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

Self-Screening for Cervical Cancer Offered through a Digital Platform in a Region of British Columbia with Lower Screening Rates

Cervical cancer is highly preventable through vaccination, early detection, and treatment, yet is the fourth most common cancer globally. HPV testing is superior to cytology for the detection of cervical pre-cancer, and jurisdictions around the world are implementing HPV primary screening, which offers the opportunity for self-screening, an important self-care intervention. Digital health solutions are also increasingly important components of self-care. In this study, we assessed the acceptability and completion of self-screening for cervical cancer offered through a digital platform within a low screening uptake region of British Columbia. The primary objective of this study was to evaluate the acceptability of self-screening for cervical cancer offered through a digital platform as measured by return rates of self-screening kits. Patients due or overdue for cervix screening were invited to participate. Eligible participants registered online to receive a self-screening kit, which included a device for vaginal self-screening, instructions, and a return envelope, sent to their home. After self-screening using the vaginal device, HPV testing was conducted. HPV-negative participants were returned to routine screening, and HPV-positive participants were recommended for cytology or colposcopy. Attendance rates at follow-up were evaluated. Participants were invited to complete an acceptability survey. From April 2019 to December 2023, 283 participants were sent kits, with 207 kits returned for a completion rate of 73%. Of valid samples (n = 202), 15 were HPV positive, and 93% attended follow-up care. Most respondents found the CervixCheck website easy to use, informative, and secure and were satisfied with receiving their results online. CervixCheck had a high completion rate among participants who were sent a self-screening kit. High compliance with recommended follow-up and high acceptability of self-screening for cervical cancer was observed. Most participants indicated they would self-screen again in the future. Innovative approaches to cervical screening, including self-screening and the use of digital health interventions, are ways to enhance equity and improve uptake of cervical screening.

Missed opportunities to provide sexually transmitted and blood-borne infections testing in British Columbia: An interpretive description of users' experiences of Get Checked Online's design and implementation

Background

Digital testing services for sexually transmitted and blood-borne infections (STBBIs), such as GetCheckedOnline, experience significant user drop-offs. For example, 32% of GetCheckedOnline users needing testing at account creation do not test, constituting missed opportunities. We explored the influence of users' expectations and experiences of GetCheckedOnline's web design and implementation on missed opportunities.

Methods

This interpretive description purposively sampled 14 GetCheckedOnline users who created accounts between April 2022 and February 2023, indicated needed testing at account creation but did not test. We conducted semi-structured interviews and cognitive walkthroughs of GetCheckedOnline on Zoom, exploring participants' expectations and experiences, including problems using the service. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analyses.

Results

Three themes were identified: (a) transitioning between GetCheckedOnline and laboratory services is a major testing barrier; (b) users' appraisal of their health and social contexts is a determinant of testing through GetCheckedOnline; and (c) tailoring GetCheckedOnline's design and implementation to accommodate varying user needs can promote equitable testing. Health equity issues occurred along sociodemographic gradients as the GetCheckedOnline-laboratory transition was more onerous for older users. Users' appraisal of their testing needs which varied by age and gender, and their assessment of time, and travel requirements for testing in remote communities influenced testing. Learning about GetCheckedOnline from healthcare providers improved testing compared with learning about the service through Google search which raised trust concerns regarding GetCheckedOnline's authenticity. Suggested improvements to promote health equity include personalized education, mail-in testing options, and simpler seamless web experiences.

Conclusions

To promote equitable access to digital STBBI testing services such as GetCheckedOnline, we can adapt web-design and implementation to suit user needs and contexts, ensuring simplicity and options for testing that reduce user burdens.

Direct-to-patient digital diagnostics in primary care: Opportunities, challenges, and conditions necessary for responsible digital diagnostics

BACKGROUND

Diagnostics are increasingly shifting to patients' home environment, facilitated by new digital technologies. Digital diagnostics (diagnostic services enabled by digital technologies) can be a tool to better respond to the challenges faced by primary care systems while aligning with patients' and healthcare professionals' needs. However, it needs to be clarified how to determine the success of these interventions.

OBJECTIVES

We aim to provide practical guidance to facilitate the adequate development and implementation of digital diagnostics.

STRATEGY

Here, we propose the quadruple aim (better patient experiences, health outcomes and professional satisfaction at lower costs) as a framework to determine the contribution of digital diagnostics in primary care. Using this framework, we critically analyse the advantages and challenges of digital diagnostics in primary care using scientific literature and relevant casuistry.

RESULTS

Two use cases address the development process and implementation in the Netherlands: a patient portal for reporting laboratory results and digital diagnostics as part of hybrid care, respectively. The third use case addresses digital diagnostics for sexually transmitted diseases from an international perspective.

CONCLUSIONS

We conclude that although evidence is gathering, the often-expected value of digital diagnostics needs adequate scientific evidence. We propose striving for evidence-based 'responsible digital diagnostics' (sustainable, ethically acceptable, and socially desirable digital diagnostics). Finally, we provide a set of conditions necessary to achieve it. The analysis and actionable guidance provided can improve the chance of success of digital diagnostics interventions and overall, the positive impact of this rapidly developing field.

Differential uptake and effects of digital sexually transmitted and bloodborne infection testing interventions among equity-seeking groups: a scoping review

BACKGROUND

Digital sexually transmitted and bloodborne infection (STBBI) testing interventions have gained popularity. However, evidence of their health equity effects remains sparse. We conducted a review of the health equity effects of these interventions on uptake of STBBI testing and explored design and implementation factors contributing to reported effects.

