Sexually transmitted and bloodborne infections testing among people who use substances: findings from the 2023 British Columbia Harm Reduction Client Survey

Sexually transmitted and bloodborne infections testing among people who use substances: findings from the 2023 British Columbia Harm Reduction Client Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sexually transmitted and bloodborne infections testing among people who use substances: findings from the 2023 British Columbia Harm Reduction Client Survey Amrit Tiwana, Katherine A Twohig, Mieke Fraser, Brooke Kinniburgh, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8436044/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Feb, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 9 You are reading this latest preprint version Abstract Background People who use substances (PWUS) experience disproportionately higher burden of sexually transmitted and bloodborne infections (STBBIs) compared to the general population. Harm reduction supply distribution sites are recognized as potential access points for STBBI testing among PWUS. However, little is known about the uptake of STBBI testing among PWUS who access these sites. This study aimed to identify factors associated with recent STBBI testing among PWUS accessing harm reduction sites. Methods We analyzed cross-sectional data from the 2023 Harm Reduction Client Survey in British Columbia, Canada, which included 433 respondents across 23 sites. Sociodemographic, substance use, and harm reduction-related factors associated with recent testing (previous 12 months) for HIV, hepatitis C virus (HCV), or syphilis were examined. Adjusted risk ratios (aRRs) and corresponding 95% confidence intervals (CIs) were estimated using Poisson regression with robust standard errors. Analysis and interpretation were guided by people with lived or living experience of substance use and/or STBBIs. Results Over one-third of respondents (38%) had not been tested for an STBBI in the previous 12 months. Those participating in smaller communities (aRR = 0.7; 95% CI: 0.48, 1.03), from health regions outside Vancouver Coastal (Fraser Health aRR = 0.66; 95% CI: 0.43–1.02), and women (aRR = 0.85; 95% CI = 0.64, 1.12) were less likely to have been recently tested. Participants prescribed alternatives to the toxic drug supply (aRR = 1.21; 95% CI: 0.93, 1.59) were more likely to report recent testing. Among those who reported a previous STBBI test, either within the previous 12 months or earlier (n = 281), HIV testing was the most common (93%), followed by syphilis (88%) and HCV (83%). Nearly one-quarter (23%) of respondents did not know their test results. The majority of respondents (73%) expressed interest in accessing STBBI self-testing kits through harm reduction sites. Conclusions Many PWUS accessing harm reduction sites reported no recent STBBI testing, particularly women and those outside large urban centres. Distributing self-testing kits through these sites could potentially help reduce the disproportionate burden of STBBIs among PWUS and contribute to progress toward eliminating STBBIs as a public health threat. Clinical trial number: Not applicable. epidemiology harm reduction people who use substances HIV Hepatitis C syphilis self-testing Figures Figure 1 Figure 2 Introduction Background Sexually transmitted and bloodborne infections (STBBIs), including human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis, are a significant global public health concern ( 1 ). These infections contribute to substantial morbidity and mortality, with serious long-term health consequences if left undiagnosed and untreated ( 2 , 3 ). For instance, STBBIs are responsible for an estimated 2.5 million deaths and 1.2 million cases of cancer worldwide each year ( 1 ). Increased testing efforts support early detection and timely treatment, which will reduce transmission and advance progress towards the World Health Organization’s (WHO) goal of eliminating STBBIs as a public health threat by 2030. The disproportionate burden of STBBIs experienced by people who use substances (PWUS) highlights the ongoing health disparities within this population. Global trends show a rising prevalence of unregulated substance use, with the proportion of people aged 15 to 64 who used unregulated substances increasing from 5.2% in 2013 to 6% in 2023 ( 4 ). This heightened exposure is reflected in STBBI outcomes, as the global median HIV prevalence among PWUS in 2021 was seven times higher than in the general adult population aged 15 to 49 ( 5 ). In British Columbia (BC), Canada, nearly half (45%) of people diagnosed with HCV in 2015 were PWUS, who also accounted for 80% of new HCV cases ( 6 ). In Alberta, Canada, 42% of individuals diagnosed with syphilis in 2022 reported unregulated stimulant use ( 7 ). These findings demonstrate the disproportionate impact of STBBIs among PWUS both globally and within Canada. Multiple factors contribute to the increased prevalence of STBBIs among PWUS. Sharing substance preparation and use equipment, including needles, syringes, and pipes, increases direct transmission risk ( 8 , 9 ). Unregulated substance use has also been associated with a greater likelihood of engaging in condomless sex and having multiple sexual partners ( 10 ). When access to prevention strategies such as condoms or biomedical interventions like HIV PrEP is limited, condomless sex with multiple sexual partners further heightens exposure risk. These risk factors are particularly concerning among young adults and men, as evidence indicates high rates of unregulated substance use in these groups and associations with increased STBBI incidence ( 11 ). Beyond transmission risk factors, PWUS often face barriers in accessing STBBI testing due to intersecting social determinants of health. These barriers include stigma, discrimination, limited health literacy, fragmented healthcare systems, unstable housing, digital exclusion, and complex health and social needs ( 12 – 16 ). For instance, moralized views of substance use and STBBIs ( 13 ), negative healthcare encounters ( 12 ), limited healthcare provider training on addiction ( 15 ), and challenges maintaining contact with providers ( 16 ) can all make it difficult for PWUS to access STBBI testing. Pilot initiatives in BC have found that low-barrier, community-based approaches, such as point-of-care HCV testing in observed consumption spaces, can increase testing uptake among PWUS ( 17 ). Addressing these gaps through strategies that reduce structural barriers and account for intersecting social determinants of health are critical to improve testing access and STBBI outcomes for PWUS. Harm reduction services play an important role in supporting PWUS with appropriate, safe care and support. Harm reduction is often delivered in community-based, low-barrier settings to provide essential services such as access to sterile syringes, safer smoking supplies, observed consumption spaces, naloxone kits, and substance checking tools for PWUS. This may include sites called overdose prevention or supervised consumption sites (OPS/SCS), where people can consume unregulated substances under the supervision of trained staff. Harm reduction services and programs also operate out of shelters, health clinics, support societies, or substance use organizations, though additional services vary by location ( 18 ). Considering the effectiveness of harm reduction services in supporting PWUS, the inclusion of STBBI testing at these sites represents a promising and emerging strategy to address STBBI vulnerabilities ( 19 ). Providing testing in these settings is especially important for PWUS who may face stigma, discrimination, or structural barriers when accessing traditional healthcare services. Purpose and aim While there is a great deal of literature characterizing and examining STBBI risk among PWUS, there is very little research examining predictors of STBBI testing – a critical step in the prevention and care continuum. This study investigated factors associated with recent STBBI testing among clients of harm reduction sites across the Canadian province of BC. By identifying testing barriers and facilitators, this study aims to contribute to the existing literature on unregulated substance use and STBBI prevention while informing targeted interventions that promote testing uptake among PWUS. Strengthening early detection contributes to minimizing transmission, improving linkage to treatment, and ultimately reducing the burden of STBBIs in populations most at risk. Methods Study design and participants This analysis used data from the 2023 iteration of the BC Harm Reduction Client Survey (HRCS), a cross-sectional survey conducted by the BC Centre for Disease Control (BCCDC) Harm Reduction and Substance Use Services within the Population and Environment Health team (2023 University of British Columbia Research Ethics Board # H23-02685). Established in 2012, the HRCS is a key instrument used to monitor substance use trends, guide harm reduction planning, and address emerging topics of interest related to harm reduction services in BC. The survey is administered annually and updated periodically to address emerging public health issues such as the rise in fentanyl-related overdose deaths ( 20 ) and decriminalization ( 21 ). Detailed descriptions of data collection methods for previous iterations have been published elsewhere ( 22 , 23 ). The 2023 survey was administered at 23 harm reduction sites across the province (Fig. 1 ) ( 24 ). The surveyed sites include a broad range of service settings, including OPS/SCS, mental health and substance use centres, community-based health and social service organizations, shelters, and supportive housing sites. Sites were strategically selected to ensure geographic diversity, with intentional oversampling in regions outside the urban centres in the lower mainland of BC to better capture provincial variations in substance use and service access. A convenience sample of people accessing harm reduction services was recruited, meaning participants were selected by trained staff members based on their availability and willingness to participate at the time of data collection. The survey gathered detailed information on participants’ demographics, substance use patterns, use of harm reduction services, and overdose experiences. The 2023 iteration was the first to include questions on STBBI testing, providing a novel opportunity to examine barriers and facilitators to testing among PWUS accessing harm reduction (see page 9 of survey instrument) ( 25 ). Participants were eligible for the survey if they were 19 years of age or older and self-reported using illicit substances in the past six months. Eligible illicit substances included those obtained from the unregulated market or considered unregulated, such as opioids/down, heroin, fentanyl, cocaine, crack, methamphetamine, and hallucinogens. The survey was conducted in English using a paper-based format and required approximately 20 minutes to complete. Participants received $ 20 CAD for their time, and survey administration sites were provided $ 5 CAD per participant to support additional incentives, survey-related supplies, or other related needs. Survey data were entered and stored in REDCap electronic data capture tools hosted at BC Children’s Hospital Research Institute. Data were extracted, cleaned, and analysed in R version 4.3.1 at BCCDC. Frequency tables were generated to facilitate data exploration in addition to the tables included in this paper. Engaging people with lived and living experience of substance use and STBBIs To ensure our research was grounded in the perspectives of people with lived and living experience (PWLLE) of substance use and STBBIs, we consulted with two advisory groups affiliated with the BCCDC. The Sexual Health Advisory Group (SHAG) includes PWLLE of STBBIs, and Professionals for the Ethical Engagement of Peers (PEEP) includes peer leaders representing PWLLE of unregulated substance use. PEEP have been actively involved in shaping the annual HRCS, providing input into survey questions, reviewing wording and response options, and helping prioritize key topics. We conducted three consultation sessions: two before the analysis to inform model building, and one after the analysis to guide the interpretation of results and implications. Each session lasted approximately one hour and was conducted via Zoom. Each session included a PowerPoint presentation with a summary of results and guiding questions to facilitate discussion. The insights shared by PWLLE helped us better understand the survey’s strengths and limitations, shaping the analysis and interpretation, and ensuring the findings and recommendations had real-world relevance. Measures The outcome of interest was recent STBBI testing based on self-report of having been tested for HIV, HCV, or syphilis in the last 12 months . Participants were asked, “When was your most recent blood test?” with response options of in the last 12 months , more than 12 months ago , I don’t remember , I have never been tested or prefer not to say . The comparison group included those reporting more than 12 months ago or I have never been tested . Responses of I don’t remember, prefer not to say , and those left blank were categorized as missing. Two additional STBBI-related questions asked participants if they knew the results of their most recent test and whether they would be interested in STBBI self-testing kits offered through harm reduction sites. The additional two questions were included for descriptive purposes only and were not part of the primary statistical analysis. Other variables of interest were selected based on a review of the literature, consultations with PWLLE of substance use and STBBIs, and the availability of relevant variables in the survey dataset. Sociodemographic variables included self-reported: age (19–39 vs. ≥40 years), gender identity (male/man vs. female/woman) ( 11 ), and employment status (employed full-time or part-time vs. not employed) ( 26 ). Individuals who identified as transgender or gender expansive were excluded from this analysis due to small counts. Housing categories were combined to define ‘has regular housing’ (living in a private residence, band-owned home, hotel/motel, rooming house, single-room occupancy, or social/supportive housing) vs. ‘no regular housing’ (living in a shelter, being homeless or houseless, couch-surfing, living in a tent, or having no fixed address) ( 14 , 16 ). Additional variables included regional health authority of the site where the survey was completed (Vancouver Coastal vs. Fraser, Interior, Northern, or Island) and community size, classified by the population centre associated with the site’s postal code (< 30,000 vs. ≥30,000) according to the 2021 Canadian Census ( 27 , 28 ). We recognize that race and ethnicity are important considerations ( 29 ); however, these variables were not included in this analysis because further work is needed to establish appropriate governance mechanisms for the collection and use of these data ( 30 ). Many substance use and harm reduction-related variables were examined. Type of substance used in the last 30 days was assessed for all participants, including use of opioids, benzodiazepines, and stimulants ( 31 , 32 ). We assessed mode of substance use within the past six months, comparing those who used substances by injection (either exclusively or in combination with smoking) with those who did not inject (i.e., smoking only or other non-injection modes of use) ( 7 , 33 ). We also considered the following self-reported substance use behaviours or related experiences in the last six months: using drugs at an OPS/SCS ( 34 , 35 ); difficulty using drugs at an OPS/SCS ( 36 ); history of opioid or stimulant overdose ( 35 ); using drug checking tools ( 34 ); receiving prescribed alternatives ( 16 , 34 ); recent skin infections ( 37 ), ownership of a naloxone kit ( 34 ); and hesitation to access services needed to be healthy due to fear of others (i.e., family services, healthcare provider, friends or family, police, or employer) finding out about their drug use ( 36 ). All the substance and harm reduction-related variables