Introduction: Canadian guidelines recommend HIV testing for individuals being evaluated or treated for syphilis. Our objective was to examine HIV testing and potential missed testing opportunities (e.g. if HIV test occurred, timing of HIV test in relation to syphilis test, proportion with a positive HIV test result) amongst individuals without a previous positive HIV diagnosis who tested for syphilis between 2017 and 2022.

Methods: Direct fluorescent antibody (DFA) and serological non-prenatal syphilis testing data from January 1, 2017 to December 31, 2022 were retrieved from the Public Health Ontario (PHO) Laboratory Information Management System. Individuals aged ≥15 years and without a previous positive HIV test result were included. Positive syphilis tests were categorized using the rapid plasma reagin (RPR) antibody titre as “active” (DFA+/RPR ≥1:8) or “historical” (RPR <1:8). Exposure categories were assigned using individually-linked HIV exposure category data.

Results: 3,039,209 syphilis tests between 2017 and 2022 were included in the analysis. Those with a positive syphilis result were less likely to be tested for HIV within 28 days of the date of their syphilis test compared to those with a negative syphilis test result (73.2% vs. 91.7%). Males overall and males with “active” syphilis were more likely to be diagnosed as HIV-positive.

Conclusion: Most individuals tested for syphilis at PHO were tested for HIV, though those positive for syphilis were less likely to be tested, representing an opportunity for enhanced HIV testing. Ensuring that syphilis-positive individuals are tested for HIV may identify previously undiagnosed people living with HIV.

Background: Pharmacists are well-positioned to offer point of care (POC) and dried bloodspot (DBS) testing for sexually transmitted and bloodborne infections (STBBI). The APPROACH 2.0 study evaluated implementation of testing for HIV, hepatitis C (HCV) and syphilis by pharmacists in Newfoundland and Labrador, Nova Scotia, and Alberta. Findings from year 1 are presented.

Methods: Testing was available through 32 pharmacies in urban and rural communities. Participants could choose to receive POC (HIV, HCV) and/or DBS testing (HIV, HCV, syphilis). Pharmacists provided pre-test counselling, collected blood samples, and provided post-test counselling including information about prevention measures [e.g. condoms, HIV Pre-exposure Prophylaxis (PrEP)]. Participants with reactive screening results were offered a laboratory requisition for confirmatory testing and linkage to care was tailored for each province. Participants completed surveys to collect demographic and risk behaviour data and feedback about their testing experience (presented separately). PrEP eligibility was assessed for interested participants to estimate impact of the intervention on improving awareness for at-risk participants. Descriptive statistics were used to analyze results.

Results: From December 1, 2022 to December 31, 2023, there were 297 testing visits; 29.5% reported being first-time testers for at least one infection. 191/199 participants with DBS testing received their results within a median of 24 days. Proportions of reactive screening results were 3/286 for HIV, 15/258 for HCV, and 13/190 for syphilis; of those with reactive results, 67%, 100%, and 77% for HIV, HCV and syphilis, respectively, accepted referral for confirmatory testing and follow-up at the time of analysis. Of 73 participants who intended to pursue PrEP, 62% met eligibility criteria.

Conclusions: STBBI testing by pharmacists may be effective in reaching first-time testers and linking those with reactive screening results to care. Confirmatory test results available at end of study will describe the number of new infections found through pharmacist testing.

Background: Effective sexually transmitted and bloodborne infection (STBBI) testing options must be both accessible and acceptable to people seeking testing, especially among vulnerable populations or those who experience social stigma. Pharmacist testing programs aim to overcome barriers and normalize the testing experience. We sought to determine participant acceptance of pharmacist testing for STBBI through the APPROACH 2.0 study, and preference for different testing modalities.

Methods: Participants were offered a choice of point-of-care (POC) and/or dried bloodspot (DBS) testing options. Participants completed voluntary pre- and post-test surveys to provide demographic and risk behaviour data and feedback about their testing experience. Survey items were based on the Theoretical Framework of Acceptability (TFA) to assess domains of Affective Attitude (AA), Burden (B), Ethicality (E), Intervention Coherence (IC), Opportunity Costs (OC), Perceived Effectiveness (PE), and Self-efficacy (SE). Surveys included multiple-choice questions and Likert-type scales. Descriptive statistics were used to analyze the results.

