-home HIV self-testing in Ontario, Canada. We implemented the GetaKit study to offer such free HIV self-testing using the INSTI® test and offered it via a website (GetaKit.ca) to eligible persons in Ontario. From April 1, 2021 to January 31, 2022, we distributed kits to 1551 persons; 40% were white and 26% were ACB. We found that ACB participants were less likely to fulfill established criteria for HIV PrEP, such as previous sexually transmitted infections diagnoses and drug use, despite having a similar test positivity rate. We also found that ACB women, who may represent a larger number of new infections than previously thought, did not have a higher rate of first-time testing. Our results suggest that HIV self-testing can enable testing, but that work is required to increase uptake among ACB persons and women. Overall, HIV self-testing thus corresponded with increased testing among persons who were Black, yet lower rates of results reporting. Patient or Public Contributions: Community members from the AIDS Committee of Ottawa, Max Ottawa, and Black Cap, and nurses from Ottawa Public Health were involved in the design, promotion, and implementation of this study.

Delivering COVID self-tests through GetaKit.ca: Creating testing access during a pandemic.

OBJECTIVES: To determine the real-world outcomes associated with using the GetaKit.ca website to distribute COVID self-tests to persons with risk factors, with a focus on facilitating testing for persons who are Black, Indigenous, or of Colour (BIPOC). METHODS: GetaKit was an open cohort observational study to distribute free self-tests, starting with HIV self-testings and then adding the Lucira Check-It® COVID self-test. Participants would register on our website and complete a risk assessment, which would calculate their need for each type of testing. RESULTS: Focusing on the COVID self-tests, from September to December 2021 (with targeted outreach in winter 2022), we distributed 6474 COVID self-tests to 3653 persons through 4161 unique orders, of which 47% came from BIPOC participants. Compared to white participants, BIPOC participants were more likely to have been a contact of COVID but less likely to be vaccinated. As well, 69% of results were reported back via the GetaKit.ca website, with 5.3% of these being positive. The positivity rate for our 3653 participants was 9.6%. CONCLUSIONS: Delivering COVID self-tests via our website provided tests to BIPOC communities and yielded positivity rates that matched local COVID testing centres. This highlights the utility of such systems for delivering testing during future pandemics.

Perceptions, motivations, and beliefs about HIV risk and pre-exposure prophylaxis (PrEP) among participants in a nurse-led PrEP service (PrEP-RN).

BACKGROUND: While HIV pre-exposure prophylaxis (PrEP) has become more readily available in Canada, its uptake among HIV priority populations continues to be affected by system-level and individual factors. Such impediments relate to challenges by healthcare providers in assessing HIV-related risk and variability in patients' motivations for PrEP initiation and continued engagement in care. METHODS: In Ottawa, Canada, a group of researchers implemented Canada's first nurse-led HIV prevention program, known as PrEP-RN. As part of this pilot, qualitative interviews were completed with fourteen patients who had accessed PrEP-RN. The purpose of these interviews was to understand participants' perspectives related to HIV prevention and experiences accessing care through a nurse-led service. Interviews were analyzed using thematic analysis, which were organized into the two major themes of (1) motivations for PrEP initiation and (2) beliefs about the benefits of PrEP. RESULTS: Findings revealed participants' motivations for PrEP differed from healthcare provider's views of risk, which were influenced by external life factors and personal perceptions of risk. In addition, participants discussed the benefits of PrEP in terms of its ability to manage their potential mistrust of sexual partners, control their sexual health, and liberate fears and anxieties related to HIV. CONCLUSIONS: Based on these findings, health and allied providers should consider incorporating individual motivations and beliefs into patient education and counselling about PrEP to better target HIV prevention care at persons are at elevated risk of HIV. These perspectives could also be used to re-structure web and social media campaigns to increase PrEP uptake among HIV priority populations.

AIDS cases in Ottawa: A review of simultaneous HIV and AIDS diagnoses.

