Systematic review of the barriers for HIV testing in Canada; 2009–2019

CCDR

Volume 47-2, February 2021: HIV Testing in Canada in the Past Decade 2009–2019

Systematic review

Understanding barriers and facilitators to HIV testing in Canada from 2009–2019: A systematic mixed studies review

Claudie Laprise1, Clara Bolster-Foucault1

Affiliation

1 Public Health Agency of Canada, Health Security and Infrastructure Branch, Public Health Capacity and Knowledge Management Unit, Québec Regional Office; Montréal, QC

Correspondence

claudie.laprise@canada.ca

Suggested citation

Laprise C, Bolster-Foucault C. Understanding barriers and facilitators to HIV testing in Canada from 2009–2019: A systematic mixed studies review. Can Commun Dis Rep 2021;47(2):105–25. https://doi.org/10.14745/ccdr.v47i02a03

Keywords: HIV, barriers, facilitators, testing, screening, Canada, systematic review, mixed studies, key populations

Abstract

Background: HIV testing is a core pillar of Canada's approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed.

Objective: To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada.

Methods: A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized.

Results: Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices.

Conclusion: Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations.

Introduction

The World Health Organization estimated that approximately 37.9 million people were living with HIV/AIDS worldwide in 2018, including about 1.7 million who were newly infected that yearFootnote 1. In Canada, more than 63,000 people were living with HIV in 2016, and nearly 23,000 new cases were diagnosed between 2008 and 2017Footnote 2.

HIV testing and diagnosis is a critical first step in the HIV care cascade (HIV diagnosis, linkage to care, antiretroviral therapy initiation and achievement of viral suppression). For people living with HIV who know their status, receiving appropriate treatment reduces the long-term impact of the disease and prevents further transmissionFootnote 3.

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Programme Coordinating Board established the 90-90-90 targets with the goal of ending the AIDS epidemic by 2020. The aim of these targets are for 90% of all people living with HIV to know their HIV status, 90% of all people diagnosed with HIV to receive appropriate antiretroviral therapy (ART) and 90% of all people receiving ART to achieve viral suppressionFootnote 4Footnote 5. Canada has yet to achieve the first of these targets, and an estimated 14% of Canadians living with HIV in 2016 were unaware of their statusFootnote 2.

Although HIV testing coverage in Canada continues to expand, testing rates vary considerably across CanadaFootnote 6. Regional testing rates may be influenced by jurisdictional policies and programs determining accessibility of testing and the types of testing available (e.g. point-of-care testing)Footnote 7. Certain populations are also known to be disproportionately affected by HIV, including gay, bisexual and other men who have sex with men (gbMSM), transgender individuals, people who inject drugs (PWID) and sex workersFootnote 8Footnote 9Footnote 10Footnote 11Footnote 12. Owing to the intersection of stigma, discrimination and social determinants of health, these populations are often marginalized and underserved, leading to greater likelihood of HIV acquisition and transmission, and limited access to and uptake of testingFootnote 13Footnote 14. The differential distribution of these populations across Canada may contribute to regional variation in HIV testingFootnote 2.

A comprehensive overview of the barriers and facilitators of HIV testing that exist across key populations and jurisdictional boundaries in the current Canadian context is currently lacking. This knowledge is essential to orient public health policies and action toward the undiagnosed and mitigate the health impact of HIV in Canada. Two reviews describe the barriers and facilitators to HIV testing in the Canadian contextFootnote 7Footnote 15 and identified many barriers and facilitators to testing at the level of the individual (e.g. low risk perception, fear), healthcare provider (e.g. time constraints, insufficient resources) and institution/policy (e.g. cost/accessibility of testing)Footnote 7Footnote 15Footnote 16Footnote 17. However, these reviews were not systematic, do not cover the last decade and did not examine trends in HIV testing in key populations and in specific jurisdictions. Moreover, few studies conducted in Canada were identified in these reviews.

The objective of this systematic mixed studies review is to examine the barriers and facilitators to HIV testing that have been reported across populations and jurisdictions in Canada throughout the last decade and to conduct a narrative synthesis of identified works.

Methods

Search strategy

A systematic mixed studies review was conductedFootnote 18 of barriers and facilitators to HIV testing in Canada in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelinesFootnote 19 (appendix available upon request). Based on a pre-specified protocol and in collaboration with information specialists, the reviewers developed an electronic search strategy to identify original quantitative, qualitative and mixed-methods studies reporting on barriers and facilitators to HIV testing in Canada and published between January 1, 2009 and December 9, 2019 (appendix available upon request). Medline, Embase, PsycInfo, ProQuest Public Health, ProQuest Sociology Collection and Scopus were searched for peer-reviewed publications, and Google and Google Scholar for grey literature, government and non-governmental organization reports, and dissertations. Government webpages from each province/territory were also searched, and partners of regional offices of the Public Health Agency of Canada were consulted to retrieve other relevant works. In addition, the reference lists of included studies were manually searched for relevant publications.

Eligibility criteria

Studies were eligible for inclusion if they were original quantitative and/or qualitative studies reporting on barriers and/or facilitators to HIV testing in one or more Canadian province or territory; published between January 2009 and November 2019; and written in French or English. There were no restrictions in terms of the study sample size, type of study population or the study context/setting. Studies were excluded if they reported barriers and facilitators to testing for multiple sexually transmitted and blood-borne infections (STBBI) without reporting results for HIV separately, or if study data were collected prior to 2009.

Study selection and data collection

Two reviewers independently screened the titles and abstracts of all identified studies. Potentially relevant records were then retrieved for independent full-text review by both reviewers. Disagreements between reviewers at screening and full-text review stages were resolved by consensus.

The two reviewers independently extracted data from included studies using a piloted data extraction form that was created based on a sample of two quantitative and four qualitative studies selected for their high-quality reporting. For all included publications, the study province/territory, study aim(s), study design, population, sample size, data collection method, years of data collection, inclusion/exclusion criteria and basic demographic data of study participants including the age, sex or gender, sexual orientation and race/ethnicity were extracted. For quantitative studies, the analytical method, study exposure(s), outcome(s), covariates and main effect measures of identified barriers and facilitators to HIV testing were extracted. For qualitative studies, the analytical method and identified themes pertaining to barriers and facilitators to HIV testing were extracted.

Quality appraisal

Two investigators independently assessed the quality of included works using the Mixed Methods Appraisal Tool (MMAT)Footnote 20Footnote 21. The MMAT has been validated to critically appraise the methodological quality of studies with diverse designs. The tool includes five questions requiring "yes," "no" or "can't tell" answers. The questions are adapted to each type of study design and assess the appropriateness of the study design for the research question, the likelihood of bias and the appropriateness of measurements and analyses.

Based on the responses to these questions, a five-point quality score was created, assigning one point for each "Yes" response. Studies with four or more "Yes" answers were considered strong in quality, studies with three "Yes" answers were considered moderate in quality and studies with two or fewer "Yes" answers were considered weak in quality. Disagreements in the score assigned by both reviewers were resolved by consensus. No studies were excluded based on their quality, as the objective of this review was to synthesize all available evidence on barriers and facilitators to HIV testing in Canada. (Appendix available upon request).

Data analysis

Barriers were defined as any obstacle or reason given by study participants for declining or being unable to access HIV testing. Conversely, facilitators were defined as any reason that study participants gave for accepting or being able to access an HIV test. Sociodemographic characteristics and behaviours (e.g. age, sex/gender, sexual behaviours) that were associated with decreased or increased HIV testing uptake were considered barriers and facilitators, respectively. To avoid repetition, sociodemographic characteristics that operate both as barriers and facilitators to HIV testing are presented in terms of characteristics associated with increased testing.