Results: During 297 participant visits, 1031 total tests were administered: 258 HIV POC, 179 HCV POC, 594 DBS. Participants chose both POCT and DBS (57%), only POCT (35%), or only DBS (9%). The immediate report of test results was important to 79% of participants; 38% wanted pharmacist testing without preference for type of test used. There were high positivity ratings (>90%) in domains AA, IC, PE and SE. Strong positivity ratings were expressed around comfort in pharmacist testing (97%) and lack of stigma/discrimination faced at the pharmacy (92%). If pharmacist testing was not available, 13% of participants indicated they would not have been tested and 28% were unsure if they would get tested elsewhere.

Conclusions: Pharmacist testing is associated with high participant acceptability and was a preferred testing option for many participants. Many participants chose to receive both POC and DBS tests indicating acceptability of both testing options, possibly for different reasons.

Background: In Ontario, HIV self-testing is available for free through provincial and federal programs. Individuals who receive positive results should receive a confirmatory test and enter care. Our objective was to examine the proportion of HIV self-testing contributing to the provincial HIV testing program.
Methods: HIV serology and point-of-care testing data for Ontario was obtained from the Public Health Ontario Laboratory. HIV self-testing information was obtained from the Public Health Agency of Canada for their funded programs and the Ontario GetaKit program. Data availability differed by program (Nov 2022-Apr or Jun 2023); therefore, monthly rates from self-testing programs were used for comparison. Test results were only available for the GetaKit program, which were used to calculate test positivity.
Results: In 2022, 643,266 HIV serology tests (excluding prenatal) were conducted, equating to 53,605.5 tests per month with an overall positivity rate of 0.10%, and 1.4 tests per unique tester (2021). Ministry of Health funded point-of-care testing programs conducted 7,562 tests in 2022, with a positivity rate of 0.20%. Over the time period provided, an average of 1700 self-test kits were distributed per month, with 2.5 kits per person. Test positivity for GetaKit was 0.23% (positive reported self-test result among all distributed kits) (2022). In 2022, 26 HIV serology tests were conducted with self-testing as the reason serological testing, presumably for confirmatory testing of a positive self-test result. In Ontario in 2022, HIV self-testing represented 3.1% of all HIV tests conducted in Ontario and approximately 1.5% of all testers.
Conclusions: Offering HIV self-testing to individuals at-risk for HIV may improve access to HIV testing and assist in reaching the first 95 goal of the UNAIDS targets regarding diagnosis. We must continue to monitor self-testing programs as part of HIV testing overall and ensure proper linkage to confirmatory testing and linkage to care.

Background: The Public Health Agency of Canada-funded Community Link Program distributes free HIV self-tests through frontline, community-based and harm reduction organizations, including community health centres, mobile distribution units, shelters, pharmacies, and public health units to reach those who are undiagnosed and key populations most impacted by HIV.
Methods: Community Link Program partnered with 347 agencies for distribution. Individuals could access up to 5 kits. Participants completed an anonymous demographic survey to evaluate the effectiveness of the program in reaching first-time testers and key populations. Chi-squared tests (significance with p<0.01) were conducted to examine the demographic characteristics of first-time testers compared to people with previous testing experiences.
Results: Over the past year, 26,281 HIV self-tests were distributed to 9,292 people, and 46% were first-time testers. Significant results obtained for first-time testers: (a) age: people <20 years had greatest proportion of first-time testers (77% overall) compared to those >20 years (51% overall); (b) gender: 47% of cisgender men, 52% of cisgender women, and 46% of transgender and non-binary participants; (c) sexual orientation: 57% of heterosexual and 59-63% of lesbian, asexual and questioning participants compared with 30% and 44% of participants who identifies as gay and bisexual, respectively; and (d) key populations: 68% of African, Caribbean and Black, 57% of women, 50% of Indigenous people, 53% of people who inject drugs, compared with 34% of participants who identify as gay, bisexual, and men who have sex with men. First-time testers were higher in the Prairies and Quebec (55% and 80%, respectively) as compared with Ontario and British Columbia (40% and 42%, respectively).
Conclusion: Community Link Program is effective in reaching high rates of first-time testers, particularly those who are younger, women, those who identify as heterosexual or with a sexual minority group, from key populations, and in previously underserved geographic regions in Canada.