were measured as binary outcomes (yes vs. no). Statistical analysis To address missing data across outcome, demographic, and predictor variables, which was generally < 10%, ( Table A.1 , Figure A.2 ), we used multiple imputation by chained equations (MICE) to generate ten imputed datasets. Descriptive statistics were calculated using complete cases, while regression analyses were based on pooled estimates across the ten imputed datasets using Rubin’s rules ( 38 ). Density plots for variables with more than 10% missingness showed good agreement between observed and imputed values ( Figure A.3 ). Any cross-tabulations that resulted in row or column totals with less than 20 participants were suppressed to align with the HRCS privacy protection protocol. Since the descriptive statistics were calculated using a sub-sample of complete cases, our statistics may differ slightly from summary statistics reported elsewhere ( 39 ). Multivariable regression models were built on the MICE imputed datasets using a purposeful selection approach ( 40 ). Least absolute shrinkage and selection operator (LASSO) regression guided variable selection, however, some variables considered theoretically important based on previous research, as well as those identified during consultations with PWLLE, were retained in the final model regardless of statistical significance. In addition, variables with a relaxed p-value threshold (p < 0.20) in univariable analyses were considered and selected based on the combination that provided the best statistical fit ( 41 ). Adjusted risk ratios (RR) and 95% confidence intervals (CI) for recent STBBI testing in the last 12 months were estimated using Poisson regression with robust standard errors. This regression model was chosen because our outcome of interest was common, and logistic regression would have produced odds ratios, which only approximate risk ratios when outcomes are rare (e.g., < 10%) ( 42 ). Analyses were conducted in R version 4.1.1 using packages including mice , lmtest , and sandwich . Results Of the 443 participants who participated in the 2023 HRCS, 158 (36%) had complete information in all required analysis fields ( Table 1a ). Among these complete cases, almost two-thirds (62%) reported being tested for an STBBI in the last 12 months (i.e., recent testers). Most participants were aged 40 or older (63.3%), identified as men (68.4%), and heterosexual or straight (86.1%). A large proportion were unemployed (77.3%), and more than half participated at harm reduction sites located in communities with populations of 30,000 or more (58.9%). Compared to those tested more than 12 months ago or who had never been tested, recent testers were more likely to be completing their survey at a site in the Vancouver Coastal Health and Island Health regions and in larger population centres. Table 1a. Sociodemographic characteristics of the study subsample with complete data for outcome, demographic, and predictor variables. Characteristic Tested for Sexually Transmitted and Bloodborne Infections In the last 12 months, n (% # ) More than 12 months ago or had never been tested, n (% # ) Total, n (% # ) Total 98 (62.0^) 60 (38.0^) 158 (100.0^) Age 19 to 39 40 or older 34 (34.7) 64 (65.3) 24 (40.0) 36 (60.0) 58 (36.7) 100 (63.3) Gender identity Male/man Female/woman Trans/gender expansive 67 (68.4) 26 (26.5) <20 & 41 (68.3) 17 (28.3) <20 & 108 (68.4) 43 (27.2) <20 & Sexual orientation Heterosexual/straight LGBQA+ 83 (84.7) 15 (15.3) 53 (88.3) 7 (11.7) 136 (86.1) 22 (13.9) Health authority Vancouver Coastal Fraser Interior Northern Island 23 (23.5) 18 (18.4) 12 (12.2) 19 (19.4) 26 (26.5) 5 (8.3) 14 (23.3) 13 (21.7) 16 (26.7) 12 (20.0) 28 (17.7) 32 (20.3) 25 (15.8) 35 (22.2) 38 (24.1) Housing % Has regular housing No regular housing 47 (48.0) 51 (52.0) 30 (50.0) 30 (50.0) 77 (48.7) 81 (51.3) Employment Work part-time or full-time Not employed 22 (23.7) 71 (76.3) 12 (21.1) 45 (78.9) 34 (22.7) 116 (77.3) Community size (population centres) Small (<30,000 people) Medium and large urban (≥30,000 people) 35 (35.7) 63 (64.3) 30 (50.0) 30 (50.0) 65 (41.1) 93 (58.9) Abbreviations: Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual plus (LGBQA+) # Column percentages ^Row percentages & Cross-tabulations that resulted in categories with <20 participants were suppressed to align with the survey privacy protection protocol. % Regular housing includes private residences, band-owned homes, or other residences (e.g., hotel/motel, single room occupancy, supportive housing). Those without regular housing reported no fixed place to stay (homeless, tent, couch-surfing) or living in a shelter. The most common substances that participants reported using in the last 30 days were stimulants (86.7%) and opioids (81.6%), and over half (51.9%) reported injection drug use in the last six months ( Table 1b ). Many participants were engaging with harm reduction services in the last six months: 71.5% had used drugs at an OPS/SCS, 53.8% had been prescribed alternatives to the toxic drug supply, and 81.6% owned a naloxone kit. Compared to those tested more than 12 months ago or who had never been tested, recent testers reported less concern about others finding out about their substance use and greater use of harm reduction services including using drugs at an OPS/SCS, receiving prescribed alternatives, and using drug checking tools. Table 1b. Substance use and harm reduction-related characteristics of the study subsample with complete data for outcome, demographic, and predictor variables. Characteristic Tested for Sexually Transmitted and Bloodborne Infections In the last 12 months, n (% # ) More than 12 months ago or had never been tested, n (% # ) Total, n (% # ) Total 98 (62.0^) 60 (38.9^) 158 (100.0^) Type of drugs used (last 30 days) Opioids Benzodiazepines Stimulants 83 (84.7) 43 (43.9) 87 (88.8) 46 (76.7) 18 (30.0) 50 (83.3) 129 (81.6) 61 (38.6) 137 (86.7) Mode of substance use (last six months) Injection drug use 54 (55.1) 28 (46.7) 82 (51.9) Harm reduction (last six months) Used drugs at an OPS/SCS Reported difficulties using drugs at OPS/SCS History of opioid or stimulant overdose Used drug checking tools Received prescribed alternatives Recent skin infection Owns a naloxone kit Fearful of others finding out about drug use 76 (77.6) 54 (55.1) 54 (55.1) 43 (43.9) 59 (60.2) 67 (68.4) 83 (84.7) 33 (33.7) 37 (61.7) 25 (41.7) 32 (53.3) 22 (36.7) 26 (43.3) 32 (53.3) 46 (76.7) 30 (50.0) 113 (71.5) 79 (50.0) 86 (54.4) 65 (41.1) 85 (53.8) 99 (62.7) 129 (81.6) 63 (39.9) Note: All variables are binary (yes/no), with "no" responses omitted. Percentages refer to the total N in each column. Abbreviations: Overdose Prevention or Supervised Consumption Site (OPS/SCS) # Column percentages ^Row percentages Multivariable regression analysis of recent STBBI testing Age, gender identity, health region, and mode of substance use were retained in the adjusted model due to their theoretical relevance through engagement with PWLLE and the existing literature. In addition, variables with p-values <0.20 in univariable analyses were considered in the adjusted model, which included using drugs at an OPS/SCS (p = 0.13), difficulties using drugs at an OPS/SCS (p = 0.17), receipt of prescribed alternatives (p = 0.15), and community size (p = 0.12). The final set of covariates included those with the best statistical fit while also retaining variables deemed theoretically important. The final model included the following covariates: age, gender identity, health region, community size, mode of substance use, and prescribed alternatives. None of the associations reached statistical significance with a nominal threshold of p=0.05; however, several associations were borderline statistically significant and may warrant further consideration. Participants from sites in smaller population centres were 30% less likely to have tested recently (95% CI: 0.48, 1.03), as were those from sites in the Fraser Health region compared to participants from sites in the Vancouver Coastal Health region (RR = 0.66; 95% CI: 0.43, 1.02) ( Table 2 ). Compared to men, women were 15% less likely to have been recently tested (95% CI: 0.64, 1.12). Participants who received prescribed alternatives were associated with a 21% higher likelihood of recent testing (95% CI: 0.93, 1.59). Table 2. Risk ratios of sexually transmitted and bloodborne infections testing in the past 12 months among harm reduction clients. Estimates were obtained from the MICE datasets using Poisson regression with robust standard errors. Characteristic Unadjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value Age 40+ years 19-39 years (Ref) 0.96 (0.74, 1.25) (Ref) 0.79 (Ref) 0.97 (0.74, 1.27) (Ref) 0.83 Gender identity Male/man Female/woman (Ref) 0.89 (0.68, 1.16) (Ref) 0.39 (Ref) 0.85 (0.64, 1.12) (Ref) 0.25 Sexual orientation LGBQA+ Heterosexual (Ref) 0.94 (0.69, 1.29) (Ref) 0.71 Health authority Vancouver Coastal Fraser Interior Northern Island (Ref) 0.74 (0.5, 1.1) 0.79 (0.52, 1.21) 0.76 (0.51, 1.12) 0.97 (0.67, 1.41) 0.39 (Ref) 0.66 (0.43, 1.02) 0.92 (0.59, 1.44) 0.85 (0.57, 1.29) 0.87 (0.58, 1.31) 0.46 Housing % No regular housing Has regular housing (Ref) 0.99 (0.83, 1.08) (Ref) 0.38 Employment Not employed Work part-time or full-time (Ref) 1.02 (0.76, 1.38) (Ref) 0.89 Community size (population centres) Medium and large urban (≥30,000 people) Small (<30,000 people) (Ref) 0.81 (0.62, 1.05) (Ref) 0.12 (Ref) 0.7 (0.48, 1.03) (Ref) 0.06 Opioid drug use* No Yes (Ref) 1.09 (0.79, 1.49) (Ref) 0.60 B enzodiazepine drug use* No Yes (Ref) 1.14 (0.89, 1.46) (Ref) 0.29 Stimulant drug use* No Yes (Ref) 0.92 (0.65, 1.30) (Ref) 0.64 Mode of substance use & Non-injection drug use only Injection drug use (Ref) 1.05 (0.81, 1.36) (Ref) 0.70 (Ref) 1.01 (0.78, 1.32) (Ref) 0.92 Used drugs at an OPS/SCS & No Yes (Ref) 1.24 (0.94, 1.63) (Ref) 0.13 Reported difficulties using drugs at OPS/SCS & No Yes (Ref) 1.19 (0.93, 1.54) (Ref) 0.17 History of opioid or stimulant overdose & No Yes (Ref) 1.04 (0.81, 1.34) (Ref) 0.75 Used drug checking tools & No Yes (Ref) 1.07 (0.84, 1.37) (Ref) 0.60 Received prescribed alternatives & No Yes (Ref) 1.21 (0.93, 1.57) (Ref) 0.15 (Ref) 1.21 (0.93, 1.59) (Ref) 0.16 Recent skin infection & No Yes (Ref) 1.11 (0.86, 1.43) (Ref) 0.43 Owns naloxone kit & No Yes (Ref) 1.14 (0.82, 1.58) (Ref) 0.44 Fearful of others finding out about drug use & No Yes (Ref) 0.91 (0.7, 1.17) (Ref) 0.46 Abbreviations: Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual+ (LGBQA+); overdose prevention or supervised consumption site (OPS/SCS) % Regular housing includes private residences, band-owned homes, or other residences (e.g., hotel/motel, single room occupancy, supportive housing). Those without regular housing reported no fixed place to stay (homeless, tent, couch-surfing) or living in a shelter. * Used substance in the last 30 days. & In the last six months. Additional STBBI testing results Among the 433 participants who completed the survey, 281 (65%) reported previous testing for any STBBI (HIV, HCV, or syphilis) either within the previous 12 months or earlier, with 208 (48%) reporting testing for all three infections ( Figure 2 ). Among those reporting a previous STBBI test (n = 281), 207 (74%) participants reported that the test was within the last 12 months. HIV was the most common test (93%), followed by syphilis (88%) and HCV (83%). Nearly one-quarter of participants who reported a previous STBBI test did not know their test results (23.5%). Out of 321 responses, 73% (n = 234) of participants were interested in accessing STBBI self-testing kits through harm reduction sites and 15% (n = 40) were possibly interested. Discussion Using data from the 2023 HRCS, this study examined factors associated with recent STBBI testing among harm reduction clients in BC, Canada. Our results showed that those participating in harm reduction sites outside of the Vancouver Coastal Health region and in small population centres were less likely to report recent STBBI testing, while those reporting greater engagement with harm reduction services, particularly prescribed alternatives, were more likely to report recent STBBI testing. To our knowledge, this is the first study to examine predictors of recent STBBI testing in the last 12 months among PWUS accessing harm reduction services. These findings highlight key gaps in service access experienced by PWUS in BC, undermining efforts to eliminate STBBIs in Canada by 2030. Although our results do not indicate statistically significant differences, our study’s findings of lower recent STBBI testing reported from those accessing harm reduction services outside large population centres align with the experiences of PWLLE and previous research demonstrating geographic disparities in STBBI testing uptake (27,28,43). Clients in rural and remote settings experience more limited healthcare service availability and higher levels of stigma; for PWUS, these may further overlap with vulnerabilities such as experiences of unstable housing, limited health literacy, sex work, and digital exclusion to create significant barriers in accessing care (15,16,44,45). STBBI self-testing is often proposed to improve testing uptake in underserved regions (45), and the high level of interest in self-testing observed in our study population suggests that this approach may be promising for some individuals. However, self-testing is found to have variable impacts on linkage to care (46). PWLLE reinforced this concern, noting that it has been challenging to distribute self-testing kits in the past, even among sexually active PWUS. They also cautioned that the high level of interest observed in this study may reflect social desirability bias. While self-testing, such as self-collection of dried blood spot specimens, has been found to improve STBBI testing and treatment uptake (47,48), further research is needed to identify effective and acceptable strategies for implementation among PWUS, including approaches that ensure reliable linkage to care. It was encouraging to find that all harm reduction-related variables considered in the analysis, although not statistically significant, were positively associated with recent STBBI testing (i.e., RR > 1). This aligns with previous research demonstrating harm reduction sites as critical, trusted points of healthcare access for PWUS that serve not only to reduce risks and harm associated with substance use, but also to promote referrals and connections to health and social services (19). For instance, a study using the 2021 HRCS found that individuals who accessed an OPS/SCS had twice the odds of receiving prescribed alternatives to the toxic drug supply compared to those who did not (18). While strengthening and expanding services through harm reduction sites holds promise for improving access to STBBI and other healthcare needs, doing so will require targeted investments to ensure site sustainability and support their frontline role in advancing public health. Recent findings from a provincial survey of harm reduction sites in BC highlight the growing strain on these services following the implementation of decriminalization (49). Many sites reported increased client demand, staffing pressures, and expanded resource needs, yet few received formal training or corresponding increases in operational funding. We observed participants that reported stimulant use were less likely to have been recently tested for STBBIs. Previous studies have similarly identified lower STBBI testing and diagnosis rates among people who use stimulants (32,33), alongside reduced engagement with healthcare services due to intersecting social determinants of health such as stigma, discrimination, and unstable housing (14,15). Stimulant use has been associated with increased injection drug use (50,51), sharing of drug preparation and use equipment (52), as well as higher-risk sexual behaviours such as engaging in unprotected sex and having multiple sex partners (53). Together, these factors may increase the risk of STBBI transmission within stimulant use networks, particularly when testing and treatment uptake is low. Among the total survey sample, 65% of participants reported ever being tested for HIV, HCV, or syphilis and 