METHODS

We followed Arksey and O'Malley's framework for scoping reviews (2005) integrating adaptations by Levac et al (2010). We searched OVID Medline, Embase, CINAHL, Scopus, Web of Science, Google Scholar and health agency websites for peer-reviewed articles and grey literature comparing uptake of digital STBBI testing with in-person models and/or comparing uptake of digital STBBI testing among sociodemographic strata, published in English between 2010 and 2022. We extracted data using the Place of residence, Race, Occupation, Gender/Sex, Religion, Education, Socioeconomic status (SES), Social capital and other disadvantaged characteristics (PROGRESS-Plus) framework, reporting differences in uptake of digital STBBI testing by these characteristics.

RESULTS

We included 27 articles from 7914 titles and abstracts. Among these, 20 of 27 (74.1%) were observational studies, 23 of 27 (85.2%) described web-based interventions and 18 of 27 (66.7%) involved postal-based self-sample collection. Only three articles compared uptake of digital STBBI testing with in-person models stratified by PROGRESS-Plus factors. While most studies demonstrated increased uptake of digital STBBI testing across sociodemographic strata, uptake was higher among women, white people with higher SES, urban residents and heterosexual people. Co-design, representative user recruitment, and emphasis on privacy and security were highlighted as factors contributing to health equity in these interventions.

CONCLUSION

Evidence of health equity effects of digital STBBI testing remains limited. While digital STBBI testing interventions increase testing across sociodemographic strata, increases are lower among historically disadvantaged populations with higher prevalence of STBBIs. Findings challenge assumptions about the inherent equity of digital STBBI testing interventions, emphasising the need to prioritise health equity in their design and evaluation.

Cost-effectiveness of internet-based HIV screening among gay, bisexual and other men who have sex with men (GBMSM) in Metro Vancouver, Canada

BACKGROUND

GetCheckedOnline is an internet-based screening service aiming to increase HIV testing among gay, bisexual and other men who have sex with men (GBMSM). We assessed the cost-effectiveness of GetCheckedOnline in its first implementation phase at different uptake scenarios compared to clinic-based screening services alone in Metro Vancouver, Canada.

METHODS

From a healthcare payer's perspective, our cost-utility analysis used an established dynamic GBMSM HIV compartmental model estimating the probability of acquiring HIV, progressing through diagnosis, disease stages and treatment over a 30-year time horizon. The base case scenario assumed 4.7% uptake of GetCheckedOnline in 2016 (remainder using clinic-based services), with 74% of high-risk and 44% of low-risk infrequent testers becoming regular testers in five years. Scenario analyses tested increased GetCheckedOnline uptake to 10% and 15%.

RESULTS

The cost per test for GetCheckedOnline was $29.40 compared to clinic-based services $56.92. Compared with clinic-based screening services, the projected increase in testing frequency with 4.7% uptake of GetCheckedOnline increased the costs by $329,600 (95% Credible Interval: -$498,200, $571,000) and gained 4.53 (95%CrI: 0, 9.20) quality-adjusted life years (QALYs) in a 30-year time horizon. The probability of GetCheckedOnline being cost-effective was 34% at the threshold of $50,000 per QALY, and increased to 73% at the threshold of $100,000 per QALY. The results were consistent in the other uptake scenarios. The probability of GetCheckedOnline being cost-effective became 80% at the threshold of $50,000 per QALY if assuming 5-year time horizon.

CONCLUSIONS

GetCheckedOnline is almost half the cost of clinic-based services on a per-test basis. However, increased access to testing should be balanced with risk profiles of patients to ensure the implementation can be a cost-effective strategy for increasing HIV screening among GBMSM in Metro Vancouver. Additional analyses are needed to understand the impact of internet-based screening including screening for other STIs and in other populations.

Important considerations regarding the widespread use of doxycycline chemoprophylaxis against sexually transmitted infections

Rates of sexually transmitted infections (STIs) continue to rise across the world and interventions are essential to reduce their incidence. Past and recent studies have indicated this may be achieved using doxycycline post-exposure prophylaxis (PEP) and this has sparked considerable interest in its use. However, many unanswered questions remain as to its long-term effects and particularly potentially negative impact on human microbiomes and antimicrobial resistance among STIs, other pathogens, and commensals. In this review, we discuss seven areas of concern pertaining to the widespread use of doxycycline PEP.

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

BACKGROUND

Canadian clinical guidelines recommend at least annual and up to quarterly bacterial sexually transmitted infection (STI) testing among sexually active gay, bisexual, and other men who have sex with men (GBM). However, testing rates are suboptimal. Innovative solutions are needed to close the gap because there is currently limited knowledge on how best to approach this issue.

OBJECTIVE

Our aim was to build consensus regarding interventions with the greatest potential for improving local STI testing services for GBM communities in Toronto, Ontario, Canada, using a web-based e-Delphi process.

METHODS

The e-Delphi method involves using a panel format to conduct successive rounds of prioritization, with feedback between rounds, to determine priorities among groups. We recruited experts separately from the community (GBM who sought or underwent STI testing in the preceding 18 months; conducted between October 2019 and November 2019) and health care providers (those who offered STI testing to GBM in the past 12 months; conducted between February 2020 and May 2020). The experts prioritized 6 to 8 potential interventions on a 7-point Likert scale ranging from definitely not a priority to definitely a priority over 3 survey rounds and ranked their top 3 interventions. Consensus was defined as ≥60% within a ±1 response point. Summaries of responses were provided in successive rounds. We reported the percentage of a priority (encompassing somewhat a priority, a priority, and definitely a priority responses) at the end of the final round of the survey.

