How can HIV/STI testing services be more accessible and acceptable for gender and sexually diverse young people? A brief report exploring young people’s perspectives in Queensland

Abstract

Issue addressed

Gender and sexually diverse young people (GSDYP) are an important target group for HIV/STI prevention and there is an immediate need to explore ways to make testing interventions accessible and appropriate for this group.

Methods

We used a modified World Café workshop with 14 GSDYP in Brisbane Australia, to inform the development of a pilot community-based testing intervention.

Results

The workshop identified the key features of an ideal service, which would include multiple, accessible sites that offer holistic, affordable services and confidential care by respectful and knowledgeable providers. The service would allow young people to engage in decision-making processes, have a culturally inclusive, comfortable and friendly atmosphere, and provide free sexual and reproductive health technologies.

Conclusion

When designing HIV/STI testing interventions for key groups, health promotion practitioners need to be cognisant of localised and nuanced expectations and ensure that services are tailored to the needs and experiences of the local population.

So what?

This study provides insights into the needs and expectations of HIV/STI testing interventions for GSDYP in Australia, a key at-risk group whose perspectives are not adequately voiced in sexual health research and intervention design.

1. Introduction

Gender and sexual minority populations bear a disproportionate burden of HIV and these inequalities are exacerbated within populations of young people (1, 2). Young people in Australia are a key at-risk group for STIs, in particular gonorrhoea and chlamydia, and 20-29 year olds account for up to one third of all HIV notifications each year (3). Increasing HIV/STI testing among young people, particularly within gender and sexual minority groups, is an immediate challenge for health promotion practitioners (1). There has been an escalation in community peer-based point of care testing services in non-clinical, community and outreach settings (e.g., shopfronts during festivals, sex on premise venues) (4–6). Most of these target priority groups such as gay men and men-who-have-sex-with-men who have never tested or test infrequently. However, these do not address the needs of the increasing number of young people in Australia (and globally) who are expressing diverse and fluid sexual and gender identities (2). It is essential to develop understandings of the risks and needs of people whose diverse intersections of age, gender, sexuality, and social contexts increase their vulnerability to HIV/STI infection (2, 7, 8). There is an emerging international body of literature exploring sexual and reproductive health (SRH) services with gender and sexually diverse young people (GSDYP), indicating a need for inclusive and holistic health service provision in accessible and non-clinical settings (9–12). Literature highlights discriminatory and non-inclusive clinical settings where GSDYP do not feel safe or understood due to gender expression, sexuality or ethnic background as key barriers to HIV/STI testing (9, 13–16). There is a gap in literature exploring GSDYP’s perspectives around key ways to increase the accessibility and acceptability of HIV/STI testing for this group.

This article explores HIV/STI testing with GSDYP in Queensland through a participatory workshop designed to understand current barriers to testing and capture ideas to increase accessibility and acceptability of HIV/STI testing for this group. This study is guided by the research questions, ‘What facilitators and barriers do GSDYP in Queensland experience in relation to HIV/STI testing?’ and ‘What would an ideal HIV/STI testing intervention look like from the perspective of GSDYP in Queensland?’

This study was conducted as part of a broader community-based research project. Identified through a community organisation serving GSDYP, a group of GSDYP participated in the formative phases of this study, identifying sexual health and HIV/STI testing as key issues and contributing to the design of research questions (17). This broader study included in-depth interviews with GSDYP from around Queensland conducted by peer-researchers, which explored sexual health knowledge, experiences and needs in detail. This article reports on findings from a modified World Café workshop conducted with 14 GSDYP in Brisbane. Findings will contribute to outcomes of the broader study that will inform the design of a pilot community-based HIV/STI testing service.

