Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada.

OBJECTIVES: Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada. DESIGN: We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis. RESULTS: Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices. CONCLUSION: Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

Acceptability of an existing online sexually transmitted and blood-borne infection testing model among gay, bisexual and other men who have sex with men in Ontario, Canada.

Objectives: Gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by sexually transmitted and blood-borne infections (STBBI) due to stigma and other factors such as structural barriers, which delay STBBI testing in this population. Understanding acceptability of online testing is useful in expanding access in this population, thus we examined barriers to clinic-based testing, acceptability of a potential online testing model, and factors associated with acceptability among GBM living in Ontario. Methods: Sex Now 2019 was a community-based, online, bilingual survey of GBM aged ≥15. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated using modified Poisson regression with robust variances. Multivariable modelling was conducted using the Hosmer-Lemeshow-Sturdivant approach. Results: Among 1369 participants, many delayed STBBI testing due to being too busy (31%) or inconvenient clinic hours (29%). Acceptability for online testing was high (80%), with saving time (67%) as the most common benefit, and privacy concerns the most common drawback (38%). Statistically significant predictors of acceptability for online testing were younger age (PR = 0.993; 95%CI: 0.991-0.996); a greater number of different sexual behaviours associated with STBBI transmission (PR = 1.031; 95%CI: 1.018-1.044); identifying as an Indigenous immigrant (PR = 1.427; 95%CI: 1.276-1.596) or immigrant of colour (PR = 1.158; 95%CI: 1.086-1.235) compared with white non-immigrants; and currently using HIV pre-exposure prophylaxis (PrEP) compared to not currently using PrEP (PR = 0.894; 95%CI: 0.828-0.965). Conclusions: Acceptability of online testing was high among GBM in Ontario. Implementing online STBBI testing may expand access for certain subpopulations of GBM facing barriers to current in-person testing.

Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada.

BACKGROUND: Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services. METHODS: Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory. RESULTS: Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic. CONCLUSIONS: Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men.

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Challenges to communicating the Undetectable equals Untransmittable (U=U) HIV prevention message: Healthcare provider perspectives.

"Undetectable equals Untransmittable", or U=U, is a public health message designed to reduce HIV stigma and help communicate the scientific consensus that HIV cannot be sexually transmitted when a person living with HIV has an undetectable viral load. Between October 2020-February 2021 we conducted 11 in-depth interviews and 3 focus groups with diverse HIV/STI service providers (nurses, public health workers, physicians, frontline providers, and sexual health educators) in Ontario, Canada (n = 18). Our objective was to understand how U=U was communicated to sexual health service users in healthcare interactions. Interview questions were embedded in a larger study focused on improving access to HIV/STI testing. Transcripts were transcribed verbatim and analysed following grounded theory. Most providers emphasized the significance of U=U as a biomedical advancement in HIV prevention but had some challenges communicating U=U in everyday practice. We discovered four interrelated barriers when communicating the U=U message: (1) provider-perceived challenges with "zero risk" messaging (e.g., wanting to "leave a margin" of HIV risk); (2) service users not interested in receiving sexual health information (e.g., in order to provide "client centered care" some providers do not share U=U messages if service users are only interested in HIV/STI testing or if other discussions must be prioritized); (3) skepticism and HIV stigma from service users (e.g., providers explained how the hesitancy of some service users accepting the U=U message was shaped by a legacy of HIV prevention messages and persistent HIV stigma); and (4) need for more culturally appropriate resources (e.g., communities other than sexual and gender minority men; non-English speaking service users; that account for broader legal context). We discuss ways to overcome barriers to communicating the U=U message as well as the limitations and potential unintended consequences of U=U framings in the context of unequal access to HIV prevention and treatment.

Stepping Stones or Second Class Donors?: a qualitative analysis of gay, bisexual, and queer men's perspectives on plasma donation policy in Canada.

