Daniel Grace, Dalla Lana School of Public Health, University of Toronto
Innovations In Testing
How can we reach the 14% of Ontarians—just over 3,000 people—who have HIV but have not yet been diagnosed? This plenary talks about innovative ways to make HIV testing more accessible to more people. What’s the potential to bring these innovations to Ontario? What else should we be doing to reach the undiagnosed?
Thanks so much. I’d like to thank the OHTN for the invitation to be on this afternoon’s panel. I have no conflicts of interest to disclose. I’m a sociologist. I don’t think that’s a conflict, but I will put that out there. So in my remarks today I’ll be drawing on the scholarship and the implementation efforts of a large number of colleagues who have been working to improve access to HIV and STI testing and diagnosis in British Columbia. The specific program I’ll be speaking about is called “Get Checked Online”, who’s heard of get checked online? Okay, so some people. That’s great. And now, you all will have. So that’s good.
This work is spearheaded by Dr. Mark Gilbert at the BC Center for Disease Control. I’ll be using “we” throughout this talk. I’m really referencing a huge group of people from epidemiologists to frontline service providers who have been spearheading, and moving this work forward. I’ll be covering a lot of ground quickly. If you’re interested in more information, I’ve got some paper copies of a report as well as electronic resources for anybody who might be interested. So many people in British Columbia find it difficult to get tested for sexually transmitted infections, and blood-borne infections, such as HIV and hepatitis C known as STBBI for short. Internet-based testing services for STBBI in other places have been shown to be acceptable to the people who use them, and to lead to new infections being diagnosed. However these programs are rarely delivered on a large scale for widespread use, and many have not been thoroughly evaluated.
So we decided early on that we would evaluate and do research during all stages of developing, implementing, and expanding GCO or get checked online in British Columbia. I’m just giving you a kind of a flavor of what we found to date. Get Checked Online is a virtual clinic that is part of the provincial STI clinic at the BC Centre for Disease Control. People provide specimens in a private lab location, called Life Labs, all tests are at the BC public health laboratory, and tests are reviewed by clinic staff. Any GCO client who test positive receives the same follow-up discussion about testing partners and connection to treatment as a client who tests in the provincial STI clinic GCO. Clients with a positive result that live in Vancouver Island or in the BC interior are then referenced to a network of walk-in and public health clinics for treatment. So this is the model which I’m going to quickly walk you through. So what does this look like for the user?
So first a person creates an account on GetCheckedOnlinec.com. Here you’re asked to enter an access code or a promo code to create an account. Get Checked Online isn’t yet available for everyone to use, and people need an a code to create an account, so these codes are included in our messaging or people can request a code from a clinic if they’ve tried to to access the clinic and can’t be seen quickly. So on the create account page you need to give your name, your date of birth, and gender. This is used to process your samples at the lab, and verify you when we speak to you on the phone. We recommend that you use either your real name or your initials and date of birth, or the same identifies that you use when you test at the the BC Centre for Disease Control STI clinic or other STI clinic.
You need to give a valid email address. To protect your privacy we suggest using an email address that only you have access to. And we also ask for a phone number and a city where you live, but this information is optional. So second you need a lab form. So to create an lab form you’ll need to fill out an online assessment, select which of the recommended tests you want, read the consent page and give your consent to testing. Your lab form is then created after you’ve gone through this consent process. You can bring your lab form into participating locations, either on your mobile device or in printed form.
Third, now it’s time to provide your samples. It sounds like a longer process when I go through it all like this, but it’s a very streamlined. So third, it’s time to provide your samples, you’ve created your lab form and you bring it into participating Life Lab locations. Appointments aren’t required, but you can use an online appointment booking system to streamline. You don’t need to use a real name again when booking an appointment. Because your name though isn’t on the form, you’ll be asked what name you want to be called up by when it’s time to give your samples. The lab technician will use then your Get Checked Online client code and your date of birth to verify your identity. The lab technician will collect urine and blood samples for testing. If throat or rectal swabs are recommended, the technician will give you a swab kit, so that you can collect the swab samples yourself where you can self swab. Instructions on how to self swab are included in the kit.
