Troy Grennan

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.

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

Confronting comorbidity risks within HIV biographies: gay men’s integration of HPV-associated anal cancer risk into their narratives of living with HIV

118 per account created and Can

O13.5 Core groups of individuals with chlamydia and/or gonorrhoea reinfections have increased odds of diagnosis with infectious syphilis: a population-based retrospective cohort study in british columbia, canada, 2006–2015

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.

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

HPV-associated anal cancer is one of the most prevalent non-AIDS defining cancers affecting gay men living with HIV. Drawing on interviews with 25 HIV-positive gay men living in Toronto in 2017, we explored their responses to anal cancer as a comorbidity risk and the necessity of preventative screening. These participants had previously been screened for anal cancer through a clinical trial. The majority of our sample did not initially consider anal cancer a health priority. They relied on narratives of living with HIV – that is, on their HIV biographies – to make sense of anal cancer’s significance given their self-described lack of knowledge. This included references to personal-level narratives of the biographical disruption and revision associated with a HIV diagnosis, as well as reflections on community-level and socio-historical trends in the HIV epidemic. Drawing on these narratives, some started to accept anal cancer as a significant comorbidity risk, while others remained ambivalent. Those who began to accept anal cancer as significant integrated it into their HIV biographies to present anal cancer as a threat to the ontological security they have gained managing HIV in an era of effective treatment and to position themselves as pragmatic, responsible health-seekers. Others drew on their HIV biographies to vocalise resistance to chronic risk and medicalisation. Our analysis points to the fundamental role narratives play on everyday risk perception practices, health decision-making and, for those managing a chronic illness, on securing ontological security and presenting a coherent self-identity under conditions of expanding risks and prevention possibilities.

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

Introduction The incidence of infectious syphilis (primary, secondary, or early latent) has increased in British Columbia (BC). Identifying core groups at risk for syphilis can inform public health programming. We assessed the odds of syphilis infection among individuals with repeat Chlamydia trachomatis (CT) and/or Neisseria gonorrhoeae (GC) infections in this population-based analysis. Methods Surveillance records for all BC residents diagnosed with ≥2 CT (CT reinfection) or ≥2 GC (GC reinfection) or ≥2 infections including CT and GC (CT/GC reinfection) from 1/1/2006 to 12/31/2015 were linked with all infectious syphilis cases from the same time period. Logistic regression models were used to measure the odds of acquiring syphilis with greater number of CT and/or GC reinfections, adjusted for age, ethnicity and population (e.g., men who have sex with men). Results Of 1 03 115 people having a CT infection, 11 458 (11.1%) had CT reinfection; of 14 713 people with a GC infection, 1514 (10.3%) had GC reinfection. Overall, 4989 individuals had CT/GC reinfection. Among these three re-infection groups (CT, GC, CT/GC), 80.9%/72.9%/63% had 2 infections, 14.4%/15.9%/19.5% had 3 infections, 3.2%/6.1%/8.9% had 4 infections and 1.6%/5.1%/8.6% had 5+ infections. Of all syphilis cases in BC, 7.4%/9.4%/12.3% were diagnosed among individuals with CT reinfection, GC reinfection and CT/GC reinfection. The odds of syphilis increased with greater number of infections, which persisted after adjustment in all three groups. Among the group with CT/GC reinfection, individuals with 3, 4 and 5+ infections had increased odds of syphilis compared to individuals with 2 infections (OR=2.2 (95%CI 1.6, 3.0), OR=2.5 (95%CI 1.7, 3.6) and OR=4.1 (95%CI 3.0, 5.7) respectively). Conclusion Increasing number of CT and/or GC reinfections is strongly and independently associated with a syphilis diagnosis. Targeting public health interventions to a core group of individuals with CT/GC reinfections may be an effective syphilis prevention strategy.

P3.104 Lymphogranuloma Venereum: a descriptive study of the epidemiology and risk factors in british columbia, canada

