Devon Haag

Get Checked… Where? The Development of a Comprehensive, Integrated Internet-Based Testing Program for Sexually Transmitted and Blood-Borne Infections in British Columbia, Canada.

Background Testing for sexually transmitted and blood-borne infections (STBBI) is an effective public health strategy that can promote personal control of one’s health and prevent the spread of these infections. Multiple barriers deter access to testing including fear of stigmatization, inaccurate health care provider perceptions of risk, and reduced availability of clinic services and infrastructure. Concurrent increases in sexually transmitted infection (STI) rates and demands on existing clinical services make this an even more pressing concern. Web-based testing offers several advantages that may alleviate existing clinical pressures and facilitate appropriate testing access. Objective This paper describes the planning, development, and usability testing of a novel Web-based testing service, GetCheckedOnline (GCO), as a complementary testing option integrated within existing sexual health services within British Columbia (BC). Methods From 2009 to 2014, we engaged a multidisciplinary team in the design and development of GCO. We conducted 3 initial research studies to ascertain the opinions of youth, men who have sex with men (MSM), and STI clinic clients regarding Web-based testing and elicited perspectives of sexual health care providers through focus groups. We developed an informed consent process, risk assessment questions, and test recommendations based on provincial and national guidelines and evaluated these through consultations with clinical and community stakeholders. We also conducted a preliminary health equity impact assessment whose findings also informed the GCO program mode. Finally, from April 2011 to December 2012 we gathered qualitative data from 25 participants on the functionality and usability of a GCO prototype and incorporated their recommendations into a final model. Results GCO launched in the fall of 2014 across 6 pilot sites in Vancouver, BC. The service involves 3 main steps: (1) create an account, complete an assessment, and print a laboratory requisition, (2) provide blood and urine specimens at participating laboratory locations, and (3) receive test results on the Internet or by phone. During this pilot phase, we promoted GCO to existing STI clinic clients and MSM in the Greater Vancouver region. A rigorous mixed-method evaluation of GCO’s uptake, acceptability, and health system impacts is currently underway. Conclusions GCO is the first comprehensive Web-based STBBI testing program in Canada that is integrated with existing sexual health services, with the potential to reduce pressures on existing clinical services and reach populations facing the greatest barriers to testing. Our experience highlights the facilitators and challenges of developing and implementing novel complex eHealth interventions within the health care system, and underscores the importance of considering broader implementation contexts.

Use of GetCheckedOnline, a Comprehensive Web-based Testing Service for Sexually Transmitted and Blood-Borne Infections

Background The British Columbia Centre for Disease Control implemented a comprehensive Web-based testing service GetCheckedOnline (GCO) in September 2014 in Vancouver, Canada. GCO’s objectives are to increase testing for sexually transmitted and blood-borne infections (STBBIs), reach high-prevalence populations facing testing barriers, and increase clinical STI service capacity. GCO was promoted through email invitations to provincial STI clinic clients, access codes to clients unable to access immediate clinic-based testing (deferred testers), and a campaign to gay, bisexual, and other men who have sex with men (MSM). Objective The objective of the study was to report on characteristics of GCO users, use and test outcomes (overall and by promotional strategy) during this pilot phase. Methods We used GCO program data, website metrics, and provincial STI clinic records to describe temporal trends, progression through the service pathway, and demographic, risk, and testing outcomes for individuals creating GCO accounts during the first 15 months of implementation. Results Of 868 clients creating accounts, 318 (36.6%) submitted specimens, of whom 96 (30.2%) tested more than once and 10 (3.1%) had a positive STI diagnosis. The proportion of clients submitting specimens increased steadily over the course of the pilot phase following introduction of deferred tester codes. Clients were diverse with respect to age, gender, and ethnicity, although youth and individuals of nonwhite ethnicity were underrepresented. Of the 506 clients completing risk assessments, 215 (42.5%) were MSM, 89 (17.6%) were symptomatic, 47 (9.3%) were STI contacts, 232 (45.8%) reported condomless sex, 146 (28.9%) reported ≥4 partners in the past 3 months, and 76 (15.0%) reported a recent STI. A total of 63 (12.5%) GCO clients were testing for the first time. For 868 accounts created, 337 (38.8%) were by clinic invitations (0 diagnoses), 298 (34.3%) were by deferred testers (6 diagnoses), 194 (22.4%) were by promotional campaign (3 diagnoses), and 39 (4.5%) were by other means (1 diagnosis). Conclusions Our evaluation suggests that GCO is an acceptable and feasible approach to engage individuals in testing. Use by first-time testers, repeated use, and STI diagnosis of individuals unable to access immediate clinic-based testing suggest GCO may facilitate uptake of STBBI testing and earlier diagnosis. Use by MSM and individuals reporting sexual risk suggests GCO may reach populations with a higher risk of STI. Motivation to test (eg, unable to access clinical services immediately) appears a key factor underlying GCO use. These findings identify areas for refinement of the testing model, further promotion, and future research (including understanding reasons for drop-off through the service pathway and more comprehensive evaluation of effectiveness). Increased uptake and diagnosis corresponding with expansion of the service within British Columbia will permit future evaluation of this service across varying populations and settings.