2. Methods

2.1. Participants

A convenience sample of 14 GSDYP was recruited via posters and flyers at a community organisation serving GSDYP and the study’s Facebook page, which shared the event information. Participants received a $50 gift voucher for their participation. As participants arrived at the venue, they completed a basic demographics form that captured gender and sexual identity/ies as well as brief information on country of origin, relationship status, living status, and work and educational activities. Participants were aged 20-25 years (median age 21 years). Participants selected their gender identities as trans male (two), cis female (two), cis male (two), gender queer (two), non-binary (two) or ‘other’ (four), three of which were specified as: “non-binary woman”, “non-binary, trans-boy”, and “trans woman, gender queer, non-binary, agender”. Participants selected their sexual identities as gay (three), bisexual (three), pansexual (two), queer (three), or ‘other’, which were specified as: “lesbian, queer, pansexual”, “gay, lesbian, bisexual, queer, asexual, pansexual, questions/exploring”; and “multi-gender attracted, panromantic, grey-aromantic”. A glossary of gender and sexuality identities is available from the American Psychological Association (18). In terms of relationship status, seven participants were single, one in a monogamous relationship, two in polyamorous relationships, and three in open relationships. One described their status as “monogamous apart from work”. Participant characteristics are summarised in Table 1. The majority (12) were born in Australia, with one born in France and one in Korea. Most (11) were studying at a tertiary institution, two were working part-time and one was unemployed. Most participants (10) were sexually active. Six had previously had a HIV test, four of these reported testing ‘less than once a year’ or ‘once’.

Table 1. Participant gender identities, sexual identities and relationship status.

Gender identity	Number	Percentage (%)
Trans male	2	14.29%
Cis female	2	14.29%
Cis male	2	14.29%
Gender queer	2	14.29%
Non-binary	2	14.29%
Othera	4	28.57%
Sexual identity	Number	Percentage (%)
Gay	3	21.43
Bisexual	3	21.43
Pansexual	2	14.29
Queer	3	21.43
Otherb	3	21.43
Relationship status	Number	Percentage (%)
Single	7	50
Monogamous relationship	1	7.14
Polyamorous relationship	2	14.29
Open relationship	3	21.43
Otherc	1	7.14

^aSpecified ‘Other’ included: “non-binary woman”, “non-binary, trans-boy”, and “trans woman, gender queer, non-binary, agender”

^bSpecified ‘Other’ included: “lesbian, queer, pansexual”, “gay, lesbian, bisexual, queer, asexual, pansexual, questions/exploring”; and “multi-gender attracted, panromantic, grey-aromantic”

^cSpecified ‘Other’ included “monogamous apart from work”

2.2. Methods

The workshop drew on World Café principles, which include creating an inclusive space, exploring lived experiences and real-life concerns, supporting participation, and capturing diverse perspectives (19). We modified the World Café approach in recognition of the potentially sensitive topics being discussed. Similar approaches have been used as effective and efficient sexual health needs assessment with diverse young people (20). The workshop was conducted in a public, youth-orientated space where participants were invited to share lunch while sitting in groups around three separate tables. One researcher facilitated the session, providing context and centring discussions on key overarching questions (19). Questions included: ‘What would an ideal HIV/STI testing service look like?’, ‘What do you see as barriers to accessing HIV/STI testing?’ and ‘What would make accessing HIV/STI testing easier for GSDYP?’ Groups of four-five participants brainstormed responses, which were shared with the room to facilitate engagement and validation of ideas (19). Groups remained together to maintain supportive, safe environments (19).The research team included two peer-researchers, one who is Aboriginal, both who identified as gender and/or sexually diverse. Four female researchers were also present, three from Australian and one from Scotland, all who have experience working with diverse groups of young people. A member of the research team joined each table to support safe discussion, ensure inclusion and active listening, facilitate the recording of discussions on the brainstorming paper, and to encourage all participants to have the opportunity to contribute (19). Each group was provided with large sheets of paper and markers to record responses to the questions in the form of brainstorming and mind mapping. The provided paper included the shape of gender neutral body to encourage practical reflection on lived experiences (see Figure 1). Participants chose to use a mix of words and illustrations. Conversations were not recorded with recognition of the sensitive topics being discussed and the need to create a safe and comfortable environment where people could to share their thoughts and experiences.