18% (n = 78/433) did not respond to any of the STBBI testing questions. The testing uptake is lower than the 80-90% lifetime HIV and HCV testing rates from similar surveys of people who inject drugs (54,55), which may be a result of several contributing factors. First, other surveys are specific to injection drug use, for which awareness of STBBI risk may be higher than for those who use substances through other modes. Second, the STBBI section in the HRCS appeared at the end of a long, self-administered questionnaire and the questions were presented in a table rather than straightforward yes/no items; therefore, it is possible that some non-response may reflect survey fatigue. Finally, internalized stigma and concerns about confidentiality are well-documented barriers to STBBI healthcare access among PWUS that may have led to an intentional avoidance of this topic (15,45). Missing responses about STBBI testing were 11-12% higher than subsequent questions about infection/wounds and treatment/counselling, and the consultations with PWLLE reinforced the experiences of a distinct STBBI-related stigma. We heard that although the survey settings in harm reduction sites would likely reduce stigma associated with substance use, participants might not feel safe reporting recent STBBI testing, and concerns about the impacts of having an STBBI or others learning about their sexual behaviours could be a barrier to seeking testing for this population. These barriers may be particularly pronounced for women and individuals who expressed hesitance to access health services due to fear of others discovering their substance use, as we found those groups were less likely to report recent STBBI testing in the statistical analyses. Whether a person is tested for a specific STBBI reflects both the accessibility of services and their willingness or ability to seek and accept testing for that infection based on perceived risk. HCV and HIV transmission through injection drug use is well-known, and many PWUS would likely be aware of the importance of being screened for these infections (6,54). Our study partially supports this assumption as the most reported test was HIV. However, an unexpected finding from our study is that HCV testing was the least reported. This could have been influenced by the survey wording, which used the acronym “HCV” instead of “hepatitis C”, and this acronym may not have been familiar to some participants. Higher syphilis testing may also be related to targeted public health efforts addressing the ongoing provincial syphilis outbreak declared in July 2019 (56,57). Given the shared transmission routes and high frequency of co-infections among STBBIs (58,59), a test for one infection presents an important opportunity to screen for others, particularly when multiple assays can be run from a single blood draw. While most participants in our study reported testing for all three infections (n = 208/281), a notable proportion did not, suggesting gaps in comprehensive testing. Missed screening carries significant implications, as it can contribute to delayed diagnosis and treatment, increase the likelihood of onward transmission, and limit opportunities for integrated prevention and care within high-risk networks. Equally concerning is that nearly one-quarter of participants (23.5%) reported not knowing their test results, underscoring persistent challenges in the STBBI care cascade. Testing is only the first step and effective linkage to care requires timely result delivery and ongoing engagement. Communication barriers such as unstable access to phones, limited phone minutes, or competing vulnerabilities (e.g., housing, food, clothing) may disproportionately affect more marginalized PWUS and hinder the continuity of care (16). These gaps highlight the importance of strengthening not only testing availability but also systems of post-test follow-up and communication, ensuring that testing translates into improved health outcomes. Strengths and limitations By using the HRCS, our study capitalized on an existing robust and standardized survey to capture consistent measures and ensure comparability across regions. Although we were exploring a different topic area from most of the survey, previous evidence of the high correlation between self-reported STBBI testing behaviors and true testing history supports the reliability of our study design and data source (54,60). However, all information in this study was self-reported, thus accuracy cannot be directly verified, and potential recall or social desirability biases cannot be quantified. In addition, incorporating feedback from PWLLE of substance use and STBBIs strengthened the relevance and contextual sensitivity of the research. It is important to note that the HRCS is a convenience sample of PWUS engaged with harm reduction and does not represent all harm reduction sites or the broader population of PWUS across the province. As a result, people who experience the greatest barriers in accessing healthcare services, such as those experiencing intersecting identities like race, ethnicity, and gender, may be underrepresented (29,44,45). Very few participants identified as transgender or gender expansive, limiting our ability to examine associations with recent STBBI testing in this group, and race and ethnicity data were not included because governance mechanisms to ensure ethical use of such information are still being developed. Given these limitations, this data source does not allow us to assess recent STBBI testing for people who are disproportionately affected by these infections, including transgender (61) and Indigenous peoples (62,63) as well as those impacted by the ongoing toxic drug crisis, which continues to disproportionately affect Indigenous peoples (64,65). Without adequate data to assess these relationships, our study lacks the critical thinking lens needed to fully understand and respond to disparities in STBBI testing. It is also important to acknowledge that our analysis may have introduced bias through the imputation of missing data based on complete cases; however, this process is more likely to reproduce existing biases in the dataset rather than create entirely new ones. Moreover, the cross-sectional survey design prevents us from inferring causal relationships between the predictors of interest and STBBI testing, and the absence of data on sexual behaviors restricts our capacity to explore important behavioral risk factors for STBBIs. Although our results may not be generalizable to all PWUS, harm reduction sites remain one of the few accessible settings for engaging with this population and our findings provide valuable insight to inform future programs and research. Public health implications and future directions This study supports several important conclusions to guide public health and harm reduction policy and practices. First, geographic disparities in STBBI testing persist, both across health regions and by community population size, and will likely require targeted strategies to improve access in small, rural, and remote areas. The option of STBBI self-testing take home kits may help reach populations that face geographic and structural barriers. From the individual perspective, people who receive the kits need clear information on how to use the tests and their accuracy; from the health system perspective, there must be appropriate mechanisms to facilitate follow-up care for those who need it (45). Self-testing has the potential to reduce stigma, increase privacy, and empower individuals to take ownership of their health, but its effectiveness depends on integration into broader health systems to ensure linkage to confirmatory testing, treatment, and support services. Community-based organizations and peer support workers could play a critical role in distributing kits and providing guidance, especially in underserved regions. Future research is needed not only to evaluate the acceptability and uptake of STBBI self-testing kits, but also to assess their impact on health equity, cost-effectiveness, and the sustainability of large-scale implementation. Second, although not statistically significant, the use of harm reduction services is positively associated with recent STBBI testing and presents a critical opportunity to expand access to testing for STBBIs and other health conditions within facilities that are known to be trusted points of contact for PWUS (35,66). To support this role, expanding harm reduction sites and providing adequate funding and resources to existing sites will be essential for sustaining and strengthening their capacity to deliver broader health services (49). Incorporating questions in plain language about broader health needs and testing uptake into future iterations of the HRCS could help monitor progress over time. This would be especially valuable when combined with targeted, community-based strategies to reach individuals who are less likely to access testing. For example, in BC, point-of-care HCV testing in supervised consumption sites have successfully increased testing uptake among PWUS (17). Similarly, in Spain, mobile harm reduction units providing point-of-care STBBI testing and on-site treatment for street-based female sex workers have demonstrated the feasibility of integrating timely diagnosis and care within trusted community settings (19). Third, meaningful community engagement throughout the model-building and interpretation process improves the relevance and impact of findings (67). In this quantitative study, the inclusion of PWLLE ensured that the variables selected for analysis and interpretation of results were grounded in community perspectives. This approach strengthens the validity of the conclusions and supports the development of public health strategies that are more responsive and aligned with community needs. Given the ongoing colonial harms experienced by Indigenous peoples related to the toxic drug crisis (64,65) and STBBIs (62,63), future research must prioritize working with Indigenous PWLLE and strive to include a distinctions-based approach. Addressing both the slow development of appropriate governance structures and the erasure of racialized and gender-diverse populations in health data is essential to move beyond replicating colonial patterns in research and to inform more equitable and culturally safe public health responses (30,68). Conclusion This analysis of factors associated with recent STBBI testing among harm reduction clients in BC, Canada demonstrates the potential of this data source in examining infectious disease testing uptake among PWUS. The findings suggest positive associations between engagement with harm reduction services and STBBI testing, while also revealing ongoing geographic and structural inequities for those in small population centres. STBBI testing uptake among people accessing harm reduction services may be shaped by factors such as stigma and social determinants of health, and we believe that increasing testing will require both targeted interventions and broader systemic changes to improve accessibility. Moving forward, expanding harm reduction services and financially supporting existing sites, evaluating innovative testing models such as self-testing kits, and embedding routine testing within trusted networks could help close critical gaps. By integrating the perspectives of PWLLE in our analytic approach, we aimed to enhance the contextual relevance for responsive and relevant public health strategies. Ultimately, improving STBBI testing uptake is not only about delivering services, but also about building systems that are trusted, inclusive, and designed to meet people where they are. List of Abbreviations BC – British Columbia BCCDC – BC Centre for Disease Control CI – Confidence interval HCV – Hepatitis C virus HIV – Human immunodeficiency virus HRCS – Harm Reduction Client Survey LASSO – Least absolute shrinkage and selection operator LGBQA+ – Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual+ OPS/SCS – Overdose prevention sites / supervised consumption sites PEEP – Professionals for the Ethical Engagement of Peers PWLLE – People with lived and living experience (of substance use and/or STBBIs) PWUS – People who use substances RR – Risk ratio SHAG – Sexual Health Advisory Group STBBIs – Sexually transmitted and bloodborne infections WHO – World Health Organization Declarations Ethics approval and consent to participate: The study was approved by the University of British Columbia’s Research Ethics Board (2023 UBC REB# H23-02685). All participants provided informed consent before participating in the survey. Consent for publication: Not applicable. Availability of data and materials: The data used in this study are not publicly available but may be available from the corresponding author upon reasonable request. Competing interests: None to declare. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: AT, KAT, and SRB contributed to the conceptualization and design of the study. AT and KAT developed the methodology and curated the data. AT conducted the formal analysis. AT and KAT created visualizations. AT drafted the initial manuscript, and AT and KAT prepared all subsequent versions. All authors contributed to the interpretation of data and were involved in reviewing and editing the manuscript. SRB provided supervision throughout the project. Acknowledgements: The authors wish to acknowledge and thank the Sexual Health Advisory Group (SHAG), the Professionals for the Ethical Engagement of Peers (PEEP), and the Harm Reduction and Substance Use Services team at the BC Centre for Disease Control for their valuable input and guidance throughout the study. We are also grateful to Max Xie and Felicity Clemens from the BC Centre for Disease Control for their biostatistical expertise and support with the statistical analyses. Authors’ information: Dr. Sofia Bartlett (she/her) is the senior author of this research article and currently serves as the Interim Scientific Director for Sexually Transmitted and Blood-Borne Infections at the BC Centre for Disease Control within Clinical Prevention Services. Her research focuses primarily on hepatitis C virus (HCV) and improving health outcomes for marginalized populations, including people who use drugs, those who are incarcerated, and individuals experiencing unstable housing. To learn more about Dr. Bartlett and her work, please visit stbbipathways.ca. References WHO. Implementing the global health sector strategies on HIV, viral hepatitis and sexually transmitted infections, 2022–2030: Report on Progress and Gaps. [Internet]. 2024 [cited 2025 Apr 4]. Available from: https://iris.who.int/bitstream/handle/10665/376814/9789240094925-eng.pdf Hamill V, Wong S, Benselin J, Krajden M, Hayes PC, Mutimer D, et al. Mortality rates among patients successfully treated for hepatitis C in the era of interferon-free antivirals: population based cohort study. BMJ. 2023 Aug 2;382:e074001. Wu MY, Gong HZ, Hu KR, Zheng H yi, Wan X, Li J. Effect of syphilis infection on HIV acquisition: a systematic review and meta-analysis. Sex Transm Infect. 2021 Nov;97(7):525–33. World Drug Report [Internet]. United Nations Office on Drugs and Crime; 2025. Available from: https://doi.org/10.18356/9789211594850c007 Global AIDS targets 2025 for people who use drugs: Where are we now? [Internet]. United Nations Programme on HIV/AIDS (UNAIDS); 2024. Available from: https://www.unaids.org/en/resources/documents/2024/global-AIDS-targets-2025-for-people-who-use-drugs-where-are-we-now Janjua NZ, Yu A, Kuo M, Alvarez M, Cook D, Wong J, et al. Twin epidemics of new and prevalent hepatitis C infections in Canada: BC Hepatitis Testers Cohort. BMC Infect Dis. 2016 Jul 19;16(1):334. Raval M, Gratrix J, Plitt S, Niruban J, Smyczek P, Dong K, et al. Retrospective Cohort Study Examining the Correlates of Reported Lifetime Stimulant Use in Persons Diagnosed With Infectious Syphilis in Alberta, Canada, 2018 to 2019. Sex Transm Dis. 2022 Aug 1;49(8):551–9. Pouget ER, Hagan H, Des Jarlais DC. Meta-analysis of hepatitis C seroconversion in relation to shared syringes and drug preparation equipment. Addiction. 