Table 2. Barriers and facilitators to HIV testing by key population in Canada, 2009–2019.

Population type	Provinces reporting on population	Barriers	Facilitators
gbMSM (including two-spirited, queer, trans or questioning)	All provinces	• Fear of positive result (51)      • Shame associated with requesting HIV testing and responding to the pre-test questionnaire (e.g. disclosure of sexual information) (41)      • Lack of anonymous testing (44,47)      • Lack of confidentiality in testing services (41)      • Lack of knowledge of trans identities and health-related concerns among testing providers (51)      • Limited availability and accessibility of HIV testing (31) (e.g. limited clinic opening hours (41))      • Low risk perception of HIV acquisition and/or transmission (24,50,51)      • Criminalization of HIV nondisclosure (36,45,47)      • Stigma and discrimination with regard to gender, sexuality, sexual identity, sexual relationships and monogamy (31)      • Stigmatization by healthcare professionals (46)	• Having a strong network among gbMSM in the community (50)      • gbMSM, queer and trans-competent sexual health care (50)      • Integrating HIV testing with other routine health services (31)      • Internet-based HIV testing (33)      • Social media campaigns promoting HIV testing (32)
Sex workers (including managers and business owners of sex work venues)	British Columbia	• Criminalization of sex work (23)      • Criminalization of third parties (managers/owners) creating harmful practices within sex work venues (e.g. restrictions on condom use, rejecting testing in the workplace) (23)      • Collaboration between public health outreach and law enforcement (e.g. arriving on site together) resulted in a mistrust of health outreach workers and a reluctance to allow them on site (23)      • Occupational stigma resulting in difficulties accessing primary health care and sexual health services (23)      • Fear of sex worker status becoming known (e.g. reluctance to request frequent tests from family doctors) (23)	• Mobile HIV prevention programs (27)      • Health outreach workers offering STBBI testing in sex work venues (23)      • Non-judgmental and non-stigmatizing attitudes of health outreach workers enabling open discussions about sexual health issues (23)
PWID	All provinces	• Low risk perception, lack of interest or perceived urgency (63)      • Fear of a positive diagnosis (63)      • Feeling healthy (63)      • Issues getting tested (e.g. accessibility of testing services) (63)      • Feeling that nothing could be done in the case of a positive diagnosis (63)	• Peer-delivered post-test counselling (43)      • Regularly seeking HIV/STBBI testing (63)      • Testing integrated with routine medical care (63)      • Testing suggested by healthcare provider (63)      • Potential recent exposure (e.g. through sex, drug use) (63)
Immigrant populations	British Columbia, Ontario, Québec	• Shame associated with requesting HIV testing and responding to the pre-test questionnaire (e.g. disclosure of sexual information) (41)      • Concerns about confidentiality (e.g. being seen in the clinic or receiving services from a member of their close-knit community, preference to answer questions on paper/electronic devices) (41)      • Difficulties accessing primary health care and sexual health services due to lack of health insurance, linguistic and cultural barriers (23,27,41,60)	• Availability of translators or multilingual health services (23)
Indigenous communities	Nova Scotia	• Geographic barriers to accessing health care in rural and remote communities; absence of primary health care and HIV testing services; inconsistent access to medical transportation (56)      • Lack of trust between clients and healthcare providers (56)      • Lack of knowledge about HIV (risk factors, risk reduction strategies, modes of transmission, treatment) and HIV testing (feasibility, available types, benefits) (56)      • HIV stigma relating to injection drug use (56)      • Low risk perception; denial of potential risk linked to certain behaviours (e.g. injection drug use) (56)      • Fear of positive result and loss of community acceptance (56)      • Stigma and homophobia; perceptions of HIV as a “gay disease,” associations with promiscuity, hierarchy of stigmatized behaviours, more social stigma is associated with homosexuality than injection drug use, linked to differential perception of HCV and HIV (56)      • Issues with confidentiality within small communities, belief that “people will know” (56)	• Normalization of HIV testing increasing both accessibility and acceptability; shifting away from targeted testing based on behaviour, sexuality and risk toward integration of testing into routine medical care (56)      • Increasing availability of testing; offering HIV testing within Indigenous reserves; increasing access to medical transportation (56)      • Reducing wait time for results by offering point-of-care testing (56)      • Harm reduction service centres integrating HIV testing (56)      • Education about HIV (modes of transmission, risk factors) and HIV testing (available types, testing as prevention); sessions delivered by HIV/AIDS service organizations (56)      • Collaboration between healthcare providers and HIV/AIDS service organizations to build trust (56)      • Practices and protocols that are acceptable to the community (56)      • Combined education about other STBBIs (e.g. HCV) (56)
African, Caribbean and Black communities	Ontario	• Cultural barriers (labelling of women who test as promiscuous) (64)      • Difficulty accessing health/testing facilities (not knowing where to get an HIV test) (60,64)      • Fear of positive results; preferring not to know (64)      • Fear of negative reaction from partner(s) upon disclosure of status (64)      • Lack of anonymous testing (64)      • Lack of confidentiality in HIV testing services (64)      • Insufficient knowledge of HIV (transmission, testing, treatment) (64)      • Stigma and discrimination of same-sex sexual behaviour, PWID or alcohol use, misconception that testing implies low masculinity (60,64)      • Resistance from family physician to test despite a request (60,64)      • Perceiving an offer of testing as a form of stereotyping or profiling (60,64)	• Being offered testing by a family physician in the context of routine care (rather than needing to specifically request it) (64)      • Eliminating stigma by normalizing HIV testing (64)      • Strategies focused on opening communication and navigating cultural silences (empowering individuals to broach the topic of HIV testing) (64)      • Testimonials from PLWHIV/AIDS reducing fear of testing (64)      • Community outreach by individuals from similar cultural or linguistic backgrounds (64)      • Increasing knowledge of treatment and outcomes, testing recommendations, risk reduction strategies (64)      • Public health messaging from government and health agencies, leveraging mainstream media (64)

Abbreviations: AIDS, acquired immunodeficiency syndrome; gbMSM, gay, bisexual and other men who have sex with men; HCV, hepatitis C virus; HIV, human immunodeficiency virus; PLWHIV/AIDS, people living with HIV/AIDS; PWID, people who inject drugs; STBBI, sexually transmitted and blood-borne infection