Identified barriers and facilitators to HIV testing were analyzed using a convergent qualitative synthesis design in which quantitative data are transformed into qualitative findingsFootnote 18Footnote 22. The results were then integrated using inductive thematic synthesis in which themes are derived from the data without a predefined coding frame. The synthesis was guided by a conceptual framework developed by Deblonde et al. (2010)Footnote 17 that categorizes determinants of HIV testing according to the level at which they occur: the individual-level; the healthcare provider-level; and the institutional or policy level. To meet research objectives, an overall synthesis of results was conducted followed by a synthesis by key population and by jurisdiction.

Results

Study selection and characteristics

The initial search yielded 1,694 peer-reviewed studies and 49 grey literature records. After the removal of duplicates and publications not meeting eligibility criteria based on their title/abstract, 156 manuscripts were retained for full-text review. Of these, 33 peer-reviewed studiesFootnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32Footnote 33Footnote 34Footnote 35Footnote 36Footnote 37Footnote 38Footnote 39Footnote 40Footnote 41Footnote 42Footnote 43Footnote 44Footnote 45Footnote 46Footnote 47Footnote 48Footnote 49Footnote 50Footnote 51Footnote 52Footnote 53Footnote 54Footnote 55 and 10 grey literature recordsFootnote 6Footnote 56Footnote 57Footnote 58Footnote 59Footnote 60Footnote 61Footnote 62Footnote 63Footnote 64 were retained (Figure 1).

Figure 1: PRISMA flow diagram

Figure 1: PRISMA flow diagram

Text description: Figure 1

The figure shows the PRISMA flow diagram of manuscript identification, selection and inclusion of peer-reviewed and grey literature, in Canada from 2010 to 2019. The number of records identified through database searching for peer-reviewed literature was 1,694. After removal of duplicates, irrelevant records, and manuscripts not meeting our inclusion criteria, 33 manuscript were retained. The number of records identified through database searching for grey literature was 49. After removal of duplicates, irrelevant records, and records not meeting our inclusion criteria, 10 manuscript were retained. In total, 43 records were included in the systematic mixed studies review.


Table 1 shows the characteristics of included studies. Included studies were conducted in British Columbia (n=12)Footnote 23Footnote 24Footnote 26Footnote 27Footnote 30Footnote 32Footnote 34Footnote 37Footnote 38Footnote 43Footnote 50Footnote 52; Manitoba (n=1)Footnote 39; Ontario (n=10)Footnote 35Footnote 36Footnote 40Footnote 44Footnote 45Footnote 46Footnote 47Footnote 51Footnote 60Footnote 64; Québec (n=5)Footnote 29Footnote 41Footnote 49Footnote 58Footnote 61; Nova Scotia (n=4)Footnote 31Footnote 42Footnote 56Footnote 59; and Newfoundland and Labrador (n=1)Footnote 25. Seven studies included multiple provinces/territories (Atlantic provincesFootnote 28Footnote 62, all of CanadaFootnote 6Footnote 33Footnote 48Footnote 54Footnote 57) and two did not specify a province/territoryFootnote 53Footnote 55. Of the 43 publications, 42 were cross-sectional studies and one was a cohort study. Of these, 20 were quantitative, 13 were qualitative and 10 were mixed methods studies.