You can either do that, take that little kit and take it home and bring it back, or do that self swab collection in the clinic, in a restroom there. So forth, now it’s time to get your results. When your results are ready, you’ll get an email telling you to log into your account. The email will never include your test results. Once you sign in you’ll see on your tests and results page. If your tests are negative you can go and review the results right there. If there was a problem with any of your test samples, or test couldn’t be performed, you’ll see a message on this page. If any of your results were positive or inconclusive, you’ll see a message telling you to call the BC Center for Disease Control.
Positive results aren’t actually stored on Get Checked Online, and will never be shown on your test results page. And then you can kind of see that the loop continues the next time you want to go and get tested, you’ve already created an account, and you’ll go through those same steps, and you can also set reminders for yourself at a three month or a twelve month mark, or whatever makes sense in order to continue the the cycle. So Get Checked Online is currently available through six Life Lab locations in Vancouver, five on Vancouver Island, and three in the BC interior. You can see here. In the coming years we hope to expand to communities in the Okanagan, Fraser Valley, and central and northern Vancouver Island. So the objectives of Get Checked Online are really to improve sexual health by increasing the uptake and frequency of STBBI testing, leading to increased timeliness of diagnosis, the program aims to reach populations at greater risk of infection, and facing barriers to testing, including youth, gay bi and other men who have sex with men, people living in rural areas, etc…
The program also aims to increase STI clinic capacity, and improve use of clinician resources. And finally we’re committed as a team to evaluating the effectiveness of the intervention at multiple levels. So in short we really position this work in relation to this kind of cycle, in terms of program development and implementation, and continued research and evaluation to inform future innovation evolution and scale-up. So the first phase of development of Get Checked Online was actually between 2009 and 2012, and this was to determine what this should look like, what the requirements would be. You can see here this involved a lot of different actors being involved in research consultations and evaluations, and reviews involving lots of different players ranging from end users through to the Public Health Service Authority executive.
So I’m obviously glossing over a lot of information quite quickly here, this next phase of development was really building Get Checked Online, building the online component. This image kind of says it all, this circle image here, this was the kind of unofficial logo of the team at the time. Kind of how complicated it was to actually develop this intervention. It was challenging work undertaken by many many people that took a lot of time. So this was funded again by the provincial Health Services Authority in 2009, and then launched in a pilot phase in September of 2014. So five years of research and development just to get to that pilot phase. For the first 18 months Get Checked Online operated as a pilot program in Vancouver, with promotion focused on gay bi and other men you have sex with men, and clients visiting STI clinics. During the pilot we worked closely with Island Health and interior health to make GCO available outside of Vancouver.
We can see it here in February 2016, GCO expanded to three communities on Vancouver Island, Victoria, Langford, Duncan, and two communities in the BC interior, Kamloops and Nelson. In 2015 we began working with Life Labs to identify a process for offering self collected throat and rectal swabs to people through GCO. So at the time we tested with focus groups, the idea of self collection, what self collection would look like, what those instructions actually should look like. So that’s now integrated into the program. We then developed a set of these instructions and modified them for trans and gender diverse populations, and piloted them to make sure that the instructions were clear. Swabs were then successfully introduced to GCO in early 2016.
So now a quick look at testing uptake. In the first 15 months of the program we noticed that only a 4 out of 10 people who created an account went on to actually do the tests, so it was kind of a new sexy thing, that people were trying out. So first people were trying it out and not actually going on to do a test. So we didn’t see a lot of positive test results in that really early phase. And then in March 2016 in close partnership with Island and interior health authorities, GCO was then expanded into several communities on Vancouver Island and in the BC interior. So here now we started to see an immediate increase in uptake, including in the Lower Mainland, where we didn’t actually do any additional marketing or promotion. So with ongoing print and digital promotion to the regional health authorities, and limited actually additional promotion in Vancouver, we’ve seen this kind of steady increase.
And then we get to this kind of “oh hell yeah”, it’s working, kind of moment where we see see a real uptake. So in 2018 we’ve seen anywhere from 300 to 600 people testing through Get Checked Online each month, and an average of 23 positive diagnosis per month. So overall one in 20 people testing through GCO, test positive for an infection. This is a high percent and is similar to rates that might be found in a STI clinic. This suggests that GCO is reaching populations that do have a higher rates of infection, which is an objective of the program. It’s also worth noting that throat and rectal chlamydia, and gonorrhea infections now make up 40 percent of all positive diagnosis. So who’s actually using Get Checked Online? There was a wide range of ages here, but the highest proportion is users between 20 and 29. Regional differences are apparent, more youth under 30 testing in regional health authorities than in Vancouver.
