Ability of a rapid HIV testing site to attract and test vulnerable populations: a cross-sectional study on Actuel sur Rue

Abstract

Quebec’s HIV epidemic persists, particularly among men who have sex with men (MSM) and in Montreal. Increasing access to HIV testing is necessary and community-based rapid testing offers one strategy. This paper examines the clienteles and activities of a rapid HIV testing site in Montreal, the pilot project Actuel sur Rue. Comparative analyses were conducted with 1357 MSM, 147 heterosexual men and 64 women who visited Actuel sur Rue between July 2012 and November 2013 on socio-demographics, health, drug use, sexual practices/infection and HIV testing/prevention. Significant group differences were observed in each category. Actuel sur Rue received 1901 clients, conducted 1417 rapid HIV tests and tested 77 never-tested individuals. Rapid testing produced a high reactive rate (2%). Only 1/28 of those with reactive tests had no previous HIV testing, and 36% had used post-exposure prophylaxis, suggesting missed opportunities for prevention. Findings highlight diverse client vulnerability profiles and the relevance of checkpoints and further prevention efforts.

Keywords

HIV AIDS screening rapid test prevention checkpoint Canada MSM heterosexual men women

Introduction

Quebec’s HIV epidemic

HIV remains a public health concern in Quebec. In 2013, Quebec was the Canadian province with the second highest number of new HIV cases (453) behind Ontario (827).¹ From 2002 to 2013, two-thirds of detected cases in Quebec (63.8%) resided in the Montreal region and a majority (67.8%) were Canada-born.² Men who have sex with men (MSM) accounted for most cases (50.5%), followed by people from an HIV-endemic country (17.1%), injection drug users (13.3%) and heterosexuals with non-specific risk (8.3%).² Almost half of female cases (48.9%) were among immigrant women from a HIV-endemic country, particularly sub-Saharan Africa and Haiti.²

There is a recognised need for improving access to HIV testing in Quebec.³ Across Canada, rapid HIV testing is seen as a critical tool in this effort.⁴ In 2013, almost half (45.0%) of newly diagnosed persons in Quebec had never previously been tested for HIV and for 23.2%, this diagnosis came late, at the stage of AIDS, when CD4 cell counts had decreased below 200 cells/mm³.² In Canada, it is estimated that 25% of HIV-positive individuals are unaware of their status.⁵ Among MSM, HIV incidence in Quebec has been stable for years and the ARGUS survey of Montreal MSM puts HIV prevalence at 13.6%.⁶

Barriers to health care among sexual minorities, migrant populations and other groups who are vulnerable to HIV are well documented in the literature.^7–9 These can similarly limit access to HIV testing. Early diagnosis and knowledge of one’s HIV status are important as they can carry both individual and public health benefits. Awareness of HIV-positive status is associated with reductions in sexual risk practices¹⁰ and initiating antiretroviral treatment earlier is linked to improved immune function, decreased morbidity and a reduced risk of transmission in HIV-negative partners.¹¹

Current HIV testing options in Montreal

In Montreal, HIV testing is available to individuals in many forms, through medical clinics, hospitals and via integrated testing and prevention services which provide HIV testing both within local community service centres and beyond them, to reach vulnerable populations (e.g. at community organisations, specialised schools, youth centres, detention centres, and on the street). Screening for HIV is also part of routine prenatal testing for pregnant women in Quebec, on an opt-out basis.

HIV testing is non-nominal in the province in that the labs receiving the blood samples do not have access to personal information about their source’s identity. Free anonymous testing without the need to provide one’s real name or medical insurance card is also available. Additionally, several Montreal clinics specialising in the treatment of sexually transmitted infections and other blood-borne infections (STIBBIs) also offer testing.

Rapid HIV testing in Montreal is not widespread. It is available at some clinics and community-based testing sites, while it is not always free of charge. At-risk MSM can access free, rapid HIV testing anonymously and, typically, by appointment through SPOT, a research and intervention project.¹² Also located in the gay village but operating within a framework of confidentiality and linkage-to-care, the pilot project Actuel sur Rue (AsR) offered free rapid HIV tests to eligible individuals using a walk-in format.¹³ AsR is the object of the present study.

