“So much other stuff going on”: Factors influencing syphilis and STBBI testing among street-involved communities in Kingston, Ontario

OBJECTIVE: Syphilis is a re-emerging public health threat in Canada, disproportionately affecting street-involved communities. This qualitative study aimed to identify the multilevel factors influencing access to timely syphilis testing among people who are street-involved in Kingston, Ontario. METHODS: Using an interpretive description approach, we conducted in-depth, semi-structured interviews with clients of local harm reduction and housing services and focus groups with community-based organization service providers to explore their perspectives surrounding factors influencing syphilis and sexually transmitted and blood-borne infection (STBBI) testing decisions. Interviews were audio-recorded, transcribed, coded using NVivo, and analysed using reflexive thematic analysis within the socio-ecological framework. RESULTS: A total of 23 individuals were included: 16 clients and 7 providers. A majority of clients identified as being un(der)housed (n = 13) and/or people who use drugs (n = 10), with a median age of 26 years. At the structural and systems level, institutional broken trust, availability of testing services and information, and transportation emerged as salient factors influencing access to testing. Social- and community-level factors included the influence of trusted providers, close social networks, and privacy and confidentiality. Knowledge level, perceived risk, competing priorities, and testing preferences also influenced testing decision-making. CONCLUSIONS: Our findings highlight the complexity of the multilevel factors that influence syphilis testing decisions among street-involved communities. Clients' and providers' concordance in their emphasis on socio-structural factors underscores the necessity of shifting the onus of syphilis testing uptake beyond the individual level, and implementing models of care that address barriers and structural interventions that address root causes.