2012 Jun;107(6):1057–65. Ball LJ, Puka K, Speechley M, Wong R, Hallam B, Wiener JC, et al. Sharing of Injection Drug Preparation Equipment Is Associated With HIV Infection: A Cross-sectional Study. J Acquir Immune Defic Syndr. 2019 Aug 1;81(4):e99–103. Ahmadi K, Javadinia SA, Saadat SH, Ramezani MA, Sedghijalal H. Triangular relationship among risky sexual behavior, addiction, and aggression: A systematic review. Electron Physician. 2017 Aug 1;9(8):5129–37. Haider MR, Kingori C, Brown MJ, Battle-Fisher M, Chertok IA. Illicit drug use and sexually transmitted infections among young adults in the US: evidence from a nationally representative survey. Int J STD AIDS. 2020 Nov;31(13):1238–46. Cunningham NE, Lamb J, Staller A, Krajden M, Hogg RS, Towle A, et al. Expanding access to healthcare for people who use drugs and sex workers: hepatitis C elimination implications from a qualitative study of healthcare experiences in British Columbia, Canada. Harm Reduct J. 2024 Apr 4;21(1):75. MacLean R. Resources to address stigma related to sexuality, substance use and sexually transmitted and blood-borne infections. Can Commun Dis Rep. 2018 Feb 1;44(2):62–7. Marshall BD, Kerr T, Shoveller JA, Patterson TL, Buxton JA, Wood E. Homelessness and Unstable Housing Associated with an Increased Risk of HIV and STI Transmission among Street-Involved Youth. Health Place. 2009 Sep;15(3):753–60. Lang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers. Substance Abuse Treatment, Prevention, and Policy. 2013 Oct 1;8(1):35. Tiwana A, Gale N, Mahay M, Barker T, Hasdell R, Young P, et al. Addressing digital exclusion to improve access to HIV and viral hepatitis care for people who experience criminalization: a mixed methods evaluation of a quality improvement project. Int J Equity Health. 2025 Dec 2;24(1):337. Hannigan A, Krishnan N, Singh K, Bytelaar S, Schmitz D, Bartlett S, et al. Scaling up hepatitis C testing and linkage-to-care among people who use drugs: lessons learned from a pilot project implemented at a supervised consumption site. BMC Health Serv Res. 2025 Feb 13;25(1):243. Palis H, Haywood B, McDougall J, Xavier CG, Desai R, Tobias S, et al. Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey. Harm Reduct J. 2024 Jan 6;21(1):5. Valencia J, Vázquez L, Lazarus JV, Cuevas G, Torres-Macho J, Domingorena J, et al. On-site testing and treatment of sexually transmitted infections among female sex workers using molecular point-of-care testing integrated into harm reduction services in Madrid, Spain. Int J Drug Policy. 2024 Jan;123:104281. Baldwin N, Gray R, Goel A, Wood E, Buxton JA, Rieb LM. Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: An observational analysis. Drug Alcohol Depend. 2018 Apr 1;185:322–7. Kinniburgh B, Liu L, Loewen O, Burgess H, Xavier C, Ge W, et al. Findings from the 2022 Harm Reduction Client Survey related to BC’s Decriminalization Policy. [Internet]. BC Centre for Disease Control; 2023. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/HRCS_2022_decriminalization_findings.pdf Karamouzian M, Papamihali K, Graham B, Crabtree A, Mill C, Kuo M, et al. Known fentanyl use among clients of harm reduction sites in British Columbia, Canada. The International journal of drug policy. 2020;77(Journal Article):102665–102665. Moustaqim-Barrette A, Papamihali K, Crabtree A, Graham B, Karamouzian M, Buxton JA. Correlates of take-home naloxone kit possession among people who use drugs in British Columbia: A cross-sectional analysis. Drug and alcohol dependence. 2019;205(Journal Article):107609–107609. Map of Participating Harm Reduction Distribution Sites [Internet]. British Columbia Centre for Disease Control; Available from: http://www.bccdc.ca/health-professionals/data-reports/harm-reduction-client-survey Harm Reduction Client Survey [Internet]. 2023. Available from: https://www.bccdc.ca/Health-Professionals-Site/Documents/HRCS%202023%20survey%20final.pdf Martin K, Olaru ID, Buwu N, Bandason T, Marks M, Dauya E, et al. Uptake of and factors associated with testing for sexually transmitted infections in community-based settings among youth in Zimbabwe: a mixed-methods study. The Lancet Child & Adolescent Health. 2021 Feb 1;5(2):122–32. Jenkins WD, Williams LD, Pearson WS. STI epidemiology and care in rural areas: a narrative review. Sex Transm Dis. 2021 Dec 1;48(12):e236–40. Pijl EM, Alraja A, Duff E, Cooke C, Dash S, Nayak N, et al. Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review. Substance Abuse Treatment, Prevention, and Policy. 2022 Aug 26;17(1):62. Scheidell JD, Chueng T, Ciraldo K, Hervera B, Dakoulas S, Mahachi M, et al. Reaching people who use drugs with sexual and reproductive healthcare through syringe services programs: potential promise and missed opportunities. Harm Reduction Journal. 2024 Nov 14;21(1):198. Disaggregated Demographic Data Collection in British Columbia: The grandmother perspective [Internet]. British Columbia’s Office of the Human Rights Commissioner; 2024. Available from: https://bchumanrights.ca/resources/publications/publication/datacollection/ Antebi-Gruszka N, Talan AJ, Reisner SL, Rendina HJ. Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men. Sex Transm Infect. 2020 Sep 1;96(6):422–7. Hwang LY, Ross MW, Zack C, Bull L, Rickman K, Holleman M. Prevalence of Sexually Transmitted Infections and Associated Risk Factors among Populations of Drug Abusers. Clinical Infectious Diseases. 2000 Oct 1;31(4):920–6. Cai Y, Dai Z, Wen S, Bhandari R. Risk factors associated with infection of blood-borne virus among people who used methamphetamine. BMC Infect Dis. 2020 Oct 9;20:742. Metzger DS, Zhang Y. Drug treatment as HIV prevention: expanding treatment options. Curr HIV/AIDS Rep. 2010 Nov;7(4):220–5. Semaan S, Fleming P, Worrell C, Stolp H, Baack B, Miller M. Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend. 2011 Nov 1;118(2–3):100–10. Duby Z, Nkosi B, Scheibe A, Brown B, Bekker LG. ‘Scared of going to the clinic’: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities. Southern African Journal of HIV Medicine. 2018 Jan 19;19(1):8. Mohseni Afshar Z, Goodarzi A, Emadi SN, Miladi R, Shakoei S, Janbakhsh A, et al. A Comprehensive Review on HIV-Associated Dermatologic Manifestations: From Epidemiology to Clinical Management. Int J Microbiol. 2023 Jul 18;2023:6203193. Buuren S van, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R. Journal of Statistical Software. 2011 Dec 12;45:1–67. Fajber K, Palis H, Fraser H, Xavier CG, Desai R, Wall C, et al. Knowledge update: Receipt and access of prescribed alternatives and opioid agonist treatment among respondents from the 2023 Harm Reduction Client Survey [Internet]. BC Centre for Disease Control; 2025. Available from: https://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/KnowledgeUpdate_HRCS2023_PSS%20barriers_FINAL_20250624.pdf Zhang Z. Model building strategy for logistic regression: purposeful selection. Ann Transl Med. 2016 Mar;4(6):111. Chowdhury MZI, Turin TC. Variable selection strategies and its importance in clinical prediction modelling. Fam Med Com Health [Internet]. 2020 Feb 16 [cited 2025 Sep 5];8(1). Available from: https://fmch.bmj.com/content/8/1/e000262 Ranganathan P, Aggarwal R, Pramesh CS. Common pitfalls in statistical analysis: Odds versus risk. Perspectives in Clinical Research. 2015 Dec;6(4):222. Hottes TS, Farrell J, Bondyra M, Haag D, Shoveller J, Gilbert M. Internet-based HIV and sexually transmitted infection testing in British Columbia, Canada: opinions and expectations of prospective clients. J Med Internet Res. 2012 Mar 6;14(2):e41. Fraser M, Fajber K, Kinniburgh B, Liu L, Loewen O, Wall C, et al. Hesitance in accessing services: Harm Reduction Client Survey 2023 [Internet]. BC Centre for Disease Control; 2024. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/HRCS2023_Hesitance_KnowledgeUpdate.pdf Snow ME, Berger MH, Tam AC, Easterbrook A, Okechukwu CE, Mohammadi T, et al. Attributes that influence testing decisions for sexually transmitted and blood-borne infections: A qualitative study among diverse people in Canada. Int J STD AIDS. 2025 Apr 30;09564624251337595. Khumalo F, Passmore JAS, Manhanzva M, Meyer B, Duyver M, Lurie M, et al. Shifting the power: scale-up of access to point-of-care and self-testing for sexually transmitted infections in low-income and middle-income settings. Current Opinion in Infectious Diseases. 2023 Feb;36(1):49. Conway A, Stevens A, Murray C, Prain B, Power C, McNulty A, et al. Hepatitis C Treatment Uptake Following Dried Blood Spot Testing for Hepatitis C RNA in New South Wales, Australia: The NSW DBS Pilot Study. Open Forum Infectious Diseases. 2023 Nov 1;10(11):ofad517. Young J, Ablona A, Klassen BJ, Higgins R, Kim J, Lavoie S, et al. Implementing community-based Dried Blood Spot (DBS) testing for HIV and hepatitis C: a qualitative analysis of key facilitators and ongoing challenges. BMC Public Health. 2022 May 31;22(1):1085. Ali F, Russell C, Law J, Imtiaz S, Budau J, Shahin R, et al. Characterizing changes to harm reduction site operations in British Columbia following the implementation of the decriminalization of drugs: Findings from a provincial survey. Harm Reduction Journal. 2025 Jul 18;22(1):122. Nyamathi A, Hudson A, Greengold B, Leake B. Characteristics of homeless youth who use cocaine and methamphetamine. Am J Addict. 2012;21(3):243–9. Cepeda JA, Vickerman P, Bruneau J, Zang G, Borquez A, Farrell M, et al. Estimating the contribution of stimulant injection to HIV and HCV epidemics among people who inject drugs and implications for harm reduction: A modeling analysis. Drug and Alcohol Dependence. 2020 Aug 1;213:108135. Broady TR, Brener L, Caruana T, Cama E, Treloar C. Factors associated with sharing equipment among people who inject drugs: The role of community attachment in harm reduction and health promotion. Drug and Alcohol Review. 2023;42(3):561–8. Grant JE, Redden SA, Lust K, Chamberlain SR. Nonmedical Use of Stimulants Is Associated With Riskier Sexual Practices and Other Forms of Impulsivity. J Addict Med. 2018;12(6):474–80. Tarasuk J, Zhang J, Lemyre A, Cholette F, Bryson M, Paquette D. National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, 2017-2019. Can Commun Dis Rep. 2020 May 7;46(5):138–48. Unlinked anonymous monitoring (UAM) survey of HIV and viral hepatitis among people who inject drugs (PWID): 2024 report [Internet]. UK Health Security Agency; 2024. Available from: https://www.gov.uk/government/publications/people-who-inject-drugs-hiv-and-viral-hepatitis-monitoring/unlinked-anonymous-monitoring-uam-survey-of-hiv-and-viral-hepatitis-among-people-who-inject-drugs-pwid-2024-report HIV, Syphilis, and Sexually Transmitted and Blood-Borne Infections (STBBI) Awareness and Perceptions Survey Executive Summary [Internet]. Health Canada; 2024. Available from: https://publications.gc.ca/site/archivee-archived.html?url=https://publications.gc.ca/collections/collection_2024/sc-hc/HP40-361-2024-1-eng.pdf BC Syphilis Action Plan, 2023-2025 [Internet]. BC Centre for Disease Control (BCCDC); 2023. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/STI/Syphilis_Action_Plan_Refresh_2023.pdf Wasserheit JN. Epidemiological Synergy: Interrelationships between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases. Sexually Transmitted Diseases. 1992 Apr;19(2):61. Nusbaum MRH, Wallace RR, Slatt LM, Kondrad EC. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. 2004 Dec;104(12):527–35. Lyons MS, Lindsell CJ, Ruffner AH, Trott AT, Fichtenbaum CJ. Relationship of Self-Reported Prior Testing History to Undiagnosed HIV Positivity and HIV Risk. Curr HIV Res. 2009 Nov;7(6):580–8. Bigio J, Butler M, Sood S, Cox J, Jackson B, Marshall Z, et al. Sexually transmitted and blood-borne infections in transgender and non-binary people in Canada: A scoping review. PLOS ONE. 2025 May 20;20(5):e0322521. Krementz DH, Macklin C, King A, Fleming T, Kafeety A, Lambert S, et al. Connections with the Land: A Scoping Review on Cultural Wellness Retreats as Health Interventions for Indigenous Peoples Living with HIV, Hepatitis C, or Both. ab-Original. 2018 Oct 1;2(1):23–47. Ryan C, Ali A, Sabourin H. A Culturally Safe and Trauma-Informed Sexually Transmitted Blood Borne Infection (STBBI) Intervention Designed by and for Incarcerated Indigenous Women and Gender-Diverse People. IJIH. 2020 Nov 5;15(1):108–18. Toxic Drug Crisis Data [Internet]. First Nations Health Authority; Available from: https://www.fnha.ca/what-we-do/mental-wellness-and-substance-use/harm-reduction-and-the-toxic-drug-crisis/toxic-drug-crisis-data Urbanoski KA. Need for equity in treatment of substance use among Indigenous people in Canada. CMAJ. 2017 Nov 6;189(44):E1350–1. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014 Dec 1;145:48–68. Rodríguez ST, Morgan JW, Bond L, Kumari S, Martinchek K. Increasing the Rigor of Quantitative Research with Participatory and Community-Engaged Methods: A Participatory and Quantitative Methods Guidebook [Internet]. Urban Institute; 2023 Oct [cited 2025 Jun 24]. Available from: https://www.urban.org/research/publication/increasing-rigor-quantitative-research-participatory-and-community-engaged Lavalley J, Steinhauer L, Bundy D (Boomer), Kerr T, McNeil R. “They talk about it like it’s an overdose crisis when in fact it’s basically genocide” : The experiences of Indigenous peoples who use illicit drugs in Vancouver’s Downtown Eastside neighbourhood. International Journal of Drug Policy. 2024 Dec 1;134:104631. Additional Declarations Competing interest reported. Sofia R. Bartlett reports a relationship with Gilead Sciences that includes: funding grants and non-financial support. Sofia R. Bartlett reports a relationship with AbbVie Inc that includes: funding grants. Sofia R. Bartlett reports a relationship with Pfizer Inc that includes: funding grants. Sofia R. Bartlett reports a relationship with TD BANK that includes: funding grants. Sofia R. Bartlett reports a relationship with Pacific Public Health Foundation that includes: funding grants. Serves as an unpaid non-executive director for Canadian registered non-profit Unlocking the Gates Services Society and Australian and Papua New Guinean registered non-profit Grass Skirt Project (SRB). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 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Control","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"A","lastName":"Twohig","suffix":""},{"id":572268883,"identity":"e5419ad0-a54b-407d-9b7e-7b325897de75","order_by":2,"name":"Mieke Fraser","email":"","orcid":"","institution":"BC Centre for Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Mieke","middleName":"","lastName":"Fraser","suffix":""},{"id":572268884,"identity":"b3cb00ff-d44c-4fc7-9758-fd9f4ad7b623","order_by":3,"name":"Brooke Kinniburgh","email":"","orcid":"","institution":"BC Centre for Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Brooke","middleName":"","lastName":"Kinniburgh","suffix":""},{"id":572268885,"identity":"2ff3081c-c6dd-4bd5-b5fa-72a499204d19","order_by":4,"name":"Charlene Burmeister","email":"","orcid":"","institution":"BC Centre for Disease 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Supply","correspondingAuthor":false,"prefix":"","firstName":"Dylan","middleName":"","lastName":"Griffith","suffix":""},{"id":572268889,"identity":"660988a7-45ba-4234-9e78-c103d6599f36","order_by":8,"name":"Chloé G Xavier","email":"","orcid":"","institution":"BC Centre for Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Chloé","middleName":"G","lastName":"Xavier","suffix":""},{"id":572268890,"identity":"d161f06c-680d-4511-a73b-6c5dc9b7cac6","order_by":9,"name":"Alannah Hannigan","email":"","orcid":"","institution":"BC Centre for Excellence in HIV/AIDS","correspondingAuthor":false,"prefix":"","firstName":"Alannah","middleName":"","lastName":"Hannigan","suffix":""},{"id":572268891,"identity":"235e820e-fc5e-4dd7-84c9-7d269070f30d","order_by":10,"name":"Kate Salters","email":"","orcid":"","institution":"BC Centre for Excellence in HIV/AIDS","correspondingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Salters","suffix":""},{"id":572268892,"identity":"11325355-f4bd-4739-ab49-8e97cd9af2c7","order_by":11,"name":"Sofia R Bartlett","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYFACxgcHGBiAiIG5AUjYMBgQ1sJsANHCxtjAcCAhjTgtDEhaDhPWIt/ezHjgB8MdefP5jY2PP/44n7id/QDjhx94tBicOcxwsIfhmeGcY4zNBgcSbifu7ElgluzBp0Ui/8ABHobDjDPYGNskQFo23GBgY+DB57AZyQwH/zActgdqaf9xIOEcWAvjH3yeuZHMcBhoSyLIFqD3D4C1MOOzBeSXwzIGz5JnsCU2S5xJSzbe2ZPYLC2Dz2Htzcwf31TcsZ3BfPjghwobO9nt7IcPfnyDz2EQu1B4wAgaBaNgFIyCUUAZAAC/d1VlhIG3ZQAAAABJRU5ErkJggg==","orcid":"","institution":"BC Centre for Disease Control","correspondingAuthor":true,"prefix":"","firstName":"Sofia","middleName":"R","lastName":"Bartlett","suffix":""}],"badges":[],"createdAt":"2025-12-23 17:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8436044/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8436044/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-026-12924-4","type":"published","date":"2026-02-23T15:58:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":100362524,"identity":"19e34710-f39c-48eb-8f69-9564179ccc55","added_by":"auto","created_at":"2026-01-16 07:46:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":463675,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/6dc51c1462873e8ee1650295.docx"},{"id":100362510,"identity":"2a62cef9-c7e1-4a75-9211-5443437fb59e","added_by":"auto","created_at":"2026-01-16 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08:11:07","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":192681,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/df0aeb078e0f90364788a3f9.html"},{"id":100362308,"identity":"93deaae2-ba4b-4fd2-ada8-4c6b6649b59b","added_by":"auto","created_at":"2026-01-16 07:46:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":143937,"visible":true,"origin":"","legend":"\u003cp\u003eMap of participating harm reduction supply distribution sites in the 2023 Harm Reduction Client Survey in British Columbia, Canada (24).