Abstract
Introduction
The HIV prevention needs of women in Canada and beyond are of great concern, particularly, given the epidemic’s feminization. In this country, the proportion of female incident HIV infections has significantly and steadily increased since the epidemic began. 1 In the province of Quebec, cases remain concentrated in men who have sex with men (MSM) and in Montreal; however, 23% occurred in women in 2013. 2 Heterosexual sex and injection drug use are their main sources of infection, with 64% of female cases in 2013 occurring among Haitian or sub-Saharan South African women. 2
While (opt-out) screening for HIV forms part of routine prenatal testing for Quebec women, testing services and practices among at-risk women are insufficient and more needs to be done to increase access and uptake. 3 Almost two-thirds (63%) of newly diagnosed women (vs 41% of newly diagnosed men) in Quebec had never previously tested for HIV in 2013. 2 Furthermore, it is estimated that among the roughly 18 000 HIV-positive individuals nationwide who were unaware of their status in 2011, a larger proportion of those exposed through heterosexual sex did not know their status (34%), than MSM (20%) or injection drug users (24%). 4
While women’s health is affected by multiple, intersecting factors, gender is recognized as a determinant of health that profoundly influences women’s vulnerability to HIV, including their access to testing. Hence, women are reported to have both diverse and unique HIV prevention needs.5,6 Women’s barriers to HIV testing include perceptions of risk (by women themselves or their health care provider), confidentiality-related concerns, discrimination and stigma, work and family roles, insufficient education and information about HIV/AIDS, testing and service provider training/capacity, as well as the availability of rapid and anonymous testing.5,7
On this last point, in the effort to facilitate access to HIV testing in developed countries, rapid testing in nonclinical settings has multiplied, 8 including in Canada, 9 with many initiatives oriented to MSM. 10 Interestingly, HIV testing programs targeting MSM or members of the LGBT (lesbian, gay, bisexual, and transgender) community, can attract heterosexuals.11-13 Little research has attended to heterosexual clients who use such services or to their motives for doing so.
This study focuses on the “heterosexual” female clientele of a rapid HIV testing site, Actuel sur Rue (AsR), located in Montreal’s gay village (Quebec, Canada). Among clients reporting only opposite-sex partners, it aims to describe the women through comparison with men to better understand their presence at AsR and how HIV prevention and sexual health services could reflect their needs.
Methods
This descriptive, cross-sectional study uses questionnaire data collected between July 2012 and November 2013 during a pilot intervention project (AsR) that aimed to provide select tests (rapid HIV/standard HIV/syphilis/hepatitis C), vaccines (hepatitis A/B) and linkage to care, particularly to Montreal MSM. AsR is located close to a francophone university and its area is characterized by both commercial and residential zones. It is also near several “hot spots” for sex, sex work, and drug consumption (eg, bathhouses, in a neighborhood with among the highest rates of prostitution in Montreal). AsR clients were served by community worker/nurse pairs who collected information from them in 2 ways with an electronic tablet. To evaluate eligibility for the rapid HIV test and service needs, the community worker and nurse independently completed a questionnaire on the client’s sexuality, drug use, and reasons for seeking HIV testing, specifying the services provided. Additionally, clients filled out a self-administered questionnaire for research purposes only. It focused on sociodemographics, HIV risk, health, their visit at AsR, and pre- and postexposure prophylaxes (PrEP/PEP). The questionnaires were based on data collection tools used at the partner clinic, l’Actuel Medical Clinic, as a part of patient care; developed specifically for this study; or inspired by measures identified in the literature, particularly as concerns client motives14,15 and PrEP/PEP. 16
A private firm (Veritas, Montreal) provided the ethics approval for AsR and its research. Clients consented to the use of their data for research purposes and received no compensation.
Among clients with both staff- and self-collected data, nontransgendered women reporting only male partners and men reporting only female partners were compared along sociodemographics; HIV-related behaviors; how they heard about AsR; their reported motives for visiting AsR (ie, reasons for choosing AsR, for the visit, and for seeking testing); and health service provision (ie, having a regular doctor, seeing the nurse at AsR, receiving a rapid HIV test at AsR, results of this test, being linked to care by AsR, nurse-reported reasons for linkage and the location of linkage).
The groups were compared with chi-square, Fisher’s exact and Kruskal-Wallis tests, as appropriate. Tests were 2-tailed and significance was set at P ≤ .05. The software R (R Foundation) was used for data analysis.
Results
AsR received 1901 clients, 1636 of which had both staff and self-completed questionnaire data. To create the “heterosexual” groups, we excluded 41 transgendered persons, 2 men reporting only transsexual partners, 10 men who did not specify the sex of their partners, and 15 respondents for missing data. Among the remaining 1568, 64 (4.1%) were female. Nine women were excluded either because they reported both male and female partners (6) or only female partners (3). A total of 55 women and 147 men were included.
Table 1 presents most results of the comparative analyses. Women were significantly younger than men (mean age = 30.1 vs 35.7 years, P = .005). No other significant differences were found in the sociodemographic variables, the HIV-related practices considered or in how the groups learned about AsR. While no significant group difference was seen in place of birth, among those born outside of Canada and specifying their birthplace, 7/19 women (36.8%) were from an HIV-endemic country (Africa = 2; Caribbean = 4; Asia (Thailand) = 1) compared with 6/43 of men (14.0%; Africa = 3; Caribbean = 3). The groups most frequently learned about AsR through l’Actuel Medical Clinic’s website (women 25.4%, men 32.7%); a friend (women 18.1%, men 12.9%); the website of Fugues, a LGBT magazine in Montreal (women 9.0%, men 14.3%); or when passing by (women 9.0%, men 13.6%).