OBJECTIVES: In Canada, HIV diagnoses continue unabated, with many of these cases being identified at a late stage of infection. While current public health surveillance data does not capture timing of diagnoses, locally, we identified a number of patients concurrently diagnosed with AIDS and HIV. DESIGN: To understand the key characteristics, presenting symptoms, and risk factors associated with an AIDS diagnosis, we undertook a prospective chart review of HIV and AIDS diagnoses in Ottawa, Canada. SAMPLE: Sixty seven charts of persons diagnosed with HIV and AIDS between 2015 and 2021 were reviewed. MEASUREMENTS: Data were analyzed using descriptive statistics. RESULTS: Results show some inconsistencies regarding HIV risk factors identified in published literature compared to those for persons diagnosed with AIDS in this study. Namely, patients in this review were more likely to be male, Black (from HIV-endemic regions), and heterosexual, and were diagnosed at critical stage in infection (total average CD4+ count of 92.9 cells/mm3 ) with 44.8% of patients concurrently diagnosed with one or more AIDS-related opportunistic infections. CONCLUSIONS: The findings can be applied to strengthen HIV screening efforts in primary care settings, particularly among patients who present with persistent symptoms or illnesses related to chronic HIV infection. Additional considerations should be made for public health nurses to provide counseling and linkage to HIV testing/prevention services for patients at the time of an STI or Tuberculosis diagnosis and to increase AIDS-specific data collection.

Exploring how the diagnostic process stratifies children with intellectual disability navigating the service system in Ontario, Canada.

Children with intellectual disability experience a higher prevalence of dental disease, obesity, challenging behaviours, and mental health disorders compared to children without intellectual disability. Children with intellectual disability concurrently face health and social service navigational barriers that are associated with unresolved health needs and hospital admissions, and parent burnout and employment interruptions. In this study, we explored the knowledge gap of how carers and governmental agencies, providing services, understand intellectual disability using discourse analysis, and a theoretical framework applying Deleuze and Guattari's concepts of the rhizome and stratification. We found that children with intellectual disability were stratified into eligible or ineligible service recipients through the diagnostic process that prioritized specified characteristics. Carers did not perceive that their children's unique characteristics and needs were accounted for within the diagnostic process and expressed feelings of being dismissed by clinicians and providers in decision-making about priority needs and services.

Injectable opioid agonist treatment: An evolutionary concept analysis.

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and under-studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

HIV self-testing: A review and analysis to guide HIV prevention policy.

HIV self-testing is a relatively new approach to HIV testing that, with increasing licensure in many countries, is an impending intervention. Considering such current or near-future implementation, it is important for HIV prevention policymakers to reflect on if and how to incorporate HIV self-testing. In this paper, using the Impact Fraction Model and the Anderson-May equation, I discuss how HIV self-testing should be an efficacious prevention approach when targeted appropriately. I then review the potential impacts of self-testing on HIV surveillance and discuss possible ethical concerns about such testing. The outcome of this analysis is that, while some issues may arise related to surveillance, and while some ethical concerns can be raised, no empirical evidence substantiates either, suggesting that HIV self-testing is an important strategy if it can be focused on and used by the persons most affected by HIV.

Discussing current syphilis case definitions: A proposal for a "probable infectious" case.

Syphilis has increased in recent years, causing difficulties for clinicians and public health practitioners alike. While one issue with the current management of syphilis is that it has both a myriad of presentations and complicated laboratory results, another issue relates to the current case definitions used to define and track syphilis in public health surveillance. One item that is missing is a "probable" case definition, which could help capture the number of likely cases of syphilis that were appropriately treated clinically, but which failed to reach public health case definition based on serologic markers. This approach could produce a more accurate picture of the breadth of syphilis transmission in North America and help better appreciate the groups most affected by syphilis change. We put forward and argue this position herein.

Active-Offer Nurse-Led PrEP (PrEP-RN) Referrals: Analysis of Uptake Rates and Reasons for Declining.

While pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, its uptake is limited. To address barriers, we piloted a nurse-led PrEP clinic in an STI clinic and had public health nurses refer patients during STI follow-up. We recorded the number of PrEP offers and declines and clinic uptake. We conducted a thematic analysis of patients' responses from nursing notes written at the time patients declined PrEP. From August 6, 2018 to August 5, 2019, nurses offered a PrEP referral to 261 patients who met our criteria; only 47.5% accepted. Qualitative analysis identified four themes: (1) perceptions of risk, (2) lack of interest, (3) inability to manage, and (4) concerns about PrEP. Our patients did not feel sufficiently at-risk for HIV to use PrEP and maintained that PrEP was for a reckless "other". This analysis sheds light on how assumptions about risk affect PrEP uptake, particularly among those at-risk for HIV.