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/c3e9356486ea995c8d44bdd0.jpeg"},{"id":100023141,"identity":"b8d1c911-0bad-4720-9ffb-9385380f62d5","added_by":"auto","created_at":"2026-01-12 08:11:07","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":212797,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-reported history of testing (ever and within last 12 months, combined) for HIV, hepatitis C virus (HCV), and syphilis, and knowledge of results among participants (N=281).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/83ce0073f5b5e41ab9c464d8.jpeg"},{"id":103765589,"identity":"fdc94da4-bade-480f-b4f8-f62d349f3bc1","added_by":"auto","created_at":"2026-03-02 16:05:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1558702,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/f1669831-0382-4356-bcb3-9af83e765325.pdf"},{"id":100023144,"identity":"10d27841-c70b-4ed9-a974-386ffba2329e","added_by":"auto","created_at":"2026-01-12 08:11:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":584453,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8436044/v1/3f7db9847ef6045513f05fa2.docx"}],"financialInterests":"Competing interest reported. Sofia R. Bartlett reports a relationship with Gilead Sciences that includes: funding grants and non-financial support. Sofia R. Bartlett reports a relationship with AbbVie Inc that includes: funding grants. Sofia R. Bartlett reports a relationship with Pfizer Inc that includes: funding grants. Sofia R. Bartlett reports a relationship with TD BANK that includes: funding grants. Sofia R. Bartlett reports a relationship with Pacific Public Health Foundation that includes: funding grants. Serves as an unpaid non-executive director for Canadian registered non-profit Unlocking the Gates Services Society and Australian and Papua New Guinean registered non-profit Grass Skirt Project (SRB). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.","formattedTitle":"Sexually transmitted and bloodborne infections testing among people who use substances: findings from the 2023 British Columbia Harm Reduction Client Survey","fulltext":[{"header":"Introduction","content":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSexually transmitted and bloodborne infections (STBBIs), including human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis, are a significant global public health concern (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These infections contribute to substantial morbidity and mortality, with serious long-term health consequences if left undiagnosed and untreated (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). For instance, STBBIs are responsible for an estimated 2.5\u0026nbsp;million deaths and 1.2\u0026nbsp;million cases of cancer worldwide each year (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Increased testing efforts support early detection and timely treatment, which will reduce transmission and advance progress towards the World Health Organization’s (WHO) goal of eliminating STBBIs as a public health threat by 2030.\u003c/p\u003e \u003cp\u003eThe disproportionate burden of STBBIs experienced by people who use substances (PWUS) highlights the ongoing health disparities within this population. Global trends show a rising prevalence of unregulated substance use, with the proportion of people aged 15 to 64 who used unregulated substances increasing from 5.2% in 2013 to 6% in 2023 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This heightened exposure is reflected in STBBI outcomes, as the global median HIV prevalence among PWUS in 2021 was seven times higher than in the general adult population aged 15 to 49 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In British Columbia (BC), Canada, nearly half (45%) of people diagnosed with HCV in 2015 were PWUS, who also accounted for 80% of new HCV cases (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In Alberta, Canada, 42% of individuals diagnosed with syphilis in 2022 reported unregulated stimulant use (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These findings demonstrate the disproportionate impact of STBBIs among PWUS both globally and within Canada.\u003c/p\u003e \u003cp\u003eMultiple factors contribute to the increased prevalence of STBBIs among PWUS. Sharing substance preparation and use equipment, including needles, syringes, and pipes, increases direct transmission risk (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Unregulated substance use has also been associated with a greater likelihood of engaging in condomless sex and having multiple sexual partners (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). When access to prevention strategies such as condoms or biomedical interventions like HIV PrEP is limited, condomless sex with multiple sexual partners further heightens exposure risk. These risk factors are particularly concerning among young adults and men, as evidence indicates high rates of unregulated substance use in these groups and associations with increased STBBI incidence (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond transmission risk factors, PWUS often face barriers in accessing STBBI testing due to intersecting social determinants of health. These barriers include stigma, discrimination, limited health literacy, fragmented healthcare systems, unstable housing, digital exclusion, and complex health and social needs (\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). For instance, moralized views of substance use and STBBIs (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), negative healthcare encounters (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), limited healthcare provider training on addiction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and challenges maintaining contact with providers (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) can all make it difficult for PWUS to access STBBI testing. Pilot initiatives in BC have found that low-barrier, community-based approaches, such as point-of-care HCV testing in observed consumption spaces, can increase testing uptake among PWUS (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Addressing these gaps through strategies that reduce structural barriers and account for intersecting social determinants of health are critical to improve testing access and STBBI outcomes for PWUS.\u003c/p\u003e \u003cp\u003eHarm reduction services play an important role in supporting PWUS with appropriate, safe care and support. Harm reduction is often delivered in community-based, low-barrier settings to provide essential services such as access to sterile syringes, safer smoking supplies, observed consumption spaces, naloxone kits, and substance checking tools for PWUS. This may include sites called overdose prevention or supervised consumption sites (OPS/SCS), where people can consume unregulated substances under the supervision of trained staff. Harm reduction services and programs also operate out of shelters, health clinics, support societies, or substance use organizations, though additional services vary by location (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Considering the effectiveness of harm reduction services in supporting PWUS, the inclusion of STBBI testing at these sites represents a promising and emerging strategy to address STBBI vulnerabilities (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Providing testing in these settings is especially important for PWUS who may face stigma, discrimination, or structural barriers when accessing traditional healthcare services.\u003c/p\u003e\n\u003ch3\u003ePurpose and aim\u003c/h3\u003e\n\u003cp\u003eWhile there is a great deal of literature characterizing and examining STBBI risk among PWUS, there is very little research examining predictors of STBBI testing – a critical step in the prevention and care continuum. This study investigated factors associated with recent STBBI testing among clients of harm reduction sites across the Canadian province of BC. By identifying testing barriers and facilitators, this study aims to contribute to the existing literature on unregulated substance use and STBBI prevention while informing targeted interventions that promote testing uptake among PWUS. Strengthening early detection contributes to minimizing transmission, improving linkage to treatment, and ultimately reducing the burden of STBBIs in populations most at risk.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\n\n\n "},{"header":"Methods","content":"\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eThis analysis used data from the 2023 iteration of the BC Harm Reduction Client Survey (HRCS), a cross-sectional survey conducted by the BC Centre for Disease Control (BCCDC) Harm Reduction and Substance Use Services within the Population and Environment Health team (2023 University of British Columbia Research Ethics Board # H23-02685). Established in 2012, the HRCS is a key instrument used to monitor substance use trends, guide harm reduction planning, and address emerging topics of interest related to harm reduction services in BC. The survey is administered annually and updated periodically to address emerging public health issues such as the rise in fentanyl-related overdose deaths (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and decriminalization (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Detailed descriptions of data collection methods for previous iterations have been published elsewhere (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe 2023 survey was administered at 23 harm reduction sites across the province (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The surveyed sites include a broad range of service settings, including OPS/SCS, mental health and substance use centres, community-based health and social service organizations, shelters, and supportive housing sites. Sites were strategically selected to ensure geographic diversity, with intentional oversampling in regions outside the urban centres in the lower mainland of BC to better capture provincial variations in substance use and service access. A convenience sample of people accessing harm reduction services was recruited, meaning participants were selected by trained staff members based on their availability and willingness to participate at the time of data collection. The survey gathered detailed information on participants’ demographics, substance use patterns, use of harm reduction services, and overdose experiences. The 2023 iteration was the first to include questions on STBBI testing, providing a novel opportunity to examine barriers and facilitators to testing among PWUS accessing harm reduction (see page 9 of survey instrument) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eParticipants were eligible for the survey if they were 19 years of age or older and self-reported using illicit substances in the past six months. Eligible illicit substances included those obtained from the unregulated market or considered unregulated, such as opioids/down, heroin, fentanyl, cocaine, crack, methamphetamine, and hallucinogens. The survey was conducted in English using a paper-based format and required approximately 20 minutes to complete. Participants received \u003cspan\u003e$\u003c/span\u003e20 CAD for their time, and survey administration sites were provided \u003cspan\u003e$\u003c/span\u003e5 CAD per participant to support additional incentives, survey-related supplies, or other related needs. Survey data were entered and stored in REDCap electronic data capture tools hosted at BC Children’s Hospital Research Institute. Data were extracted, cleaned, and analysed in R version 4.3.1 at BCCDC. Frequency tables were generated to facilitate data exploration in addition to the tables included in this paper.\u003c/p\u003e\u003ch3\u003eEngaging people with lived and living experience of substance use and STBBIs\u003c/h3\u003e\u003cp\u003eTo ensure our research was grounded in the perspectives of people with lived and living experience (PWLLE) of substance use and STBBIs, we consulted with two advisory groups affiliated with the BCCDC. The Sexual Health Advisory Group (SHAG) includes PWLLE of STBBIs, and Professionals for the Ethical Engagement of Peers (PEEP) includes peer leaders representing PWLLE of unregulated substance use. PEEP have been actively involved in shaping the annual HRCS, providing input into survey questions, reviewing wording and response options, and helping prioritize key topics. We conducted three consultation sessions: two before the analysis to inform model building, and one after the analysis to guide the interpretation of results and implications. Each session lasted approximately one hour and was conducted via Zoom. Each session included a PowerPoint presentation with a summary of results and guiding questions to facilitate discussion. The insights shared by PWLLE helped us better understand the survey’s strengths and limitations, shaping the analysis and interpretation, and ensuring the findings and recommendations had real-world relevance.\u003c/p\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003cp\u003eThe outcome of interest was recent STBBI testing based on self-report of having been tested for HIV, HCV, or syphilis \u003cem\u003ein the last 12 months\u003c/em\u003e. Participants were asked, “When was your most recent blood test?” with response options of \u003cem\u003ein the last 12 months\u003c/em\u003e, \u003cem\u003emore than 12 months ago\u003c/em\u003e, \u003cem\u003eI don’t remember\u003c/em\u003e, \u003cem\u003eI have never been tested\u003c/em\u003e or \u003cem\u003eprefer not to say\u003c/em\u003e. The comparison group included those reporting \u003cem\u003emore than 12 months ago\u003c/em\u003e or \u003cem\u003eI have never been tested\u003c/em\u003e. Responses of \u003cem\u003eI don’t remember, prefer not to say\u003c/em\u003e, and those left blank were categorized as missing. Two additional STBBI-related questions asked participants if they knew the results of their most recent test and whether they would be interested in STBBI self-testing kits offered through harm reduction sites. The additional two questions were included for descriptive purposes only and were not part of the primary statistical analysis.