Ten percent of people living with HIV remain undiagnosed. Novel ways to access testing is key to reaching these individuals for diagnosis and care, especially those who have never tested for HIV. This study examines the effectiveness of the I’m Ready, Test app in reaching first-time testers.

The I’m Ready, Test, a mobile app, provides participants the ability to order free HIV self-tests anonymously for home delivery or pick-up across Canada. We examined the first 5,000 consenting participants who completed a pre-test survey between June 2021 and November 2022. The survey collected information on participant demographics and previous testing behaviour. Binary logistic regression was conducted to examine demographic and geographic correlates of first-time testers across key population groups (gay, bisexual, and other men who have sex with men; African, Caribbean, and Black people; Indigenous people; persons who use substances).

Overall, participants enrolled in program were mostly aged <35 years (71%), male (66%), had greater than a high school education (75%), were employed full time (58%), and lived in very large urban areas (58%). The 18-24 age group had the highest prevalence of first-time testers (53%) compared with 20-30% in other age groups (OR=3.30, 95% CI=2.88, 3.78). Results showed the I'm Ready, Test app was more successful in reaching first-time testers who were: (1) women (OR=1.61, 95% CI=1.40, 1.84), (2) transgender (OR=2.10, 95% CI=1.29, 3.42); (3) lived in small cities and rural areas (39%) compared with very large urban areas (29%; OR=1.67, 95% CI=1.19, 2.34), and (4) lived in the Atlantic provinces compared with Ontario (OR=1.29, 95% CI=1.06, 1.58).

Use of a digital health app to provide access to HIV self-testing more effectively reaches first-time testers who are younger adults, women and transgender people, and those living in small cities and rural areas with limited access to facility-based HIV testing.

Background: The scale-up of online STBBI testing services has changed the testing landscape yet questions remain about how people use these services in relation to provider-based testing. We surveyed repeat users of GetCheckedOnline, British Columbia’s online STBBI testing service, about their concurrent use of provider-based testing services.

Methods: Between Nov 21-Dec 6, 2022, we invited GetCheckedOnline users who had consented to be contacted for research, were ≥16 years old, and had tested at least twice through the service (once in the past 6 months) to an online survey. Descriptive results are presented.

Results: Of 1798 invited users, 789 (44%) participated, with 46% identifying as women, 68% as White, and 38% as straight/heterosexual. Over half (57%) reported usually testing for STBBI at least every 3-4 months. Approximately 48% reported only testing through GetCheckedOnline. The remaining 52% reported provider-based testing scenarios that included during health visits for other reasons (50%), needing to speak to providers about sexual health (35%), testing as part of HIV treatment or PrEP (27%), needing tests not offered through GetCheckedOnline (26%), experiencing symptoms (29%), or having had a partner with an STI (14%). Most (88%) agreed that GetCheckedOnline allowed them to test sooner than through a provider, and 86% agreed they test more often because of GetCheckedOnline. If GetCheckedOnline had not been available, most (89%) would have accessed provider-based testing; however, 11% (80/747) would not have sought further testing.

Conclusion: Our findings suggest that most repeat users had shifted all or part of their current testing to GetCheckedOnline, which they perceived as facilitating more frequent and earlier testing. For some, GetCheckedOnline appeared to be the only testing option they would use. Our findings position online STBBI testing as an important complement to provider-based services and suggest that online testing services may help alleviate demands on provider-based testing services.

Background: The COVID-19 pandemic had impacts on STBBI services including engagement and retention of HIV clients in Canada. This study aimed to (1) estimate the proportion of individuals on treatment among people living with HIV in Big River First Nation and neighboring areas receiving their HIV services (BRFN area) in 2020, and (2) compare the findings of objective (1) with Saskatchewan First Nations communities, provincial and national data.

Methods: Individuals included in the analysis were persons diagnosed in BRFN area who were living with HIV as of December 31, 2020. The variables of interest were total clients on HIV treatment and virally suppressed as per the national PHAC definitions.

Results: Overall, among persons living with HIV in BRFN area, 95% were on treatment and 80% were virally suppressed at the end of 2020. When compared to the overall Saskatchewan First Nations, and general Saskatchewan and Canadian populations, the percentage of clients on treatment and virally suppressed were higher among people with HIV in BRFN area (Table 1).

Conclusions: Despite the disruptions of COVID-19 pandemic, HIV continuum of care estimates for treatment and viral suppression in BRFN area were higher compared to provincial and national estimates. These outcomes are likely related to locally developed and community-led Know Your Status program since 2011 in BRFN area that has provided stability, trust and care to allow for successful treatment outcomes through the pandemic. This success was due to the combined efforts of leadership, its Elders and healthcare workers in a culturally appropriate manner.