Towards targeted screening for acute HIV infections in British Columbia

BackgroundOur objective was to describe the characteristics of acute and established HIV infections diagnosed in the Canadian province of British Columbia. Province-wide HIV testing and surveillance data were analyzed to inform recommendations for targeted use of screening algorithms to detect acute HIV infections.MethodsAcute HIV infection was defined as a confirmed reactive HIV p24 antigen test (or HIV nucleic acid test), a non-reactive or reactive HIV EIA screening test and a non-reactive or indeterminate Western Blot. Characteristics of unique individuals were identified from the British Columbia HIV/AIDS Surveillance System. Primary drug resistance and HIV subtypes were identified by analyzing HIV pol sequences from residual sera from newly infected individuals.ResultsFrom February 2006 to October 2008, 61 individuals met the acute HIV infection case definition, representing 6.2% of the 987 newly diagnosed HIV infections during the analysis period. Acute HIV infection cases were more likely to be men who have sex with men (crude OR 1.71; 95% CI 1.01-2.89], to have had a documented previous negative HIV test result (crude OR 2.89; 95% CI 1.52-5.51), and to have reported a reason for testing due to suspected seroconversion symptoms (crude OR 5.16; 95% CI 2.88-9.23). HIV subtypes and rates of transmitted drug resistance across all classes of drugs were similar in persons with both acute and established HIV infections.ConclusionsTargeted screening to detect acute HIV infection is a logical public health response to the HIV epidemic. Our findings suggest that acute HIV infection screening strategies, in our setting, are helpful for early diagnosis in men who have sex with men, in persons with seroconversion symptoms and in previously negative repeat testers.

Examining E-Loyalty in a Sexual Health Website: Cross-Sectional Study

Background Web-based sexual health resources are typically evaluated in terms of their efficacy. Information is lacking about how sexual health promotion websites are perceived and used. It is essential to understand website use to address challenges with adherence and attrition to Web-based health interventions. An existing theoretical framework for examining loyalty to electronic health (eHealth) interventions has been not yet been applied in the context of sexual health promotion nor has the association between e-loyalty and intended intervention efficacy outcomes been investigated. Objective The objectives of this study were to investigate users’ loyalty toward a sexual health website (ie, e-loyalty), measure user perceptions of the website, and measure the association between e-loyalty and perceived knowledge increase and intent to change behavior. Methods Over 4 months, website users (clients and health care providers) participated in an open, online, cross-sectional survey about their user experiences that measured e-loyalty, user perceptions, and intended website efficacy outcomes. Relationships between user perceptions and e-loyalty were investigated using structural equation modeling (SEM). Associations between e-loyalty and website efficacy outcomes were tested using Spearman rank correlation. Results A total of 173 participants completed user perception questions and were included in the analysis. E-loyalty was high for both clients and providers and was significantly correlated with clients’ perceived knowledge increase (ρ(171)=.30, P<.001), their intent to have safer sex (ρ(171)=.24, P=.01), and their intent to get tested for sexually transmitted infections (ρ(171)=.37, P<.001). The SEM showed that trustworthiness, overall experience, active trust, and effectiveness were directly related to e-loyalty. Finding the website “easy to understand” was significantly related to active trust (ie, participants’ willingness to act upon information presented on the website). Conclusions E-loyalty may be related to the efficacy of the selected website in improving one’s sexual health and was significantly associated with all three intended knowledge and behavioral outcomes. To increase e-loyalty, trustworthiness and active trust are important user perceptions to deliberately engender. Our findings indicate that understanding a website contributes to active trust, thereby highlighting the importance of considering eHealth literacy in designing health promotion websites. Our study confirms the relevance of e-loyalty as an outcome for evaluating the antecedents of the use and efficacy of online public health interventions across disciplines by adapting and validating an existing e-loyalty framework to the field of sexual health promotion. Our findings suggest that e-loyalty is positively associated with measures of website efficacy, including increased knowledge and intent to change behavior. Longitudinal research with larger samples could further investigate the relationships between e-loyalty, website understandability, and outcomes of online health interventions to determine how the manipulation of website characteristics may impact user perceptions and e-loyalty.