\u003c/p\u003e\u003cp\u003eOther variables of interest were selected based on a review of the literature, consultations with PWLLE of substance use and STBBIs, and the availability of relevant variables in the survey dataset. Sociodemographic variables included self-reported: age (19–39 vs. ≥40 years), gender identity (male/man vs. female/woman) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and employment status (employed full-time or part-time vs. not employed) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Individuals who identified as transgender or gender expansive were excluded from this analysis due to small counts. Housing categories were combined to define ‘has regular housing’ (living in a private residence, band-owned home, hotel/motel, rooming house, single-room occupancy, or social/supportive housing) vs. ‘no regular housing’ (living in a shelter, being homeless or houseless, couch-surfing, living in a tent, or having no fixed address) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Additional variables included regional health authority of the site where the survey was completed (Vancouver Coastal vs. Fraser, Interior, Northern, or Island) and community size, classified by the population centre associated with the site’s postal code (\u0026lt; 30,000 vs. ≥30,000) according to the 2021 Canadian Census (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). We recognize that race and ethnicity are important considerations (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e); however, these variables were not included in this analysis because further work is needed to establish appropriate governance mechanisms for the collection and use of these data (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMany substance use and harm reduction-related variables were examined. Type of substance used in the last 30 days was assessed for all participants, including use of opioids, benzodiazepines, and stimulants (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). We assessed mode of substance use within the past six months, comparing those who used substances by injection (either exclusively or in combination with smoking) with those who did not inject (i.e., smoking only or other non-injection modes of use) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). We also considered the following self-reported substance use behaviours or related experiences in the last six months: using drugs at an OPS/SCS (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e); difficulty using drugs at an OPS/SCS (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e); history of opioid or stimulant overdose (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e); using drug checking tools (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e); receiving prescribed alternatives (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e); recent skin infections (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), ownership of a naloxone kit (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e); and hesitation to access services needed to be healthy due to fear of others (i.e., family services, healthcare provider, friends or family, police, or employer) finding out about their drug use (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). All the substance and harm reduction-related variables were measured as binary outcomes (yes vs. no).\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eTo address missing data across outcome, demographic, and predictor variables, which was generally \u0026lt; 10%, (\u003cb\u003eTable A.1\u003c/b\u003e, \u003cb\u003eFigure A.2\u003c/b\u003e), we used multiple imputation by chained equations (MICE) to generate ten imputed datasets. Descriptive statistics were calculated using complete cases, while regression analyses were based on pooled estimates across the ten imputed datasets using Rubin’s rules (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Density plots for variables with more than 10% missingness showed good agreement between observed and imputed values (\u003cb\u003eFigure A.3\u003c/b\u003e). Any cross-tabulations that resulted in row or column totals with less than 20 participants were suppressed to align with the HRCS privacy protection protocol. Since the descriptive statistics were calculated using a sub-sample of complete cases, our statistics may differ slightly from summary statistics reported elsewhere (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMultivariable regression models were built on the MICE imputed datasets using a purposeful selection approach (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Least absolute shrinkage and selection operator (LASSO) regression guided variable selection, however, some variables considered theoretically important based on previous research, as well as those identified during consultations with PWLLE, were retained in the final model regardless of statistical significance. In addition, variables with a relaxed p-value threshold (p \u0026lt; 0.20) in univariable analyses were considered and selected based on the combination that provided the best statistical fit (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Adjusted risk ratios (RR) and 95% confidence intervals (CI) for recent STBBI testing in the last 12 months were estimated using Poisson regression with robust standard errors. This regression model was chosen because our outcome of interest was common, and logistic regression would have produced odds ratios, which only approximate risk ratios when outcomes are rare (e.g., \u0026lt; 10%) (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Analyses were conducted in R version 4.1.1 using packages including \u003cem\u003emice\u003c/em\u003e, \u003cem\u003elmtest\u003c/em\u003e, and \u003cem\u003esandwich\u003c/em\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 443 participants who participated in the 2023 HRCS, 158 (36%) had complete information in all required analysis fields (\u003cstrong\u003eTable 1a\u003c/strong\u003e). Among these complete cases, almost two-thirds (62%) reported being tested for an STBBI in the last 12 months (i.e., recent testers). Most participants were aged 40 or older (63.3%), identified as men (68.4%), and heterosexual or straight (86.1%). A large proportion were unemployed (77.3%), and more than half participated at harm reduction sites located in communities with populations of 30,000 or more (58.9%). Compared to those tested more than 12 months ago or who had never been tested,\u0026nbsp;recent testers were more likely to be completing their survey at a site in the Vancouver Coastal Health and Island Health regions and in larger population centres.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1a. Sociodemographic characteristics of the study\u0026nbsp;subsample with complete data for outcome, demographic, and predictor variables.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u0026nbsp;Characteristic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003eTested for Sexually Transmitted and Bloodborne Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eIn the last 12 months, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMore than 12 months ago or had never been tested, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTotal, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e98 (62.0^)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e60 (38.0^)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e158 (100.0^)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e19 to 39\u003c/p\u003e\n \u003cp\u003e40 or older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (34.7)\u003c/p\u003e\n \u003cp\u003e64 (65.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (40.0)\u003c/p\u003e\n \u003cp\u003e36 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58 (36.7)\u003c/p\u003e\n \u003cp\u003e100 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender identity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale/man\u003c/p\u003e\n \u003cp\u003eFemale/woman\u003c/p\u003e\n \u003cp\u003eTrans/gender expansive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67 (68.4)\u003c/p\u003e\n \u003cp\u003e26 (26.5)\u003c/p\u003e\n \u003cp\u003e\u0026lt;20\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41 (68.3)\u003c/p\u003e\n \u003cp\u003e17 (28.3)\u003c/p\u003e\n \u003cp\u003e\u0026lt;20\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e108 (68.4)\u003c/p\u003e\n \u003cp\u003e43 (27.2)\u003c/p\u003e\n \u003cp\u003e\u0026lt;20\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual orientation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHeterosexual/straight\u003c/p\u003e\n \u003cp\u003eLGBQA+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e83 (84.7)\u003c/p\u003e\n \u003cp\u003e15 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53 (88.3)\u003c/p\u003e\n \u003cp\u003e7 (11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e136 (86.1)\u003c/p\u003e\n \u003cp\u003e22 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth authority\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVancouver Coastal\u003c/p\u003e\n \u003cp\u003eFraser\u003c/p\u003e\n \u003cp\u003eInterior\u003c/p\u003e\n \u003cp\u003eNorthern\u003c/p\u003e\n \u003cp\u003eIsland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (23.5)\u003c/p\u003e\n \u003cp\u003e18 (18.4)\u003c/p\u003e\n \u003cp\u003e12 (12.2)\u003c/p\u003e\n \u003cp\u003e19 (19.4)\u003c/p\u003e\n \u003cp\u003e26 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (8.3)\u003c/p\u003e\n \u003cp\u003e14 (23.3)\u003c/p\u003e\n \u003cp\u003e13 (21.7)\u003c/p\u003e\n \u003cp\u003e16 (26.7)\u003c/p\u003e\n \u003cp\u003e12 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (17.7)\u003c/p\u003e\n \u003cp\u003e32 (20.3)\u003c/p\u003e\n \u003cp\u003e25 (15.8)\u003c/p\u003e\n \u003cp\u003e35 (22.2)\u003c/p\u003e\n \u003cp\u003e38 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousing\u003c/strong\u003e\u003csup\u003e%\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eHas regular\u003csup\u003e\u0026nbsp;\u003c/sup\u003ehousing\u003c/p\u003e\n \u003cp\u003eNo regular housing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e47 (48.0)\u003c/p\u003e\n \u003cp\u003e51 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (50.0)\u003c/p\u003e\n \u003cp\u003e30 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77 (48.7)\u003c/p\u003e\n \u003cp\u003e81 (51.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eWork part-time or full-time\u003c/p\u003e\n \u003cp\u003eNot employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (23.7)\u003c/p\u003e\n \u003cp\u003e71 (76.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (21.1)\u003c/p\u003e\n \u003cp\u003e45 (78.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34 (22.7)\u003c/p\u003e\n \u003cp\u003e116 (77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity size (population centres)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSmall (\u0026lt;30,000 people)\u003c/p\u003e\n \u003cp\u003eMedium and large urban (\u0026ge;30,000 people)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (35.7)\u003c/p\u003e\n \u003cp\u003e63 (64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (50.0)\u003c/p\u003e\n \u003cp\u003e30 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e65 (41.1)\u003c/p\u003e\n \u003cp\u003e93 (58.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual plus (LGBQA+)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e#\u003c/sup\u003eColumn percentages\u003c/p\u003e\n\u003cp\u003e^Row percentages\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003eCross-tabulations that resulted in categories with \u0026lt;20 participants were suppressed to align with the survey privacy protection protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e%\u003c/sup\u003e\u003c/strong\u003eRegular housing includes private residences, band-owned homes, or other residences (e.g., hotel/motel, single room occupancy, supportive housing). Those without regular housing reported no fixed place to stay (homeless, tent, couch-surfing) or living in a shelter.\u003c/p\u003e\n\u003cp\u003eThe most common substances that participants reported using in the last 30 days were stimulants (86.7%) and opioids (81.6%), and over half (51.9%) reported injection drug use in the last six months (\u003cstrong\u003eTable 1b\u003c/strong\u003e). Many participants were engaging with harm reduction services in the last six months: 71.5% had used drugs at an OPS/SCS, 53.8% had been prescribed alternatives to the toxic drug supply, and 81.6% owned a naloxone kit. Compared to those tested more than 12 months ago or who had never been tested, recent testers reported less concern about others finding out about their substance use and greater use of harm reduction services including using drugs at an OPS/SCS, receiving prescribed alternatives, and using drug checking tools.\u003c/p\u003e\n\u003cp\u003eTable 1b. Substance use and harm reduction-related characteristics of the study\u0026nbsp;subsample with complete data for outcome, demographic, and predictor variables.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 310px;\"\u003e\n \u003cp\u003eTested for Sexually Transmitted and Bloodborne Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eIn the last 12 months, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003eMore than 12 months ago or had never been tested, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eTotal, n (%\u003csup\u003e#\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e98 (62.0^)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e60 (38.9^)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e158 (100.0^)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of drugs used (last 30 days)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOpioids\u003c/p\u003e\n \u003cp\u003eBenzodiazepines\u003c/p\u003e\n \u003cp\u003eStimulants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e83 (84.7)\u003c/p\u003e\n \u003cp\u003e43 (43.9)\u003c/p\u003e\n \u003cp\u003e87 (88.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46 (76.7)\u003c/p\u003e\n \u003cp\u003e18 (30.0)\u003c/p\u003e\n \u003cp\u003e50 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e129 (81.6)\u003c/p\u003e\n \u003cp\u003e61 (38.6)\u003c/p\u003e\n \u003cp\u003e137 (86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of substance use (last six months)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eInjection drug use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e54 (55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e28 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e82 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 314px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHarm reduction (last six months)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUsed drugs at an OPS/SCS\u003c/p\u003e\n \u003cp\u003eReported difficulties using drugs at OPS/SCS\u003c/p\u003e\n \u003cp\u003eHistory of opioid or stimulant overdose\u003c/p\u003e\n \u003cp\u003eUsed drug checking tools\u003c/p\u003e\n \u003cp\u003eReceived prescribed alternatives\u003c/p\u003e\n \u003cp\u003eRecent skin infection\u003c/p\u003e\n \u003cp\u003eOwns a naloxone kit\u003c/p\u003e\n \u003cp\u003eFearful of others finding out about drug use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76 (77.6)\u003c/p\u003e\n \u003cp\u003e54 (55.1)\u003c/p\u003e\n \u003cp\u003e54 (55.1)\u003c/p\u003e\n \u003cp\u003e43 (43.9)\u003c/p\u003e\n \u003cp\u003e59 (60.2)\u003c/p\u003e\n \u003cp\u003e67 (68.4)\u003c/p\u003e\n \u003cp\u003e83 (84.7)\u003c/p\u003e\n \u003cp\u003e33 (33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37 (61.7)\u003c/p\u003e\n \u003cp\u003e25 (41.7)\u003c/p\u003e\n \u003cp\u003e32 (53.3)\u003c/p\u003e\n \u003cp\u003e22 (36.7)\u003c/p\u003e\n \u003cp\u003e26 (43.3)\u003c/p\u003e\n \u003cp\u003e32 (53.3)\u003c/p\u003e\n \u003cp\u003e46 (76.7)\u003c/p\u003e\n \u003cp\u003e30 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e113 (71.5)\u003c/p\u003e\n \u003cp\u003e79 (50.0)\u003c/p\u003e\n \u003cp\u003e86 (54.4)\u003c/p\u003e\n \u003cp\u003e65 (41.1)\u003c/p\u003e\n \u003cp\u003e85 (53.8)\u003c/p\u003e\n \u003cp\u003e99 (62.7)\u003c/p\u003e\n \u003cp\u003e129 (81.6)\u003c/p\u003e\n \u003cp\u003e63 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: All variables are binary (yes/no), with \u0026quot;no\u0026quot; responses omitted. Percentages refer to the total N in each column.