Table 1: Summary of included studies reporting on barriers and facilitators to HIV testing in Canada, 2009–2019
Citation and location Years of data collection Study population Sample
size
Age (years) Male (%) Study type Research question Quality score (/5)
Peer-reviewed literature
Anderson et al., 2016Footnote 23
Vancouver, British Columbia
2011–2014 Migrant sex workers, managers and business owners of indoor sex work venues 46 Median: 42
(IQR: 24–54)
2 Qualitative: Semi-structured interviews with thematic analysis Assess the impact of criminalization of sex work on HIV/STI prevention 5
Armstrong et al., 2019Footnote 24
Vancouver, British Columbia
2012–2014 gbMSM 535 Median: 30
(IQR: 24–39)
100 Quantitative: Questionnaire (self-administered) Determine the reasons for HIV testing and never having tested, and explore correlates of testing 4
Boyd et al., 2019Footnote 25
Newfoundland and Labrador
2006–2016 Patients diagnosed with HIV Quantitative: 58
Qualitative: 10
Categorical:
20–29 (20.7%),
30–39 (19.0%),
40–49 (41.4%),
50+ (19.0%)
91.4 Mixed methods: Semi-structured interviews with thematic analysis, and retrospective chart review Determine the timeliness of HIV testing, missed opportunities for testing, and barriers to HIV testing 4
Brondani et al., 2016Footnote 26
Vancouver, British Columbia
2010–2015 General population 519 Categorical:
19–24 (15 %),
25–44 (74%),
45+ (11%)
71.3 Quantitative: Questionnaire (self-administered) Identify patients' response to, and attitudes toward opt-out HIV rapid screening in a dental setting 3
Deering et al., 2015Footnote 27
Vancouver, British Columbia
2010–2012 Women sex workers 435 Median 35
(IQR: 38–42)
0 Quantitative: Questionnaire (interviewer-administered) Assess prevalence and correlates of accessing HIV testing 5
Dube et al., 2017Footnote 28
Atlantic provinces
NR Stakeholders including policy makers, healthcare providers and youth 68 NR NR Qualitative: Semi-structured interviews and focus-group discussions with thematic analysis Explore the scope and accessibility of existing youth-oriented HIV and HCV prevention 5
Engler et al., 2016Footnote 29
Montréal, Québec
2012–2013 Heterosexual clients of an MSM-oriented clinic 202 NR 72.8 Quantitative: Questionnaire (self-administered) Understand the HIV prevention and sexual health service needs of heterosexual women clients of an MSM-oriented clinic 3
Feng et al., 2018Footnote 30
Vancouver, British Columbia
2015–2016 General population 114 NR 31.2 Mixed methods: Focus groups and individual interviews, and questionnaire (self-administered) Determine the feasibility and acceptability of point-of-care HIV screening in dental hygiene settings 4
Gahagan et al., 2011Footnote 31
Nova Scotia
2009–2010 General population Quantitative: 15,518
Qualitative: 50
NR 38 Mixed methods: Semi-structured interviews with thematic analysis, and regional HIV laboratory surveillance data Explore the individual and structural barriers and facilitators to HIV counselling and testing 4
Gilbert et al., 2013Footnote 1Footnote 32
Vancouver, British Columbia
2006–2012 MSM NR NR 100 Quantitative: HIV testing laboratory surveillance data Examine the impact of NAAT HIV testing and social marketing campaign on diagnosis of acute HIV infection among MSM 2
Gilbert et al., 2013Footnote 2Footnote 33
All provinces
2011–2012 MSM 8,388 Median: 43
(IQR: 18–84)
100 Quantitative: Questionnaire (self-administered) Assess the perceived advantages and disadvantages of internet-based testing among MSM 5
Holtzman et al., 2016Footnote 34
Vancouver, British Columbia
2010–2011 MSM living outside major urban centres 153 Mean: 39.7
(SD: 15.4)
100 Quantitative: Questionnaire (self-administered) Investigate behaviours and predictors of HIV testing among MSM living outside major urban centres 5
Iqbal et al., 2014Footnote 35
Ontario
2011 Women in labour 92 Mean: 32
(SD: 4.4)
0 Quantitative: Questionnaire (self-administered) Assess attitudes and opinions surrounding point-of-care HIV testing 2
Kesler et al., 2018Footnote 36
Toronto, Ontario
2010–2012 MSM 150 Median: 44.5
(IQR: 37–50)
100 Quantitative: Questionnaire (self-administered) Quantify the potential impact of nondisclosure prosecutions on HIV testing and transmission among MSM 4
Knight et al., 2016Footnote 1Footnote 37
Vancouver, British Columbia
2013 Young men 50 Mean: 21.7
(SD: NR)
100 Qualitative: Semi-structured interviews with critical discourse analysis Explore the values that influence decisions and motivations to voluntarily access HIV testing 4
Knight et al., 2016Footnote 2Footnote 38
Vancouver, British Columbia
2013 Young men 50 NR
Presumed to be the same as Knight et al., 2016Footnote 37
100 Qualitative: Semi-structured interviews with grounded theory analysis Determine how HIV-related stigma is experienced differentially across subgroups of young men within voluntary and routine testing practices 5
Lau et al., 2017Footnote 39
Winnipeg, Manitoba
2016 Patients admitted to inpatient care 144 Median: 58
(IQR: 42–68)
48 Quantitative: Questionnaire (interviewer-administered) Evaluate the attitudes toward routine point-of-care HIV testing in patients admitted to inpatient care 3
Lazarus et al., 2016Footnote 40
Ottawa, Ontario
2013 PWID 550 Median: 43
(IQR 34–50),
No: 39
(IQR: 30–48)
78.2 Quantitative: Questionnaire (interviewer-administered) Determine the factors associated with the uptake of community-based HIV point-of-care testing 4
Lessard et al., 2015Footnote 41
Montréal, Québec
2013–2014 Immigrant MSM 40 Mean: 33
(SD: 10)
100 Mixed methods: Phone interview with thematic analysis Analyze factors contributing to immigrant MSM's use of a community-based rapid HIV testing 3
Lewis et al., 2013Footnote 42
Halifax, Nova Scotia
2011 General population 258 78.1% 20–40 53.5 Quantitative: Questionnaire (self-administered) Gauge community demand for rapid point-of-care HIV testing 4
Markwick et al., 2014Footnote 43
Vancouver, British Columbia
2011–2012 PWID 600 50.8% >48 67.5 Quantitative: Questionnaire (interviewer-administered) Characterize PWID's willingness to receive peer-delivered voluntary counselling and HIV testing 4
O'Byrne & Bryan, 2013Footnote 44
Ottawa, Ontario
NR Individuals who identify as gay, bisexual, transsexual, two-spirited, queer or questioning 721 Mean: 37.8
(SD: 12.1)
97.2 Quantitative: Questionnaire (self-administered) Examine sexual practices and STI/HIV testing and diagnosis histories 5
O'Byrne et al., 2013Footnote 1Footnote 45
Ottawa, Ontario
NR MSM 441 Mean: 38.0
(SD: 13.1)
100 Quantitative: Questionnaire (self-administered) Investigate impact of nondisclosure prosecutions and HIV prevention 5
O'Byrne & Watts, 2014Footnote 46
Ottawa, Ontario
NR Gay male youth 8 Mean: 23.3
(SD: NR)
100 Qualitative: Semi-structured interviews with thematic analysis Explore perceptions of stigma in health care in gay male youth 5
O'Byrne et al., 2013Footnote 2Footnote 47
Ottawa, Ontario
NR MSM 27 Categorical:
19–30 (48%),
31–40 (30%),
41–50 (13%),
51–60 (9%)
100 Mixed methods: Semi-structured interviews with thematic analysis Examine HIV testing and attitudes of MSM following regional media releases about a local nondisclosure prosecution 4
Pai et al., 2018Footnote 48
All provinces
2015 Stakeholders involved in HIV self-testing initiatives across Canada 183 NR NR Mixed methods: Questionnaire (self-administered), open-ended questions and comments Identify the concerns, opportunities and challenges to implementing HIV self-testing in Canada 4
Pai et al., 2014Footnote 49
Montréal, Québec
2011–2012 Students from a university health clinic 145 Median: 22
(IQR: NR)
39.8 Mixed methods: Questionnaire (self-administered), open-ended questions Investigated the feasibility of offering an unsupervised self-testing strategy to Canadian students 5
Rich et al., 2017Footnote 50
Vancouver, British Columbia
2012–2014 Gay, bisexual and queer transgender men 11 Median: 26
(IQR: 25–28)
100 Qualitative: Semi-structured interviews with thematic analysis Explore sexual HIV risk for transgender men in an environment of publicly funded universal access to healthcare including HIV testing and treatment 5
Scheim & Travers, 2017Footnote 51
Ontario
2013 Transgender MSM 40 Categorical:
18–24 (25%),
25–34 (48%),
35v44 (23%),
45+ (5%)
100 Qualitative: Semi-structured interviews with thematic analysis Identify trans MSM's perspectives on barriers and facilitators to HIV and STI testing 5
Stenstrom et al., 2016Footnote 52
Vancouver, British Columbia
2009–2011 Tertiary care emergency patients 1,402 Mean: 43.3
(SD: 11.6)
58.4 Quantitative: Questionnaire (self-administered) Estimate the acceptability of point-of-care HIV testing in an emergency department 4
Stephenson et al., 2014Footnote 53
Not specified
2011–2012 Male Facebook users indicating an interest in men 344 Categorical:
18–24 (42%),
25–34 (26%),
35–44 (13%),
45+ (19%)
100 Quantitative: Questionnaire (self-administered) Examine the associations between individual characteristics and willingness of MSM couples to use couples' voluntary HIV counselling and testing 5
Worthington et al., 2015Footnote 54
All provinces/territories
2011 General population 2,139 Categorical:
16–29 (23.3%),
30–59 (50.8%),
60+ (25.9%)
48.2 Quantitative: Questionnaire (self-administered and interviewer-administered) Describe voluntary HIV testing in the general population and examine individual knowledge, behaviours and sociodemographic factors associated with testing 5
Worthington et al., 2016Footnote 55
Not specified
NR Nurses 40 NR NR Mixed methods: Semi-structured interviews with thematic analysis Assess the impact of an HIV care mentorship intervention on knowledge, attitudes and practices with nurses and PLWHIV 4
Grey literature
Barbour, 2017Footnote 56
Halifax, Nova Scotia
NR Indigenous communities 6 NR 50 Qualitative: Semi-structured interviews with thematic analysis Obtain community knowledge and understanding of the perceived barriers/facilitators associated with the access/acceptability of HIV testing within Indigenous populations 5
CATIE (Community AIDS Treatment
Information Exchange), 2016Footnote 57
All provinces/territories
2016 Stakeholders working in HIV programming 65 NR NR Qualitative: Deliberative group dialogue Produce key priority directions in HIV testing and linkage programming to improve the ability to reach the undiagnosed and link them to care 2
Centre Sida amitié, 2019Footnote 58
Laurentides, Québec
NR PLWHIV, PWID, expert partners 196 NR NR Qualitative: Questionnaire (self-administered and interviewer-administered) Generate recommendations for communities to attain the 90-90-90 targets 2
Gahagan et al., 2012Footnote 59
Halifax, Nova Scotia
2011 Clients of the Halifax Sexual Health Centre 258 NR NR Mixed methods: Questionnaire (self-administered), open-ended questions Assess performance of Anonymous HIV Testing Program, gauge clients' interest in rapid point-of-care HIV testing and willingness to pay a fee to have this testing option 3
Konkor, 2019Footnote 60
London/Ottawa
/Toronto/Windsor, Ontario
2018–2019 Heterosexual men of ACB communities 156 Categorical:
16–19 (14%),
20–29 (32%),
30–39 (26%),
40–49 (16%),
50+ (12%)
100 Quantitative: Questionnaire (self-administered) Identify the factors that influence uptake of HIV testing services among heterosexual ACB men 4
Messier-Peet et al., 2018Footnote 61
Montréal, Québec
2017–2018 gbMSM 551 NR 100 Quantitative: Questionnaire (self-administered) Investigate factors associated with not being tested for HIV among gbMSM at high-risk for HIV 4
Our Youth, Our Response, 2014Footnote 62
Atlantic provinces
2011–2013 Stakeholders from government, community and research sectors, health service providers and clients of community organizations 69 Categorical:
16–25 (16%),
26–35 (20%),
36–45 (19%),
46–55 (20%),
56+ (19%)
45.4 Mixed methods: Interviews and focus groups with thematic analysis Develop evidence-based recommendations for stakeholders in government, community and research sectors on prevention, policy and programming approaches needed to help mitigate the impact of HIV/HVC 4
PHAC, 2018Footnote 63
All provinces/territories
2010–2012 PWID 2,687 Mean: 39.4
(SD: NR)
68.2 Quantitative: Questionnaire (interviewer-administered) To inform HIV prevention and control efforts, public health policy development, and program evaluation 4
Vannice, 2016Footnote 64
Ottawa, Ontario
NR Women in ACB communities 10 Range: 18–60 0 Qualitative: Semi-structured interviews with thematic analysis Examine the experiences, perceptions and knowledge regarding HIV testing among ACB women 3
Wertheimer, 2011Footnote 6
All provinces/territories
2009–2010 Service providers Quantitative: 75
Qualitative: 15
NR NR Mixed methods: Questionnaire (self-administered online), individual interviews Identify the barriers that affect women's access to HIV testing 2