Click yes to consent: Acceptability of incorporating informed consent into an internet-based testing program for sexually transmitted and blood-borne infections

BACKGROUND Autonomous use of online health care services without interaction with a health care provider challenges existing models for achieving informed consent (IC); current examinations of this issue have focused on commercial direct-to-consumer genetic testing. As IC is integral to publicly funded clinical testing services, we incorporated pre-test concepts necessary for IC in GetCheckedOnline (GCO), British Columbias online sexually transmitted and blood-borne infection (STBBI) testing service. OBJECTIVE We assessed the acceptability of this IC step and its design options among potential users during usability testing of GCO. METHODS English-speaking participants≥19years were recruited from Craigslist and among provincial STI clinic clients for usability testing of an early version of GCO, which included a consent webpage presenting 8 pre-test statements for review prior to completing testing. Participants were interviewed regarding their acceptability, perceptions, and understanding of the consent page; transcripts were analyzed thematically. RESULTS We conducted 13 interviews (9 males, 4 females; 9 self-identified as heterosexual; all had previously tested for STBBI). We identified three main themes: i) the meaning of IC (consent page viewed as important and for protection of individual and organization; participants demonstrated varying understandings of specific components); ii) the impact of previous experience on understanding IC (participants understood difference between online and in-person testing; IC concepts were better understood by participants with more testing experience); iii) the role of website design on achieving IC (design of page to disrupt speedy click-throughs was valued and demonstrated seriousness of the consent page). CONCLUSIONS Our careful attention to both content and design of the consent page of GCO was highly valued by potential users of the service, and effective in disrupting routinization of consent on websites. We argue that principles of IC apply equally in online self-testing programs as in clinical practice, and can be effectively achieved without detracting from the user experience.

Differences in experiences of barriers to STI testing between clients of the internet-based diagnostic testing service GetCheckedOnline.com and an STI clinic in Vancouver, Canada

Objectives Internet-based STI testing programmes may overcome barriers posed by in-clinic testing, though uptake could reflect social gradients. The role these services play in comparison to clinical testing services is unknown. We compared experiences of testing barriers between STI clinic clients to clients of GetCheckedOnline.com (GCO; where clients take a printed lab form to a lab). Methods Our 10-month cross-sectional study was conducted after GCO was promoted to STI clinic clients and men who have sex with men (MSM). Clinic and GCO clients completed an online survey assessing testing barriers and facilitators; responses were compared using bivariate analysis (level of significance P<0.01; significant results below). Results Compared with 321 clinic clients, the 73 GCO clients were more likely to be older (median 35 vs 30 years), MSM (45% vs 16%), be testing routinely (67% vs 39%), have delayed testing for any reason (76% vs 54%) and due to clinic distance (28% vs 9%), report delays due to wait times (50% vs 17%), embarrassment with testing (16% vs 6%), discomfort discussing sexual health where they usually go for testing (39% vs 22%), as well as discomfort discussing sexual history with (19% vs 5%) and fearing judgement from (30% vs 15%) any healthcare provider. GCO clients were less likely to have found clinic hours convenient (59% vs 77%) and clinic appointments easy to make (49% vs 66%), and more likely to report long wait times (50% vs 17%). We found no differences in technology skills/use. Conclusions In this urban setting, an internet-based testing service effectively engaged individuals experiencing testing barriers, with few social gradients in uptake. While some testing barriers could be addressed through increasing access to clinical services, others require social and structural changes, highlighting the importance of internet-based STI testing services to increasing test uptake.