RESULTS

Of the community experts (CEs), 84% (43/51) completed all rounds; 19% (8/43) were living with HIV; 37% (16/43) were HIV negative and on pre-exposure prophylaxis; and 42% (18/43) were HIV negative and not on pre-exposure prophylaxis. We reached consensus on 6 interventions: client reminders (41/43, 95%), express testing (38/43, 88%), routine testing (36/43, 84%), an online booking app (36/43, 84%), online-based testing (33/43, 77%), and nurse-led testing (31/43, 72%). The CEs favored convenient interventions that also maintain a relationship with their provider. Of the provider experts (PEs), 77% (37/48) completed all rounds; 59% (22/37) were physicians. Consensus was reached on the same 6 interventions (range 25/37, 68%, to 39/39, 100%) but not for provider alerts (7/37, 19%) and provider audit and feedback (6/37, 16%). Express testing, online-based testing, and nurse-led testing were prioritized by >95% (>37/39) of the PEs by the end of round 2 because of streamlined processes and decreased need to see a provider.

CONCLUSIONS

Both panels were enthusiastic about innovations that make STI testing more efficient, with express testing rating highly in both the prioritizations and top 3 rankings. However, CEs preferred convenient interventions that involved their provider, whereas PEs favored interventions that prioritized patient independence and reduced patient-provider time.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13801.

Treatment and Partner Notification Outcomes for Clients Diagnosed With Chlamydia and Gonorrhea Through GetCheckedOnline Compared With Sexually Transmitted Infection Clinics in British Columbia, Canada

A study comparing treatment and partner notification outcomes for people diagnosed with chlamydia or gonorrhea found no differences between clients of Internet-based and clinic-based testing services.

Background

Whether treatment, engagement in partner notification (PN), and PN outcomes differ between clients of Internet-based and clinic-based testing services is poorly understood. We compared these outcomes between people diagnosed with chlamydia and/or gonorrhea (CT/GC) through a sexually transmitted infection (STI) clinic service and GetCheckedOnline (GCO), an Internet-based testing service in British Columbia.

Methods

We conducted a retrospective matched cohort study among CT/GC cases where each case diagnosed through GCO in 2016 to 2017 was matched to 2 STI clinic cases by diagnosis, sex, age group, and specimen collection date. Data were collected through chart review, with outcomes compared using appropriate statistical tests.

Results

Of 257 GCO and 514 matched clinic cases, case treatment was high and did not differ between GCO (254 of 257 [98.9%]) and clinic (513 of 514 [99.8%]) cases, as was engagement in PN (250 of 257 [97.2%] vs. 496 of 514 [96.5%]). There was no difference in the proportion of notified partners between GCO (159 of 270 [58.9%]) and clinic (253 of 435 [58.2%]) cases, although a greater proportion of partners reported by clinic cases were notified by STI nurses (43 of 435 [9.9%]) versus GCO cases (6 of 270 [2.2%]).

Conclusions

GetCheckedOnline clients diagnosed with CT/GC demonstrated similar treatment uptake and engagement in PN to clinic clients, and PN outcomes did not differ. The greater reliance on STI clinic nurses for PN among clinic clients may be related to having had an initial in-person testing visit.

Acceptability of an existing online sexually transmitted and blood-borne infection testing model among gay, bisexual and other men who have sex with men in Ontario, Canada

Objectives

Gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by sexually transmitted and blood-borne infections (STBBI) due to stigma and other factors such as structural barriers, which delay STBBI testing in this population. Understanding acceptability of online testing is useful in expanding access in this population, thus we examined barriers to clinic-based testing, acceptability of a potential online testing model, and factors associated with acceptability among GBM living in Ontario.

Methods

Sex Now 2019 was a community-based, online, bilingual survey of GBM aged ≥15. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated using modified Poisson regression with robust variances. Multivariable modelling was conducted using the Hosmer-Lemeshow-Sturdivant approach.

Results

Among 1369 participants, many delayed STBBI testing due to being too busy (31%) or inconvenient clinic hours (29%). Acceptability for online testing was high (80%), with saving time (67%) as the most common benefit, and privacy concerns the most common drawback (38%). Statistically significant predictors of acceptability for online testing were younger age (PR  =  0.993; 95%CI: 0.991-0.996); a greater number of different sexual behaviours associated with STBBI transmission (PR  =  1.031; 95%CI: 1.018-1.044); identifying as an Indigenous immigrant (PR  =  1.427; 95%CI: 1.276-1.596) or immigrant of colour (PR  = 1.158; 95%CI: 1.086-1.235) compared with white non-immigrants; and currently using HIV pre-exposure prophylaxis (PrEP) compared to not currently using PrEP (PR  =  0.894; 95%CI: 0.828-0.965).

Conclusions

Acceptability of online testing was high among GBM in Ontario. Implementing online STBBI testing may expand access for certain subpopulations of GBM facing barriers to current in-person testing.

Community perspectives on ideal bacterial STI testing services for gay, bisexual, and other men who have sex with men in Toronto, Canada: a qualitative study

BACKGROUND

Innovation is needed to produce sustained improvements in bacterial sexually transmitted infections (STI) testing given suboptimal access and uptake among sexually active gay, bisexual or other men who have sex with men (GBM). Yet, the STI testing processes and technologies that best address local testing barriers among GBM in Toronto is unknown. We aimed to explore men's perspectives regarding STI testing services for GBM to identify and prioritize new STI testing interventions in Toronto, Ontario, Canada.