Quality appraisal

Most of the included publications were of strong quality (n=32; 74%), while some were moderate (n=6; 14%) or weak quality (n=5; 12%). (Appendix available upon request). The weakest element in the qualitative studies was a lack of the detail necessary for an evaluation of whether the data substantiated the interpretation of results. The weakest element in the quantitative studies was the risk of non-response bias, which is expected as many of these studies were conducted in hard-to-reach populations. The weakest element in the mixed methods studies was a lack of consideration of divergence between qualitative and quantitative results.

Synthesis of results

The following narrative synthesis of results summarizes identified barriers and facilitators overall and by key population and jurisdiction. Sociodemographic characteristics and behaviours associated with HIV testing are presented separately because they represent individual-level drivers of testing uptake rather than external barriers/facilitators.

Overview of barriers and facilitators to HIV testing

At the level of the individual, several barriers to HIV testing emerged across multiple contexts: fear of receiving a positive resultFootnote 6Footnote 25Footnote 39Footnote 56Footnote 58Footnote 64; stigma surrounding HIV and behaviours or identities perceived to be associated with HIVFootnote 23Footnote 31Footnote 38Footnote 41Footnote 56Footnote 58Footnote 60Footnote 64; the perception of being at low risk for exposure to HIVFootnote 6Footnote 24Footnote 26Footnote 50Footnote 51Footnote 61Footnote 62; insufficient knowledge of HIV and testing optionsFootnote 56Footnote 61Footnote 64 ; difficulty accessing testing services, for example, limited clinic opening hours, difficulty getting an appointmentFootnote 23Footnote 28Footnote 41Footnote 58Footnote 60Footnote 64; and insufficient confidentiality in testing servicesFootnote 28Footnote 41Footnote 42Footnote 56Footnote 58Footnote 64. Certain sociodemographic characteristics were identified as being associated with increased testing, including engaging in behaviours associated with HIV (e.g. increased number of sexual partners, injection drug use)Footnote 24Footnote 27Footnote 40Footnote 54Footnote 60Footnote 61Footnote 63 and having been previously tested for STBBIFootnote 24Footnote 25Footnote 38.

At the level of the healthcare provider, common barriers were identified as HIV-related stigma from healthcare providersFootnote 46Footnote 57; perception that a patient is at low risk of HIV exposureFootnote 6Footnote 64; and reluctance/refusal to offer testing for individuals who were not perceived to be at riskFootnote 38Footnote 58. Many studies reported healthcare providers suggesting an HIV testFootnote 25Footnote 26Footnote 58 and that non-stigmatizing healthcare practicesFootnote 23Footnote 50Footnote 51 facilitated testing.

At the institutional or policy level, the criminalization of certain behaviours (e.g. sex work, drug use, HIV nondisclosure)Footnote 23Footnote 57 and the lack of resources and adequate healthcare infrastructure in rural and remote regionsFootnote 28Footnote 56Footnote 58Footnote 62 represent structural barriers to testing. Conversely, policies and institutional practices that increase the accessibility, convenience and confidentiality of testing (e.g. broad range of testing options, reducing wait times, low-cost testing)Footnote 6Footnote 23Footnote 25Footnote 26Footnote 27Footnote 29Footnote 41Footnote 49Footnote 50Footnote 51Footnote 58Footnote 62 and integrate testing with routine healthcare servicesFootnote 25Footnote 31Footnote 38Footnote 51Footnote 58Footnote 63Footnote 64, educational/promotional campaignsFootnote 6Footnote 28Footnote 32Footnote 62Footnote 64 and intersectoral collaborationFootnote 6Footnote 28Footnote 62 were reported as facilitators to testing.

Results by key population

A large number of studies focused on gbMSM (n=15)Footnote 24Footnote 32Footnote 33Footnote 34Footnote 36Footnote 37Footnote 38Footnote 44Footnote 45Footnote 46Footnote 47Footnote 50Footnote 51Footnote 53Footnote 61, reflecting the historical epidemiology of HIV in Canada. Other key populations include sex workers (n=2)Footnote 23Footnote 27, PWID (n=3)Footnote 43Footnote 58Footnote 63 , immigrant populations (n=3)Footnote 23Footnote 41Footnote 60, Indigenous communities (n=1)Footnote 56, and African, Caribbean and Black communities (n=2)Footnote 60Footnote 64. Results are summarized by key population to highlight the unique needs and context of each population in Table 2.

