Perceived benefits, barriers, and health system consequences of introducing new models of online sexually transmitted and blood-borne infection testing in Ontario, Canada

Abstract

Background

Internet-based testing services for sexually transmitted and blood-borne infections have increased in prevalence and altered the testing landscape and testing behaviours in many jurisdictions. Our objective was to understand how system partners perceived the possible benefits and drawbacks of adapting and implementing an online testing program like GetCheckedOnline which was already operating in British Columbia, Canada, into a new provincial context where it did not exist.

Methods

We conducted in-depth interviews and focus groups with sexual healthcare providers, program managers and developers, and other public health professionals with expertise in sexually transmitted infections testing (N = 41) in Ontario, Canada. Our interview questions were part of a larger study focused on improving equitable access to sexually transmitted infections testing. Transcripts were transcribed verbatim and analysed using NVivo software following grounded theory.

Results

We created a conceptual figure to chart tensions from participant accounts onto a model of GetCheckedOnline. We describe five key tensions in the accounts of our participants to elucidate perspectives on the possible benefits and barriers/concerns of implementing a digital testing model like GetCheckedOnline in another province: (1) access, (2) privacy, (3) co-ordination/communication, (4) agency, and (5) health system impacts. We map these five tensions across the core elements of the online testing program (i.e., from creating an online account, completing an assessment, and submitting specimens to getting results and engaging in repeat testing).

Conclusion

Our analysis elucidates the multiple advantages that online testing modalities may provide for service users as well as substantive barriers and concerns perceived by health system partners, including the potential (unintended) consequences and paradoxes of introducing digital sexually transmitted infections testing.

Introduction

Sexually transmitted and blood-borne infections (STBBI) remain a global health issue despite the numerous prevention and treatment options available [1]. In Canada, there were 2,434 new HIV diagnoses in 2023, a 35% increase from the previous year [2]. In the province of Ontario, the rate of new HIV diagnoses in 2023 was 6.0 per 100,000.While this is marginally lower than the national average of 6.1 per 100,000, HIV continues to be overrepresented in certain populations such as gay, bisexual, queer, and other men who have sex with men (GBQM), Indigenous communities, African, Caribbean, and Black communities, and individuals who use injection drugs [2, 3]. When examining trends in rates of gonorrhea, chlamydia, and syphilis in Ontario, there have been significant increases in diagnosis in the past decade across these STBBIs [4–6]. Given the burden of STBBIs in made marginalized populations, it is vital we find ways of reducing this health disparity among those most affected both within Ontario and Canada more broadly.

One public health strategy to help achieve this goal is through increased STBBI testing, which would lead to the identification and treatment of positive cases more quickly, therefore supporting the treatment of individuals as well as reducing the spread of infections in the population [7]. However, many communities report experiencing general barriers to accessing in-person clinical STBBI testing services such as long wait times, inconvenient clinic hours, and long travel times to clinics [8, 9]. In addition, experiences of various forms of systemic discrimination (e.g., homophobia, transphobia, racism) when interacting with healthcare providers and clinic staff pose a barrier for some made marginalized communities when trying to access in-person clinical STBBI testing services [9–11]. Thus, in addition to improving current services, alternative forms of STBBI testing may be needed to help meet the sexual health needs of people in and beyond GBQM communities.

Our larger study examined the acceptability of online STBBI testing as a complementary service to provider-based testing in the Ontario landscape by interviewing GBQM and STBBI testing professionals. We queried specific benefits an alternative testing model may have for GBQM in Ontario given the overrepresentation of STBBI diagnosis for these communities [2, 3]. We found high acceptability for online and alternative testing models from GBQM, with 81% reporting that they would be likely to use an online STBBI testing service when asked in a survey, and significant interest in qualitative interviews on this testing modality [9, 12, 13].

Currently, a number of platforms offer STBBI testing services facilitated by online platforms in Ontario, [14] TeleTest, [15] Get A Kit, [16, 17] and I’m Ready [18]. Despite the diversity of online STBBI testing options that exist in Ontario, many options can be cost prohibitive (TeleTest and self-purchasing an INSTI HIV self-test[19]), or encourage the user to follow-up with a health provider themselves in the case of a positive result (GetAKit, I’m Ready) instead of facilitating connection to care through their own services [15, 17–20]. Considering the lack of available testing options for rural and remote areas in Ontario, programs such as I’m Ready and GetAKit do provide HIV self-tests for anyone with a mailing address within the province [17–19]. However, swabs, urine and blood tests provided by TeleTest and GetAKit require access to a lab, which may be a barrier for rural and remote communities who do not have access to a lab in their areas [15, 17]. Please see the affiliated websites linked in the references above for detailed program information including the STBBI tests available and the specifics of on-site specimen collection vs. self-collection. While these programs have helped to fill significant gaps in the testing landscape, Ontario has a need for wide-spread, publicly-funded, accessible testing to meet the STBBI testing needs of diverse, intersectional communities including GBQM.

GetCheckedOnline

In the province of British Columbia, one publicly funded and reasonably comprehensive online STBBI testing service exists: GetCheckedOnline [21]. As reviewed below, our study presented the GetCheckedOnline model to participants in order to gauge if it would be acceptable and feasible to implement in Ontario. The GetCheckedOnline model allows users to create an account online and answer an online click-through screener about their sexual history; then print or download a requisition form to their mobile device, which they then take to a select laboratory that is partnered with GetCheckedOnline in select communities across British Columbia to provide specimens (blood for syphilis, HIV and Hepatitis-C; urine, oral and rectal swabs for chlamydia and gonorrhea); and receive their test results online or over the phone (see Fig. 1) [21]. GetCheckedOnline’s model provides a space for service users to be tested without direct interaction with a healthcare provider unless they receive a positive result from one of their tests, when they receive a follow-up call from a public health nurse from the British Columbia Centre for Disease Control [22].

Fig. 1.

Pervieved benefits, barriers, and system consequences of introducing online STBBI testing

The GetCheckedOnline model of testing, as it exists in British Columbia, would provide comprehensive, free, lab-based testing with direct follow-up from a public health nurse which at the time of data collection differed from all existing services in Ontario. After testing, the public health nurse would follow up with the person receiving a positive result [22]. This conversation would outline the clinics that are partnered with GetCheckedOnline to seek treatment if they do not already have a healthcare provider, and how to notify partners of this positive result [22]. The nurse can also provide support for receiving the potentially upsetting news of a positive result. Additionally, knowing that receiving a positive STBBI test, particularly HIV, may be distressing, there is also a webpage linked on the GetCheckedOnline website for those in distress after learning their results to access [22]. These conversations with a public health nurse may also be gateway conversations or answer questions around future STBBI mitigation, such as HIV pre-exposure prophalxis (PrEP), HIV post exposure prophalxis (PEP), or other resources that are available on the GetCheckedOnline website. While we acknowledge the importance of providing information to testers, especially those testing for the first time, GetCheckedOnline users in British Columbia demonstrated higher incidence of knowledge surrounding HIV than their counterparts who test in-clinic. [23]. Between providing information on the GetCheckedonline website about STBBIs, and higher knowledge around STBBIs from this testing group, even those who test negative and do not have contact with a nurse have opportunities for education around STBBIs or are already informed.