METHODS

We conducted four focus groups with twenty-seven GBM in 2017: two with cisgender men living with HIV, one with cisgender HIV-negative men, and one with transgender men. Twenty-seven men participated in the focus groups with 40% 18-30 years of age, 48% self-identifying as white, and the remainder self-identifying as Middle Eastern, Latino/Hispanic, Asian/Pacific Islander, South Asian, First Nations, African/Caribbean/Black, or mixed race. 59% of participants self-identified as living with HIV. Participants were asked about their STI testing experiences in Toronto, barriers and facilitators to testing, and ideal STI testing process. Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Core concepts included how clinical context, bacterial STI testing delivery, and interactions with healthcare providers can create barriers and recommendations for ways to improve. Regarding clinical context, participants desired more clinics with accessible locations/hours; streamlined testing that minimized use of waiting rooms and wait times; and improved clinic ambience. Bacterial STI testing delivery recommendations included standardization to ensure consistency in sexual history intake, tests offered, follow-up and public health reporting between clinics. Men also recommended reducing the multistep process testing by offering components such as lab requisitions and results online. Participants also recommended interactions with healthcare providers be professional and non-judgmental, offer compassionate and competent care with destigmatizing and lesbian, gay, bisexual and trans (LGBT) affirming communication.

CONCLUSION

Concrete and practical solutions for improving existing sexual health services and facilitating optimal STI testing include streamlining testing options and providing patient-centred, LGBT-affirming care to enable optimal STI testing.

Access to, usage and clinic outcomes of, online postal sexually transmitted infection services: a scoping review

BACKGROUND

There has been considerable expansion in online postal self-sampling (OPSS) STI services in many parts of the UK, driven by increasing demand on sexual health services and developments in diagnostics and digital health provision. This shift in service delivery has occurred against a backdrop of reduced funding and service fragmentation and the impact is unknown. We explored characteristics of people accessing and using OPSS services for STIs in the UK, the acceptability of these services and their impact on sexual health inequalities.

METHODS

A scoping review was conducted of studies published in English-language based on pre-agreed inclusion/exclusion criteria, between 01 January 2010 and 07 July 2021. Nine databases were searched, and 23 studies that met the eligibility criteria were included. Studies were appraised using the Mixed Methods Appraisal Tool.

RESULTS

Study designs were heterogeneous, including quantitative, qualitative and mixed-methods analyses. The majority were either evaluating a single-site/self-sampling provider, exploratory or observational and of variable quality. Few studies collected comprehensive user demographic data. Individuals accessing OPSS tended to be asymptomatic, of white ethnicity, women, over 20 years and from less deprived areas. OPSS tended to increase overall STI testing demand and access, although return rates for blood samples were low, as was test positivity. There were varied results on whether services reduced time to treatment. OPSS services were acceptable to the majority of users. Qualitative studies showed the importance of trust, confidentiality, discretion, reliability, convenience and improved patient choice.

CONCLUSION

OPSS services appear highly acceptable to users. However, uptake appears to be socially patterned and some groups who bear a disproportionate burden of poor sexual health in the UK are under-represented among users. Current provision of online self-sampling could widen health inequalities, particularly where other options for testing are limited. Work is needed to fully evaluate the impact and cost-effectiveness of OPSS services.

Direct Access for Patients to Diagnostic Testing and Results Using eHealth: Systematic Review on eHealth and Diagnostics

BACKGROUND

The number of people with chronic diseases and the subsequent pressure on health care is increasing. eHealth technology for diagnostic testing can contribute to more efficient health care and lower workload.

OBJECTIVE

This systematic review examines the available methods for direct web-based access for patients to diagnostic testing and results in the absence of a health care professional in primary care.

METHODS

We searched the PubMed, Embase, Web of Sciences, Cochrane Library, Emcare, and Academic Search Premier databases in August 2019 and updated in July 2021. The included studies focused on direct patient access to web-based triage leading to diagnostic testing, self-sampling or testing, or web-based communication of test results. A total of 45 studies were included. The quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Most studies had a quantitative descriptive design and discussed a combination of services. Diagnostic test services mainly focused on sexually transmitted infections. Overall, the use was high for web-based triage (3046/5000, >50%, who used a triage booked a test), for self-sampling or self-testing kits (83%), and the result service (85%). The acceptability of the test services was high, with 81% preferring home-based testing over clinic-based testing. There was a high rate of follow-up testing or treatment after a positive test (93%).

CONCLUSIONS

The results show that direct access to testing and result services had high use rates, was positively evaluated, and led to high rates of follow-up treatment. More research on cost-effectiveness is needed to determine the potential for other diseases. Direct access to diagnostic testing can lower the threshold for testing in users, potentially increase efficiency, and lower the workload in primary care.

Defining Digital Public Health and the Role of Digitization, Digitalization, and Digital Transformation: Scoping Review

Background

The recent proliferation and application of digital technologies in public health has spurred interest in digital public health. However, as yet, there appears to be a lack of conceptual clarity and consensus on its definition.

Objective

In this scoping review, we seek to assess formal and informal definitions of digital public health in the literature and to understand how these definitions have been conceptualized in relation to digitization, digitalization, and digital transformation.

Methods

We conducted a scoping literature search in Ovid MEDLINE, Embase, Google Scholar, and 14 government and intergovernmental agency websites encompassing 6 geographic regions. Among a total of 409 full articles identified, we reviewed 11 publications that either formally defined digital public health or informally described the integration of digital technologies into public health in relation to digitization, digitalization, and digital transformation, and we conducted a thematic analysis of the identified definitions.