Table 2: Barriers and facilitators to HIV testing by key population in Canada, 2009-2019
Population type Provinces reporting on population Barriers Facilitators
gbMSM (including two-spirited, queer, trans or questioning) All provinces
  • Having a strong network among gbMSM in the communityFootnote 50
  • gbMSM, queer and trans-competent sexual health careFootnote 50
  • Integrating HIV testing with other routine health servicesFootnote 31
  • Internet-based HIV testingFootnote 33
  • Social media campaigns promoting HIV testingFootnote 32
Sex workers (including managers and business owners of sex work venues) British Columbia
  • Criminalization of sex workFootnote 23
  • Criminalization of third parties (managers/owners) creating harmful practices within sex work venues (e.g. restrictions on condom use, rejecting testing in the workplace)Footnote 23
  • Collaboration between public health outreach and law enforcement (e.g. arriving on site together) resulted in a mistrust of health outreach workers and a reluctance to allow them on siteFootnote 23
  • Occupational stigma resulting in difficulties accessing primary health care and sexual health services Footnote 23
  • Fear of sex worker status becoming known (e.g. reluctance to request frequent tests from family doctors)Footnote 23
  • Mobile HIV prevention programsFootnote 27
  • Health outreach workers offering STBBI testing in sex work venuesFootnote 23
  • Non-judgmental and non-stigmatizing attitudes of health outreach workers enabling open discussions about sexual health issuesFootnote 23
PWID All provinces
  • Low risk perception, lack of interest or perceived urgencyFootnote 63
  • Fear of a positive diagnosisFootnote 63
  • Feeling healthy Footnote 63
  • Issues getting tested (e.g. accessibility of testing services)Footnote 63
  • Feeling that nothing could be done in the case of a positive diagnosisFootnote 63
Immigrant populations British Columbia, Ontario, Québec
  • Shame associated with requesting HIV testing and responding to the pre-test questionnaire (e.g. disclosure of sexual information)Footnote 41
  • Concerns about confidentiality (e.g. being seen in the clinic or receiving services from a member of their close-knit community, preference to answer questions on paper/electronic devices)Footnote 41
  • Difficulties accessing primary health care and sexual health services due to lack of health insurance, linguistic and cultural barriersFootnote 23Footnote 27Footnote 41Footnote 60
  • Availability of translators or multilingual health services Footnote 23
Indigenous communities Nova Scotia
  • Geographic barriers to accessing health care in rural and remote communities; absence of primary health care and HIV testing services; inconsistent access to medical transportationFootnote 56
  • Lack of trust between clients and healthcare providersFootnote 56
  • Lack of knowledge about HIV (risk factors, risk reduction strategies, modes of transmission, treatment) and HIV testing (feasibility, available types, benefits)Footnote 56
  • HIV stigma relating to injection drug useFootnote 56
  • Low risk perception; denial of potential risk linked to certain behaviours (e.g. injection drug use)Footnote 56
  • Fear of positive result and loss of community acceptanceFootnote 56
  • Stigma and homophobia; perceptions of HIV as a "gay disease," associations with promiscuity, hierarchy of stigmatized behaviours, more social stigma is associated with homosexuality than injection drug use, linked to differential perception of HCV and HIVFootnote 56
  • Issues with confidentiality within small communities, belief that "people will know" Footnote 56
  • Normalization of HIV testing increasing both accessibility and acceptability; shifting away from targeted testing based on behaviour, sexuality and risk toward integration of testing into routine medical careFootnote 56
  • Increasing availability of testing; offering HIV testing within Indigenous reserves; increasing access to medical transportationFootnote 56
  • Reducing wait time for results by offering point-of-care testingFootnote 56
  • Harm reduction service centres integrating HIV testingFootnote 56
  • Education about HIV (modes of transmission, risk factors) and HIV testing (available types, testing as prevention); sessions delivered by HIV/AIDS service organizationsFootnote 56
  • Collaboration between healthcare providers and HIV/AIDS service organizations to build trustFootnote 56
  • Practices and protocols that are acceptable to the communityFootnote 56
  • Combined education about other STBBIs (e.g. HCV)Footnote 56
African, Caribbean and Black communities Ontario
  • Cultural barriers (labelling of women who test as promiscuous)Footnote 64
  • Difficulty accessing health/testing facilities (not knowing where to get an HIV test)Footnote 60Footnote 64
  • Fear of positive results; preferring not to knowFootnote 64
  • Fear of negative reaction from partner(s) upon disclosure of statusFootnote 64
  • Lack of anonymous testingFootnote 64
  • Lack of confidentiality in HIV testing servicesFootnote 64
  • Insufficient knowledge of HIV (transmission, testing, treatment)Footnote 64
  • Stigma and discrimination of same-sex sexual behaviour, PWID or alcohol use, misconception that testing implies low masculinityFootnote 60Footnote 64
  • Resistance from family physician to test despite a requestFootnote 60Footnote 64
  • Perceiving an offer of testing as a form of stereotyping or profilingFootnote 60Footnote 64
  • Being offered testing by a family physician in the context of routine care (rather than needing to specifically request it)Footnote 64
  • Eliminating stigma by normalizing HIV testingFootnote 64
  • Strategies focused on opening communication and navigating cultural silences (empowering individuals to broach the topic of HIV testing)Footnote 64
  • Testimonials from PLWHIV/AIDS reducing fear of testingFootnote 64
  • Community outreach by individuals from similar cultural or linguistic backgroundsFootnote 64
  • Increasing knowledge of treatment and outcomes, testing recommendations, risk reduction strategiesFootnote 64
  • Public health messaging from government and health agencies, leveraging mainstream media Footnote 64

Several barriers to HIV testing were common across key populations. These included the fear of a positive diagnosisFootnote 23Footnote 41Footnote 51Footnote 56Footnote 64; experiences of HIV-related stigmaFootnote 41Footnote 56, the perception of being at low risk for exposure to HIVFootnote 24Footnote 50Footnote 51Footnote 56Footnote 63; limited accessibility of testing servicesFootnote 23Footnote 27Footnote 41Footnote 56Footnote 60Footnote 64; and insufficient knowledge about HIVFootnote 56Footnote 64. Other common barriers represent particularly significant obstacles to testing for marginalized populations, including stigma relating to behaviours or identities perceived to be associated with HIV (e.g. sexual behaviours, sexual orientation, sex work, injection drug use)Footnote 23Footnote 24Footnote 31Footnote 41Footnote 46Footnote 50Footnote 51Footnote 56Footnote 60Footnote 64 and insufficient confidentiality in testing services, including the lack of anonymous testing and concerns about privacy in small or remote communitiesFootnote 23Footnote 41Footnote 44Footnote 47Footnote 56Footnote 64.

Other barriers were unique to key populations. Legislation that criminalizes HIV nondisclosure and sex work are barriers to testing among gbMSMFootnote 36Footnote 45Footnote 47 and sex workersFootnote 23, respectively. In addition, insufficient knowledge about the health-related concerns and needs of certain populations (e.g. gbMSM/transgender identities, sex workers) by healthcare providers is an obstacle to testing in these populationsFootnote 23Footnote 51Footnote 56Footnote 60. Many populations also face distinct issues of accessibility, such as limited availability of multilingual health services and lack of health insurance among immigrant populationsFootnote 23Footnote 41Footnote 60, and geographic barriers to health care in rural and remote Indigenous communitiesFootnote 56.

Despite the diverse contexts of these populations, several common facilitators emerged. Offering HIV testing in a broad range of modalities (e.g. anonymous testing, unsupervised self-testing) and settings (e.g. mobile clinics, point-of-care testing)Footnote 23Footnote 27Footnote 33Footnote 56 as well as the integration of members of key populations with lived experience (e.g. peer-delivered post-test counselling, community-based outreach initiatives)Footnote 43Footnote 56Footnote 64 were frequently identified as means to improve the accessibility and acceptability of HIV testing services to key populations.

Finally, some facilitators were uniquely relevant for certain key populations. Healthcare practices that are inclusive and non-stigmatizing were identified as important facilitators by queer and transgender communitiesFootnote 50Footnote 51. The availability of translators or multilingual health services facilitated testing for immigrant populationsFootnote 23. Among the African, Caribbean and Black community, enabling social connections with people living with HIV and educational initiatives focused on navigating cultural silences around HIV facilitated testingFootnote 64.

Results by jurisdiction

Identified sociodemographic characteristics associated with HIV testing, and barriers and facilitators to HIV testing are summarized by jurisdiction in Table 3.