Introduction: GetaKit is a nurse-led study that evaluates real-world outcomes of mailing HIV self-tests in Ontario. Initially launched in July 2020, a few months ahead of Health Canada’s approval of the HIV self-test device, GetaKit has delivered over 5,000 HIV self-test kits across Ontario. The challenge that GetaKit seeks to address is to ensure that HIV self-testing is accessible, appropriate, and linked to care.

Methods: Public health systems are open systems that develop complexities as a result of individuals’ nonlinear relationships with their surrounding environment. As such, GetaKit uses both Complex Adaptive System and Multiple Intervention frameworks to evaluate implementation success and inform changes over time.

Results: Since April 2021, GetaKit has implemented the following strategies to lower participant barriers for registration (1) offering curbside pick-up at local agencies, (2) offering on-site registration, (3) staff ability to register and manage participant accounts. While this has resulted in an increase in total number of kits delivered, the GetaKit team observed the limits in transferability from a clinical setting to a non-clinical one. Organizational challenges at ASOs included the following: high staff turnover, barriers to logging into staff accounts, lack of staff buy-in with respect to the utility of the self-assessment. This resulted in creating further barriers for participant registration. The GetaKit team implemented the following strategies: (1) adapting language around the self-assessment algorithm to reflect its nature as a clinical tool, (2) introducing centralized follow-up, (3) launching a revised streamlined registration and self-assessment website that does not require logging in.

Conclusions: Lowering participant barriers only resolved part of the challenges encountered by individuals engaging in the GetaKit system. Further adaptations were required to ensure that partner site staff had sufficient understanding of the system, its application, and resources to support participants.

Background: To address needs for novel HIV testing access, we developed a community-based implementation science study that distributed free HIV self-tests in-person at Pride festival events and community venues across Canada.
Methods: Participants were recruited in-person from 06/2022-09/2022 in English, French, and Spanish. Eligible participants for the Sex Now questionnaire were at least 15 years old, lived in Canada, and identified as part of one of the following: Two-Spirit; gay, bisexual, queer and other non-heterosexual men (cis and trans); non-binary. After completing the questionnaire, participants ≥18 years old could opt-into Test Now and receive up to 2 free HIV self-tests, which could be used immediately on-site or kept for future use/distribution. Trained peer support was available in-person and subsequently via text, email, or telephone. Chi-square and t-tests compared participants who opted into Test Now versus not (p<0.05 significant).
Results: Recruitment occurred at 41 events in 21 cities across all provinces and the Yukon Territory. Of the eligible participants who completed Sex Now (n=3,169/3,476), 56.4% (n=1,786/3,169) opted into Test Now with a total of 2,433 HIV self-tests used or distributed (mean=1.36/participant). Compared with those who did not opt-in, Test Now participants were more likely to self-identify as gay (60.7% versus 56.2%, p=0.011), be a person of colour (34.9% versus 27.9%, p<0.001), have higher HIRI-MSM scores (mean=13.0 versus mean=11.5, p<0.001), be on HIV PrEP (18.5% versus 15.2%, p<0.001), and report illicit substance use (34.7% versus 29.6%, p=0.006). Test Now participants were less likely to be living with HIV (3.4% versus 6.4%, p<0.001), have ever previously tested for STIs (14.4% versus 20.5%, p<0.001), and to self-identify as trans (18.2% versus 21.7%, p=0.016).
Conclusions: Pride festival events were efficient implementation sites for HIV self-test distribution while also highlighting challenges of HIV self-test use in community settings and effective recruitment strategies for key sub-populations.

Background:
The HIV care cascade measures how people living with diagnosed HIV are engaged in care and treatment. Geographic and subpopulation differences indicate where, among whom, and which cascade metrics require additional supports.

Methods: Using provincial laboratory-based surveillance data, HIV diagnoses between 2009-2020 were linked with viral load (VL) tests within Ontario. HIV care cascade metrics were proportions: 1-In care among diagnosed (≥1 VL test/year), 2-On antiretroviral treatment (ART) among diagnosed (reported on last VL requisition or VL<200 copies/ml), and 3-Virally suppressed among diagnosed (<200 copies/ml at last VL test). Tester’s address and risk factor information defined Ontario region and select subpopulations: gay, bisexual, and other men who have sex with men (GBMSM), people who use injection drugs (PWID), and males and females who reported heterosexual contact.