Advantages of rapid community-based HIV testing

In resource-rich countries, community-based HIV testing is successful at identifying previously undiagnosed individuals, increasing the uptake of HIV test results when rapid tests are used, and expanding options for HIV testing, according to a review by Thorton et al.¹⁴ A research review specifically on rapid testing suggests outcomes are largely favourable, including engagement of at-risk and hard-to-reach populations, increased uptake of testing and the linkage of proportionately more newly diagnosed individuals to HIV care.¹⁵ High levels of client satisfaction with rapid and community-based HIV testing are also observed^12,14,15 and a further benefit of rapid testing is continuity in clients’ counselling experience (e.g. same counsellor provides pre- and post-test counselling).⁴ These are among the founding reasons for piloting the community-based rapid HIV testing project, AsR. The main objective of this study is to describe some of the main clienteles and activities of AsR to evaluate its ability to attract vulnerable populations and increase access to HIV testing.

Methods

Actuel sur Rue

Modelled on European checkpoints,¹⁶ AsR opened in July 2012 on a busy street in Montreal’s gay village with the intention of reaching populations who are vulnerable to HIV and other STIBBIs and who have weak ties to health care. Its aim was to provide, on a walk-in basis, a limited number of medical tests (rapid HIV, standard HIV and syphilis), vaccines (hepatitis A and B) and linkage-to-care in a non-medical environment, primarily to MSM. Clients were served by a community agent and nurse team who assessed relevant health risks and adapted services and linkage accordingly. All individuals undergoing an HIV test received pre-test and post-test counselling.

AsR was a pilot intervention and research project that received ethics approval by an independent research ethics board (Veritas, Montreal). Clients signed a consent form prior to receiving services and were not compensated for providing study data. Accessing services involved three steps of data collection to better tailor services to client needs. First, clients entering AsR were greeted by a community agent, who conducted a risk assessment, entering the information collected via an electronic tablet. Then, clients completed a self-administered questionnaire, also via tablet. Finally, when meeting with clients, the nurse accessed the community agent’s risk assessment (but not the questionnaire data) and entered more information on the tablet concerning which, if any, tests or vaccines were given and the nature of linkage-to-care recommended. Access to the rapid HIV test was determined based on the recommendations outlined by Quebec’s National Public Health Institute (INSPQ).¹⁷ With cross-sectional data collected from these data sources from July 2012 to November 2013, we provide descriptive and comparative statistics on AsR clients according to three groups: MSM, heterosexual men and women. The characteristics examined relate to four areas: socio-demographic and general health characteristics; current drug use; sexual practices and infection; and HIV testing and prevention (see Table 1). Data analysis was performed with the software R (The R Foundation) and consisted of Chi-square or Fisher’s exact tests, as appropriate, for group comparisons. Tests were two-tailed and significance was set at p ≤ .05.

Table 1.

Characteristics of MSM (n = 1357), heterosexual men (n = 147) and women (n = 64) clients of Actuel sur Rue and of persons testing positive on the rapid HIV test (n = 28).