Introduction: In Canada, 20% of new HIV cases are attributable to people who use substances. Amidst the national overdose crisis, there is a need to democratize access to harm reduction materials and testing for those with complex healthcare needs. Our Healthbox (Notre Boîtesanté) is building a network of ‘smart,’ interactive dispensing systems hosted by community-based organizations, providing free, low-barrier, anonymous access to HIV self-testing (HIVST) kits, harm reduction supplies, sexual health and other wellness items along with educational resources and service directory for people to find the care they need.
Methods: Our Healthbox launched in January 2023 in four New Brunswick communities: Moncton (large urban), Sackville (small urban), Richibucto (small rural) and Woodstock First Nation (Indigenous rural). Program evaluation included describing participant demographics, supplies dispensed and reason for accessing items using data collected from sign-up, dispensing and post-access survey questions between January 23 to December 23, 2023.
Results: From the four Healthboxes 1,512 persons accessed 10,380 items. Overall: 59% participants were male, 78% were under 40, 44% identified as heterosexual, 64% educated (≥high school), 67% had difficulty paying for basic needs, and 63% were under-housed. A total of 6,284 harm reduction materials were dispensed (45% were safe injecting supplies), including 156 naloxone kits. Overall, 217 participants accessed 386 HIVST kits; 50% were first-time testers, 12% gave a kit to someone, 5% identified as gay, bisexual or men who have sex with men, 10% as African, Caribbean or Black, 30% as Indigenous, 36% were women and 59% indicated using substances. Overall, 76% would recommend Our Healthbox to others.
Conclusion: Our Healthbox program is reaching underserved people where they live in both large urban and small rural areas. By the end of 2024, we aim to implement 50 machines in communities across Canada and scale-up to 100 communities over the 3-year program.

Background: Despite innovative testing and prevention strategies, new HIV diagnoses continue to affect gay, bisexual and other men who have sex with men (gbMSM), persons who identify as African, Caribbean or Black (ACB), Indigenous persons, and people who use injection drugs. To improve access to HIV testing, as consequently to HIV treatment and/or prevention, we developed and launched GetaKit, an online assessment and mail-out system for HIV self-tests and other sexual health services.

Methods: GetaKit is a study to evaluate the real-world outcomes associated with offering online sexual health services. Individuals who consent to participate and create their accounts are invited to complete the online risk assessment to determine if the HIV self-test is appropriate based on self-reported demographics and risk.

Results: During the first 10 months that GetaKit was available across Ontario, 882 participants who identified as gbMSM, ordered an HIV self-test. Of these 882 participants, 25% (n=220) reported that this was their first-time testing for HIV. These participants tended to be younger than repeat testers, more likely to be a member of a racial/ethnic minority population and reported invalid results more frequently than other repeat testers.

Conclusions: The demographics of first-time testers raise important questions about how HIV self-tests may or may not facilitate access to HIV prevention and treatment services. The success of HIV self-testing may say more about the shortcomings within the traditional HIV prevention system. So, while we work together to improve access and supports around HIV self-testing, we should not forget about the importance of continuing professional learning for clinicians to deliver services in a culturally safe environment. More research is needed to gain a better understanding of why first-time HIV self-testers use that method, their attitudes and beliefs about healthcare systems, and more broadly sexual health education.

Background: Health Canada’s approval of the HIV self-test raised a number of questions: would people find the device easy to use? Would people know what to do when they received their result? Are systems in place to support self-referral to prevention and treatment services, if needed? To answer these questions a team of nurses developed GetaKit, an online risk-assessment and mail-out system to distribute HIV self-tests.

Methods: GetaKit is a real-world evaluation of an online platform to deliver sexual health services. We applied Multiple Intervention Framework to understand the socio-ecological features of the problem (defined as access to HIV testing), identify and develop interventions to overcome barriers, optimize the impact of implemented strategies and offer ongoing monitoring and evaluation of the project.

Results: To understand the socio-ecological features of the problem, the research team used evidence from the previous implementation of HIV point-of-care in Ontario to make the following assumptions: there is no process to determine whether the HIV self-test will be used in a way that is clinically appropriate; self-tests would not naturally be available in regions and within communities that have historically undertested; and post-test linkage to care can be unclear for users. We worked with community partners to develop interventions to ensure self-testing was (1) appropriate, (2) accessible, and (3) linked to care. Throughout implementation, we observed some barriers to uptake among community-based organizations especially in light of high staff turnover and competing mandates.

Conclusions: HIV self-testing can increase testing rates, especially within communities that have historically undertested. However, we argue that one device, by itself, cannot overcome decades of unequal and inequitable access to HIV services. Successful integration into community requires thoughtful implementation that includes resource development and ongoing support to ensure that both clinically trained staff and non-clinical staff can support HIV self test users.