Understanding barriers and facilitators to HIV testing in Canada from 2009–2019: A systematic mixed studies review

Background: HIV testing is a core pillar of Canada’s approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed. Objective: To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada. Methods: A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized. Results: Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices. Conclusion: Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations. Affiliation 1 Public Health Agency of Canada, Health Security and Infrastructure Branch, Public Health Capacity and Knowledge Management Unit, Québec Regional Office; Montréal, QC


Introduction
The World Health Organization estimated that approximately 37.9 million people were living with HIV/AIDS worldwide in 2018, including about 1.7 million who were newly infected that year (1).
In Canada, more than 63,000 people were living with HIV in 2016, and nearly 23,000 new cases were diagnosed between 2008 and 2017 (2).
HIV testing and diagnosis is a critical first step in the HIV care cascade (HIV diagnosis, linkage to care, antiretroviral therapy initiation and achievement of viral suppression). For people living with HIV who know their status, receiving appropriate treatment reduces the long-term impact of the disease and prevents further transmission (3).
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Programme Coordinating Board established the 90-90-90 targets with the goal of ending the AIDS epidemic by 2020. The aim of these targets are for 90% of all people living with HIV to know their HIV status, 90% of all people diagnosed with HIV to receive appropriate antiretroviral therapy (ART) and 90% of all people receiving ART to achieve viral suppression (4, 5). Canada has yet to achieve the first of these targets, and an estimated 14% of Canadians living with HIV in 2016 were unaware of their status (2).
Although HIV testing coverage in Canada continues to expand, testing rates vary considerably across Canada (6). Regional testing rates may be influenced by jurisdictional policies and programs determining accessibility of testing and the types of testing available (e.g. point-of-care testing) (7). Certain populations are also known to be disproportionately affected by HIV, including gay, bisexual and other men who have sex with men (gbMSM), transgender individuals, people who inject drugs (PWID) and sex workers (8)(9)(10)(11)(12). Owing to the intersection of stigma, discrimination and social determinants of health, these populations are often marginalized and underserved, leading to greater likelihood of HIV acquisition and transmission, and limited access to and uptake of testing (13,14). The differential distribution of these populations across Canada may contribute to regional variation in HIV testing (2).
A comprehensive overview of the barriers and facilitators of HIV testing that exist across key populations and jurisdictional boundaries in the current Canadian context is currently lacking. This knowledge is essential to orient public health policies and action toward the undiagnosed and mitigate the health impact of HIV in Canada. Two reviews describe the barriers and facilitators to HIV testing in the Canadian context (7,15) and identified many barriers and facilitators to testing at the level of the individual (e.g. low risk perception, fear), healthcare provider (e.g. time constraints, insufficient resources) and institution/policy (e.g. cost/accessibility of testing) (7, [15][16][17]. However, these reviews were not systematic, do not cover the last decade and did not examine trends in HIV testing in key populations and in specific jurisdictions. Moreover, few studies conducted in Canada were identified in these reviews.
The objective of this systematic mixed studies review is to examine the barriers and facilitators to HIV testing that have been reported across populations and jurisdictions in Canada throughout the last decade and to conduct a narrative synthesis of identified works.

Search strategy
A systematic mixed studies review was conducted (18) of barriers and facilitators to HIV testing in Canada in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (19) (appendix available upon request). Based on a pre-specified protocol and in collaboration with information specialists, the reviewers developed an electronic search strategy to identify original quantitative, qualitative and mixed-methods studies reporting on barriers and facilitators to HIV testing in Canada and published between January 1, 2009 and December 9, 2019 (appendix available upon request). Medline, Embase, PsycInfo, ProQuest Public Health, ProQuest Sociology Collection and Scopus were searched for peer-reviewed publications, and Google and Google Scholar for grey literature, government and non-governmental organization reports, and dissertations. Government webpages from each province/territory were also searched, and partners of regional offices of the Public Health Agency of Canada were consulted to retrieve other relevant works. In addition, the reference lists of included studies were manually searched for relevant publications.