While it is important to understand acceptability and the perceived benefits and drawbacks of online STBBI testing among key populations living in Ontario, such as GBQM, it is also necessary to examine the perspectives of healthcare service providers working in the province. In an anonymous survey of health care providers practicing in Toronto, participants reported that STBBI testing could be improved through online screening and delivery of test results and through specimen self-collection by testers, despite only 61% of participants endorsing an online testing model [24]. Health professionals working in Ontario also agree that in-person clinical services could improve if an online STBBI testing platform like GetCheckedOnline were to exist in the province, since it could lead to many clinic users to switch over to GetCheckedOnline, therefore leading to shorter wait times for those who want or need to see a provider in-person [24].

We were interested in assessing the feasibility of implementing this service in Ontario. Given that Canada operates on a federalist framework of healthcare, each provincial and territorial government is responsible for legislating healthcare policies and budgets. While some barriers have been identified in the implementation of GetCheckedOnline in British Columbia, Ontario and British Columbia landscapes have unique differences for implementation of a program such as GetCheckedOnline [25]. These unique differences must be accounted for in thinking about the feasibility of translating the program to Ontario; and we cannot assume that similar barriers would not occur in the Ontario context [26]. Our aim was to further ascertain the perceived benefits, drawbacks, and unintended consequences in implementing an online STBBI testing service, similar to GetCheckedOnline, in Ontario, from the perspective of healthcare providers, sexual health program managers and developers, and other public health professionals with expertise in STBBI testing working in the province.

Methods

Recruitment of health system partners and service providers of STBBI testing was completed in two phases: between June 2019 and April 2020, and October 2020 to February 2021 (N = 41). The qualitative research with service providers and partners that we present in this paper occurred in the context of a larger mixed methods study investigating the use and adaptation of online STBBI testing services in British Columbia and Ontario, Canada. [26, 27].

Research was conducted using a community-based participatory research (CBPR) framework. CBPR is a method that values partnerships from organizations and members of the communities being studied during the research process to centre the well-being and involvement of these communities in the research process [28, 29]. As part of the CBPR process, four peer researchers who identified as part of the GBQM community were hired to conduct focus groups and synthesize data. However, we acknowledge the complicated nature of intersecting identities where professionals may also identify as a member of the community they are researching. Indeed, many of the lead investigators on this study (including the first and last author on this paper) identify as members of the GBQM community.

The first phase of data collection included in-depth interviews lasting 35–70 min. All interviews were conducted in-person in private meeting rooms or offices except for two that were held over the telephone. In this sample, we interviewed people who held professional positions in a range of institutional settings such as public health clinics, governmental public health and community sexual health agencies, public health laboratories, private digital healthcare services, and private laboratories, among others. Health system partner participants (n = 23) were public health physicians (n = 8), nurses (n = 2), program managers (2), frontline AIDS Service Organization (ASO) workers (4), health profession regulators (n = 1), ASO senior management (n = 4), pharmacists (n = 1), and policymakers (n = 1). Interview topics reflected individual participants’ specific work knowledges and led us to selectively index and analyse institutional texts. This paper will expand upon the results of these interviews and analysis from health system partners where we used an institutional ethnography lens of analysis, to include service provider of STBBI testing interviews where a reflexive framework was employed as methodology [30, 31]. We have integrated some findings from the health systems partner interviews, because of the applicability of themes that came out of the interviews with those working in health systems.

In the second phase of the study, peer researchers conducted 60–90-minute semi-structured individual interviews and focus groups with service providers (n = 18) of STBBI testing and other sexual health services. Participants were recruited through purposive sampling [32]. Posters advertising the study were distributed through email to ASOs, Community Health Centres, Public Health units, and sexual health clinics that serve sexual and gender minorities within the province. Recruitment posters were also posted online on the social media platform Facebook, specifically within the group Toronto 2SLGBTQ+ Service Providers Network. To be included, participants needed to self-identify as sexual health service professionals in STI/HIV testing and care in Ontario. Participants were excluded if they did not have direct experience working with service users of STI/HIV testing and/or if they currently worked outside of Ontario. Potential participants were invited to complete an eligibility screener on SurveyMonkey and qualifying participants were selected to participate. Of those selected to participate, none declined. Using theoretical saturation, we stopped recruitment once we reached a point where no new themes or insights were identified from participant interviews. After iteratively reviewing the study findings, at this point we felt we had sufficient data to provide in-depth descriptions, explanations, and interpretations across the different sectors our participants worked in, despite their varied professions [33].

Analysis used constructivist grounded theory, informed by commitments of community-based participatory research [CBPR], to develop initial codes and then overarching themes with consultation from a community advisory board, research coordinator, and principal investigator [33]. Constructivist grounded theory was chosen due to its alignment with approaching the study from a CBPR perspective and hiring peer researchers to create relationships with participants from shared lived experiences and health equity concerns [33]. Codes were developed from close engagement with the data through regular discussion and meetings between the peer researchers during data collection and not developed in advance, following multiple rounds of initial and focused coding. The peer researchers practiced reflexivity throughout the analysis process by writing post-interview memos and diaries, then bringing these memos to the other researchers during their regular meetings. These diaries were then discussed and paralleled with other interviews to create themes that were being noticed across the data. Peer researchers also drew upon their identities and lived experiences with STBBI testing and health systems to reflect on their positionalities and approach to data collection and analysis. Codes were initially created by the peer researchers based on detailed review and discussion of transcripts and interview themes, and then reviewed by the research coordinator and principal investigator. We worked closely with an Ontario-wide community advisory board of GBQM that included public health workers, therapists, ASO workers, and GBQM who had experience with or an interest in testing innovations. Any disagreements between analysts were discussed as a team and, if needed, brought to the community advisory board to receive feedback and help resolve discrepancies. The community advisory board was consulted during data collection, analysis, and interpretation phases.