Table 3: Sociodemographic characteristics associated with increased HIV testing, barriers and facilitators of HIV testing by jurisdiction in Canada, 2009–2019
Province/territory Individual level Healthcare provider level Policy level
British Columbia
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • NA
  • NA
Barriers
  • NA
  • Criminalization of sex workFootnote 23
  • Collaboration between public health agencies and law enforcement creating mistrust of health outreach workersFootnote 23
Facilitators
  • Having a strong network in the gbMSM communityFootnote 50
  • Having been previously tested for other STBBIsFootnote 24
  • gbMSM, queer and trans-competent sexual health care and HIV testingFootnote 50
  • HIV testing initiated/offered by healthcare providersFootnote 26
  • Non-judgmental and non-stigmatizing attitudes of healthcare providersFootnote 23
Manitoba
Barriers
  • NA
  • NA
Ontario
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • NA
  • NA
Barriers
  • Lack of knowledge of trans identities and health-related concerns among healthcare providersFootnote 51
  • Stigma from healthcare professionalsFootnote 46
  • Low risk perception among healthcare providersFootnote 64
  • NA
Facilitators
  • Integrating HIV testing with routine care (de-stigmatize and normalize HIV testing)Footnote 38Footnote 51Footnote 64
  • Increasing HIV knowledge and education in the community (e.g. via television and radio), particularly from government health agenciesFootnote 64
  • Providing social connections with PLWHIVFootnote 64
Québec
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • NA
  • NA
Barriers
  • Fear of positive result, of being judged or rejected, and of disclosing status to partner(s)Footnote 58
  • Shame associated with requesting HIV test and responding to the pre-test questionnaire (e.g. disclosure of sexual information)Footnote 61
  • Lack of confidentiality in testing servicesFootnote 41Footnote 58
  • Insufficient knowledge of HIV testing services, locations and recommendationsFootnote 61
  • Limited access to healthcare providersFootnote 61
  • Limited opening hours of HIV testing clinicsFootnote 41
  • Low risk perceptionFootnote 61
  • Testing not covered by public health insuranceFootnote 58
  • HIV stigmaFootnote 58
  • NA
Facilitators
  • NA
  • Healthcare providers never refusing a request for HIV testing from a patientFootnote 58
  • Unsupervised oral self-testingFootnote 48
  • Integrating HIV testing with routine healthcare without a pre-test questionnaire (e.g. on sexual behaviours)Footnote 58
  • Accessible, confidential, convenient (no need for appointment) testing services, including non-nominal testing, rapid testingFootnote 29Footnote 41Footnote 58
  • Offering a variety of HIV testing modalities: unsupervised oral self-testingFootnote 49
  • Offering HIV testing in various settings: in the community, at the pharmacyFootnote 58
  • Prevention efforts based on harm reduction principles, focusing on the person as well as the virusFootnote 58
  • Safe HIV testing settingFootnote 58
Nova Scotia
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • NA
  • NA
Barriers
  • Fear of positive test result, of rejection and of being associated with promiscuity and PWIDFootnote 56
  • Lack of confidentiality in testing servicesFootnote 42Footnote 56
  • Insufficient knowledge about HIV and testingFootnote 56
  • Stigma and discrimination with regard to gender, sexuality, sexual identity, sexual relationships and monogamyFootnote 31Footnote 56
  • NA
  • Geographic barriers to accessing health care in rural and remote communities; absence of primary health care and HIV testing services in smaller communities; inconsistent access to medical transportationFootnote 56
Facilitators
  • NA
  • Integrating HIV testing with routine health services (e.g. systematic prenatal HIV testing)Footnote 31
  • Normalizing of HIV testingFootnote 56
  • Availability of rapid testingFootnote 42
Newfoundland and Labrador
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • MSM (heterosexual men diagnosed later than MSM)Footnote 25
  • NA
  • NA
Barriers
  • Hospital settings (e.g. patients in STBBI clinics diagnosed earlier than those in hospitals)Footnote 25
  • Fear of diagnosis; denial of riskFootnote 25
  • Negative interactions with the healthcare systemFootnote 25
  • Stigma surrounding HIV and testing
  • NA
  • Insufficient knowledge of HIV among the general population (fear of HIV, misconceptions about HIV and drug use)
  • Lack of adequate support for PLWHIVFootnote 25
Facilitators
  • Having been tested for other STBBIs previouslyFootnote 25
  • HIV testing initiated/proposed by healthcare providersFootnote 25
  • Integrating HIV testing with routine health servicesFootnote 25
  • Offering a broad range of HIV testing optionsFootnote 25
Atlantic provinces
Barriers
  • Difficulty accessing timely, gender-appropriate and youth-adapted HIV testing servicesFootnote 28
  • Lack of accessibility and confidentiality in small community settings (e.g. personal relationships between family and healthcare professionals)Footnote 28Footnote 62
  • Low risk perception; lack of HIV knowledgeFootnote 62
  • NA
  • Lack of personnel and resources for collaboration between Atlantic provincesFootnote 62
  • Lack of guiding policy for programs, resulting in discordance across sectorsFootnote 28
Facilitators
  • HIV testing for youth in dedicated sexual health centres
  • Increasing awareness, education and information about HIV; highlighting the importance of prevention, reducing misconceptions related to HIV to reduce stigmaFootnote 28Footnote 62
  • Continuing education to deliver pre and post-test counselling and referrals to appropriate health services following testingFootnote 62
  • Increasing awareness, education and information about HIV; highlighting the importance of prevention, reducing misconceptions related to HIV to reduce stigmaFootnote 28Footnote 62
  • Access to nonjudgmental and gender-responsive approaches (services without gender-based stereotypes or inequities)Footnote 28
  • Education and promotional materials adapted to youth (e.g. age-appropriate content, peer mentoring, social media, phone and Internet-based programs, art-based projects)Footnote 62
  • Increase awareness, education and information about HIV; highlighting the importance of prevention, reducing misconceptions related to HIV to reduce stigmaFootnote 28Footnote 62
  • Increasing the number and types of testing sites, (e.g. clinics in schools, mobile testing sites) and modalities (e.g. point-of-care, anonymous testing)Footnote 62
  • Inter-organizational and intersectoral collaborationFootnote 28Footnote 62
  • Youth engagement in the development and implementation of HIV/HCV prevention initiativesFootnote 28Footnote 62
Canada-wide or unspecified provinces/territories
Sociodemographic characteristics and behaviours associated with increased HIV testing
  • NA
Barriers
  • Anxiety and fear (due to long time between testing and obtaining results, being judged, sickness and death, family or community violence)Footnote 6Footnote 63
  • Difficulty accessing health/testing services (limited medical facilities)Footnote 6Footnote 63
  • Geographical barriers to accessing health careFootnote 6
  • Difficulty accessing testing servicesFootnote 63
  • Lack of confidentiality in testing servicesFootnote 6
  • Lack of pre and post-test counsellingFootnote 6
  • Lack of trust in healthcare providers due to historical context of racism, colonization and homophobiaFootnote 6Footnote 57
  • Low risk perception, lack of interest, feeling healthyFootnote 6Footnote 63
  • HIV-related stigma and criminalization of HIV nondisclosureFootnote 57
  • HIV-related stigmaFootnote 57
  • Lack of trust in healthcare providers due to historical context of racism, colonization and homophobiaFootnote 57
  • Low risk perception by healthcare providersFootnote 6
  • HIV-related stigma and criminalization of HIV nondisclosureFootnote 57
Facilitators
  • Anonymous testingFootnote 6
  • Integrating HIV testing into routine medical careFootnote 63
  • Availability of different testing modalities: rapid testingFootnote 6, couples voluntary HIV counselling and testingFootnote 53, Internet-based HIV testingFootnote 33, unsupervised oral-self testingFootnote 48
  • Enhancing the capacity of health service providers (e.g. clinics, AIDS service organizations, community organizations)Footnote 6
  • Gender-responsive interventions and programsFootnote 6
  • Increasing awareness about HIV (e.g. via educational campaigns and tools)Footnote 6

Although jurisdictions share many common barriers and facilitators to HIV testing, several trends emerged in particular jurisdictions. Studies conducted in British Colombia highlight the criminalization and stigmatization of sex work and issues related to immigrant status as major barriers to HIV testingFootnote 23Footnote 24Footnote 27. Studies conducted in Ontario feature cultural barriers and issues of stigma and fear of behaviours associated with HIV more prominently than other jurisdictionsFootnote 38Footnote 60Footnote 64. Studies conducted in the Atlantic provinces uniquely highlight youth-adapted services as a key facilitatorFootnote 28Footnote 62. Differences in the barriers and facilitators to HIV testing across jurisdictions were driven primarily by differential presence of key populations across jurisdictions and reflect regional public health priorities.

Discussion

In this systematic mixed studies review, it included results from 43 studies conducted in Canada to document and understand recent and emerging barriers and facilitators to HIV testing in the last decade. The principal motivation was to orient future research and public health action toward reaching the first global HIV target in Canada, taking into consideration key populations and jurisdictional contexts. Another motivation was to identify specific areas for intervention to improve access to HIV testing in a broad range of contexts, including providing accessible, low-cost and convenient testing, ensuring confidentiality, reducing HIV-related stigma, improving education about HIV (e.g. modes of transmission, testing, treatments), normalizing offering HIV testing and integrating testing into routine healthcare practices.