Eligibility criteria
Studies were eligible for inclusion if they were original quantitative and/or qualitative studies reporting on barriers and/or facilitators to HIV testing in one or more Canadian province or territory; published between January 2009 and November 2019; and written in French or English. There were no restrictions in terms of the study sample size, type of study population or the study context/setting. Studies were excluded if they reported barriers and facilitators to testing for multiple sexually transmitted and blood-borne infections (STBBI) without reporting results for HIV separately, or if study data were collected prior to 2009.

Study selection and data collection
Two reviewers independently screened the titles and abstracts of all identified studies. Potentially relevant records were then retrieved for independent full-text review by both reviewers. Disagreements between reviewers at screening and full-text review stages were resolved by consensus.
The two reviewers independently extracted data from included studies using a piloted data extraction form that was created based on a sample of two quantitative and four qualitative studies selected for their high-quality reporting. For all included publications, the study province/territory, study aim(s), study design, population, sample size, data collection method, years of data collection, inclusion/exclusion criteria and basic demographic data of study participants including the age, sex or gender, sexual orientation and race/ethnicity were extracted. For quantitative studies, the analytical method, study exposure(s), outcome(s), covariates and main effect measures of CCDR • February 2021 • Vol. 47 No. 2 identified barriers and facilitators to HIV testing were extracted. For qualitative studies, the analytical method and identified themes pertaining to barriers and facilitators to HIV testing were extracted.

Quality appraisal
Two investigators independently assessed the quality of included works using the Mixed Methods Appraisal Tool (MMAT) (20,21). The MMAT has been validated to critically appraise the methodological quality of studies with diverse designs. The tool includes five questions requiring "yes," "no" or "can't tell" answers. The questions are adapted to each type of study design and assess the appropriateness of the study design for the research question, the likelihood of bias and the appropriateness of measurements and analyses.
Based on the responses to these questions, a five-point quality score was created, assigning one point for each "Yes" response. Studies with four or more "Yes" answers were considered strong in quality, studies with three "Yes" answers were considered moderate in quality and studies with two or fewer "Yes" answers were considered weak in quality. Disagreements in the score assigned by both reviewers were resolved by consensus. No studies were excluded based on their quality, as the objective of this review was to synthesize all available evidence on barriers and facilitators to HIV testing in Canada. (Appendix available upon request).

Data analysis
Barriers were defined as any obstacle or reason given by study participants for declining or being unable to access HIV testing. Conversely, facilitators were defined as any reason that study participants gave for accepting or being able to access an HIV test. Sociodemographic characteristics and behaviours (e.g. age, sex/gender, sexual behaviours) that were associated with decreased or increased HIV testing uptake were considered barriers and facilitators, respectively. To avoid repetition, sociodemographic characteristics that operate both as barriers and facilitators to HIV testing are presented in terms of characteristics associated with increased testing.
Identified barriers and facilitators to HIV testing were analyzed using a convergent qualitative synthesis design in which quantitative data are transformed into qualitative findings (18,22). The results were then integrated using inductive thematic synthesis in which themes are derived from the data without a predefined coding frame. The synthesis was guided by a conceptual framework developed by Deblonde et al. (2010) (17) that categorizes determinants of HIV testing according to the level at which they occur: the individual-level; the healthcare provider-level; and the institutional or policy level. To meet research objectives, an overall synthesis of results was conducted followed by a synthesis by key population and by jurisdiction.

Quality appraisal
Most of the included publications were of strong quality (n=32; 74%), while some were moderate (n=6; 14%) or weak quality (n=5; 12%). (Appendix available upon request). The weakest element in the qualitative studies was a lack of the detail necessary for an evaluation of whether the data substantiated the interpretation of results. The weakest element in the quantitative studies was the risk of non-response bias, which is expected as many of these studies were conducted in hard-toreach populations. The weakest element in the mixed methods studies was a lack of consideration of divergence between qualitative and quantitative results. Abstracts reviewed n=819

Synthesis of results
The following narrative synthesis of results summarizes identified barriers and facilitators overall and by key population and jurisdiction. Sociodemographic characteristics and behaviours associated with HIV testing are presented separately because they represent individual-level drivers of testing uptake rather than external barriers/facilitators. At the level of the healthcare provider, common barriers were identified as HIV-related stigma from healthcare providers (46,57); perception that a patient is at low risk of HIV exposure (6,64); and reluctance/refusal to offer testing for individuals who were not perceived to be at risk (38,58). Many studies reported healthcare providers suggesting an HIV test (25,26,58) and that non-stigmatizing healthcare practices (23,50,51) facilitated testing.