Results

Two explicit definitions of digital public health were identified, each with divergent meanings. The first definition suggested digital public health was a reimagination of public health using new ways of working, blending established public health wisdom with new digital concepts and tools. The second definition highlighted digital public health as an asset to achieve existing public health goals. In relation to public health, digitization was used to refer to the technical process of converting analog records to digital data, digitalization referred to the integration of digital technologies into public health operations, and digital transformation was used to describe a cultural shift that pervasively integrates digital technologies and reorganizes services on the basis of the health needs of the public.

Conclusions

The definition of digital public health remains contested in the literature. Public health researchers and practitioners need to clarify these conceptual definitions to harness opportunities to integrate digital technologies into public health in a way that maximizes their potential to improve public health outcomes.

International Registered Report Identifier (IRRID)

RR2-10.2196/preprints.27686

Beyond the binary: sexual health outcomes of transgender and non-binary service users of an online sexual health service

Sexual health data on transgender and non-binary (TNB) people in the United Kingdom are limited. TNB individuals experience significant socioeconomic and stigma-related disadvantages. Sexual health morbidity and unmet need is likely to be significant. We compared the sexual health outcomes of TNB and cisgender users of London's online sexual health service. Of 119329 users that registered with the e-service between 30.4.19 and 31.12.19, 504 (0.42%) identified as TNB: 302 TNB users requested 463 kits. 78.4% (363/463) of kits were returned. 99.4% of dispatched kits included throat and rectal swabs for gonorrhoea and chlamydia testing. STI/HIV test positivity was: 5.5% syphilis, 4.8% chlamydia, 3.4% gonorrhoea and 0.7% HIV positive. HIV prevalence amongst TNB individuals was: 4.3%. 19.9% of TNB individuals engaged in chemsex, group sex, or fisting and were more likely to engage in sex work. 97.7% gave the service 4/5 or 5/5 star rating. We observed high positivity rates of HIV/STIs amongst TNB individuals and significant levels of high-risk sexual activity. Service users rated the service highly. Given TNB often have complex healthcare needs, some of which cannot be met entirely online, physical clinics must work collaboratively with e-services to support and protect this marginalised population.

Gay and Bisexual Men's Recommendations for Effective Digital Social Marketing Campaigns to Enhance HIV Prevention and Care Continuity

Because use of geosocial-networking smartphone applications ('apps') is ubiquitous among men who have sex with men (MSM), online-to-offline service models that include advertisements on these apps may improve engagement with effective HIV prevention and treatment services. Through our formative qualitative study, we conducted individual in-depth interviews (n = 30) and focus group discussions (n = 18) with MSM in Rhode Island to develop a digital social marketing campaign aimed at increasing HIV testing, including how best to reach men by advertising on apps. Qualitative data analysis revealed that participants were frequently exposed to pop-up advertisements on apps. These advertisements are viewed as invasive and, as such, many expressed a preference for other formats (e.g., direct messages, banner advertisements). Men expressed a preference for provocative images and phrases to catch their attention followed with fact-driven messaging to motivate them to engage with services offline. Findings from this study offer several practical recommendations for developing a social marketing campaign that uses advertisements on apps to increase HIV testing among MSM, including using formats other than pop-up advertisements and pairing fact-driven messaging with eye-catching images to direct them to trusted local clinical services.

Sexual Health Knowledge, Attitudes, and Perceptions Among Men Who Have Sex With Men During Co-Occurring Sexually Transmitted Infection Epidemics in Toronto, Canada: A Qualitative Study

BACKGROUND

Our objective was to explore the sexual health knowledge, attitudes, and perceptions of men who have sex with men (MSM).

METHODS

In-depth interviews were conducted with 31 MSM who lived, worked, or socialized in Toronto in June and July 2016. Participants were asked about concepts of risky sex and knowledge of, and attitudes toward, sexually transmitted infections (STIs), especially syphilis, and potential interventions. Thematic analysis was used to analyze interview transcripts.

RESULTS

The prevention of STI relied on HIV prevention strategies. No one used condoms for oral sex, nor did they intend to. Pre-exposure prophylaxis was perceived as both threatening and liberating. Concepts of risky sex included emotional risk. Conversations with partners about STI testing were easier than STI status. Stigma and concealment of sexual identity were barriers to sexual health care. None of the participants recommended sexual behavior or sexual health interventions. Instead, recommendations centered on social changes to reduce or eliminate shame, embarrassment, stigma, and discrimination around both STIs and sexual orientation.

CONCLUSION

Participants were thinking about sexual risk and using a variety of ways to prevent STI transmission, although most relied on HIV prevention strategies, possibly because they knew little about other STIs, and other STIs were perceived as curable, especially syphilis. Interventions promoting conversations about STI testing may be promising and will also reduce stigma as STI testing is normalized. Social and clinic interventions focused on creating psychologically safe spaces to disclose sexual identity and providing sexual orientation affirming health care may reduce STIs and improve sexual health for MSM.