Figure 1. Examples of group work exploring barriers and facilitators to HIV/STI testing.

2.1. Ethical Approval

This study received ethical clearance from the University of Queensland’s Human Research Ethics Committee (2017001611). Eligibility criteria included being between the ages of 16 and 25 years and identifying as gender and/or sexually diverse (i.e. lesbian, gay, bi-sexual, transgender, queer, intersex, asexual plus).

2.3. Data analysis

Data included responses generated by a series of brainstorming and mind mapping activities that were recorded by participants on the provided paper. We conducted initial content analysis, recording the number of times key words appeared, and noting when key words appeared across one, two or all of the groups’ data (21). We then grouped key words into themes. Two members of the research team conducted the analysis. The analysis was validated through discussion and agreement with the broader team, which included a peer researcher (21).

3. Results

Results are described across four key themes: i) location, ii) type of service, iii) setting, and iv) provider, outlining the components of an ideal HIV/STI testing service and describing current barriers and facilitators to accessing testing. Table 2 provides a detailed summary of findings across the four key themes.

Table 2. Key themes to guide HIV/STI testing interventions.

	Location	Type of service	Setting	Provider
Description of an ideal service	Diverse locations e.g. clubs, sex shops, LGBTIQA+ events, educational settings, home.	Holistic care including prevention, testing and treatment. Provisions of free SRH technologies and food.	Comfortable, non-clinical and safe, including flags and posters to represent inclusion. Allow pets and include pet therapy.	Informed about diverse bodies and unique needs of diverse young people, relatable and respectful.
Current barriers	Difficulties related to distance required to travel, particularly for those living outside the city and those who rely on parents for transport. Lack of knowledge about where to be tested.	Costs associated with consultations and SRH technologies. Universal healthcare insurance in the name of parents, undermining confidentiality and privacy. Wait times and language barriers. Fear associated with results, examination procedures, and forced disclosure of sexual practices. Prioritising basic needs over sexual health.	Discriminatory settings, including experiences of cis-ism, heterosexism, racism.	Judgemental, use of binary language, lack of knowledge related to diverse bodies and sexual practices. Privacy and confidentiality, particularly from health professionals with regard to parents.
Facilitators	A discreet physical location that is well known and accessible via public transport. The need for more testing services outside urban areas. Close proximity to broader health care services, including general practices, pharmacies, and mental health and homelessness services.	Free consultations and provision of SRH technologies. Access to broader health and wellbeing services and professionals. Broader sexual and relationship health awareness and education that is inclusive of GSDYP’s experiences and needs. Incentives.	Inclusive and non-judgemental.	Choice of providers who are non-judgemental and support young people in decision-making processes.

3.1. Location

An ideal service would be available across a range of locations, including: clubs, sex-shops, “LGBTIQA+” and “pride” events, educational settings and at home. An ideal service would be physically easy to access. A mobile van and/or vending machines were identified as potential means of service provision. The participants outlined barriers related to travel and distance. Locating a service in a well-known, yet discreet location, accessible via public transport, was presented as a facilitator. Proximity to other services, including general practices, pharmacies, mental health and homelessness services, was noted as important.

3.2. Type of service

The concept of a one-stop-shop was consistent across all groups with notes suggesting an ideal service would include treatment, prevention and access to health and wellbeing services such as counsellors and social workers. Costs associated with consultations and prevention technologies were outlined as barriers, and facilitators included free contraceptives, female and male condoms, dental dams, family planning, and hygiene products. Data suggested some GSDYP may be unable to prioritise sexual health due to a lack of basic needs and the provision of food was presented as a facilitator. Participants highlighted that services must include provisions of privacy, particularly from parents. The need for education around examination procedures and treatment as well as broader, inclusive sexual and relationship health education was identified.