\u003c/p\u003e\n\u003cp\u003eAbbreviations: Overdose Prevention or Supervised Consumption Site (OPS/SCS)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e#\u003c/sup\u003eColumn percentages\u003c/p\u003e\n\u003cp\u003e^Row percentages\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMultivariable regression analysis of recent STBBI testing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAge, gender identity, health region, and mode of substance use were retained in the adjusted model due to their theoretical relevance through engagement with PWLLE and the existing literature. In addition, variables with p-values \u0026lt;0.20 in univariable analyses were considered in the adjusted model, which included using drugs at an OPS/SCS (p = 0.13), difficulties using drugs at an OPS/SCS (p = 0.17), receipt of prescribed alternatives (p = 0.15), and community size (p = 0.12). The final set of covariates included those with the best statistical fit while also retaining variables deemed theoretically important.\u003c/p\u003e\n\u003cp\u003eThe final model included the following covariates: age, gender identity, health region, community size, mode of substance use, and prescribed alternatives. None of the associations reached statistical significance with a nominal threshold of p=0.05; however, several associations were borderline statistically significant and may warrant further consideration. Participants from sites in smaller population centres were 30% less likely to have tested recently (95% CI: 0.48, 1.03), as were those from sites in the Fraser Health region compared to participants from sites in the Vancouver Coastal Health region (RR = 0.66; 95% CI: 0.43, 1.02) (\u003cstrong\u003eTable 2\u003c/strong\u003e). Compared to men, women were 15% less likely to have been recently tested (95% CI: 0.64, 1.12). Participants who received prescribed alternatives were associated with a 21% higher likelihood of recent testing (95% CI: 0.93, 1.59).\u003c/p\u003e\n\u003cp\u003eTable 2. Risk ratios of sexually transmitted and bloodborne infections testing in the past 12 months among harm reduction clients. Estimates were obtained from the MICE datasets using Poisson regression with robust standard errors.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eUnadjusted RR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eAdjusted RR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e40+ years\u003c/p\u003e\n \u003cp\u003e19-39 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.96 (0.74, 1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.97 (0.74, 1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender identity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale/man\u003c/p\u003e\n \u003cp\u003eFemale/woman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.89 (0.68, 1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.85 (0.64, 1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual orientation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLGBQA+\u003c/p\u003e\n \u003cp\u003eHeterosexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.94 (0.69, 1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth authority\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVancouver Coastal\u003c/p\u003e\n \u003cp\u003eFraser\u003c/p\u003e\n \u003cp\u003eInterior\u003c/p\u003e\n \u003cp\u003eNorthern\u003c/p\u003e\n \u003cp\u003eIsland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.74 (0.5, 1.1)\u003c/p\u003e\n \u003cp\u003e0.79 (0.52, 1.21)\u003c/p\u003e\n \u003cp\u003e0.76 (0.51, 1.12)\u003c/p\u003e\n \u003cp\u003e0.97 (0.67, 1.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.66 (0.43, 1.02)\u003c/p\u003e\n \u003cp\u003e0.92 (0.59, 1.44)\u003c/p\u003e\n \u003cp\u003e0.85 (0.57, 1.29)\u003c/p\u003e\n \u003cp\u003e0.87 (0.58, 1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousing\u003csup\u003e%\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo regular housing\u003c/p\u003e\n \u003cp\u003eHas regular housing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.99 (0.83, 1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNot employed\u003c/p\u003e\n \u003cp\u003eWork part-time or full-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.02 (0.76, 1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity size (population centres)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMedium and large urban (\u0026ge;30,000 people)\u003c/p\u003e\n \u003cp\u003eSmall (\u0026lt;30,000 people)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.81 (0.62, 1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.7 (0.48, 1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpioid drug use*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.09 (0.79, 1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003cstrong\u003eenzodiazepine drug use*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.14 (0.89, 1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStimulant drug use*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.92 (0.65, 1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of substance use\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNon-injection drug use only\u003c/p\u003e\n \u003cp\u003eInjection drug use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.05 (0.81, 1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.01 (0.78, 1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsed drugs at an OPS/SCS\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.24 (0.94, 1.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReported difficulties using drugs at OPS/SCS\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.19 (0.93, 1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of opioid or stimulant overdose\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.04 (0.81, 1.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsed drug checking tools\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.07 (0.84, 1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived prescribed alternatives\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.21 (0.93, 1.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.21 (0.93, 1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecent skin infection\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.11 (0.86, 1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOwns naloxone kit\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e1.14 (0.82, 1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFearful of others finding out about drug use\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.91 (0.7, 1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Ref)\u003c/p\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual+ (LGBQA+); overdose prevention or supervised consumption site (OPS/SCS)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e%\u003c/sup\u003eRegular housing includes private residences, band-owned homes, or other residences (e.g., hotel/motel, single room occupancy, supportive housing). Those without regular housing reported no fixed place to stay (homeless, tent, couch-surfing) or living in a shelter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003eUsed substance in the last 30 days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003eIn the last six months.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdditional STBBI testing results\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 433 participants who completed the survey, 281 (65%) reported previous testing for any STBBI (HIV, HCV, or syphilis)\u0026nbsp;either within the previous 12 months or earlier, with 208 (48%) reporting testing for all three infections (\u003cstrong\u003eFigure 2\u003c/strong\u003e). Among those reporting a previous STBBI test (n = 281), 207 (74%) participants reported that the test was within the last 12 months. HIV was the most common test (93%), followed by syphilis (88%) and HCV (83%). Nearly one-quarter of participants who reported a previous STBBI test did not know their test results (23.5%). Out of 321 responses, 73% (n = 234) of participants were interested in accessing STBBI self-testing kits through harm reduction sites and 15% (n = 40) were possibly interested.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing data from the 2023 HRCS, this study examined factors associated with recent STBBI testing among harm reduction clients in BC, Canada. Our results showed that those participating in harm reduction sites outside of the Vancouver Coastal Health region and in small population centres were less likely to report recent STBBI testing, while those reporting greater engagement with harm reduction services, particularly prescribed alternatives, were more likely to report recent STBBI testing. To our knowledge, this is the first study to examine predictors of recent STBBI testing in the last 12 months among PWUS accessing harm reduction services. These findings highlight key gaps in service access experienced by PWUS in BC, undermining efforts to eliminate STBBIs in Canada by 2030.\u003c/p\u003e\n\u003cp\u003eAlthough our results do not indicate statistically significant differences, our study\u0026rsquo;s findings of lower recent STBBI testing reported from those accessing harm reduction services outside large population centres align with the experiences of PWLLE and previous research demonstrating geographic disparities in STBBI testing uptake (27,28,43). Clients in rural and remote settings experience more limited healthcare service availability and higher levels of stigma; for PWUS, these may further overlap with vulnerabilities such as experiences of unstable housing, limited health literacy, sex work, and digital exclusion to create significant barriers in accessing care (15,16,44,45). STBBI self-testing is often proposed to improve testing uptake in underserved regions (45), and the high level of interest in self-testing observed in our study population suggests that this approach may be promising for some individuals. However, self-testing is found to have variable impacts on linkage to care (46). PWLLE reinforced this concern, noting that it has been challenging to distribute self-testing kits in the past, even among sexually active PWUS. They also cautioned that the high level of interest observed in this study may reflect social desirability bias. While self-testing, such as self-collection of dried blood spot specimens, has been found to improve STBBI testing and treatment uptake (47,48), further research is needed to identify effective and acceptable strategies for implementation among PWUS, including approaches that ensure reliable linkage to care.\u003c/p\u003e\n\u003cp\u003eIt was encouraging to find that all harm reduction-related variables considered in the analysis, although not statistically significant, were positively associated with recent STBBI testing (i.e., RR \u0026gt; 1). This aligns with previous research demonstrating harm reduction sites as critical, trusted points of healthcare access for PWUS that serve not only to reduce risks and harm associated with substance use, but also to promote referrals and connections to health and social services (19). For instance, a study using the 2021 HRCS found that individuals who accessed an OPS/SCS had twice the odds of receiving prescribed alternatives to the toxic drug supply compared to those who did not (18). While strengthening and expanding services through harm reduction sites holds promise for improving access to STBBI and other healthcare needs, doing so will require targeted investments to ensure site sustainability and support their frontline role in advancing public health. Recent findings from a provincial survey of harm reduction sites in BC highlight the growing strain on these services following the implementation of decriminalization (49). Many sites reported increased client demand, staffing pressures, and expanded resource needs, yet few received formal training or corresponding increases in operational funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe observed participants that reported stimulant use were less likely to have been recently tested for STBBIs. Previous studies have similarly identified lower STBBI testing and diagnosis rates among people who use stimulants (32,33), alongside reduced engagement with healthcare services due to intersecting social determinants of health such as stigma, discrimination, and unstable housing (14,15). Stimulant use has been associated with increased injection drug use (50,51), sharing of drug preparation and use equipment (52), as well as higher-risk sexual behaviours such as engaging in unprotected sex and having multiple sex partners (53). Together, these factors may increase the risk of STBBI transmission within stimulant use networks, particularly when testing and treatment uptake is low.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the total survey sample, 65% of participants reported ever being tested for HIV, HCV, or syphilis and 18% (n = 78/433) did not respond to any of the STBBI testing questions. The testing uptake is lower than the 80-90% lifetime HIV and HCV testing rates from similar surveys of people who inject drugs (54,55), which may be a result of several contributing factors. First, other surveys are specific to injection drug use, for which awareness of STBBI risk may be higher than for those who use substances through other modes. Second, the STBBI section in the HRCS appeared at the end of a long, self-administered questionnaire and the questions were presented in a table rather than straightforward yes/no items; therefore, it is possible that some non-response may reflect survey fatigue. Finally, internalized stigma and concerns about confidentiality are well-documented barriers to STBBI healthcare access among PWUS that may have led to an intentional avoidance of this topic (15,45). Missing responses about STBBI testing were 11-12% higher than subsequent questions about infection/wounds and treatment/counselling, and the consultations with PWLLE reinforced the experiences of a distinct STBBI-related stigma. We heard that although the survey settings in harm reduction sites would likely reduce stigma associated with substance use, participants might not feel safe reporting recent STBBI testing, and concerns about the impacts of having an STBBI or others learning about their sexual behaviours could be a barrier to seeking testing for this population. These barriers may be particularly pronounced for women and individuals who expressed hesitance to access health services due to fear of others discovering their substance use, as we found those groups were less likely to report recent STBBI testing in the statistical analyses.\u003c/p\u003e\n\u003cp\u003eWhether a person is tested for a specific STBBI reflects both the accessibility of services and their willingness or ability to seek and accept testing for that infection based on perceived risk. HCV and HIV transmission through injection drug use is well-known, and many PWUS would likely be aware of the importance of being screened for these infections (6,54). Our study partially supports this assumption as the most reported test was HIV. However, an unexpected finding from our study is that HCV testing was the least reported. This could have been influenced by the survey wording, which used the acronym \u0026ldquo;HCV\u0026rdquo; instead of \u0026ldquo;hepatitis C\u0026rdquo;, and this acronym may not have been familiar to some participants. Higher syphilis testing may also be related to targeted public health efforts addressing the ongoing provincial syphilis outbreak declared in July 2019 (56,57).