Dried blood spot testing at community-based locations

What is the program? 

PEERS Alliance offers dried blood spot (DBS) testing for HIV, hepatitis C, hepatitis B and syphilis specifically for the Two-Spirit, gay, bisexual, trans and queer (2SGBTQ+) communities in Charlottetown, P.E.I. This is done through an external partnership with an ordering provider (registered nurse) and a program coordinator who performs the test at community-based locations (e.g., the PEERS Alliance office).

This program is run by PEERS Alliance, whose mandate is to support those living with and at risk for HIV, hepatitis C and all other sexually transmitted and blood-borne infections (STBBIs) by offering a variety of programs and services targeted to diverse communities.

Why was the program developed? 

The DBS testing program was developed to reduce barriers to testing by providing an alternative means of STBBI testing for 2SGBTQ+ communities. Barriers to STBBI testing in P.E.I. can include lack of access to sexual health clinics and healthcare providers, as well as stigma associated with sexual health and STBBIs. In addition, the lack of separation between healthcare providers and community members in rural and small communities can make it difficult for people to obtain care anonymously.

To address these barriers, an approach to testing was developed to try to keep testing results anonymous (i.e., having different people provide the test and complete follow-up). The DBS program also helps to increase the accessibility of testing outside of overburdened sexual health clinics by providing DBS testing at community-based locations (e.g., the PEERS Alliance office).

How does the program work? 

DBS testing is offered for confirmatory testing for HIV, hepatitis C and hepatitis B and for screening for syphilis. Participants can either walk into a community-based location (e.g., the PEERS Alliance office) or call, text or email the program coordinator to make an appointment for testing. Testing is offered on-site at the PEERS Alliance office two days per month and occasionally at other community-based locations (e.g., events). The program is promoted through the PEERS Alliance website, posts on social media that promote testing days and posters at medical and sexual health clinics.

When a participant arrives for walk-in testing or contacts the program to make an appointment, they are provided with a pre-test intake form to complete. The intake form is used to collect contact information for follow-up if there is a positive test result. The form collects the person’s name, pronouns, phone number, email address and emergency contact information. After participants complete the intake form, they are asked to sign a governing law and jurisdiction agreement and fill out the required portion of the provincial laboratory requisition. These forms are required by the ordering provider (i.e., registered nurse) to complete testing. All forms require a signature.

After completion of the paperwork, the program coordinator discusses testing options with the participant. Participants may do an HIV self-test with the assistance of the program coordinator or DBS testing, which can be used to confirm an HIV, hepatitis C or hepatitis B infection or serve as a screening test for syphilis. The type of testing done depends mainly on a participant’s preference; the decision also involves factors such as the waiting times for results. The HIV self-test provides immediate (same-day) results, whereas DBS test results can take four to six weeks. In making their decision, people can also consider the window period, which is typically shorter for DBS testing than for the HIV self-test. Regardless of which test a person chooses to do on-site, they can also request HIV self-test kits to take home.

If the participant opts for DBS testing, the program coordinator collects the DBS sample. Each DBS testing appointment takes approximately 20 minutes.

After a DBS test, the participant is asked to stay for 10 minutes to ensure that the blood in the finger prick clots and to give them a chance to rest (participants are given juice and a cookie while they wait). This also gives the program coordinator time to provide post-test information, including sexual health information and information on follow-up in the event of a positive test result. Post-test conversations include:

• the accuracy of DBS testing
• the four- to six-week waiting period for DBS test results
• information on who will have access to the test results, including the fact that the program coordinator will not have access to the results (to alleviate any privacy concerns)
• the fact that those with a positive test result will be contacted directly by the ordering provider (i.e., registered nurse)
• the fact that the ordering provider will help those with a positive test result to link to care and complete any required follow-up (e.g., contact tracing)
• information on how to access mental health services (e.g., Health PEI mental health walk-in clinic)
• information on how to access confirmatory testing for other STBBIs
• STBBI prevention best practices (e.g., vaccinations, pre-exposure prophylaxis, condom use)

All participants receive a resource package when they are tested. This includes:

• Access to STBBI Testing on PEI pamphlet (see Program materials section)
• HIV Pathways to Care and Prevention pamphlet (see Program materials section)
• Health PEI Mental Health and Addictions Access Line card
• safer sex kit
  • two condoms
  • one lube
  • one dental dam
  • one safer sex booklet
• The program coordinator’s contact information in case of any follow-up questions

The program coordinator brings samples to the local laboratory the day after they are collected. The local laboratory forwards them to the National Laboratory for HIV Reference Services (NLHRS) as needed.