Comparative Analyses of Women (n = 55) and Men (n = 147) Who Reported Only Opposite-Sex Partners and Used a Rapid HIV Testing Site Located in Montreal’s Gay Village (Actuel sur Rue). a
Abbreviations: CAD, Canadian dollars; LGBT, lesbian, gay, bisexual, and transgender; STI, sexually transmitted infection; STIBBI, sexually transmitted and blood-borne infections.
Values in boldface indicate statistical significance (P ≤ .05).
Staff-completed measure.
On motives for vising AsR, 3 variables proved significant. First, a greater proportion of women than men chose AsR for the convenience of not having to make an appointment. Second, a significantly smaller proportion of women reported visiting AsR to receive syphilis testing. Finally, proportionately more women sought testing because of a condom failure. Both groups mainly chose AsR for the rapid test results, visited it to receive rapid HIV testing, and sought testing due to unprotected vaginal sex.
On health service provision, one result was significant: Proportionately more women than men reported not having a regular doctor. Similar proportions saw the nurse at AsR, received the rapid HIV test, and were linked to a medical clinic, especially, to receive complete STI testing. Among those linked, linkage was to l’Actuel Medical Clinic for about two-thirds of each group.
Given the significant group difference in age, age-adjusted logistic regression analyses were performed on the 4 significant variables. While visiting AsR for a syphilis test (odds ratio [OR] = 0.41, P = .039), choosing AsR for reasons of convenience (OR = 2.13, P = .025) and seeking testing for condom failure (OR = 4.42, P = .005) remained significant, having a regular doctor did not (OR = 1.82; P = .074). Furthermore, as we performed many statistical tests (39), we corrected for multiple testing using the Benjamini-Hochberg approach to control false discovery rates. 17 Once this control was applied, none of the tests reached significance at P ≤ .05. The 4 variables that were initially found to be significant had an adjusted P value of about .40 meaning that we could expect 1 or 2 of them to be false positives.
Discussion
This study aimed to better understand the presence of “heterosexual” female clients at Actuel sur Rue, an HIV checkpoint targeting Montreal MSM, by comparing women and men with only opposite-sex partners. The results suggest many similarities between these “heterosexual” client groups in terms of sociodemographics, HIV-related behavior, ways of learning about AsR, and motives for visiting it. They also suggest that the groups received equal access to the nurse, the rapid HIV test, linkage, and to the clinics available for linkage. The reasons provided by staff for linkage were also similar.
Several potential differences were, however, observed. A greater proportion of women sought testing due to condom failure. While it is possible that “heterosexual” men are more reluctant to admit condom failure, independent of other factors that can affect infectivity, women are at greater risk of acquiring HIV than men during unprotected vaginal sex with an HIV-positive partner14,18 and this could make condom failure a greater cause of concern to them. As to the proportionately fewer women visiting AsR for syphilis testing, almost all cases of this disease in Quebec occur among men 19 ; women may thus feel less at risk.
The greater proportion of women without a regular doctor (44%), almost 4 times a national estimate for heterosexual women (12%), 20 underscores AsR’s ability to attract clients with weaker ties to health care and the relevance of providing linkage services at rapid testing sites. Through them, roughly half of the “heterosexual” groups were referred to Montreal clinics to allow more of their sexual health issues to be addressed, most often screening for sexually transmitted and blood-borne infections.
“Heterosexual” clients were drawn to AsR mainly by the appeal of receiving rapid results and, especially for women, the convenience of the no-appointment format. The gay-friendliness of the venue or an aversion to medical facilities had little bearing on their apparent pragmatic choice of AsR. Along these lines, same-day results and testing without an appointment were identified as system-level facilitators in a review of factors affecting HIV testing and counseling among heterosexuals in Canada and the United Kingdom. 21 Furthermore, another review suggests that rapid HIV testing may be preferred to standard testing largely because of quick access to results. 22 As to the drop-in format, women’s work and care-giving responsibilities can affect access to services 5 and it may be more accommodating to busy or unpredictable schedules. Given the importance of adapting HIV prevention services to women’s needs, 5 increased availability of no-appointment rapid testing may offer one way forward.
Finally, approximately 3% and 9% of AsR clients were “heterosexual” women and men, respectively. While observed in other gay community testing centers, 11 the reason for this overrepresentation of men is unclear. One possibility is that AsR attracted heterosexual men working at local businesses that cater to gay men.
Conclusions
This innovative study focused on the small “heterosexual” female clientele of an MSM-oriented community-based rapid HIV testing site in Montreal. Its limitations include missing data, especially in staff-completed measures, insufficient information to offer a more in-depth gender-based analysis (eg, on caregiving responsibilities) and the small sample of women, which likely reduced the power to detect significant differences between the “heterosexual” groups. These groups showed many similarities. Nevertheless, further investigation is warranted into the results that point to the particular importance to women users of such rapid HIV testing sites of the drop-in format and their possible lesser access to regular care, which would make offering linkage services all the more relevant. Motivations to test for HIV and where are affected by multiple interpersonal and extrapersonal factors that could be explored with qualitative research into individuals’ lived experience around HIV testing. 23 This would help further explain women’s presence at such sites and advance knowledge on how to better adapt HIV prevention and sexual health services to women’s needs.
Footnotes
Acknowledgements
The authors thank AsR study participants and staff as well as Sahir Rai Bhatnagar for statistical assistance.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Actuel sur Rue was made possible with funding from l’Actuel Medical Clinic. D. Lessard holds an Interdisciplinary Postdoctoral Award from Canada’s Health Research Foundation. B. Lebouché is supported by a Research Scholar Award of the Quebec Research Funds in Health (FRQS).