Participants’ occupation varied from frontline workers at community-based or HIV/AIDS service organizations (n = 7), sexual health nurses (n = 4), physicians (n = 2), public health workers (n = 2), clinic counsellors/HIV testing professionals (n = 2), and managers of sexual health nurses (n = 1). Participants served a wide range of regions from the Greater Toronto Area (n = 7), Ottawa (n = 2), and other large urban areas (> 100,000) (n = 8) to rural communities (1,000–29,000) (n = 1). Most had over five years of experience (n = 9), followed by 1–5 years (n = 7), and less than one (n = 2). We conducted a total of 11 individual interviews and 3 small focus groups (with 2–3 participants per group). Within the focus groups the terms “client” and “service user” were used synonymously. The focus group format provided participants an opportunity to reflect and engage with the opinions and experiences of their peers. While this phase of the research was originally designed to be primarily focus groups, many participants were healthcare workers who were on the front lines of the COVID-19 response and took part in individual interviews because of scheduling/availability conflicts. Drawing on the principles of theoretical saturation, data collection was completed when no new themes or insights about key study themes were derived from the focus groups and individual interviews [33].

During the interview, participants were shown a video describing the GetCheckedOnline testing model, which detailed the process to fill out the required screening questions, receive test recommendations that service users could select and de-select, create a requisition, and then take into a select lab location, as well as described that a public health nurse would follow up over the phone for any positive results. Participants were then asked a series of questions related to the GetCheckedOnline model, and other relevant sexual health topics. For the full focus group and interview guides, see Grace et al. 2022 supplemental file 1 [34]. The study received ethics approval from the University of Toronto Research Ethics Board.

Due to the social distancing and lockdown measures in place during the COVID-19 pandemic, data collection after March 2020 took place remotely over the phone or Microsoft Teams. Interviews and focus groups were recorded and then transcribed verbatim. NVivo 12 software was used for coding transcripts.

Results

Overall, the views from the 41 health system partners we interviewed were primarily positive and encouraging of the integration of a GetCheckedOnline-like model into the Ontario healthcare landscape. Many believed that such a virtual platform could reduce their burden of care and allow them to prioritize patients who require in-clinic testing, or who are symptomatic, and increase the quality of care they provide to their clients. However, some participants also expressed hesitancy and raised questions surrounding GetCheckedOnline’s operating model and how it would translate to the Ontario context. Participants also highlighted the benefits of individualized or client centred care for some testers that may be missing from an online interaction. Additionally, the health system partners we interviewed reflected upon the macro-level policies and politics that have shaped the healthcare landscape in the province, and may result in challenges when implementing a service like GetCheckedOnline. Below we map out our results across five categories identified across participants narratives: (1) access, (2) privacy, (3) co-ordination/ communication, (4) agency, and (5) health systems (see Fig. 1).

Access

Benefits: Increased access—time and geographic location

Participants in our study believed that GetCheckedOnline could benefit clients who seek STBBI testing. They thought a primary benefit would be reducing wait times for STBBI testing on the side of service users through the requisition being immediately accessible to download or print, instead of waiting for testing hours at clinics, waiting for appointments with care providers, or going to their primary healthcare provider and being given a requisition to then go to a secondary location, such as a lab site. For example, an ASO worker in the Greater Toronto Area (GTA) noted the delay in being tested through current models and how GetCheckedOnline could benefit clients by streamlining the testing experience for both clients and providers. Primarily, the participant noted the ‘time-consuming process’ clients had to go through to be tested:

[S]ome clinics keep you waiting there for two hours, that’s also not something that’s enjoyed for folks. But an option [like GetCheckedOnline] to get all that done and just walk through straight in and get your appointment and walk back out again, that’s really helpful. (ASO Worker, GTA, Focus Group)

In response to this account, a different sexual health nurse in the same focus group noted the efficiency that a model like GetCheckedOnline could foster by removing in-person screening, which could be ideal for ‘experienced’ or ‘routine’ testers.

Participants also noted that service users who live in remote areas often must travel farther for in-clinic testing, sometimes across municipalities depending on where a clinic with testing capacity is located. Participants believed the GetCheckedOnline model would be more accessible and enable these people to get tested ‘closer to home’; as private lab locations are more numerous and accessible across Ontario.

An ASO worker in Toronto shared their thoughts about the benefits of GetCheckedOnline being a geographically accessible model for people seeking testing, while highlighting the barriers that could potentially still exist:

I think this will help persons that are isolated or in remote access, but then there’s still like they need to come to certain labs. […] I find if you live in the outskirts or outside of the GTA, it’s kinda hard to come see [clinics] and access services. So I think it will mitigate that case if the labs are close to them. (ASO Worker, Toronto, interview)

Another ASO worker in the GTA concisely summarized the perceived benefit of GetCheckedOnline’s accessibility in their interview when they stated:

Look, I know that our jobs are being taken over by the robots and the computers and all that stuff, but this would make the STI process so much more streamlined. I feel like more people would be able to have access to [testing].

Overall, the health system partners we interviewed found the idea of a GetCheckedOnline model to be highly acceptable to reduce wait times and the geographic barriers that can be faced by clients when seeking testing in-clinic or through their primary care providers. However, as participants mentioned, it is only some clinics that experience excessive wait times. The benefits of the GetCheckedOnline model exist beyond just benefiting those who do experience wait times in the streamlining of the process of testing, as described above.

Barriers: Limited access to technology

When online testing models were discussed, it became evident that mechanisms to access the online service would not be available to all populations. Multiple participants pointed out that an online-based service like GetCheckedOnline may not be accessible to clients who are not technologically inclined or savvy. Members of certain populations who do not feel as comfortable with using the internet and online-based services in comparison to face-to-face interactions were also highlighted as a group who may not find GetCheckedOnline to be beneficial in its current iteration.

Two participants in the same focus group agreed that technological support and proficiency would be key to the implementation of GetCheckedOnline, sharing what they believed would make the program more available to those with technology challenges:

Because some people, like have different levels of understanding and literacy around technology. So, it could, but it would probably be worth time, worth spending, if we can help people go through it at least once (Clinic Counsellor, outside the GTA, focus group).

I do think there are certain demographics that aren’t going to be as comfortable using an online platform for testing… the Indigenous [community] locally and then the folks that I know, like that comes to mind, um, right off the bat, is folks that would definitely – if they had other options they would choose not to go online. […] we have a lot of folks that we deal with at the [sexual health centre] are street involved and substance users, and some with sexualized substance use as well… it’s all up to the individual, right on what their comfort level will allow them to do (ASO Worker, outside the GTA, focus group).