BACKGROUND: Men who have sex with men (MSM) are not eligible to donate blood or plasma in Canada if they have had sex with another man in the last 3 months. This time-based deferment has reduced since 2013; from an initial lifetime ban, to five-years, one-year, and now three-months. Our previous research revealed that gay, bisexual, queer, and other MSM (GBM) supported making blood donation policies gender-neutral and behaviour-based. In this analysis, we explored the willingness of Canadian GBM to donate plasma, even if they were not eligible to donate blood. METHODS: We conducted in-depth interviews with 39 HIV-negative GBM in Vancouver (n = 15), Toronto (n = 13), and Montreal (n = 11), recruited from a large respondent-driven sampling study called Engage. Men received some basic information on plasma donation prior to answering questions. Transcripts were coded in NVivo following inductive thematic analysis. RESULTS: Many GBM expressed a general willingness to donate plasma if they became eligible; like with whole blood donation, GBM conveyed a strong desire to help others in need. However, this willingness was complicated by the fact that most participants had limited knowledge of plasma donation and were unsure of its medical importance. Participants' perspectives on a policy that enabled MSM to donate plasma varied, with some viewing this change as a "stepping stone" to a reformed blood donation policy and others regarding it as insufficient and constructing GBM as "second-class" donors. When discussing plasma, many men reflected on the legacy of blood donor policy-related discrimination. Our data reveal a significant plasma policy disjuncture-a gulf between the critical importance of plasma donation from the perspective of Canada's blood operators and patients and the feelings of many GBM who understood this form of donation as less important. CONCLUSIONS: Plasma donor policies must be considered in relation to MSM blood donation policies to understand how donor eligibility practices are made meaningful by GBM in the context of historical disenfranchisement. Successful establishment of a MSM plasma donor policy will require extensive education, explicit communication of how this new policy contributes to continued/stepwise reform of blood donor policies, and considerable reconciliation with diverse GBM communities.

It's in Me to Give: Canadian Gay, Bisexual, and Queer Men's Willingness to Donate Blood If Eligible Despite Feelings of Policy Discrimination.

Blood donation policies governing men who have sex with men have shifted significantly over time in Canada-from an initial lifetime ban in the wake of the AIDS crisis to successive phases of time-based deferment requiring periods of sexual abstinence (5 years to 1 year to 3 months). We interviewed 39 HIV-negative gay, bisexual, queer, and other sexual minority men (GBM) in Vancouver, Toronto, and Montreal to understand their willingness to donate blood if eligible. Transcripts were coded following inductive thematic analysis. We found interrelated and competing expressions of biological and sexual citizenship. Most participants said they were "safe"/"low risk" and "willing" donors and would gain satisfaction and civic pride from donation. Conversely, a smaller group neither prioritized the collectivizing biological citizenship goals associated with expanding blood donation access nor saw this as part of sexual citizenship priorities. Considerable repair work is required by Canada's blood operators to build trust with diverse GBM communities.

Changes in smoking status among a longitudinal cohort of gay, bisexual, and other men who have sex with men in Vancouver, Canada.

BACKGROUND: Cigarette smoking is common among gay, bisexual, and other men who have sex with men (GBMSM) and most of the mortality gap between HIV-positive and HIV-negative individuals is attributable to smoking. METHODS: We recruited sexually active HIV-positive and HIV-negative GBMSM age ≥16 years using respondent-driven sampling. Study visits occurred every six months for up to four years and included a computer-assisted self-interview and clinical assessment. We conducted bivariate analyses to compare factors associated with "never", "former", "daily", or "non-daily" smoking at baseline and longitudinal mixed effects models to examine factors associated with cessation and (re)initiation. RESULTS: 774 participants completed a baseline visit and 525 enrolled in the cohort and completed at least one follow-up visit. At baseline, the median age was 34 years and 31.5% were daily smokers. In follow-up (median=2.5years), 116 daily or non-daily smokers (41%) quit at least once and of these, 101 (87%) remained former smokers at their last visit. Smoking cessation was positively associated with incomes ≥$60,000 and self-reported excellent health. Alcohol use, ecstasy use, and having a partner who smokes were associated with decreased odds of cessation. Substance use (cannabis, GHB, and crystal methamphetamine) and having a partner who smokes were positively associated with increasing to/resuming daily smoking. HIV-positive GBMSM were more likely to smoke but not more likely to quit. CONCLUSIONS: Targeted, culturally relevant smoking cessation resources are needed, especially for HIV-positive GBMSM. Engaging couples in cessation interventions may be useful.