Gay, bisexual and other men who have sex with men (gbMSM) with lived/living experience who have sought sexually transmitted infection (STI) testing and healthcare providers were recruited to complete multiple survey rounds to build consensus on which interventions had the greatest potential to improve testing services for STIs for gbMSM in Toronto, Ontario. The study used an online consensus-building approach called the e-Delphi process in which participants ranked interventions and could provide open-text responses to justify their rankings. Both the gbMSM who participated (referred to as community experts) and the healthcare providers (provider experts) ranked express STI testing among their top three interventions. Text responses indicated that both groups supported shortened wait times, the use of technology to improve convenience, and the need to normalize testing.
STI testing approaches considered
The study assessed participants’ views on the following interventions for their potential to improve STI testing among gbMSM in Toronto. The interventions included in the study were chosen through a separate process of literature review, focus group review by community members and surveys with healthcare providers.
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Streamlining STI testing for asymptomatic people |
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Online-based testing |
A person requests an STI test via a website, downloads a laboratory form and then visits a laboratory in person for testing. |
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Express testing with self-collected samples |
Testing is completed at a clinic. A questionnaire helps to determine whether a person has symptoms. If the person is not symptomatic, samples are self-collected and there is no clinical examination. If the person has symptoms, they meet with a healthcare provider, who conducts a clinical examination. |
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Nurse-led testing in primary care clinics |
People are screened (i.e., asked questions related to their sexual history and STI symptoms) at primary care clinics by a nurse or allied health professional. If the person has symptoms, they are seen by a physician. If they have no symptoms, STI tests are completed on the basis of their sexual history, and they are called only if test results are positive. |
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Routine testing |
STI testing is part of standard orders that are provided to people during regular healthcare visits. |
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Client-targeted interventions |
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Client reminders |
People who have previously had STI testing receive testing reminders via text message, email or postal mail to remind them to retest. |
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Online booking for STI testing |
People book an appointment for STI testing on an app or website that contains information about STI infections, their transmission and how testing works. |
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Provider-targeted interventions |
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Provider alerts |
Healthcare providers receive prompts through electronic medical records to alert them to test patients. |
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Provider audit and feedback |
Healthcare providers receive regular reports on their own STI testing practices and how these compare with guideline recommendations. The report contains goals and targets to improve and reinforce good performance. |
e-Delphi process
Two separate e-Delphi processes were undertaken: one with community experts (members of the gbMSM community with lived/living experience who have sought testing) and one with provider experts (healthcare providers and public health professionals with expertise in providing STI testing for gbMSM communities). Delphi studies are used to build consensus and consist of experts completing a series of anonymous surveys. Subsequent surveys are based on the results of previous surveys until consensus around preferred approaches is reached.
Community experts and provider experts were asked to rate interventions on a seven-point Likert scale, and in the second and third survey rounds they were asked to rank their top three interventions. Only provider experts were asked to rank the provider-targeted interventions. Participants were also given the opportunity to explain why they chose their ratings or provide additional information about their choices through open-text responses. In subsequent rounds of the survey, participants were shown the results of the previous survey; if they disagreed with rankings, they could indicate why. Those who completed a survey round were invited to participate in the next round, and multiple reminders were sent during each round to encourage survey completion. Participants were compensated up to $100 for completing all three rounds.
Results and implications for service providers
Community experts were surveyed from October 2019 to November 2019, with three survey rounds. There were 51 participants, and 46 completed the first round of the survey. Overall, 76% (35/46) of participants were less than 40 years of age, 87% (40/46) identified as gay, 52% (24/46) identified as part of an ethnoracial group (e.g., African, Caribbean and Black), 20% (9/46) were living with HIV and of the 80% who were HIV negative, 49% (18/37) were on pre-exposure prophylaxis (PrEP).
Provider experts were surveyed from February 21, 2020, to May 13, 2020, with three surveys rounds. There were 48 service provider participants, and 45 completed the first round of the survey. Overall, 67% (30/45) were less than 40 years of age, 58% (26/45) identified as men, 56% (25/45) practised in primary care, 60% (27/45) had graduated less than 10 years earlier and 56% (25/45) were physicians. Provider experts were experienced in sexual health care, with 51% (23/45) reporting seeing more than 20 gbMSM per week.
Express testing ranked in top three interventions by both community and provider experts
Both the provider expert and community expert groups were supportive of interventions that made STI testing more efficient, and both groups ranked express testing in their top three interventions with the potential to improve STI testing among gbMSM. This was the only overlap in each group’s top three interventions. The top three interventions were determined by the number of votes in the second and third rounds of the survey.
- In addition to express testing, community experts ranked routine testing and online booking for STI testing in their top three interventions. According to the study’s authors, this suggests that gbMSM are looking for multiple options for testing and that they want testing to be accessible and convenient, while still having access to a non-stigmatizing healthcare provider as needed.
- In addition to express testing, provider experts ranked online-based testing and nurse-led testing in primary care clinics in their top three interventions. The study’s authors indicated that this suggests that providers are looking for ways to ease the existing burden of testing.
The open-text responses showed that community experts preferred interventions that involved providers, and provider experts preferred interventions that prioritized patient independence and reduced patient–provider time. They also showed that both groups supported shortened wait times, the use of technology to improve convenience, and the need to normalize testing.
It should be noted that the provider expert survey was interrupted by the COVID-19 pandemic in March 2020 and the second and third rounds of the survey were delayed. The authors suggested that the fact that these rounds took place during the state of emergency of the pandemic may have influenced providers’ responses and led them to prioritize interventions with less in-person patient–provider contact (e.g., online-based testing).
Service providers should consider ways to make STI testing more convenient and accessible to gbMSM, while maintaining relationships with clients that are non-stigmatizing and non-judgmental. The findings of this study suggest that reorganizing how STI testing is delivered, rather than creating a new intervention, would probably satisfy both community and provider needs.
This work was completed by Dr. Ann Burchell and team at the MAP Centre for Urban Health Solutions.
Related resources
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Reference
Yeung A, Lisk R, Rana J et al. Community and health care provider preferences for bacterial sexually transmitted infection testing interventions for gay, bisexual, and other men who have sex with men: e-Delphi study. Journal of Medical Internet Research. 2023;25:e40477.