In our health system partner interviews, a project coordinator of a gay men’s health program also highlighted the barriers of those who occupy a space of marginalization through race and noted that there may be additional assistance needed for these communities:

So we’re talking, um, there’s an assumption of a certain level of online literacy and self-navigation capacity. Um, the groups who would be under-represented in this area would be Indigenous folks. Potentially Black communities who just have like not as accessible access — access to online tools — or like the knowledge or part of communities who will be able to disseminate this knowledge. (Toronto, interview)

Additionally, people who are homeless or otherwise do not have consistent access to technology and the internet would face barriers with an online testing model. One public health worker in a city outside the GTA highlighted not only the technology barriers these populations would face, but the benefits of in-person testing beyond STBBIs:

The one group that I think that this really wouldn’t work well for is that more like transient, homeless, addictions and mental health issues, like needing testing for – because of like risk of injection drug use, things like that. I think that population, I mean, one, like doesn’t have the same kind of access to like a smartphone, and internet, and whatnot, and also needs like – […] like in a place where that client feels comfortable, be able to do the testing, and not have to, you know, go and wait in line at a LifeLabs, and maybe get like experience stigma, or be like re-traumatised in a healthcare setting. I think – like I think there’s still really a need for that outreach testing (interview).

Overall, a testing service like GetCheckedOnline was understood as a model that would not be accessible for everyone. Participants noted multiple barriers for populations that would need to be addressed including resources to support less technology-literate people seeking testing and the importance of understanding the unique cultural nuances of communities who may have their own rituals and needs when being tested for STBBI. Some participants also raised concerns for people who are unable to consistently access technology, such as homeless populations, who would be unable to access an online testing model and may receive more comprehensive benefits from in-person testing.

Barriers: Lab access

After reviewing the GetCheckedOnline model in British Columbia where clients are required to visit a participating lab location in order to get tested through the online-based service, many raised concerns regarding barriers to accessing these lab sites. In Ontario, some patients are able to be tested through a hospital or clinic, but many are referred out to private lab sites for specimen collection.

Some health system partners were concerned about the potential lack of access to testing at lab sites for clients without an Ontario Health Insurance Plan (OHIP) card. This concern related to the fact that while many sexual health clinics, AIDS service organizations (ASOs), community-based organizations (CBOs), and public health units provide STBBI testing for free without requiring OHIP or any other payment from clients. There are two private lab companies in Ontario that provide approximately 46% of lab testing in the province, and they require OHIP or other health insurance to be presented by the clients at the time of testing and if no insurance can be presented, clients are required to pay for their tests out of pocket [35, 36]. Within this context in the province, many participants wondered what the funding structure of GetCheckedOnline in Ontario would be, whether OHIP will be required to access the online service and testing at lab sites, and hence whether clients without OHIP would still be able to access the service and be able to test at labs without needing to present a health card. For example, one sexual health nurse who worked in the GTA noted the perceived difficulties for potential clients without health insurance:

We see a fair number of people who don’t have OHIP whether they’re visiting from outside of Canada, whether international students, or even people who have, you know, managed to let their health card lapse and don’t have it active […] it gets really – people are surprised at how costly it is if they’re going for STI testing without a health card. (Focus group)

Providers we interviewed also pointed out another kind of lab access barrier: while there are many lab locations throughout the province, some clients may still not have access to a lab location nearby due to long distances or lack of reliable transportation. Ontario is a province that is stratified by its dense urban areas and remote northern communities, therefore lab locations may not be available equitably across the province, and may create further barriers for testing if a service user must travel to a lab site that does not exist in their rural or remote area. One report from the auditor general about one lab company noted that private companies decide on distribution of lab sites, and that they are not required to ensure equitable representation across marginalized and rural communities [33]. One ASO worker from outside the GTA noted these challenges by saying:

My concern – that [the other participant] expressed as well – folks that, um, in more outlining areas that might not have access either to the internet and in some cases, especially in our area here, um, but more importantly access to be able to actually get into a [lab]. That might be a challenge for, for some of our more remote areas here in [rural health district]… Um, and I think it’s important that folks realize that they have to go to a specific [lab site]. I know when I go in to get my lab work, I have to present my health card every time – not, not an issue for me. (focus group)

Other barriers arose regarding the types of specimen collections these sites do, and whether they were more accessible than being tested in a clinic. A physician in Toronto highlighted that the testing at lab sites were not comprehensive and still required patients to be tested in-clinic:

[One lab company] in Ontario currently are not accepting vaginal samples, throat samples or rectal samples. So, you can really only do urine and blood work. So, then what ends up happening is we prepare all of the swabs and everything in- at [my clinic] and so the client still has to come to [my clinic] and do the swabs in the bathroom and then leave them at [the clinic] for us. […] (interview).

Despite the higher number of lab sites available to potential GetCheckedOnline users, these sites do not exist without barriers. These barriers were noted by client-facing health system partners that reported clients who live in rural or more siloed communities may still have to travel long distances to be tested.

Privacy

Benefits: Increased anonymity, privacy, and confidentiality

Participants believed that an online-based STTBI testing service like GetCheckedOnline would be more anonymous, private, and confidential for GBQM than a traditional clinic-based testing service. They thought that because of the online assessment and quick testing process at lab sites, clients would not have to discuss and explain their sexuality, sexual practices and risks, or their personal circumstances for wanting and needing certain tests to service providers in-person. Participants shared that GetCheckedOnline could also help clients keep certain personal information private from their general practitioner who they may be close to socially and feel judged by, or who treat their client’s other family members, friends, or community members that they fear being outed to, particularly those who live in rural or communities.

For example, one clinic counsellor outside the GTA spoke about the feedback they received from clients regarding testing privacy:

It’s a bit removed, right? They’re practicing and doing the screening online. You don’t have to answer anyone’s questions. Like someone was telling me the other day, they lived out of town and they didn’t want to go to their Health Unit because their neighbour is a nurse there […] So I think giving people the option to do something different is of great benefit. (Focus group)

Service providers and health system partners also expressed that a service like GetCheckedOnline would remove the possibility for clients to be seen going into a sexual health clinic or running into their acquaintances in the waiting rooms. This was especially concerning for clients in rural or socially conservative areas who remain closeted due to stigma and homophobia within their local community. Thus, service providers believed that GetCheckedOnline could allow such individuals to get tested safely because of the provided anonymity, privacy, and confidentially from the online-based service. For example, one sexual health educator explained:

[GetCheckedOnline is] definitely appealing for people who want some anonymity or to have some sort of discomfort talking to humans about getting STI testing. […] You don’t have to go to the clinic where you might get recognized. You don’t have to show up at an STI clinic where everyone is going to know that you’re at an STI clinic. There’s lots of privacy-stigma [related benefits]. (Sexual Health Educator, Toronto, interview)

Participants also shared that they believed many of their clients would be interested in a testing service like GetCheckedOnline simply because in the presented model, the requisition form does not have the user’s name identified, but rather used a QR code that was scanned at the lab. This added layer of anonymity was believed to make testing feel much safer and more comfortable for those clients who want to be confidential and discreet about accessing STBBI testing services; “Some people don’t feel comfortable giving their name especially when they’re at that lab… just being there is one thing but having, you know, to let the world know you’ve been there or whoever’s around” (ASO Worker, Ottawa, interview).