Results: In 2020, 15,419 males and 4,288 females were living with diagnosed HIV in Ontario. Cascade metrics (in care, on ART, virally suppressed) varied by subpopulation: GBMSM (90.8%-88.0%-86.2%); PWID (83.2%-73.2%-69.2%); heterosexual males (89.8%-86.3%-83.6%); and heterosexual females (91.2%-88.3%-85.3%). Among GBMSM, cascade metrics were higher in Eastern and Southwest and lower in Northern, Ottawa, and Central West (still above other subpopulations). PWID varied widely: Southwest had the highest metrics (91.5%-80.9%-77.7%, but still below other subpopulations), Eastern had the lowest in care (68.0%), and Northern had the lowest on ART (60.0%) and virally suppressed (56.0%). Among heterosexual males, Eastern had the highest proportion in care (92.3%), but second lowest on ART (80.8%) and virally suppressed (76.9%). Heterosexual females had higher metrics in most regions compared to heterosexual males, particularly in Northern and Eastern regions.

Conclusions:
GBMSM and heterosexual females had the highest cascade metrics while heterosexual males and PWID had lower metrics, particularly among PWID in the Northern and Eastern regions. Tailored efforts across the care cascade should prioritize regions and subpopulations with lower cascade engagement.

Background:
The 95-95-95 targets monitor treatment and viral suppression, but we must examine those not in care to optimize health for people living with HIV and reduce ongoing transmission.

Methods: Using provincial laboratory-based surveillance data, HIV diagnoses are linked with viral load (VL) tests in the Ontario HIV datamart. In care (IC) was defined as having a VL test within the past 24 months, those never linked to care (NL) have a diagnosis with no linked VL, and lost-to-care (LC) is having no VL for 2 years. A lost-to-follow-up rule is applied, excluding observations more than two years after a VL and seven years after an unlinked nominal diagnosis. Unlinked non-nominal diagnoses were excluded from this analysis.

Results: In 2020, 19,723 people were living with diagnosed HIV in Ontario, with 17,811 people in care (IC), 332 had never linked to care (NL) and 1,580 were lost-to-care (LC) (90% IC, 2% NL, 8% LC). Those not in care were more likely to be female (89% IC,2% NL, 9% LC) and aged 25-34 years (87% IC, 4% NL, 10% LC). Within the northern region, there were lower rates in care (84% IC, 4% NL, 12% LC), with the highest rates in Southwest (92% IC, 1% NL, 6% LC). Men reporting male to male sexual contact were more likely to be in care (92% IC, 2% NL, 6% LC), while people reporting injection drug use were less likely (83% IC, 4% NL, 13% LC). White individuals were more likely to be in care (92% IC, 3% NL, 5% LC) than non-white individuals (89% IC, 5% NL, 6% LC).

Conclusions:
HIV care outcomes in Ontario differ by population and geography. Linkage to care and ensuring people stay in care are key to ensuring optimal health of people living with HIV and reducing HIV infections.

Background
Long-acting injectable cabotegravir and rilpivirine (CAB/RPV-LA) is a novel regimen for maintenance of HIV treatment in virologically suppressed individuals, and may benefit those facing social and structural barriers in obtaining and adhering to oral antiretroviral therapy. Whether these benefits will be realized during real-world implementation remains to be seen.

Methods
Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation science framework, we analyzed the use of CAB/RPV-LA at a large academic HIV clinic during the first 12 months of its listing on the Ontario Drug Benefit formulary (Dec2021-Nov2022). To assess Reach, we collected demographic, drug coverage, and HIV risk factor data from patient charts, and used postal codes and the Ontario-Marginalization Index (ON-Marg) to assess two dimensions of marginalization: Material Deprivation and Ethnic Concentration. These dimensions evaluate marginalization due to income, education and family structure; and due to structural racism in healthcare, respectively. We further report CAB/RPV-LA Effectiveness (proportion achieving undetectable viral load (HIV RNA<200 copies/mL), Adoption (proportion of clinic physicians prescribing CAB/RPV-LA) and Maintenance (proportion of patients still undetectable at study end).

Results
Thirty-two individuals received CAB/RPV-LA during the study period. Mean age was 43 years, 88% were assigned male sex at birth, 39% were white, 38% had private insurance coverage, and 66% were MSM. Equal proportions were categorized within the lowest and highest quintiles of material deprivation, whereas a majority (59%) had ethnic concentration scores in the highest two quintiles. Effectiveness, Adoption and Maintenance were high, with 100% of patients retaining virological suppression while on CAB/RPV-LA, all clinic physicians prescribing CAB/RPV-LA to ≥1 patient, and 97% of patients remaining on CAB/RPV-LA at the end of the study period.

Conclusion
Preliminary data suggest that CAB/RPV-LA is reaching individuals experiencing varying degrees of marginalization. Further implementation research may be beneficial in studying health equity outcomes during its ongoing rollout.