Safeguarding outcomes of 16 and 17-year-old service users of Sexual Health London (SHL.uk), a pan-London online sexual health service

Guidance around how to safeguard young people using online sexual health services (e-SHSs) is limited. Sexual Health London (SHL.uk) is an e-SHS, integrated with London's sexual health clinics (SHCs), offering users aged 16 years and above sexually transmitted infection (STI) testing. For a safeguarding risk assessment, under 18s must complete a safeguarding e-triage, and any concern raised results in a 'call back' (CB) by the SHL.uk team. The safeguarding outcomes of CBs between 8 January 2018 and 18 September 2018 were reviewed; 261/454 (57.5%) users never triggered a CB on their e-triage (non-CB group) and 193/454 (42.5%) users triggered one or more CB(s) (CB group). Safeguarding concerns disclosed predominantly related to drug/alcohol use and partner's age imbalance. Successful telephonic risk assessment took place in 84.5% CB cases. Safeguarding outcomes comprised referrals to: SHC in 35.5%; child protection team in 8.5%; social services in 7%. STI positivity was 16.4% and 15.2% in the CB and non-CB groups, respectively. Although a high number of safeguarding triggers were disclosed, only a small proportion warranted referral for further support/intervention. Using e-triage with telephony support to screen and safeguard adolescents accessing an e-SHS was acceptable to users and enabled their clinical and safeguarding needs to be safely met. e-SHS integration within a network of SHCs further supported this model.

A review of current guidelines and research on the management of sexually transmitted infections in adolescents and young adults

Adolescents and young adults are at high risk for sexually transmitted infections (STIs). Providers have the responsibility to accurately manage these infections to prevent medical complications and the spread of STIs. This article will review the epidemiology, screening recommendations, diagnostic tests, and treatment guidelines for STIs most commonly encountered in this population: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus, and Trichomonas vaginalis, as well as the sexually associated infection bacterial vaginosis. This review will discuss ongoing research that explores ways to improve the management of STIs in adolescents and young adults.

A cohort study comparing rate of repeat testing for sexually transmitted and blood-borne infections between clients of an internet-based testing programme and of sexually transmitted infection clinics in Vancouver, Canada

OBJECTIVES

Internet-based sexually transmitted and blood-borne infection (STBBI) testing services reduce testing barriers through bypassing face-to-face clinical encounters, potentially enabling clients at ongoing sexual risk to test more frequently. To our knowledge, this hypothesis has not been previously tested. We compared the frequency of repeat testing between Vancouver-based clients of GetCheckedOnline (GCO)-an internet-based STBBI testing service in British Columbia, Canada-and clients of three sexually transmitted infection (STI) clinics in Vancouver for 29 months after GCO launched.

METHODS

An administrative data cohort (n=19 497) was assembled using GCO, clinical and laboratory databases. We included all individuals who tested for HIV, gonorrhoea/chlamydia, syphilis or hepatitis C at three STI clinics or using GCO, between September 2014 and February 2017. The rate of repeat testing (>30 days after first episode) was compared between clients who used GCO at least once and those who tested only in STI clinics. Poisson regression was used to generate relative rate (RR) for repeat testing, with adjustment for age, gender/sexual orientation, risk factors (eg, history of STI diagnosis) and rate of testing before GCO launched.

RESULTS

1093 GCO clients were identified, of whom 434 (40%) had repeat test episodes; 8200/18 404 (45%) of clinic clients tested more than once. During the 29-month analysis period, GCO clients repeat tested 1.87 times per person-year, whereas clinic clients repeat tested 1.53 times per person-year, resulting in a crude RR of 1.22 (95% CI: 1.14 to 1.31). Adjustment for covariates increased the RR to 1.26 (95% CI: 1.15 to 1.37).

CONCLUSIONS

In this cohort, individuals using internet-based STBBI testing had a rate of repeat testing 22% greater than clinic-based clients. This effect was increased after adjusting for characteristics associated with higher test frequency. The online interface of GCO may facilitate more frequent testing and may therefore contribute to earlier STBBI diagnosis.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care (The FACTS Study Phase II) After Surgical Abortion: User-Centered Design

Background

Human-centered design is a methodology that applies an iterative participatory process that engages the end-user for whom an innovation or intervention is designed for from start to end. There is general evidence to support the use of human-centered design for development of tools to affect health behavior, but specifically for family planning provision. This study is part two of a three-phase study that uses a user-centered design methodology which uses the findings from Phase I to design, develop, and test a digital health solution to support follow-up after an induced surgical abortion.

Objective

The objectives for this study were to: (1) develop a Web-based intervention based on preferences and experiences of women who underwent an abortion as measured in the formative phase of the Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care Study; (2) conduct usability testing of the intervention to determine user-friendliness and appropriateness of the intervention; and (3) finalize a beta version of the Web-based intervention for pilot testing.

Methods

The study design was based on the “development-evaluation-implementation” process from the Medical Research Council Framework for Complex Medical Interventions. This study is in Phase II of III and is based on user-centered design methodology. Phase I findings demonstrated that women engage with technology to assist in clinical care and they preferred a comprehensive website with email or text notifications to support follow-up care. In Phase II we collaborated with family planning experts and key stakeholders to synthesize evidence from Phase I. With them and a development partner we built a prototype. Usability testing was completed with 9 participants using a validated System Usability Scale. This was then used to refine the intervention for Phase III pilot study. This study was approved by the local Ethics board.

Results

We developed a comprehensive Web-based tool called myPostCare.ca, which includes: Post-Procedure Care, Emotional Well-Being Tool, Contraception Explorer, Sexual Health, Book an Appointment, and Other Resources. Additionally, over the course of a month after the procedure, automatic email notifications were sent to women as a form of virtual follow-up support, directing them to myPostCare.ca resources. The Web-based tool was refined based on usability testing results.

Conclusions

This study demonstrated that user-centered design is a useful methodology to build programs and interventions that are women-centered, specifically for abortion care.