GetCheckedOnline’s ability to provide anonymity for people seeking testing was seen as a benefit by providers who understood the stigma that some testers may feel from their community around them, particularly those in smaller, marginalized communities. The social politics of living in these smaller, more marginalized communities could also be averted by allowing testers to create their own requisition and choose which lab site they wish to attend for testing.

Benefits: Reduced perceived stigma, anxiety, and judgement

Participants conveyed that with an online-based service like GetCheckedOnline, there may be less stigma, judgment, and anxiety involved and associated with STBBI testing for their clients. They shared that many GBQM have internalized stigma about their sexuality, which results in feelings of shame, guilt, and embarrassment when accessing testing within a clinic or in-person testing space. Along with this internalized stigma, many relayed experiences that clients had shared where they had faced stigma and judgement from healthcare or testing providers.

Participants believed that a service like GetCheckedOnline could allow such clients to avoid the potential for discrimination, disapproval, and judgment from in-person assessment and intake entirely, making STBBI testing feel much safer and accessible. At the same time, the health system partners we interviewed also acknowledged that some clients prefer in-person assessment and services, and that they enjoy the personal and social aspects of their interactions with staff. One CBO worker outside the GTA relayed that while there was what they called “cultural capacity” within community testing spaces or other organizations, some potential service users did not feel comfortable accessing these spaces:

I think that one of the big benefits that stood out to me is kind of being able to reduce the stigma and being able to provide a stigma-free way for folks to get tested because with my experience at an ASO there is a lot of cultural capacity and there’s a lot of, you know, awareness as to the folks that serve and work with. […] So I think that having an online forum for folks to just easily create the forms and go get tested themselves is a way to prevent [stigma] and to make sure that the populations that we all aim to work with and work alongside with are still getting tested regardless of where they are doing it at. (Focus group)

Furthermore, service providers suggested that GetCheckedOnline could be a way to introduce GBQM to STBBI testing in general, removing the social and psychological barriers that prevented certain clients from accessing testing services. They believed that online testing may in turn encourage such clients to seek in-person help and support from their local service providers regarding STBBI testing and treatments. Participants also suggested that GetCheckedOnline could reintroduce STBBI testing to GBQM who may have had negative experiences with the traditional clinic-based testing model and were reluctant to get tested since. With the low barrier testing method presented by GetCheckedOnline, such clients could be encouraged to get tested again in a less triggering or safer environment.

One ASO worker that covered both urban and rural populations outside the GTA hoped that accessible testing would create a positive experience for service users to then create a dialogue with service providers in their community:

I think it will have a positive effect – as I mentioned earlier and as [the other participant] mentioned – the idea of folks being able to have access to alternative ways of, of getting this information and getting tested, is only a good thing. And the more folks that do get tested and maybe generates questions and I’m hopeful that that would mean, you know, more folks reaching out to me asking questions about STIs and, and treatments. (Focus group)

A director of a queer men’s advocacy group summarized the frustration that many GBQM face when seeking testing, as well as ways that GetCheckedOnline could address the stigma from providers:

I think that, you know, there is an enormous frustration among queer guys, and others, but among queer guys as is relates to, testing like when they want uh, how they want, you know, uh, avoiding often the sort of stigmatising, sex-negative, sometimes homophobic, transphobic you know, racist, you know, other sort of like, barriers, time, [like] the lectures that you get again and again from people who don’t understand gay sexual cultures. So, I think…getting checked online is an opportunity to…to reduce some of those barriers. (Toronto, interview)

Barriers: Lack of platform trust and legitimacy

Some service providers believed some clients may not be comfortable with entering their information online, or that they may have some privacy concerns related to data storage. For example, there may be concerns as to whether testing through GetCheckedOnline will truly be anonymous and whether they could be somehow identified with the information they provide. Hence, they suggested that both service users and providers should be able to trust the online-based service and that they should be reassured of the service’s legitimacy. A clinic counsellor outside the GTA highlighted the difficulty surrounding client referrals to services like GetCheckedOnline:

But I think that’s another piece of this, you know, when you’re doing something online, there has to be a lot, a lot of evidence that you’re legitimate, that what you’re doing is mapped by an organization. So, that’s just a piece that I always look for, as a service provider. Because I have people coming to me asking me like, ‘Is this legit?’ And I… sometimes it’s a bit tricky. (Focus group)

Other providers noted that they felt as though clients may be anxious because of the inherent lack of privacy in an online platform and the potential to make mistakes through online platforms:

But yes, some patients may feel uncomfortable, because afraid that they hit the wrong button and the email goes off to someone else, or the text message goes to the wrong person. Um, or someone they could phone, or some – a place they can go physically to, you know, if you have questions and you want to – confidentially, you can go completely anonymously to these five clinics, ten, you know, convenient locations that are accessible to the patient. (Microbiologist/Public Health Physician, outside the GTA, interview)

Barriers: Lack of/limited face-to-face interactions

One of the biggest drawbacks suggested by study participants was the lack of in-person interactions between service providers and clients. They believed that without the face-to-face human interactions, there would be missed opportunities for ‘incidental’ education, emotional support, capacity building, personal connections, and referrals to other services even outside of sexual health. There were particular concerns regarding the lack of extensive pre- and post-test counselling for HIV, hepatitis, and syphilis. One participant stated that many of their conversations with clients happen when clients do not come in expecting to learn more about STBBI, and without readily accessible resources these moments may be lost:

In terms of cons, you definitely miss out on opportunities for incidental education and for building emotional and social supports around STI testing, and building those kinds of capacities. Like I said, there’s lots of clients who come in and they think they just want an STI test and then they have a really good experience, and they learn a thing that they did not expect to learn because we don’t know what we don’t know. So, you do miss out on some of those opportunities, I think. You also miss out on some opportunities potentially for clinicians to offer other services while people are coming in to get an STI test… people come in for STI testing and have a conversation about things like PrEP [pre-exposure prophylaxis for HIV] and be able to get started on streaming for eligibility for that. (Sexual health educator, Toronto, interview)

In a separate interview, a sexual health clinic manager outside the GTA also noted the lack of STBBI risk awareness that some clients have:

I feel that the nursing, you know, even myself being a nurse, is the role of the counselling of the nurse is quite valuable. Because when you are actually in front of someone, sometimes when they – when you start discussing and talking to them, there presents an opportunity of, ‘oh, that’s actually a risk factor I didn’t realise,’ or ‘oh, I can decrease that risk factor by doing this.’ […] So ultimately the goal of a lot of these clinics is to reduce risk. It doesn’t mean people can’t get tested, or treated, or things happen, but if the idea is to reduce risk, I don’t know what that, you know, allows that interaction.