Variable	Client group (%)			p	Reactive test
Variable	MSM	Hetero-sexual men	Women	p	% (n)
Socio-demographic/general health characteristics
Less than 25 years old	16.7	17.8	28.1	0.059	14.8 (4/27)
50 years old or over	15.8	15.1	3.1	0.022	3.7 (1/27)
High school degree or less	20.8	31.5	25.0	0.012	28.0 (7/25)
Immigrant (permanent resident, refugee)	19.2	28.7	24.4	0.047	5.3 (1/19)
No occupation (not retired/worker/student)	9.8	10.3	11.1	0.853	4.0 (1/25)
Annual income of less than 20,000 CAD	25.7	34.7	47.6	<0.001	16.0 (4/25)
No medical insurance	4.6	8.2	7.9	0.073	12.0 (3/25)
Less than ‘good’ self-rated health (poor or alright)	6.0	11.6	9.5	0.028	4.0 (1/25)
No doctor/family physician	19.7	27.2	42.2	<0.001	21.4 (6/28)
Current drug use
Inhaled drug (poppers)	29.7	3.0	0.0	<0.001	66.7 (10/15)
Opiate (e.g. heroin)	1.9	3.0	0.0	<0.001	0 (0/7)
Stimulant (e.g. ecstasy)	5.7	7.1	0.0	0.642	21.4 (3/14)
Hallucinogen (e.g. LSD)	1.9	0.0	0.0	1.000	12.5 (1/8)
Marijuana	4.4	5.7	3.7	0.848	31.6 (6/19)
Cocaine	4.0	3.8	0.0	1.000	11.1 (1/9)
Sexual practices and infection
Over 10 partners (past three months)	15.5	4.1	6.3	<0.001	17.9 (5/28)
Unprotected vaginal/anal sex with a partner of unknown or HIV-positive status (past six months)	49.8	55.8	51.6	0.383	75.0 (21/28)
Unprotected sex with a partner from an HIV-endemic country (ever)	10.3	27.9	33.3	<0.001	11.5 (3/26)
Sold sex for money, drugs, goods or services (ever)	7.6	16.1	6.3	0.026	27.3 (3/11)
No past STI test (not including HIV)	5.9	5.4	10.9	0.236	3.6 (1/28)
STI (past 12 months)	14.0	12.2	18.8	0.434	17.9 (5/28)
HIV testing and prevention
No past HIV-test	5.5	5.4	9.4	0.421	3.6 (1/28)
Percent rapidly tested at AsR with a positive test	2.2	0.0	0.0	0.795	–
No knowledge^a of PEP	33.3	76.7	47.6	<0.001	28.0 (7/25)
Used PEP for unprotected anal/vaginal sex (ever)	14.1	1.4	6.5	<0.001	36.0 (9/25)
No knowledge^a of PrEP	69.0	94.4	83.6	<0.001	72.0 (18/25)

MSM: men who have sex with men; CAD: Canadian dollars; STI: sexually transmitted infection; PEP: post-exposure prophylaxis; PrEP: pre-exposure prophylaxis.

Answering ‘no’ or ‘I don’t know’ to this question: ‘Have you ever heard of [PEP/PrEP]?’ which was followed by a definition of the prevention strategy.

Using data collected over the same period, we also provide descriptive statistics on some of AsR’s activities, namely, the number of: clients, visits, HIV tests conducted, persons tested for HIV, tested clients who had never previously been tested for HIV, and positive rapid tests. Finally, we present the characteristics of individuals who received a positive rapid test.

Results

Over the study period, AsR received 1901 clients. The three groups compared were created with the 1636 clients who filled out all data collection tools and based on their reported sex and that of their partners. For the comparative analyses, we excluded 41 persons identified as transgendered, as their sexual identity as male or female was not recorded; two men reporting transsexual partners; 10 men who did not specify the sex of their partners and 15 respondents for missing data. Among the remaining 1568, 1357 (86.5%) were classified as MSM (male sex, male partners), 147 (9.4%) as heterosexual men (male sex, female partners only) and 64 (4.1%) as women (female sex).

Group comparisons

Table 1 presents the results of the three-group comparisons. Significant differences were observed in socio-demographics. MSM and heterosexual men included a greater proportion of individuals in their 50s or older (16–15%) than women. On education, heterosexual men contained proportionately more people with a high school degree or less (32%) than the other groups. The MSM group included the smallest proportion of immigrants (19%). Lastly, having an income below 20,000 CAD was most common among women (48%) and least so among MSM.

Significant results were also found on measures of general health. Reporting less than ‘good’ health was most prevalent among heterosexual men (12%) and least so among MSM (6%), while having no regular physician was especially reported by women (42%), followed by heterosexual men (27%) and MSM (20%). Significant results on drug use include current use of inhaled drugs, which was almost exclusively reported by MSM (30%) and current use of opiates, indicated by 3% of heterosexual men, 2% of MSM and no women.

On sexual practices and infection, reporting over 10 partners in the past three months was most common among MSM (16%). Significant group differences also emerged in ever having unprotected sex with a partner from an HIV-endemic country, reported by proportionately more women (33%) and heterosexual men (28%) than MSM, and finally in selling sex, reported to a greater extent by heterosexual men (16%) than by MSM and women.