Community-Directed Bacterial Sexually Transmitted Infection Testing Interventions Among Men Who Have Sex With Men: Protocol for an E-Delphi Study in Toronto, Canada

Background

HIV-positive and HIV-negative (gay, bisexual, and other) men who have sex with men (MSM) have experienced a dramatic increase in bacterial sexually transmitted infections (STIs)—syphilis, gonorrhea, and chlamydia. STI testing and treatment mitigate adverse health outcomes and substantially reduce transmission; yet, testing rates remain below recommended levels. Innovation is needed to produce the required increases in testing levels, frequency, and the use of appropriate testing technologies in ways that are engaging, nonstigmatizing, and acceptable to men.

Objective

The aim of this study is to build consensus with regard to interventions with the greatest potential for improving local STI testing services for MSM communities in Toronto, Canada.

Methods

Following a literature review of evidence regarding the effectiveness of novel testing interventions, and focus groups, and surveys to describe local barriers and facilitators of testing among MSM, we will conduct a Web-based, modified Delphi study (e-Delphi). We will form expert panels of community members and STI test providers. Panelists will rate potential interventions in terms of their priority, using a 7-point Likert scale from definitely not a priority to definitely a priority. They will also rank their preferences by selecting their top 3 preferred interventions. Surveys will be distributed in 3 rounds, with feedback on the distribution of responses from preceding rounds provided in rounds 2 and 3. We will define consensus as having ≥60% (18/30) members indicate a preference within 2 adjacent response points. Qualitative data on disagreements will be obtained using open-ended text responses to explain for ratings and rankings that are different from the majority.

Results

On the basis of a literature review and identification of barriers and facilitators to STI testing among community members and test providers in Toronto, we have selected 8 potential interventions for inclusion in the e-Delphi panel surveys. These include 4 interventions that streamline STI testing for asymptomatic individuals, 2 interventions that are targeted at clients and 2 interventions that are targeted at providers.

Conclusions

Findings will provide community direction for informed decision making regarding the implementation of STI testing interventions in this setting. They will characterize the intervention climate for innovation to STI testing services, including perceived needs for changes to test delivery, relative priorities for change, and readiness for implementation. These methods may be transferable to other urban jurisdictions experiencing similar epidemics and for other contexts where stakeholder input is needed to manage sensitive areas of concern.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13801

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care in British Columbia: Phase I

Background

Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. The vast majority of care is concentrated in urban settings. There is evidence to support utilization of innovative mobile and other technology solutions to empower women to safely and effectively self-manage aspects of the abortion process. This study is part 1 of a 3-phase study that utilizes user-centered design methodology to develop a digital health solution to specifically support follow-up after an induced surgical abortion.

Objective

This study aimed to (1) understand how women at 3 surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access health care information and (2) understand women’s preferences of content and design of an intervention that will support follow-up care after an induced abortion, including contraceptive use.

Methods

The study design was based on development-evaluation-implementation process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed-methods formative study. Women (aged 14-45 years) were recruited from 3 urban abortion facilities in British Columbia who underwent an induced abortion. Adaptation of validated surveys and using the technology acceptance model and theory of reasoned action, a cross-sectional survey was designed. Interview topics included demographic information; type of wireless device used; cell phone usage; acceptable information to include in a mobile intervention to support women’s abortion care; willingness to use a mobile phone to obtain reproductive health information; optimal strategies to use a mobile intervention to support women; understand preferences for health information resources; and design qualities in a mobile intervention important for ease of use, privacy, and security. Responses to questions in the survey were summarized using descriptive statistics. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the local ethics board.

Results

A waiting-room survey was completed by 50 participants, and semistructured interviews were completed with 8 participants. The average age of participants was 26 years. Furthermore, 94% (47/50) owned a smartphone, 85% (41/48) used their personal phones to go online, and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health, and postprocedure care.

Conclusions

A community-based mixed-methods approach allowed us to understand how women use their cell phones and what women desire in a mobile intervention to support their postabortion care. The findings from this formative phase will assist in the development and testing of a mobile intervention to support follow-up care after an induced surgical abortion.

Post-test comparison of HIV test knowledge and changes in sexual risk behaviour between clients accessing HIV testing online versus in-clinic

OBJECTIVE

Internet-based HIV testing offers the potential to address privacy-related barriers to testing and increase frequency of testing but may result in missed opportunities related to sexual health education and prevention that typically occur in face-to-face encounters. In this study, we assessed the HIV test knowledge and sexual risk behaviour of clients testing for HIV through GetCheckedOnline, an internet-based sexually transmitted and bloodborne infection testing platform inclusive of HIV testing, in comparison to clients testing through a large sexual health clinic.

METHODS

We concurrently recruited GetCheckedOnline clients and clinic clients from Vancouver, Canada, over the course of a 10-month period during 2015-2016. Participants completed baseline and 3-month questionnaires, anonymous and online. A six-item score was used to estimate knowledge of HIV test concepts typically conveyed during an HIV pretest encounter in a clinic. We used multiple regression to estimate associations between testing modality (online vs clinic based) and two outcomes-HIV test knowledge and change in condom use pre/post-test-with adjustment for relevant background factors.

RESULTS

Among 352 participants, online testers demonstrated higher HIV post-test knowledge than clinic-based testers (mean score 4.65/6 vs 4.09/6; p<0.05); this difference was reduced in adjusted analysis (p>0.05). Men who have sex with men, clients with a university degree, those who have lived in Canada >10 years and English speakers had higher HIV post-test knowledge (p<0.05). Eighteen per cent of online testers and 10% of clinic-based testers increased condom use during the 3 months post-test (p>0.05).