Common barriers emerge across key populations and jurisdictions, including low risk perception, fear and stigma surrounding HIV, lack of knowledge of HIV and testing, insufficient patient confidentiality, limited access to cultural and linguistically appropriate services and lack of resources for testingFootnote 7Footnote 15. This review identified several emerging innovative practices, including integrating HIV point-of-care testing in a variety of new settings including Internet-based HIV testingFootnote 33, sex work venuesFootnote 27, dental careFootnote 26Footnote 30 , emergency roomsFootnote 52, pharmaciesFootnote 59 and in mobile testing unitsFootnote 26Footnote 27. Several innovative testing modalities were also identified: couples voluntary HIV counselling and testingFootnote 53, oral swab and oral-self testingFootnote 26Footnote 49 and peer-delivered post-test counsellingFootnote 43. Gender-based approachesFootnote 28, queer and transgender-competent healthcare providers and adapted interventions and approachesFootnote 50, age-adapted education and promotion material, testing sites (e.g. school-based clinics for youth) and youth engagement in the development and implementation of HIV prevention initiatives were also clearly identified as important facilitatorsFootnote 62.

The evidence summarized above highlights the importance of adapting public health policy and programming to the unique contexts of each jurisdiction, including the distribution of key populations and burden of disease. Potential strategies for improving access to HIV testing among key populations include increasing the accessibility of HIV testing by expanding available testing options and promoting health outreach initiatives for hard-to-reach populations. In addition, ensuring inclusive and non-stigmatizing healthcare services and integrating the knowledge of members of these communities are essential to improve the acceptability of HIV testing to key populations. Policy makers and healthcare providers should also consider the intersectionality of identities and experiences in order to better understand the specific drivers of HIV testing in each populationFootnote 65. These results underscore the importance of adopting a person-centred approach to HIV testing and the need to reach people where they are.

Many of the barriers and facilitators identified in this review operate at the institutional/policy level, potentially indicating an increased focus on up-stream determinants of HIV testing in the last decade. This recent trend underscores the importance of public health action at the systemic level and suggests that HIV testing initiatives could be enhanced by leveraging the expertise of a range of stakeholders including community partners, primary health care, harm reduction services and public health authorities. Expanding intersectoral partnership and collaboration may offer important opportunities to bridge testing gaps and ensure equitable access to HIV testing.

The Pan-Canadian Framework recognizes the importance of testing in achieving global STBBI targets and outlines specific opportunities for action that align with the facilitators identified in this reviewFootnote 66. As outlined in the Government of Canada STBBI action planFootnote 67, improving access to STBBI testing is a core component of a coordinated approach to reducing the impact of STBBI in Canada, with a particular focus on populations that are disproportionately affected by STBBI. This review contributes to existing knowledge of the drivers of HIV testing in Canada and highlights several important gaps and opportunities that can be used to inform public health action toward this goal.

Strengths and limitations

A major strength of this work is the systematic mixed studies review design, which synthesizes quantitative and qualitative data in order to answer complex research questions such as the identification of determinants of HIV testingFootnote 18. The inclusion of multiple forms of evidence creates a rich synthesis of extant barriers and facilitators by combining diverse perspectives (i.e. population-level data and individual experiences) and produces results that are directly relevant to decision-makersFootnote 22. In addition, the broad scope allows for the identification of emerging and lesser known barriers and facilitators, as well as population and jurisdiction-specific trends in HIV testing in Canada, informing targeted public health actionFootnote 68.

Nevertheless, this review has limitations. It is possible that some relevant works were not identified by our search strategy and so certain barriers/facilitators may be absent from this synthesis. In addition, the intrinsic nature of the data made it impossible to assess the causal nature of any of the identified barriers or facilitators.

This review may also be limited by publication bias, as published literature reflects historical and regional contexts and priorities, potentially resulting in gaps in the literature to do with non-priority populations and settings. As such, although this review presents results across populations and jurisdictions, some key populations (e.g. PWID, sex workers, immigrants, Indigenous communities and African, Caribbean and Black communities) and some provinces (e.g. Alberta, Manitoba, Saskatchewan) and the territories are underrepresented, potentially limiting the generalizability of results. In addition, emerging key populations may be missing.

Finally, the scope of this review was limited to barriers and facilitators of HIV testing and may omit other important shared barriers and facilitators to testing for other STBBI.

Conclusion

HIV testing acts as the gateway for HIV treatment and prevention and is a core pillar of Canada’s efforts to reduce the health impact of HIV and other STBBI. This work provides a comprehensive and detailed understanding of the barriers and facilitators to HIV testing in Canada and highlights several important factors that can be leveraged to increase HIV testing. The results provide key evidence to influence practice, policy and future research toward achieving global HIV targets.

Authors’ statement

CL and CBF contributed equally to this work: conceptualization, development of search strategy, screening of identified works for inclusion, quality appraisal, data extraction, analysis and interpretation of data and manuscript preparation.

Competing interests

The authors have no conflicts of interest to declare.

Acknowledgements

We would like to thank L Pogany, J  Insogna and G  Tremblay from the Public Health Agency of Canada’s Centre for Communicable Disease and Infection Control, in Ottawa, as well as A Blair, L Turcotte and D  Parisien from the Public Health Agency of Canada’s Québec Regional Office, in Montréal for their contribution to the conceptualization and design of this review. Finally, we would like to thank K  Merucci and L  Glandon from the Health Canada Library, in Ottawa, for their assistance in the development of the search strategy.

Funding

This work was supported by the Public Health Agency of Canada.

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Lau L, Wudel B, Lee E, Darraj M, Richert Q, Trajtman A, Bresler K, Bullard J, Kasper K, Becker M, Keynan Y. Evaluation of the utility of point-of-care HIV testing on a Canadian internal medicine inpatient unit. Can J Infect Dis Med Microbiol 2017;2017:8495307. https://doi.org/10.1155/2017/8495307

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Footnote 40

Lazarus L, Patel S, Shaw A, Leblanc S, Lalonde C, Hladio M, Mandryk K, Horvath C, Petrcich W, Kendall C, Tyndall MW; Proud Community Advisory Committee. Uptake of community-based peer administered HIV point-of-care testing: findings from the PROUD study. PLoS One 2016;11(12):e0166942. https://doi.org/10.1371/journal.pone.0166942

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Footnote 41

Lessard D, Lebouché B, Engler K, Thomas R, Machouf N. Explaining the appeal for immigrant men who have sex with men of a community-based rapid HIV-testing site in Montreal (Actuel sur Rue). AIDS Care 2015;27(9):1098–103. https://doi.org/10.1080/09540121.2015.1028880

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Footnote 42

Lewis NM, Gahagan JC, Stein C. Preferences for rapid point-of-care HIV testing in Nova Scotia, Canada. Sex Health 2013;10(2):124–32. https://doi.org/10.1071/SH12100

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Footnote 43

Markwick N, Ti L, Callon C, Feng C, Wood E, Kerr T. Willingness to engage in peer-delivered HIV voluntary counselling and testing among people who inject drugs in a Canadian setting. J Epidemiol Community Health 2014;68(7):675–8. https://doi.org/10.1136/jech-2013-203707

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Footnote 44

O’Byrne P, Bryan A. Anonymous HIV testing and public health in Ontario, Canada: understanding HIV surveillance. Surveill Soc 2013;11(1):35–54. https://doi.org/10.24908/ss.v11i1/2.4326

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Footnote 45

O’Byrne P, Bryan A, Woodyatt C. Nondisclosure prosecutions and HIV prevention: results from an Ottawa-based gay men’s sex survey. J Assoc Nurses AIDS Care 2013;24(1):81–7. https://doi.org/10.1016/j.jana.2012.01.009