Providers used their own lived experiences with providing patients important information through incidental education and face-to-face interactions to highlight the work and education that happens outside the scripted interactions within clinics that clients who test negative or do not have contact with a public health nurse from GetCheckedOnline may not be able to provide.

Co-ordination and communication

Barriers: Lack of/reduced coordination with partner agencies

Participants emphasized that in the implementation of a service like GetCheckedOnline, it is paramount for all partnering organizations such as lab sites to have a clear understanding of the service, its procedures, and what is expected from each organization to best coordinate the services for clients. Participants believed that to streamline services, there had to be thorough communication and coordination between the online testing service and the other branches to make sure there were no gaps in services and clients would face minimal barriers to both the online screener, going to the lab, and follow-up on a positive test result. For example, many believed that lab technicians and staff at lab sites should be properly trained and be familiar with the online-based service requisition form so that clients accessing testing are not turned away or made to feel uncomfortable. They also highlighted the need for the staff to receive proper education and training to not stigmatize or make clients uncomfortable while getting tested. One participant explained it like this:

Like my roommate the other day had to go get blood work done and they brought their requisition on their phone, but then the person at the lab was like, ‘Oh, we can’t use this. You need to have printed this out yourself and then brought it here in like printed form.’ […] So, in terms of like printing and stuff, I could see how maybe if that’s not like established or like if that’s not, if that’s not clear to the partner [organization]… I think that could potentially throw up some issues. (STI/HIV Testing Professional, Ottawa, interview)

Similarly, service providers wanted to have clear information on what is expected for clients at lab sites when accessing the testing services:

[For GetCheckedOnline] if you don’t put in a health card, maybe yeah, a warning popping up being like, “just so you know, you don’t need a health card to get testing, but there will be, you know, this fee charged to you, or like some fee charged to you at [the lab site]. And if you don’t want to pay that fee, here’s where else you can go”. (Public Health Worker, outside the GTA, interview).

These service providers highlighted that the GetCheckedOnline process needed to be fully explained and comprehensive to all parties who may interact with the service, from people being tested to those who see clients who may use the service.

Barriers: Results delivery and linkage to care

Many participants discussed that with an online-based service like GetCheckedOnline, there needs to be timely and reliable linkages to treatment, counselling, sexual health education, and other related services that are available virtually through instant messaging, through the phone, or in-person once the results are delivered. There were also concerns that while GetCheckedOnline could reduce time to access testing, if the turnaround between testing and result delivery is too long, that clients may experience wait time distress:

The only [concern] I could see based on the model of GetCheckedOnline was that the results could potentially come in at like midnight and then you can only access someone at business hours, so that’s going to be like a horrific nine hours for you while you’re waiting. (Physician, Toronto, interview)

Increased personal agency

Benefits: Client agency, control and empowerment

Many service providers expressed that an online-based service like GetCheckedOnline could give their clients greater agency, control, and empowerment when being tested for STBBIs. This was because with the GetCheckedOnline model providers were presented, clients would be able to determine exactly when and where they wanted to be tested without having to navigate various clinic hours and availabilities [21]. Using this model, clients can also determine what they would be tested for without service providers as gatekeepers.

In particular, service providers were excited that clients would be able to go through a comprehensive risk assessment at their own pace to receive recommendations on what to get tested for without pre-screening assumptions on the type of sex they’ve engaged in; as well as the ability to add other tests that they would wish to have. This aspect of self-determination was considered an asset to the program, as many providers felt as though clients relied on their testing professionals to recommend tests that may not reflect their needs. Providers also expressed that one of the strengths of the program was the test reminder feature that is available on the website:

I liked that you pretty much go through at your own pace. […] I like that you can basically pick and choose what you want to get tested for […] It’s nice to even change that from 12 months to 6 months to 3 months depending on your sexual activity or depending on how often you want to get tested; so that’s really cool. (Sexual Health Nurse, outside the GTA)

Participants thought that with the comprehensive risk assessment, STBBI testing recommendations, and reminder system on the GetCheckedOnline website that clients could be better informed and educated about sexual health risks, STBBI, and treatments. They further believed that the resources and information about STBBI and treatment available on the GetCheckedOnline website could further assist in better informing and educating clients about STBBI and risk behaviours. One ASO worker outside the GTA noted that this model would especially benefit GBQM, “I love the idea of sending reminders, particularly if they’re at higher risk for other STIs or HIV. And questions that are centered on their lived experiences and that are competent in understanding queer sexuality – queer male sexuality in particular”.

Other participants added that some clients already know a great deal about sexual health and STBBIs, or about which tests they needed if they’re routine testers. As such, they believed that an online-based service like GetCheckedOnline would provide an option for such clients to get tested quickly and timely without delays or without repeated conversations with testing providers. While some clients may continue to seek in-person services, having the option for online services would improve what one sexual health nurse called “patient-empowered care”.

Providers, such as one ASO worker from the GTA, also appreciated that clients would be able to conduct and go through the same quality of risk assessment through the GetCheckedOnline website as an in-person clinic:

[With a service like GetCheckedOnline] the worker when they’re having that conversation with that individual, does it right then and there, you know. [Service users] have their [requisitions] they go, they get tested, they have all the things they need. So like instead of us trying getting a referral, trying to contact them – I feel that that would be a huge thing for some of our folk, for sure. […] So I think like creating based on the risk factors and stuff like that, creating individualised requisitions, I think that’s great.

Another sexual health educator in Toronto made a counterpoint to the above perspectives, that while service providers can provide STBBI information and care, service users need to be at the forefront of the care they receive and that they know what they have the capacity for and need, “And I think clients are often really good at determining when they need testing and what they need. And I think it’s really in alignment with both what I see my clients needing and with my values around how people should be able to access care”.