We’ve adjusted the gender categories here so we can get better capture of the diverse gender identities of users, the ethnicity of users is largely white but we’ve also seen regional differences. For example we have a higher proportion of individuals identifying as indigenous testing in interior health. So another aspect of Get Checked Online we’ve explored early on was a comparison of the experiences of people testing through GCO versus those testing through a provincial STI clinic. So we found that it was more common for people using GCO to face barriers to getting tested in the past, and we think this demonstrates the success of the program, reaching people who face barriers to testing is obviously one of the major program objectives. The team has also conducted qualitative research with youth and diverse gay bi and other men who have sex with men on their get checked online testing experience. Both groups describe the convenience of GCO and being motivated not having to wait to get tested at a clinic, increased privacy and anonymity, and avoiding judgment from health care providers.
Rural men that were interviewed highlighted GCO was a way to discreetly test without actually having to come out to their healthcare providers. And just to briefly highlight some client perspectives of GCO. GCO is an excellent program, a totally unbiased sample here that I’ve collected. I’m just exemplifying there’s a lot of really great research behind this. So GCO is an excellent program keep on developing it. It’s the Gateway to a more efficient medical system, allowing more patients to have control of their health without getting caught up in the bureaucracy of our walk-in clinic system. A man in Kamloops, we interviewed, said it took me a while to find a doctor when I moved to Kamloops. I told him I was a gay man and as part of my health routine I wanted to be tested for SDI’s and HIV, and he was reluctant to do that. He said he’d never seen a case of HIV in Kamloops. So now to Olivia. Meeting our program objectives, we found internet-based testing to be an acceptable and feasible way to improve access to testing and diagnosis of sexually transmitted in blood-borne infections.
Again one in 20 people using Get Checked Online tested positive for an infection. People who use get checked online are highly satisfied with the service, have a higher chance of infection, and face barriers to accessing face-to-face testing, and many have never previously tested. Get Checked Online is an effective and scalable health intervention, with different impacts in major and smaller urban and suburban communities. Users outside of Vancouver are different in terms of their demographics and behaviors, including a greater proportion of males and youth testing for HIV for the first time. We’ve also traced a high level of diffusion about Get Checked Online within networks, and a high proportion of people who’ve heard of Get Checked Online referring to a friend, and kind of communicating about the intervention. So as we move, we went from kind of a paper airplane through to this like rocket ship.
So as we move forward with this work and consider further scale up, and raise questions regarding expansion, as a team we really return to core questions about implementation science. So as Edwards puts it, implementation science allows us to examine what works for whom, under what contextual circumstances and whether interventions are scalable in equitable ways. So the current characteristics of GCO users and differences between expansion sites, speak to the importance of understanding how contextual factors, at multiple levels, may be influencing program outcomes. As we know the effectiveness of health interventions, as well as their success in reaching all relevant target populations, is critically influenced by their implementation in a given context.
Understanding context requires a team, multidisciplinary efforts, and I like to say a broad sociological and Public Health imagination. In implementation science context is often seemingly the elephant in the room. One of our important jobs as a team currently is to understand the context of Get Checked Online implementation in a robust way, recognizing that our individual experiences and vantage points, or sources of data about how we understand context, may only be partial, and in fact obvious gates, salient contextual factors beyond our view. And one thing I’m really excited about, and happy to take some of these conversations offline, is about what this means for the context of Ontario, and the particular kind of implementation context we’re in here.
So I won’t review this in any detail, just to say that this is our implementation science model, we’re deeply committed to working with diverse partners in thinking about the Ontario context. We currently have a CIHR implementation science grant to begin to ask some of these questions, and if anybody’s interested I’d love to to connect with you and think about your reflections on the current HIV STBBI testing landscape in Ontario, and if and how digital interventions might complement what’s currently on offer. And by thanking our broad team and community partners who make this work possible. Thanks very much. [Applause]