The Northern, Remote and Isolated Indigenous Communities Initiative: Community-based testing from COVID-19 to HIV and STBBI

Access to HIV and STBBI testing

Laboratory testing for HIV and other sexually transmitted and blood-borne infections (STBBI) can be inaccessible to certain populations such as northern, remote and isolated Indigenous (NRI) communities. This is due to several factors, such as:

• lack of access to a healthcare provider
• the need to travel to centralized testing facilities
• long wait times to receive results
• concerns about confidentiality and stigma

Decentralized, community-owned, community-based testing (CBT) and health services help address these factors and reduce historical health inequities faced by people living in NRI communities throughout Canada. Providing a variety of innovative testing options can be particularly useful for reaching the undiagnosed by offering greater accessibility, privacy and convenience, as well as by reducing the stigma associated with accessing conventional methods of HIV and STBBI testing.

Establishing a community-based testing program

At the beginning of the COVID-19 pandemic, when global testing supplies were extremely limited, scientists from the Public Health Agency of Canada’s National Microbiology Laboratory (NML) identified the need for a mechanism to support NRI populations. The NML worked with partners at the Canadian Public Health Laboratory Network to publish a position statement about prioritization of testing supplies for these communities.

The NML worked to secure a supply of COVID-19 tests and instruments that were authorized for use by Health Canada as point-of-care diagnostic tests. The lab team then developed materials to support non-laboratory personnel to use the tests, including user-friendly, plain-language training plans for each test. Training materials also included:

• videos
• printed quick reference guides
• standard operating procedures 

To provide further support, the NML engaged with community members and leaders to talk about the tests and answer questions about their use.

Expanding the community-based testing network

The NML worked closely with Indigenous Services Canada (ISC) and provincial/territorial (P/T) public health laboratory systems to coordinate on reporting of results, biosafety considerations and linkages to care.

After the initial instrument-based testing and training had been established, the program evolved to include rapid antigen detection tests (RADTs) and modified sampling, including nasal or oral swabs and saliva/spit/gargle specimens. Specimen collection by trained peers evolved to self-collected specimens for some tests. 

Over the course of 32 months, the NRI initiative helped establish a testing network that provided more than 3 million tests at more than 400 sites. The NML continues to evaluate new tests and provide ongoing quality oversight for sites implementing CBT.

Expanding from COVID-19 testing to HIV and STBBI testing

In the summer of 2022, conversations with different partners identified how this CBT network could be sustained and expanded beyond COVID-19 to address the priorities of communities for other types of testing and health transformation services. Many communities were requesting information about testing for STBBI, including HIV, hepatitis C and syphilis. One of the priorities identified by community leadership during these discussions was that they be able to direct the expansion of testing in their communities.

On August 1, 2022, the Honourable Jean-Yves Duclos, Federal Minster of Health, announced $9.9 million of funding support for reaching the undiagnosed for HIV in NRI communities. Bolstered by this funding, the goals of the NRI initiative going forward are to expand the testing already taking place in NRI communities to include options for HIV/STBBI testing, and to implement CBT in additional communities who have not yet begun the process. The testing toolbox will include:

• GeneXpert-based molecular testing
• rapid point-of-care/self-tests
• collection of dried-blood-spot specimens for laboratory-based testing services 

The Government of Canada is supporting Indigenous healthcare transformation by ensuring that Indigenous communities take the lead on deciding how funds will be used to support CBT activities. The focus is also on maintaining the progress that evolved during the COVID-19 pandemic in order to support NRI citizens’ access to STBBI testing, including HIV. Funding will also support health human resources for NML staff to support the testing services, including training and ongoing quality oversight. 

The future of the NRI initiative

As NRI communities plan for the future, they will be able to work closely with the NML, ISC and P/Ts to develop a strategic plan for the governance, expansion and sustainability of the CBT network. This will bring together key priorities for supporting health services in communities, including wastewater surveillance, harm reduction initiatives and wrap-around care for communicable and non-communicable diseases affecting citizens living in NRI communities.

 

Adrienne Meyers, PhD, is currently on secondment with Indigenous Services Canada as the director of laboratory integration in the Office of Population and Public Health. Prior to that she was the associate director of the National STBBI Laboratory Division for Underserved Population Health at the National Microbiology Laboratory Branch of the Public Health Agency of Canada. She is also adjunct professor in the Department of Medical Microbiology and Infectious Disease at the University of Manitoba and adjunct professor in the Department of Medical Microbiology at the University of Nairobi. Meyers’ most recent work has focused on directing the development of innovative HIV and STBBI testing strategies and facilitating their use by vulnerable and underserved populations in Canada. During the COVID-19 response, Meyers has worked with Indigenous leadership to implement community-based testing, reduce health inequities and strengthen access to diagnostic testing as part of the Northern, Remote and Isolated initiative.

Paul Sandstrom, PhD, is the director of the National HIV and Retrovirology Laboratories, Public Health Agency of Canada (PHAC). In this role, he has been responsible for planning, directing and managing laboratory research, surveillance and clinical testing programs as part of the Federal Initiative on HIV/AIDS. Sandstrom frequently serves as an advisor to the World Health Organization on laboratory programming pertaining to HIV drug resistance genotyping and sequencing. During the COVID-19 response, Sandstrom has worked with Indigenous leadership to implement community-based testing, reduce health inequities and strengthen access to diagnostic testing as part of the PHAC Northern, Remote and Isolated (NRI) initiative.