Health system implications: Macro-level impacts of digital health services

Benefits: Decrease in work burden

Many participants also took a macro-level view of the effects that a service like GetCheckedOnline could have on the overall testing landscape and health system. For instance, many believed that an online-based service like GetCheckedOnline would decrease the workload and burden that is being placed on sexual health clinics and organizations by reducing the amount of time, resources, and personnel being dedicated towards risk assessment, pre-counselling, and intake. Many noted that since the COVID-19 pandemic, health systems were “overwhelmed” and “over-burdened” and freeing up space where possible would reduce strain on the healthcare system. Particularly when these testing resources were being spent on “asymptomatic” individuals who were seeking regular testing and who may not need the more in-depth assessment of first-time testers or symptomatic individuals. Instead, they believed that with the availability of a service like GetCheckedOnline, service providers and their organizations can turn their resources and attention towards other aspects of their work such as treatment, counselling, education, and outreach. At the same time, health system partners believed that more space would be available for clients who need or prefer in-person testing services, or clients who need treatment or urgent care if GetCheckedOnline were implemented in the current healthcare system. A physician in Toronto noted the ratio of clients to providers is very high, and that a service like GetCheckedOnline could benefit those who need access to care:

Oh my gosh, I think it could reduce volumes and open up the space for other clients. I mean anything that reduces burden on the healthcare system, like because it – it really is like a bottleneck of clients that need to access providers and there’s only a certain number of providers and there’s a ton of clients. (Interview)

An ASO worker in the GTA spoke from personal experience in their interview when noting the benefits of GetCheckedOnline reducing client burden, “I spend a lot of time doing [STI] testing and it definitely takes away from some of the other things that I have to do, and I feel like I could be way more efficient”.

Others also shared positive views regarding the automatic delivery of negative results on the GetCheckedOnline website helps service providers save time while also providing reassurance to service users. For positive results however, they believed that a call or in-person visit would be necessary:

So, I think for the client to have access to their negative results automatically is really, really, really helpful… in our clinic we have a no-news-is-good-news policy, so as long as you haven’t heard back from us after two weeks, you know that everything’s come back negative. But we have to put a lot of like quality control measures in place to be able to provide that guarantee to people, and a lot of clinics like don’t have that in place, and I don’t know how you would set that up on the backend of the site. (Public Health Worker, outside the GTA, interview)

Service providers also believed that with the greater and faster access to STBBI testing being provided by a service like GetCheckedOnline, there would be increased number of STBBI testing, diagnoses, treatment, and prevention which would not only support individual level health of clients (i.e., through treatment), but also support community and population level health (i.e., though preventing STBBI transmission).

Overall, health system partners believed that an online-based STBBI testing service like GetCheckedOnline would make changes to macro-level problems that exist within Ontario’s current healthcare systems. However, the caveat to the acceptability of GetCheckedOnline in Ontario was that the program would be a supplement to in-clinic testing, and not meant to replace sexual health clinics. With both traditional clinic-based testing and online-based testing services available, health system partners expressed that the greater choice and options for testing will likely lead to increased testing rates, reduced need for individual client care, and a way to ease the burden that has been placed on the Ontario’s healthcare system.

Concerns: Unintended funding and administrative implications

Conversely, there were also concerns from some health system partners that if an online-based service like GetCheckedOnline facilitates and increases STBBI testing within the province—while being much more cost efficient by automating parts of the testing process—that some policy and decision-makers may use GetCheckedOnline as an excuse to reduce or limit funding to in-person sexual health clinics and services.

Some participants shared that while an online-based testing service may make testing much more accessible and provide an easier and safer way to get tested for many clients, for STBBI testing to become normalized and efficient, clients should be able to choose whether online testing or in-person testing fits their needs best. A public health worker and sexual health nurse discussed the necessity for an online-based service to be complementary to existing in-person services rather than substitutional, and noted his anxieties around the politics of introducing new, efficient programs into the current healthcare landscape:

My concern with GetCheckedOnline is that it could provide a very convenient excuse to stop providing in-person services from a fiscal perspective, right, depending who the decision makers are. And then you’ve really lost a lot of opportunities [laughs]. So, if you really only need like one or two sexual health clinics in a major urban centre versus eight or 10, because you’ve got these other online services. As long as it’s [GetCheckedOnline’s] not presented as a complete replacement [of clinic-based services] and that it’s really replacing a segment of what is available at a routine sexual health clinic, then I think it’s excellent and it can it take some of that weight off [of clinics]. (Public Health Worker, Toronto).

Several service providers highlighted that if anonymous testing is offered through the platform, it can be beneficial and necessary as it creates safer testing environment for many clients; but it also raises administrative and public health concerns regarding testing history records and contact tracing. For instance, a public health worker outside the GTA shared that their public health unit tends to collect the official name of clients as per their health card as it allows their organization to create a single record for the specific client and thus collect and organize their STBBI testing history:

I think one thing that we find at our clinic – and this is something that there’s benefits and drawbacks, but we always collect the name as per your health card, which has the benefit of keeping that name consistent, so that say someone is already known to our clinic, or is already known to public health, if we got another positive result on them, then we wouldn’t create a duplicate. Because say like – say you’re Elizabeth, but you go by Beth, so you may be known as Elizabeth, but then we get a lab result for Beth, and then it just creates some confusion like from an administrative standpoint. (Public Health Worker, outside the GTA, interview)

An ASO worker outside the GTA shared the same concerns about anonymous testing and service users who wish to remain anonymous because they do not want their family physicians or other people in their life to know they are being tested, and their use of potentially false or duplicate records for reporting purposes:

[I am] wondering when someone is registering to do the testing, what is there that prevents them from putting in a name that isn’t a legitimate name. If I type in John Doe and I made up an email specifically for the purposes of, of registering for GetCheckedOnline. So, send the email to johndoe@gmail.com and I’ll get that confirmation. So I don’t know what there is around that as far as anonymity for folks who want to get tested… A lot of folks who are, who are married or on the down low and the idea of their family physician getting access to these results… I think folks just need to realize that by giving this information, it doesn’t necessarily mean that their family doctor is going to have access to these testing results.

Discussion

The STBBI testing landscape is changing as new modalities have shifted how and where testing is possible. The clinic has gone online. The importance of equitable and timely access to STBBI testing was a core belief that health system partners shared across their narrative accounts. Interviews revealed the key access-related benefits of an online testing model from the perspective of providers and health system health system partners, based on their knowledge and experience with current STBBI testing mechanisms, as well as potential concerns related to access. Overall, participants believed that the immediacy of online testing allowed for flexibility of time and removal of most geographic barriers that many face when seeking testing. However, the two concerns that were primarily raised were related to limited access to technology and lab accessibility. As such, access was a paradox for many participants—online testing both removing and adding access related barriers. Some of the noted barriers around geographic access may be mitigated using different testing mechanisms, such as mail-in testing, that other current testing online platforms such as GetaKit and I’m Ready offer and could be investigated around the feasibility of implementing into a GetcheckedOnline model [17–19].