In terms of HIV testing and prevention, significant group differences were revealed in past use of post-exposure prophylaxis (PEP) and having no knowledge of both PEP and pre-exposure prophylaxis (PrEP). Having no knowledge of these prevention strategies was least common in MSM and most so among heterosexual men. However, the greater majority of each group had no knowledge of PrEP (69–94%) and considerable proportions of each group did not know about PEP (33–77%). Finally, PEP use was reported by more MSM (14%) than the other groups.

Central AsR activities and characteristics of positive rapid-testers

Over the study period, AsR received 1901 different clients, had 2159 visits, conducted 1913 HIV tests (1417 rapid; 496 standard), on 1406 individuals (rapid test only: 926 [65.9%]; standard test only: 95 [6.8%]; both: 385 [27.4%]). Among tested individuals, 77 (5.5%) had never been tested and 28 (2.1%) had reactive (positive) rapid tests. Most notable among the characteristics of those receiving a positive rapid test was a history of PEP for unprotected intercourse in over a third and past HIV testing in all but one individual (see Table 1).

Discussion

This study examined key clienteles and activities of a Montreal HIV-checkpoint and thus provides rare Canadian data on the outcomes of such services and characteristics of its users. Its significant results suggest contrasting vulnerability profiles between MSM, heterosexual male and female clients of AsR. MSM were characterised by greater inhaled drug use, numbers of sexual partners and PEP use and all positive rapid HIV-test results occurred in this group. Heterosexual men contained the highest proportions of clients reporting a high school degree or less, an immigrant status, less than good health, opiate drug use, selling sex and lack of knowledge of both PEP and PrEP. Disproportionately, women were younger, reported a low income, had no regular doctor and had unprotected sex with a partner from a HIV-endemic country.

Our findings suggest that exposure to HIV was greatest among MSM clients, reinforcing the need to ensure their access to timely sexual health and preventive services. Despite similar proportions of each group reporting unprotected intercourse with a partner of unknown or HIV-positive status (50–56%), the absence of knowledge of PEP among most heterosexual men (77%), suggests more could be done to inform about this option and PrEP, particularly since 16% have engaged in sex work. Knowledge of PrEP, overall, was low, even among MSM, where it was highest at 31%. Among women clients, the large proportion without a regular doctor (42%) was alarming and considerably above Canadian national probability estimates reported by Tjepkema,⁹ which ranged from 12 to 24%, depending on women’s sexual orientation. Interestingly, the proportions for men in the same study (22–26%) were comparable to our own (20–27%). This suggests that comprehensive linkage-to-care at rapid testing sites could help increase women’s access to health services in general. Women’s reasons for visiting AsR may differ from those of men and this will be explored in a future publication.

AsR activity rates indicate that 69% of clients were judged eligible for and received rapid HIV testing, 6% of those who received a HIV test had never previously been tested and 2% of rapid tests were reactive, which is high. For example, a 1% preliminary positive rate based on 17,029 point-of-care tests was observed in British Columbia, and the highest site-specific positivity rates did not surpass 2%.¹⁸ AsR can therefore be considered to reach at-risk individuals.

The data on those who received a reactive rapid test – 96% had previously tested for HIV, 36% had past PEP use, 72% had no knowledge of PrEP, 36% had no knowledge of PEP – suggest that HIV prevention and education opportunities were lost or ineffectual despite past contacts with sexual health providers.

Conclusion

Overall, this study’s results highlight AsR’s diverse client vulnerability profiles, the relevance of checkpoints, and the need for further HIV prevention efforts, including education about biomedical prevention options, which could be done in rapid testing sites.

Footnotes

Authors’ contributions

BL and RT designed the Actuel sur Rue intervention study. BL, DL and KE developed the data collection tools. DL participated in data acquisition. KE planned the analyses and wrote and revised the manuscript. KR conducted the statistical analyses. BL, KR, DL and RT commented the manuscript.

Acknowledgements

The authors warmly thank the study participants of Actuel sur Rue and its staff.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for Actuel sur Rue was provided by Clinique médicale l’Actuel.

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