Linking ad views to test results: Assessing the impact of a social marketing campaign on program outcomes for users of an internet-based testing service for sexually transmitted and blood-borne infections (Preprint)

Background While social marketing (SM) campaigns can be effective in increasing testing for sexually transmitted and blood-borne infections (STBBIs), they are seldom rigorously evaluated and often rely on process measures (eg, Web-based ad click-throughs). With Web-based campaigns for internet-based health services, there is a potential to connect campaign process measures to program outcomes, permitting the assessment of venue-specific yield based on health outcomes (eg, click-throughs per test). Objective This study aims to evaluate the impact of an SM campaign by the promotional venue on use and diagnostic test results of the internet-based STBBI testing service GetCheckedOnline.com (GCO). Methods Through GCO, clients create an account using an access code, complete a risk assessment, print a lab form, submit specimens at a lab, and get results online or by phone. From April to August 2015, a campaign promoted GCO to gay, bisexual, and other men who have sex with men in Vancouver, Canada. The campaign highlighted GCO’s convenience in 3 types of promotional venues—location advertisements in print or video displayed in gay venues or events, ads on a queer news website, and ads on geosocial websites and apps. Where feasible, individuals were tracked from campaign exposures to account creation and testing using venue-specific GCO access codes. In addition, Web-based ads were linked to alternate versions of the campaign website, which used URLs with embedded access codes to connect ad exposure to account creation. Furthermore, we examined the number of individuals creating GCO accounts, number tested, and cost per account created and test for each venue type. Results Over 6 months, 177 people created a GCO account because of the campaign, where 22.0% (39/177) of these completed testing; the overall cost was Can

Anticipating the potential for positive uptake and adaptation in the implementation of a publicly funded online STBBI testing service: a qualitative analysis

118 per account created and Can

P2.27 High satisfaction with and loyalty to getcheckedonline.com among first-time users of an online sti testing service in british columbia, canada

533 per test. Ads on geosocial websites and apps accounted for 46.9% (83/177) of all accounts; ads on the news website had the lowest testing rate and highest cost per test. We observed variation between different geosocial websites and apps with some ads having high click-through rates yet low GCO account creation rates, and vice versa. Conclusions Developing mechanisms to track individuals from Web-based exposure to SM campaigns to outcomes of internet-based health services permits greater evaluation of the yield and cost-effectiveness of different promotional efforts. Web-based ads with high click-through rates may not have a high conversion to service use, the ultimate outcome of SM campaigns.

P2.44 No differences in knowledge of key hiv test concepts between users of an online sti testing service (getcheckedonline.com) and in-clinic testers in vancouver, canada

BackgroundOnline health services are a rapidly growing aspect of public health provision, including testing for sexually transmitted and other blood-borne infections (STBBI). Generally, healthcare providers, policymakers, and clients imbue online approaches with great positive potential (e.g., encouraging clients’ agency; providing cost-effective services to more clients). However, the promise of online health services may vary across contexts and be perceived in negative or ambiguous ways (e.g., risks to ‘gold standard’ care provision; loss of provider control over an intervention; uncertainty related to budget implications). This study examines attitudes and perceptions regarding the development of a novel online STBBI testing service in Vancouver, Canada. We examine the perceptions about the intervention’s potential by interviewing practitioners and planners who were engaged in the development and initial implementation of this testing service.MethodsWe conducted in-depth interviews with 37 healthcare providers, administrators, policymakers, and community-based service providers engaged in the design and launch of the new online STBBI testing service. We also conducted observations during planning and implementation meetings for the new service. Thematic analysis techniques were employed to identify codes and broader discursive themes across the interview transcripts and observation notes.ResultsSome study participants expressed concern that the potential popularity of the new testing service might increase demand on existing sexual health services or become fiscally unsustainable. However, most participants regarded the new service as having the potential to improve STBBI testing in several ways, including reducing waiting times, enhancing privacy and confidentiality, appealing to more tech-savvy sub-populations, optimizing the redistribution of demands on face-to-face service provision, and providing patient-centred technology to empower clients to seek testing.ConclusionsParticipants perceived this online STBBI testing service to have the potential to improve sexual health care provision. But, they also anticipated actions-and-reactions, revealing a need to monitor ongoing implementation dynamics. They also identified the larger, potentially system-transforming dimension of the new technology, which enables new system drivers (consumers) and reduces the amount of control health care providers have over online STBBI testing compared to conventional in-person testing.