Considerations for Research on Sexually Transmitted Infections (STIs): Reflections of an STI Clinician-Researcher.

Sexually transmitted infections (STIs) have been explored in various sexual subgroups. While excellent, these analyses have primarily occurred from uniquely biologic, epidemiologic, or sociologic perspectives. Missing from these discussions has been in-depth presentations of the dynamics of STI transmission from all three viewpoints simultaneously. In this paper, I present information about STI transmission for each STI, including considerations of prevalence, and then review the STI research and of the concept of risk. I then apply these three considerations to a fictitious case study to show their importance and utility. I close by arguing that this information could strengthen future sociologic reviews of STIs and sexual health by helping such researchers include more nuanced understandings about STIs.

Inconclusive Syphilis Results: A Retrospective Review of Public Health Results.

In the context of increasing syphilis incidence in many Western countries, we sought to better understand the frequency and outcomes associated with inconclusive serologic syphilis results. To accomplish this, we reviewed all inconclusive results that arose from an indeterminant confirmatory treponemal screen (specifically the Treponema pallidum particulate agglutination test), which were reported to Ottawa Public Health from January 1, 2019, through December 31, 2019. Our case review identified that 52 persons generated such test results during the study period, of whom 44.4% were cases requiring treatment, 46.3% were persons without new risk factors or symptoms of syphilis who had been previously treated for this infection, and 9.3% were not syphilis. Overall, these untreated syphilis cases accounted for 8.6% of all new syphilis diagnoses in our local jurisdiction during the study period. These results highlight that case investigation and prompt management of inconclusive syphilis results is an appropriate public health and clinical approach and that such a strategy could contribute to efforts to reduce increasing syphilis incidence.

Population Health and Social Governance: A Review, an Update, Some Clarifications, and a Response.

Critical theory is a paradigm that promotes viewpoints that are alternative and, at times, contrary to mainstream beliefs and dictates. In 2012, I adopted this perspective to review the role of ethnography and surmised that the data which arise from this research approach, which I described as an in-depth study of cultures, can be used to discipline and control these groups. In this edition of Qualitative Health Research, another author has critiqued this position. In this article, I review this critique, reiterate my position, update the data I used for my 2012 article, and highlight how I navigate what I feel is a tension between critical theory and practice.

'I don't care if you think I'm gay that won't make me either promiscuous or HIV positive': HIV, stigma, and the paradox of the gay men's sexual health clinic - An exploratory study.

Young gay men are affected by HIV. Due to a lack of studies on these males, and that previous research notes youth's minimal healthcare seeking, we recruited young gay men at a gay men's STI testing clinic to explore their perceptions of care. Eight men participated in semi-structured interviews. Our results identified that, while our participants experienced stigma in some interactions, particularly when healthcare workers emphasized the probability of contracting HIV for gay men, overall they reported positive experiences with healthcare providers, particularly at the gay men's STI clinic. The gay men's STI clinic diminishes stigma and promotes HIV testing among a group of gay male youth who are affected by HIV, while its very existence propagates the association between gay males and HIV that most of the participants found stigmatizing. The association between sexuality and HIV was reported as stigmatizing in some situations, while the construction of a clinic on the premise that gay men require such testing was not. This reinforces the idea that stigma is a personal experience independent of action and locale.

Methadone maintenance treatment as social control: Analyzing patient experiences.

Methadone maintenance treatment (MMT) is a harm reduction approach for persons who wish to stop using opioids and is rather effective if used for a minimum of 12 months. Notably, research demonstrates that many persons enrolled in MMT programs discontinue care before this time, limiting its effects. To better understand this process, we undertook an exploratory descriptive qualitative study and interviewed 12 men and women who were using MMT. Using the theoretical work of Foucault and Hardt and Negri, the interview data highlighted that MMT continues to be strongly stigmatized, and that it is a system of care that involves rewards and penalties, based on if patients behave according to prescribed norms. These results suggest that MMT is a disciplinary mechanism, albeit one that impedes its own access. We consequently recommend that healthcare providers work to facilitate access to MMT, which means altering care delivery.