These results are notable because they demonstrate the shift in perception of online testing since GetCheckedOnline was implemented in British Columbia. When healthcare providers and other health systems partners were interviewed about the acceptability of an online testing system in British Columbia, many seemed resigned rather than excited about this next step of STBBI testing [37, 38]. Our interviews showed an appetite for these types of services from providers and partners who were overworked and recognized the barriers the current health system presents to many services users trying to access it.

Participants noted that privacy was an important aspect of STBBI testing. Stigma surrounding STBBI testing, particularly for GBQM, was raised in the focus groups and interviews, which highlighted the necessity of privacy as a foundational aspect of testing. However, while there was agreement that digital testing would lend more anonymity to the testing process, providers believed that the mechanisms of digital security led to a different type of concern surrounding the data of people seeking testing. These concerns and attention to data security may have been heightened due to a recent data breach of one of the primary private lab sites at the time of the interviews. [39]. Additionally, there were unresolved tensions around the concerns surrounding the lack of in-person interaction with providers, even with the highlighted benefits of online testing. Consequently, privacy also functioned somewhat paradoxically across accounts. On one hand, health system partners noted the privacy benefits of digital testing (e.g., increased anonymity, privacy, and confidentiality; reduced perceived stigma, anxiety, and judgement). However, health system partners also discussed significant barriers that may present obstacles (e.g., lack of platform trust and legitimacy; lack of face-to-face interactions with this new modality).

Study participants acknowledged that the systems that existed for STBBI testing in the province did not exist in a vacuum, and that collaboration between agencies and other resources would be integral to the success of developing a new testing platform. These resources included how positive, inconclusive, or negative STBBI results were delivered to clients. Unlike the tensions above, coordination/communication was understood as a cross-cutting barrier; that is, health system partners did not understand a model like GetCheckedOnline to increase possibilities of coordination or communication. Here, two tensions arose related to accessing a digital testing platform: lack of/reduced coordination with partner agencies and results delivery. Our participants noted the importance of timely and direct access to care and support for clients.

One of the key perceived benefits articulated by participants was the belief that digital STBBI testing will allow clients to have increased ‘agency’ with testers able to ‘take control’ over their own testing practices and sexual health decision-making. These perceived benefits are important considerations for GBQM in particular, because not all healthcare providers feel comfortable or competent in providing care for GBQM, or know what testing is needed for more intersectional populations such as trans, non-binary, and Two-Spirit GBQM in particular [40]. Furthermore, many GBQM who test routinely may not require a healthcare provider to guide them in every interaction, making digital testing a way to streamline testing for both the individual and health system.

While all participants spoke to their specific lived experiences of working within the field of STBBI testing and public health, some also noted the institutional changes that a health service like GetCheckedOnline may have on both their individual positions and work lives, as well as the macro changes to the way healthcare is processed and facilitated in Ontario. Within these narratives, providers noted that they anticipated the benefit of having a decrease in work burden due to the streamlining of testing. However, this perceived benefit was contrasted with the possible unintended consequence some participants were concerned about: having public services being defunded by the government, as well as other public health administrative implications for in-person services. These concerns regarding funding and other administrative implications are important to consider in a landscape where increasing privatization of the healthcare system has resulted in less funding and fractured communication across organizations [26, 27]. Additionally, the increased burden on public health to follow up on positive tests, versus other care providers, may mean additional labour and cost to the public system. While GetCheckedOnline has been proven to be cost-effective in British Columbia, before implementation of a model like GetCheckedOnline in a new provincial context, a cost/benefit analysis may be necessary [41].

We recognize a number of strengths with our study, including the broad range of experiences, locations and positions held by participants, few similar studies examining provider perceptions of online testing, a community advisory board that included service providers, and interviews that occurred prior to the COVID-19 pandemic, as well as during the pandemic; which reflects the impact of system and perspective changes under the strain of the pandemic. However, we recognize the limitations of our research including: only holding interviews and focus groups in English, having the second phase of interviews only online which prevented anyone without adequate internet access to participate, as well as recruiting during the COVID-19 pandemic when many healthcare providers were unable to participate due to their workload and burnout from surges of COVID-19 infections. These limitations may have led to only recruiting service providers who felt strongly about online testing to participate in the study, as others may have not had the energy during the COVID-19 pandemic to be reflexive about their positions, particularly if they had been redeployed to COVID-19 testing sites.

Conclusion

As the STBBI testing landscape continues to evolve, health equity must be at the heart of this implementation work. Our analysis helps to elucidate the multiple advantages that online testing modalities may provide for service users, as well as barriers and tensions perceived by health system partners, including the potential (unintended) consequences of introducing digital STBBI testing in a new provincial context. We must continue to address deficiencies and access challenges to current STBBI testing in the province, including ensuring all STBBI testing services meet the intersectional needs of clients in ways that are stigma-free and client-centred. While the overall acceptability for online testing was high, service providers and health system partners highlighted the fact there needed to be a plethora of options for clients to test at their own comfort level and pace. Online testing and our focus on health equity underscores the fact there is no universal system that works for everyone, and that users accessing STBBI testing must be given options to pick the model that suits their needs most. Online testing is not a one-size-fits-all method and is not meant to replace provider-based testing.

Abbreviations

STBBI

Sexually transmitted and bloodborne infection

GBQM

Gay, bisexual, queer and other men who have sex with men

CBO

Community-based organization

ASO

AIDS service organization

CBPR

Community-based participatory research

GTA

Greater Toronto Area

OHIP

Ontario Health Insurance Plan

PEP

Post-exposure prophylaxis for HIV

PrEP

Pre-exposure prophylaxis for HIV

STI

Sexually transmitted infection

Author contributions

DG designed the parent study, research question, drafted the manuscript, and supervised all research activities. MS collected and analyzed data, as well as supported writing the draft. HR collected and analyzed data, as well as provided substantial edits and feedback for the draft. JD, CW and MG provided substantial feedback and edits during the development and editing of the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Canadian Institute of Health Research (CIHR). DG is supported by a Canada Research Chair in Sexual and Gender Minority Health.

Data availability

Due to the nature of this research, participants of this study did not agree for full transcripts to be shared publicly, so this data is not available.

Declarations

Ethics approval and consent to participate

Ethics approval was granted by the University of Toronto Research Ethics Boards. All participants provided written and verbal informed consent to participate in the study. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.