CONCLUSIONS

In this comparative study between online and clinic-based testers, we found no evidence of decreased HIV test knowledge or decreased condom use following HIV testing through GetCheckedOnline. Our findings suggest that with careful design and attention to educational content, online testing services may not lead to missed opportunities for HIV education and counselling.

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: Observational Study

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 $118 per account created and Can $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.

Qualitative analysis of the experiences of gay, bisexual and other men who have sex with men who use GetCheckedOnline.com: a comprehensive internet-based diagnostic service for HIV and other STIs

Objectives

To describe the factors that influence gay, bisexual and other men who have sex with men’s (gbMSM) experiences with GetCheckedOnline.com (GCO) in British Columbia (BC), Canada. GCO clients complete an internet-based risk assessment and print a laboratory test requisition form for HIV and other STIs to take to a private laboratory for diagnostic services.

Methods

Drawing on a purposive stratified sampling framework, we conducted 37 in-depth semistructured interviews with gbMSM who had used GCO at least once between 2015 and 2017.

Results

Participants expressed a preference for GCO (instead of clinic-based testing) because of convenience, privacy and control over specimen collection (specifically with doing one’s own throat or anal swab). Participants preferred receiving their results online via GCO compared with phone or email follow-up by clinic staff. GCO was viewed positively because it offers gbMSM living outside of urban city centres easy access to diagnostic services, including access to pooled nucleic acid amplification testing. Many participants also continued to positively view the clinic-based services available for gbMSM in their community. These services were frequently described as highly competent, tailored and comprehensive in responding to more complex needs. For example, attending a clinic was viewed as preferential to GCO in instances where there was a desire to access services addressing co-occurring health issues (eg, mental health; substance use disorders). Almost all of the participants anticipated using both GCO and clinic-based services in the future.

Conclusions

gbMSM report positive experiences and perceptions of GCO; however, they do not view GCO as a panacea. The results of this study point to the need to ensure that a wide range of integrated service options (eg, online; clinic-based) are available to address the range of sexual health needs of gbMSM living in BC's diverse settings.

Using Geosocial Networking Apps to Understand the Spatial Distribution of Gay and Bisexual Men: Pilot Study

BACKGROUND

While services tailored for gay, bisexual, and other men who have sex with men (gbMSM) may provide support for this vulnerable population, planning access to these services can be difficult due to the unknown spatial distribution of gbMSM outside of gay-centered neighborhoods. This is particularly true since the emergence of geosocial networking apps, which have become a widely used venue for meeting sexual partners.

OBJECTIVE

The goal of our research was to estimate the spatial density of app users across Metro Vancouver and identify the independent and adjusted neighborhood-level factors that predict app user density.

METHODS

This pilot study used a popular geosocial networking app to estimate the spatial density of app users across rural and urban Metro Vancouver. Multiple Poisson regression models were then constructed to model the relationship between app user density and areal population-weighted neighbourhood-level factors from the 2016 Canadian Census and National Household Survey.

RESULTS

A total of 2021 app user profiles were counted within 1 mile of 263 sampling locations. In a multivariate model controlling for time of day, app user density was associated with several dissemination area-level characteristics, including population density (per 100; incidence rate ratio [IRR] 1.03, 95% CI 1.02-1.04), average household size (IRR 0.26, 95% CI 0.11-0.62), average age of males (IRR 0.93, 95% CI 0.88-0.98), median income of males (IRR 0.96, 95% CI 0.92-0.99), proportion of males who were not married (IRR 1.08, 95% CI 1.02-1.13), proportion of males with a postsecondary education (IRR 1.06, 95% CI 1.03-1.10), proportion of males who are immigrants (IRR 1.04, 95% CI 1.004-1.07), and proportion of males living below the low-income cutoff level (IRR 0.93, 95% CI 0.89-0.98).

CONCLUSIONS

This pilot study demonstrates how the combination of geosocial networking apps and administrative datasets might help care providers, planners, and community leaders target online and offline interventions for gbMSM who use apps.

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.

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

Background

Online 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.

Methods

We 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.

Results

Some 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.

Conclusions

Participants 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.

Online-to-offline models in HIV service delivery

PURPOSE OF REVIEW

Half the world's population has access to Internet and technologies, and utilization is near-ubiquitous among providers and key populations. Despite being so well connected; identifying, reaching and linking vulnerable populations to HIV clinical services remains a global challenge. This review highlights the emerging online-to-offline (O2O) models, their potential in scaling up services, and evaluating impact, and implications for future research.

RECENT FINDINGS

Globally, four major types of O2O models have been implemented, primarily in the West and Asia, especially among MSM and transgender women. These models have varying levels of impact in terms of reach, engagement, participation, linkage, and ability to track and monitor participants, and assess outcomes. Those integrated with offline sites enable seamless transition, dramatically reduce the O2O linkage time and demonstrate high linkage success (>73%). O2O models are ideal for at-risk, stigmatized, criminalized populations and for scaling-up biomedical prevention interventions such as preexposure and postexposure prophylaxis.

SUMMARY

O2O models represent novel and powerful solutions to reverse the pandemic and could help fill significant programmatic gaps in tracking individuals through HIV cascades. Providers, especially in resource-limited settings, could choose between a variety of current approaches highlighted in this review and employ no-cost or cost-effective technologies to transform their traditional models and leverage O2O models.