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Footnote 46

O’Byrne P, Watts J. Include, differentiate and manage: gay male youth, stigma and healthcare utilization. Nurs Inq 2014 Mar;21(1):20–9. https://doi.org/10.1111/nin.12014

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Footnote 47

O’Byrne P, Willmore J, Bryan A, Friedman DS, Hendriks A, Horvath C, Massenat D, Bouchard C, Remis RS, Etches V. Nondisclosure prosecutions and population health outcomes: examining HIV testing, HIV diagnoses, and the attitudes of men who have sex with men following nondisclosure prosecution media releases in Ottawa, Canada. BMC Public Health 2013;13(1):94. https://doi.org/10.1186/1471-2458-13-94

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Footnote 48

Pai NP, Smallwood M, Gulati D, Lapczak N, Musten A, Gaydos C, Johnston C, Steben M, Wong T, Engel N, Kim J. What do key stakeholders think about HIV self-testing in Canada? Results from a cross-sectional survey. AIDS Behav 2018;22(2):606–15. https://doi.org/10.1007/s10461-017-1764-z

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Footnote 49

Pant Pai N, Bhargava M, Joseph L, Sharma J, Pillay S, Balram B, Tellier PP. Will an unsupervised self-testing strategy be feasible to operationalize in Canada? Results from a pilot study in students of a large canadian university. Aids Res Treat 2014;2014(747619):1–8. https://doi.org/10.1155/2014/747619

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Footnote 50

Rich A, Scott K, Johnston C, Blackwell E, Lachowsky N, Cui Z, Sereda P, Moore D, Hogg R, Roth E. Sexual HIV risk among gay, bisexual and queer transgender men: findings from interviews in Vancouver, Canada. Cult Health Sex 2017;19(11):1197–209. https://doi.org/10.1080/13691058.2017.1299882

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Footnote 51

Scheim AI, Travers R. Barriers and facilitators to HIV and sexually transmitted infections testing for gay, bisexual, and other transgender men who have sex with men. AIDS Care 2017;29(8):990–5. https://doi.org/10.1080/09540121.2016.1271937

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Footnote 52

Stenstrom R, Ling D, Grafstein E, Barrios R, Sherlock C, Gustafson R, Osati F, Poureslami I, Anis A. Prevalence of HIV infection and acceptability of point-of-care testing in a Canadian inner-city emergency department. Can J Public Health 2016 Oct;107(3):e291–5. https://doi.org/10.17269/CJPH.107.5318

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Footnote 53

Stephenson R, Chard A, Finneran C, Sullivan P. Willingness to use couples voluntary counseling and testing services among men who have sex with men in seven countries. AIDS Care 2014;26(2):191–8. https://doi.org/10.1080/09540121.2013.808731

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Footnote 54

Worthington CA, Calzavara LM, White SJ, Allman D, Tyndall MW. Individual and jurisdictional factors associated with voluntary HIV testing in Canada: results of a national survey, 2011. Can J Public Health 2014;106(2):e4–9. https://doi.org/10.17269/CJPH.106.4625

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Footnote 55

Worthington CA, O’Brien KK, Mill J, Caine V, Solomon P, Chaw-Kant J. A mixed-methods outcome evaluation of a mentorship intervention for Canadian nurses in HIV care. J Assoc Nurses AIDS Care 2016;27(5):677–97. https://doi.org/10.1016/j.jana.2016.02.011

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Footnote 56

Barbour TL. HIV testing in Nova Scotia: an Indigenous perspective on access and acceptability. Halifax, (NS): Dalhousie University; 2017. https://dalspace.library.dal.ca/bitstream/handle/10222/73293/Barbour-Tammy-MA-August-29-2017.pdf?sequence=3&isAllowed=y

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Footnote 57

CATIE. National deliberative dialogue on reaching the HIV undiagnosed: scaling up effective programming approaches to HIV testing and linkage to prevention and care. Thursday, October 13 and Friday, October 14, 2016. Meeting report. Toronto (ON): Canada's source for HIV and hepatitis C information; 2016. https://www.catie.ca/ga-pdf.php?file=sites/default/files/Reaching-the-hiv-undiagnosed-EN.pdf

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Footnote 58

Centre SIDA Amitié. Rapport d58e recommandations de lutte contre le VIH et le sida pour atteindre les cibles mondiales à l'échelle régionale. Saint-Jérôme (QC) : Centre SIDA Amitié; 2019. https://centresidaamitie.app.box.com/s/2bq649o1iueolzfpzzqqydz7oc9t4l9n

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Footnote 59

Gahagan J, Stein C, Campbell A. Report on anonymous HIV Testing program and perceptions of acceptability of rapid point-of-care testing at Halifax Sexual Health Centre, Halifax, Nova Scotia. Halifax (NS): Halifax Sexual Health Center; 2012. https://novascotia.ca/aids/documents/Report-Anonymous-HIV-Testing-Program-HSHC-2012.pdf

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Footnote 60

Konkor I. HIV vulnerabilities among heterosexual African, Caribbean and other Black men in London, Ontario. London (ON): University of Western Ontario; 2019. https://ir.lib.uwo.ca/etd/6243/

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Messier-Peet M, Apelian H, Moodie E, Cox J, Hart T, Grace D, Moore D, Lachowsky N, Jollimore J, Rodrigues R, Sparling D, Noor S, Olarewaju G, Armstrong H, Lambert G. Investigating factors associated with sub-optimal HIV testing among high-risk gay, bisexual, and other men who have sex with men: results from Engage Montreal 2017-2018. Canadian Association of HIV Researchers Conference; 2019 May 10-12; Saskatoon, SK. https://www.engage-men.ca/our-work/posters/

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Footnote 62

Gender and Health Promotion Studies Unit. Our Youth, Our Response: Building capacity for effective HIV/HCV policy and programming responses across the Atlantic Region. Final report. Halifax (NS): Dalhousie University; 2014. https://www.dal.ca/diff/gahps/research-projects/oyor.html

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Public Health Agency of Canada. I-Track: Enhanced surveillance of HIV, hepatitis C, and associated risk behaviours among people who inject drugs in Canada - Phase 3 (2010-2012) Report. Ottawa (ON): Government of Canada; 2018. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/itrack-enhanced-surveillance-hiv-hepatitis-associated-risk-behaviours-people-who-inject-drugs-canada-phase-3.html

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Footnote 64

Vannice S. Barriers, access, resources, and knowledge (B.A.R.K.): an analysis of HIV testing vis Women’s Voices in Ottawa: Ottawa (ON): University of Ottawa; 2016. https://ruor.uottawa.ca/bitstream/10393/35602/5/Vannice_Sarah_2016_thesis.pdf

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Heard E, Fitzgerald L, Wigginton B, Mutch A. Applying intersectionality theory in health promotion research and practice. Health Promot Int 2020;35(4):866–76. https://doi.org/10.1093/heapro/daz080

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Footnote 66

Public Health Agency of Canada. Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030: A pan-Canadian STBBI framework for action. Ottawa (ON): Government of Canada; 2018. https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/reports-publications/sexually-transmitted-blood-borne-infections-action-framework.html

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Footnote 67

Public Health Agency of Canada. Accelerating our response: Government of Canada five-year action plan on sexually transmitted and blood-borne infections. Ottawa (ON): Government of Canada; 2019. https://www.canada.ca/en/public-health/services/reports-publications/accelerating-our-response-five-year-action-plan-sexually-transmitted-blood-borne-infections.html

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Footnote 68

Cerigo H, Quesnel-Vallée A. Systematic mixed studies reviews: leveraging the literature to answer complex questions through the integration of quantitative and qualitative evidence. Int J Public Health 2020;65(5):699–703. https://doi.org/10.1007/s00038-020-01386-3

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