Introduction Positive user experiences are key to trust and repeated use of online services (known as e-Loyalty). GetCheckedOnline (GCO) is an online testing service for HIV/STI where clients complete a risk assessment, print lab forms, submit specimens at a lab, and retrieve results online (if negative) or by phone. We surveyed GCO clients on their perceptions of using the service. Methods We invited first-time GCO users (who consented to be contacted for research) to complete an anonymous online survey 2 weeks following reporting of test results. Survey questions were analysed descriptively and included demographics, reason for test, and how participants heard about GCO. Satisfaction, convenience, ease of use, and e-Loyalty (intention to use again, recommend to others) were measured using 5-point Likert scales and collapsed (low to neutral vs high responses). Results Between July 2015-Sept 2016, 23% of 1099 first-time GCO users consented to be contacted for research and 136/208 (65%) of users contacted agreed to participate in the survey. Participants had a median age of 33 years, 80% were white, 67% male, 43% straight, and 43% men who have sex with men. The most common testing reasons were: routine test (64%), risk event/exposure (44%) and new relationship (22%). Participants heard about GCO from clinics/health providers (38%), campaigns (26%), social media (18%), and friends or partners (13%). Almost all participants were satisfied with GCO overall (93%) and with their experience of receiving results (96%), 92% agreed GCO was convenient, 87% found GCO easy to use, and 83% rated the experience of submitting specimens as good or excellent. E-Loyalty was also high: 97% intended to use GCO again and 96% would recommend GCO to others. Conclusion We found very high satisfaction with and loyalty to GCO among first-time users, indicating a successful service model from a client perspective. In addition to uptake and test outcomes, user experience is a key outcome for evaluation of online HIV/STI testing services.

P3.82 An upward trend in ocular syphilis cases in british columbia, canada, 2013–2016: a descriptive analysis

Introduction Online HIV/STI testing is an alternative to in-clinic testing, but may lead to missed opportunities for education due to the lack of provider-delivered pre/post-test counselling. GetCheckedOnline (GCO) is an online testing service offered through an urban STI clinic in Vancouver. It was designed to include concepts typically conveyed during in-clinic HIV counselling sessions (e.g., window period, public health reporting). The aim of this study was to compare knowledge of key HIV test concepts between clients testing through GCO and in-clinic. Methods GCO and clinic participants were concurrently recruited over 11 months. Participants were invited to complete an anonymous online survey 2 weeks after receipt of test results. Knowledge of key concepts related to HIV testing was measured using a 6-item true/false test previously developed through a modified Delphi process, cognitive testing and psychometric evaluation. Linear regression was used to assess the association between site (GCO vs. clinic) and overall test scores, after adjustment for age, education, immigration history, language, sexual orientation, and testing history. Results 404 HIV-negative participants were included in the analysis (73 GCO, 331 in-clinic). HIV test knowledge scores averaged 0.4 points higher among GCO (mean score 4.5) than among clinic (4.1) testers (p=0.01). Following adjustment for relevant covariates, this difference decreased to 0.2 points (p=0.15). Likewise, there was no difference in mean HIV test knowledge scores among first-time testers (n=50; 3.7 GCO, 3.6 in-clinic; p=0.75). Conclusion Post-test knowledge of HIV test concepts addressed in standard pre-test counselling was high in both groups and not significantly different following adjustment. Our study suggests that equivalent education about core HIV testing concepts can be achieved through web-based HIV/STI testing, and illustrates the importance of designing services to intentionally address relevant educational messages covered in provider-delivered HIV test counselling.

P4.113 Reach and acceptability of an online hiv/sti testing service (getcheckedonline) among gay, bisexual, and other men who have sex with men living in british columbia, canada

Introduction Lymphogranuloma venereum (LGV) continues to be difficult to diagnose and can lead to significant sequelae. Since 2011, all rectal specimens testing positive for Chlamydia trachomatis were tested for LGV serovars, leading to a greater number of LGV cases (mean, 21 cases/year for 2011–2014). In 2015, case reports of LGV doubled to 42 cases. We sought to characterise LGV cases reported in BC since 2011, and assess possible reasons for the 2015 increase. Methods Demographic and behavioural information about all LGV cases reported in BC from January 1, 2011 to December 31, 2015 were identified. Provincial laboratory data were reviewed for potentially missed cases. LGV cases were categorised by reporting year (i.e., 2011–2014 and 2015) and analysed using the chi-square test or Fisher’s exact test. LGV percent positivity was calculated as the number of LGV cases over the number of positive rectal chlamydia. Results From 2011–2014, 83 cases were reported versus 42 in 2015. All were among men who have sex with men (MSM). The median age for cases was 46 years and 44 years for 2011–2014 and 2015, respectively (p=0.26). HIV co-infection was similar in both periods (54/83 in 2011–2014, 25/42 in 2015, p=0.61). Of those known to be co-infected with HIV, the majority had undetectable viral loads (34/54 in 2011–2014 and 18/25 in 2015). There was a decrease in the proportion of cases who identified as Caucasian from 2011–2014 to 2015 (p=0.004) and an increase in proportion of asymptomatic cases, although not statistically significant (p=0.06). Percent positivity was 7.1% and 7.2% in 2011–2014 and 2015, respectively. Conclusion The similar case characteristics and percent positivity during both periods, and increase in proportion of asymptomatic cases, suggest that increased screening for rectal sexually transmitted infections may be the reason for the observed increase in LGV cases. Further evaluation is needed to understand LGV trends, particularly among HIV-positive MSM who are disproportionately affected by LGV.