Ordering provider

The DBS testing program has an established connection with a local clinical provider (registered nurse) who acts as the ordering provider and signs off on the testing requisition forms for the DBS tests, receives the test results and follows up with people if they have a positive result. When following up, the nurse provides information and counselling and refers/links participants to appropriate providers.

Pathways to care

The program worked with the Chief Public Officer of Health for P.E.I. to develop the following referral pathways:

• People who test positive for HIV are referred to a specialist HIV care provider.
• People who test positive for hepatitis C and/or hepatitis B are referred to the provincial hepatitis C program.
• A person with a reactive syphilis screening test is referred to the Sexual Health, Options & Reproductive Services (SHORS) clinic for confirmatory testing.

Training

Staff at PEERS Alliance were trained to administer DBS tests by one of the following:  Community-Based Research Centre, the National Laboratory for HIV Reference Services (NLHRS) or the P.E.I. provincial laboratory. Any PEERS Alliance staff member who wants to administer DBS testing must be trained by one of these providers or the program coordinator.

Required resources 

• One or more staff members trained in DBS testing
• DBS testing materials
  • Testing cards
  • Lancets
  • Sterile wipes
  • Disposal container
• A resource package that includes pamphlets on testing and care for STBBIs, information on community organizations for referrals and a safer sex kit (condoms, lube, dental dam, safer sex booklet)
• A laboratory (provincial or national) able and willing to analyze the DBS tests
• An ordering provider willing to sign the requisition forms and perform follow-up for participants with positive test results, including linkage to care
• A space to perform the DBS tests
• Referral pathways to connect participants to the care they need after testing

Evaluation

During the initial phase of the program (October 2023 to March 2024), 50 DBS tests were performed by one program coordinator. In the future, the program plans to expand its promotion and attend additional events for community-based testing.

Challenges

• Finding an ordering provider was a challenge because of a lack of capacity among public health nurses and other clinical staff in the province.
• Funding for DBS testing can be a challenge as offering this service requires staff time and DBS testing supplies, which can be costly.
• It can be a challenge to build community trust, which is needed to ensure that people feel comfortable utilizing tests, especially in small communities.
• There can be bureaucratic hurdles if the governing health authority does not have a process in place for DBS testing. This may require building relationships with an ordering provider and the creation of a pathway for follow-up and linkage to care after DBS testing.
• For a community-based organization that does not have its own trained clinical staff, it can be challenging to build trust with other clinical providers.

Lessons learned 

• Leveraging resources from multiple projects and community connections can be beneficial in helping to secure an ordering provider. By partnering with a local college, the DBS testing program was able to offer presentations for their staff and in turn utilize their nurse as an ordering provider.
• Using an online scheduling app can help decrease the time spent scheduling appointments. This can free up staff to spend more time performing tests and interacting with participants.
• Performing run-throughs of the process with friends or colleagues before the clinic goes public can help program organizers to gather information on how the process works and what people are comfortable with.
• Building trust in the community takes time and dedication and is essential to ensuring that community members are comfortable with the program and will utilize it.
• Program staff should ensure they are comfortable with saying "I don’t know" or "you should talk to a doctor about that" if they are not a healthcare provider and don’t know how to answer a question. It is important to refer participants to other service providers, clinical or otherwise, as needed.

Program materials

• Access to STBBI Testing on PEI pamphlet front
• Access to STBBI Testing on PEI pamphlet back
• HIV Pathways to Care and Prevention pamphlet front
• HIV Pathways to Care and Prevention pamphlet back
• Social media post
• DBS registration form

Contact information 

Scott Alan (they/them)
Program coordinator
PEERS Alliance
250 B Queen Street
Charlottetown, PE C1A 4B8
Scott@peersalliance.ca
902-388-7837