Overview of barriers and facilitators to HIV testing
At the institutional or policy level, the criminalization of certain behaviours (e.g. sex work, drug use, HIV nondisclosure) (23,57) and the lack of resources and adequate healthcare infrastructure in rural and remote regions (28,56,58,62) represent structural barriers to testing. Conversely, policies and institutional practices that increase the accessibility, convenience and confidentiality of testing (e.g. broad range of testing options, reducing wait times, low-cost testing) ( 64). Other common barriers represent particularly significant obstacles to testing for marginalized populations, including stigma relating to behaviours or identities perceived to be associated with HIV (e.g. sexual behaviours, sexual orientation, sex work, injection drug use) (23,24,31,41,46,50,51,56,60,64) and insufficient confidentiality in testing services, including the lack of anonymous testing and concerns about privacy in small or remote communities (23,41,44,47,56,64).
Other barriers were unique to key populations. Legislation that criminalizes HIV nondisclosure and sex work are barriers to testing among gbMSM (36,45,47) and sex workers (23), respectively. In addition, insufficient knowledge about the health-related concerns and needs of certain populations (e.g. gbMSM/transgender identities, sex workers) by healthcare providers is an obstacle to testing in these populations (23,51,56,60). Many populations also face distinct issues of accessibility, such as limited availability of multilingual health services and lack of health insurance among immigrant populations (23,41,60), and geographic barriers to health care in rural and remote Indigenous communities (56).
Despite the diverse contexts of these populations, several common facilitators emerged. Offering HIV testing in a broad range of modalities (e.g. anonymous testing, unsupervised self-testing) and settings (e.g. mobile clinics, point-of-care testing) (23,27,33,56) as well as the integration of members of key populations with lived experience (e.g. peer-delivered post-test counselling, community-based outreach initiatives) (43,56,64) were frequently identified as means to improve the accessibility and acceptability of HIV testing services to key populations.
Finally, some facilitators were uniquely relevant for certain key populations. Healthcare practices that are inclusive and non-stigmatizing were identified as important facilitators by queer and transgender communities (50,51). The availability of translators or multilingual health services facilitated testing for immigrant populations (23). Among the African, Caribbean and Black community, enabling social connections with people living with HIV and educational initiatives focused on navigating cultural silences around HIV facilitated testing (64).

Results by jurisdiction
Identified sociodemographic characteristics associated with HIV testing, and barriers and facilitators to HIV testing are summarized by jurisdiction in Table 3.
Although jurisdictions share many common barriers and facilitators to HIV testing, several trends emerged in particular jurisdictions. Studies conducted in British Colombia highlight the criminalization and stigmatization of sex work and issues related to immigrant status as major barriers to HIV testing (23,24,27). Studies conducted in Ontario feature cultural barriers and issues of stigma and fear of behaviours associated with HIV more prominently than other jurisdictions (38,60,64). Studies conducted in the Atlantic provinces uniquely highlight youth-adapted services as a key facilitator (28,62). Differences in the barriers and facilitators to HIV testing across jurisdictions     were driven primarily by differential presence of key populations across jurisdictions and reflect regional public health priorities.