3.3. Setting

Participants described the ideal space as comfortable and safe, suggesting worn couches and beanbags as well as representative flags and information posters. An ideal service would allow pets and potentially provide pet therapy to ease anxiety and stress associated with testing. All groups noted discriminatory clinical settings as a barrier. Some examples from the data included: forms with sexuality or gender categories that participants did not identify with, the use of binary language by staff, and not feeling safe due to gender expression, sexuality or ethnic background.

3.4. Provider

Participants described ideal health professionals as informed, relatable and respectful. Judgement, negative past experiences and being turned away due to health professionals not understanding young, diverse peoples’ bodies and needs, were noted as barriers to testing. Choice in health professionals, including peer testers, and discretion were presented as facilitators and participants highlighted the importance of being respected and actively engaged in decision-making.

4. Discussion

Findings provide important insights to inform HIV/STI testing services for GSDYP in Australia. Resonating with literature exploring effective SRH services with young people more broadly, locating services across multiple and non-clinical sites may support testing among GSDYP (11). Further, it is important to consider the need for holistic health service provision and addressing social determinants of health, including homeless and poverty, which are disproportionally experienced by GSDYP (9, 10, 12). Providing free testing services, close to public transport and accompanied with free sexual and reproductive health technologies and food may support GSDYP in accessing HIV/STI testing. Our findings further indicate a need to explore innovative approaches to encouraging and supporting HIV/STI among GSDYP such as providing incentives and including pet therapy. These approaches are under-explored in the literature (22, 23).

Findings are consistent with broader literature that highlights the importance of health professionals who are trustworthy and discreet, informed, relatable, respectful and include young people in decision-making processes (9, 14, 16, 24, 25). Providing GSDYP with choice of health professionals, including peer testers, and ensuring services support confidentiality, privacy and discretion may encourage testing among this group (14–16).

Finally, findings highlight the need for broader and inclusive sexual and relationship health education that considers diverse identities and practises, explores HIV/STI prevention in addition to contraceptives, and explains the where, when, why and how of HIV/STI testing, as well as treatment options (1, 10).

4.1. Strengths and limitations

The modified World Café design ensured diverse voices and perspectives were captured and shared in a safe and inclusive space. The use of a gender neutral body on the provided paper (see Figure 1) allowed responses to centre on realities and lived experiences, facilitating practical insights. None of the participants identified as Aboriginal or Torres Strait Islander and culturally and linguistically diverse populations were under represented. There were no participants under the age of 20 years and the number of participants who had some tertiary education may have biased results. We chose not to audio-record the workshops to ensure a safe and comfortable environment, this created limitations for the depth of data collected. The participatory nature of the research design and data collection helped ensure findings were valid and relevant for the community. Researchers acted only as facilitators to group discussions helping to ensure that all participants were given space to speak and for discussions to be recorded on brainstorming paper, rather than directing the group discussions. The presence of peer researchers at the workshop and their input in the data analysis worked to minimise bias brought by the research team.

5. Conclusion

Finding from this workshop resonate with an emerging body of literature exploring SRH services with GSDYP and provide important insights into nuanced, localised expectations regarding appropriate services for GSDYP in Queensland. Findings provide useful insights that can inform accessible and appropriate HIV/STI testing services with this group. These findings will directly inform the development of a pilot community-based testing intervention in Brisbane. Drawing on these findings, this service will be trialled in a non-clinical, community organisation, which already works with GSDYP to support other health and wellbeing needs. The HIV/STI service will be conducted by peer testers, who will be supported by health professionals experienced in working with GSDYP. Free sexual health technologies will be provided with this service and the ability to provide of food is being explored. A comprehensive evaluation will be undertaken.

Summary.

This study explores facilitators and current barriers to HIV/STI testing with a group of gender and sexually diverse young people in Brisbane, Australia. Outcomes provide insights into the needs and expectations of HIV/STI testing services for this group.