Discussion
In this systematic mixed studies review, it included results from 43 studies conducted in Canada to document and understand recent and emerging barriers and facilitators to HIV testing in the last decade. The principal motivation was to orient future research and public health action toward reaching the first global HIV target in Canada, taking into consideration key populations and jurisdictional contexts. Another motivation was to identify specific areas for intervention to improve access to HIV testing in a broad range of contexts, including providing accessible, low-cost and convenient testing, ensuring confidentiality, reducing HIV-related stigma, improving education about HIV (e.g. modes of transmission, testing, treatments), normalizing offering HIV testing and integrating testing into routine healthcare practices.  (52), pharmacies (59) and in mobile testing units (26,27). Several innovative testing modalities were also identified: couples voluntary HIV counselling and testing (53), oral swab and oral-self testing (26,49) and peer-delivered post-test counselling (43). Gender-based approaches (28), queer and transgender-competent healthcare providers and adapted interventions and approaches (50), age-adapted education and promotion material, testing sites (e.g. school-based clinics for youth) and youth engagement in the development and implementation of HIV prevention initiatives were also clearly identified as important facilitators (62).
The evidence summarized above highlights the importance of adapting public health policy and programming to the unique contexts of each jurisdiction, including the distribution of key populations and burden of disease. Potential strategies for improving access to HIV testing among key populations include increasing the accessibility of HIV testing by expanding available testing options and promoting health outreach initiatives for hard-to-reach populations. In addition, ensuring inclusive and non-stigmatizing healthcare services and integrating the knowledge of members of these communities are essential to improve the acceptability of HIV testing to key populations.
Policy makers and healthcare providers should also consider the intersectionality of identities and experiences in order to better understand the specific drivers of HIV testing in each population (65). These results underscore the importance of adopting a person-centred approach to HIV testing and the need to reach people where they are.
Many of the barriers and facilitators identified in this review operate at the institutional/policy level, potentially indicating an increased focus on up-stream determinants of HIV testing in the last decade. This recent trend underscores the importance of public health action at the systemic level and suggests that HIV testing initiatives could be enhanced by leveraging the expertise of a range of stakeholders including community partners, primary health care, harm reduction services and public health authorities. Expanding intersectoral partnership and collaboration may offer important opportunities to bridge testing gaps and ensure equitable access to HIV testing.
The Pan-Canadian Framework recognizes the importance of testing in achieving global STBBI targets and outlines specific opportunities for action that align with the facilitators identified in this review (66). As outlined in the Government of Canada STBBI action plan (67), improving access to STBBI testing is a core component of a coordinated approach to reducing the impact of STBBI in Canada, with a particular focus on populations that are disproportionately affected by STBBI. This review contributes to existing knowledge of the drivers of HIV testing in Canada and highlights several important gaps and opportunities that can be used to inform public health action toward this goal.

Strengths and limitations
A major strength of this work is the systematic mixed studies review design, which synthesizes quantitative and qualitative data in order to answer complex research questions such as the identification of determinants of HIV testing (18). The inclusion of multiple forms of evidence creates a rich synthesis of extant barriers and facilitators by combining diverse perspectives (i.e. population-level data and individual experiences) and produces results that are directly relevant to decision-makers (22). In addition, the broad scope allows for the identification of emerging and lesser known barriers and facilitators, as well as population and jurisdiction-specific trends in HIV testing in Canada, informing targeted public health action (68).
Nevertheless, this review has limitations. It is possible that some relevant works were not identified by our search strategy and so certain barriers/facilitators may be absent from this synthesis. In addition, the intrinsic nature of the data made it impossible to assess the causal nature of any of the identified barriers or facilitators.
This review may also be limited by publication bias, as published literature reflects historical and regional contexts and priorities, potentially resulting in gaps in the literature to do with non-priority populations and settings. As such, although this review presents results across populations and jurisdictions, some key populations (e.g. PWID, sex workers, immigrants, Indigenous communities and African, Caribbean and Black communities) and some provinces (e.g. Alberta, Manitoba, Saskatchewan) and the territories are underrepresented, potentially limiting the generalizability of results. In addition, emerging key populations may be missing.
Finally, the scope of this review was limited to barriers and facilitators of HIV testing and may omit other important shared barriers and facilitators to testing for other STBBI.

Conclusion
HIV testing acts as the gateway for HIV treatment and prevention and is a core pillar of Canada's efforts to reduce the health impact of HIV and other STBBI. This work provides a comprehensive and detailed understanding of the barriers and facilitators to HIV testing in Canada and highlights several important factors that can be leveraged to increase HIV testing.
The results provide key evidence to influence practice, policy and future research toward achieving global HIV targets.