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the shared transmission routes and high frequency of co-infections among STBBIs (58,59), a test for one infection presents an important opportunity to screen for others, particularly when multiple assays can be run from a single blood draw. While most participants in our study reported testing for all three infections (n = 208/281), a notable proportion did not, suggesting gaps in comprehensive testing. Missed screening carries significant implications, as it can contribute to delayed diagnosis and treatment, increase the likelihood of onward transmission, and limit opportunities for integrated prevention and care within high-risk networks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEqually concerning is that nearly one-quarter of participants (23.5%) reported not knowing their test results, underscoring persistent challenges in the STBBI care cascade. Testing is only the first step and effective linkage to care requires timely result delivery and ongoing engagement. Communication barriers such as unstable access to phones, limited phone minutes, or competing vulnerabilities (e.g., housing, food, clothing) may disproportionately affect more marginalized PWUS and hinder the continuity of care (16). These gaps highlight the importance of strengthening not only testing availability but also systems of post-test follow-up and communication, ensuring that testing translates into improved health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrengths and limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBy using the HRCS, our study capitalized on an existing robust and standardized survey to capture consistent measures and ensure comparability across regions. Although we were exploring a different topic area from most of the survey, previous evidence of the high correlation between self-reported STBBI testing behaviors and true testing history supports the reliability of our study design and data source (54,60). However, all information in this study was self-reported, thus accuracy cannot be directly verified, and potential recall or social desirability biases cannot be quantified. In addition, incorporating feedback from PWLLE of substance use and STBBIs strengthened the relevance and contextual sensitivity of the research.\u003c/p\u003e\n\u003cp\u003eIt is important to note that the HRCS is a convenience sample of PWUS engaged with harm reduction and does not represent all harm reduction sites or the broader population of PWUS across the province. As a result, people who experience the greatest barriers in accessing healthcare services, such as those experiencing intersecting identities like race, ethnicity, and gender, may be underrepresented (29,44,45). Very few participants identified as transgender or gender expansive, limiting our ability to examine associations with recent STBBI testing in this group, and race and ethnicity data were not included because governance mechanisms to ensure ethical use of such information are still being developed. Given these limitations, this data source does not allow us to assess recent STBBI testing for people who are disproportionately affected by these infections, including transgender (61) and Indigenous peoples (62,63) as well as those impacted by the ongoing toxic drug crisis, which continues to disproportionately affect Indigenous peoples (64,65). Without adequate data to assess these relationships, our study lacks the critical thinking lens needed to fully understand and respond to disparities in STBBI testing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is also important to acknowledge that our analysis may have introduced bias through the imputation of missing data based on complete cases; however, this process is more likely to reproduce existing biases in the dataset rather than create entirely new ones. Moreover, the cross-sectional survey design prevents us from inferring causal relationships between the predictors of interest and STBBI testing, and the absence of data on sexual behaviors restricts our capacity to explore important behavioral risk factors for STBBIs. Although our results may not be generalizable to all PWUS, harm reduction sites remain one of the few accessible settings for engaging with this population and our findings provide valuable insight to inform future programs and research.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePublic health implications and future directions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study supports several important conclusions to guide public health and harm reduction policy and practices. First, geographic disparities in STBBI testing persist, both across health regions and by community population size, and will likely require targeted strategies to improve access in small, rural, and remote areas. The option of STBBI self-testing take home kits may help reach populations that face geographic and structural barriers. From the individual perspective, people who receive the kits need clear information on how to use the tests and their accuracy; from the health system perspective, there must be appropriate mechanisms to facilitate follow-up care for those who need it (45). Self-testing has the potential to reduce stigma, increase privacy, and empower individuals to take ownership of their health, but its effectiveness depends on integration into broader health systems to ensure linkage to confirmatory testing, treatment, and support services. Community-based organizations and peer support workers could play a critical role in distributing kits and providing guidance, especially in underserved regions. Future research is needed not only to evaluate the acceptability and uptake of STBBI self-testing kits, but also to assess their impact on health equity, cost-effectiveness, and the sustainability of large-scale implementation.\u003c/p\u003e\n\u003cp\u003eSecond, although not statistically significant, the use of harm reduction services is positively associated with recent STBBI testing and presents a critical opportunity to expand access to testing for STBBIs and other health conditions within facilities that are known to be trusted points of contact for PWUS (35,66). To support this role, expanding harm reduction sites and providing adequate funding and resources to existing sites will be essential for sustaining and strengthening their capacity to deliver broader health services (49). Incorporating questions in plain language about broader health needs and testing uptake into future iterations of the HRCS could help monitor progress over time. This would be especially valuable when combined with targeted, community-based strategies to reach individuals who are less likely to access testing. For example, in BC, point-of-care HCV testing in supervised consumption sites have successfully increased testing uptake among PWUS (17). Similarly, in Spain, mobile harm reduction units providing point-of-care STBBI testing and on-site treatment for street-based female sex workers have demonstrated the feasibility of integrating timely diagnosis and care within trusted community settings (19).\u003c/p\u003e\n\u003cp\u003eThird, meaningful community engagement throughout the model-building and interpretation process improves the relevance and impact of findings (67). In this quantitative study, the inclusion of PWLLE ensured that the variables selected for analysis and interpretation of results were grounded in community perspectives. This approach strengthens the validity of the conclusions and supports the development of public health strategies that are more responsive and aligned with community needs. Given the ongoing colonial harms experienced by Indigenous peoples related to the toxic drug crisis (64,65) and STBBIs (62,63), future research must prioritize working with Indigenous PWLLE and strive to include a distinctions-based approach. Addressing both the slow development of appropriate governance structures and the erasure of racialized and gender-diverse populations in health data is essential to move beyond replicating colonial patterns in research and to inform more equitable and culturally safe public health responses (30,68).\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion ","content":"\u003cp\u003eThis analysis of factors associated with recent STBBI testing among harm reduction clients in BC, Canada demonstrates the potential of this data source in examining infectious disease testing uptake among PWUS. The findings suggest positive associations between engagement with harm reduction services and STBBI testing, while also revealing ongoing geographic and structural inequities for those in small population centres. STBBI testing uptake among people accessing harm reduction services may be shaped by factors such as stigma and social determinants of health, and we believe that increasing testing will require both targeted interventions and broader systemic changes to improve accessibility. Moving forward, expanding harm reduction services and financially supporting existing sites, evaluating innovative testing models such as self-testing kits, and embedding routine testing within trusted networks could help close critical gaps. By integrating the perspectives of PWLLE in our analytic approach, we aimed to enhance the contextual relevance for responsive and relevant public health strategies. Ultimately, improving STBBI testing uptake is not only about delivering services, but also about building systems that are trusted, inclusive, and designed to meet people where they are.\u003c/p\u003e"},{"header":"List of Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eBC \u0026ndash; British Columbia\u003c/li\u003e\n \u003cli\u003eBCCDC \u0026ndash; BC Centre for Disease Control\u003c/li\u003e\n \u003cli\u003eCI \u0026ndash; Confidence interval\u003c/li\u003e\n \u003cli\u003eHCV \u0026ndash; Hepatitis C virus\u003c/li\u003e\n \u003cli\u003eHIV \u0026ndash; Human immunodeficiency virus\u003c/li\u003e\n \u003cli\u003eHRCS \u0026ndash; Harm Reduction Client Survey\u003c/li\u003e\n \u003cli\u003eLASSO \u0026ndash; Least absolute shrinkage and selection operator\u003c/li\u003e\n \u003cli\u003eLGBQA+ \u0026ndash; Lesbian, gay, bisexual/pansexual, queer/questioning, or asexual+\u003c/li\u003e\n \u003cli\u003eOPS/SCS \u0026ndash; Overdose prevention sites / supervised consumption sites\u003c/li\u003e\n \u003cli\u003ePEEP \u0026ndash; Professionals for the Ethical Engagement of Peers\u003c/li\u003e\n \u003cli\u003ePWLLE \u0026ndash; People with lived and living experience (of substance use and/or STBBIs)\u003c/li\u003e\n \u003cli\u003ePWUS \u0026ndash; People who use substances\u003c/li\u003e\n \u003cli\u003eRR \u0026ndash; Risk ratio\u003c/li\u003e\n \u003cli\u003eSHAG \u0026ndash; Sexual Health Advisory Group\u003c/li\u003e\n \u003cli\u003eSTBBIs \u0026ndash; Sexually transmitted and bloodborne infections\u003c/li\u003e\n \u003cli\u003eWHO \u0026ndash; World Health Organization\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The study was approved by the University of British Columbia\u0026rsquo;s Research Ethics Board (2023 UBC REB# H23-02685). All participants provided informed consent before participating in the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe data used in this study are not publicly available but may be available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eAT, KAT, and SRB contributed to the conceptualization and design of the study. AT and KAT developed the methodology and curated the data. AT conducted the formal analysis. AT and KAT created visualizations. AT drafted the initial manuscript, and AT and KAT prepared all subsequent versions. All authors contributed to the interpretation of data and were involved in reviewing and editing the manuscript. SRB provided supervision throughout the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe authors wish to acknowledge and thank the Sexual Health Advisory Group (SHAG), the Professionals for the Ethical Engagement of Peers (PEEP), and the Harm Reduction and Substance Use Services team at the BC Centre for Disease Control for their valuable input and guidance throughout the study. We are also grateful to Max Xie and Felicity Clemens from the BC Centre for Disease Control for their biostatistical expertise and support with the statistical analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information:\u0026nbsp;\u003c/strong\u003eDr. Sofia Bartlett (she/her) is the senior author of this research article and currently serves as the Interim Scientific Director for Sexually Transmitted and Blood-Borne Infections at the BC Centre for Disease Control within Clinical Prevention Services. Her research focuses primarily on hepatitis C virus (HCV) and improving health outcomes for marginalized populations, including people who use drugs, those who are incarcerated, and individuals experiencing unstable housing. To learn more about Dr. Bartlett and her work, please visit stbbipathways.ca.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Implementing the global health sector strategies on HIV, viral hepatitis and sexually transmitted infections, 2022\u0026ndash;2030: Report on Progress and Gaps. [Internet]. 2024 [cited 2025 Apr 4]. Available from: https://iris.who.int/bitstream/handle/10665/376814/9789240094925-eng.pdf\u003c/li\u003e\n\u003cli\u003eHamill V, Wong S, Benselin J, Krajden M, Hayes PC, Mutimer D, et al. Mortality rates among patients successfully treated for hepatitis C in the era of interferon-free antivirals: population based cohort study. BMJ. 2023 Aug 2;382:e074001. \u003c/li\u003e\n\u003cli\u003eWu MY, Gong HZ, Hu KR, Zheng H yi, Wan X, Li J. Effect of syphilis infection on HIV acquisition: a systematic review and meta-analysis. Sex Transm Infect. 2021 Nov;97(7):525\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eWorld Drug Report [Internet]. United Nations Office on Drugs and Crime; 2025. Available from: https://doi.org/10.18356/9789211594850c007\u003c/li\u003e\n\u003cli\u003eGlobal AIDS targets 2025 for people who use drugs: Where are we now? [Internet]. United Nations Programme on HIV/AIDS (UNAIDS); 2024. Available from: https://www.unaids.org/en/resources/documents/2024/global-AIDS-targets-2025-for-people-who-use-drugs-where-are-we-now\u003c/li\u003e\n\u003cli\u003eJanjua NZ, Yu A, Kuo M, Alvarez M, Cook D, Wong J, et al. Twin epidemics of new and prevalent hepatitis C infections in Canada: BC Hepatitis Testers Cohort. BMC Infect Dis. 2016 Jul 19;16(1):334. \u003c/li\u003e\n\u003cli\u003eRaval M, Gratrix J, Plitt S, Niruban J, Smyczek P, Dong K, et al. Retrospective Cohort Study Examining the Correlates of Reported Lifetime Stimulant Use in Persons Diagnosed With Infectious Syphilis in Alberta, Canada, 2018 to 2019. Sex Transm Dis. 2022 Aug 1;49(8):551\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003ePouget ER, Hagan H, Des Jarlais DC. Meta-analysis of hepatitis C seroconversion in relation to shared syringes and drug preparation equipment. Addiction. 2012 Jun;107(6):1057\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eBall LJ, Puka K, Speechley M, Wong R, Hallam B, Wiener JC, et al. Sharing of Injection Drug Preparation Equipment Is Associated With HIV Infection: A Cross-sectional Study. J Acquir Immune Defic Syndr. 2019 Aug 1;81(4):e99\u0026ndash;103. \u003c/li\u003e\n\u003cli\u003eAhmadi K, Javadinia SA, Saadat SH, Ramezani MA, Sedghijalal H. Triangular relationship among risky sexual behavior, addiction, and aggression: A systematic review. Electron Physician. 2017 Aug 1;9(8):5129\u0026ndash;37. \u003c/li\u003e\n\u003cli\u003eHaider MR, Kingori C, Brown MJ, Battle-Fisher M, Chertok IA. Illicit drug use and sexually transmitted infections among young adults in the US: evidence from a nationally representative survey. Int J STD AIDS. 2020 Nov;31(13):1238\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eCunningham NE, Lamb J, Staller A, Krajden M, Hogg RS, Towle A, et al. Expanding access to healthcare for people who use drugs and sex workers: hepatitis C elimination implications from a qualitative study of healthcare experiences in British Columbia, Canada. Harm Reduct J. 2024 Apr 4;21(1):75. \u003c/li\u003e\n\u003cli\u003eMacLean R. Resources to address stigma related to sexuality, substance use and sexually transmitted and blood-borne infections. Can Commun Dis Rep. 2018 Feb 1;44(2):62\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eMarshall BD, Kerr T, Shoveller JA, Patterson TL, Buxton JA, Wood E. Homelessness and Unstable Housing Associated with an Increased Risk of HIV and STI Transmission among Street-Involved Youth. Health Place. 2009 Sep;15(3):753\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eLang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers. Substance Abuse Treatment, Prevention, and Policy. 2013 Oct 1;8(1):35. \u003c/li\u003e\n\u003cli\u003eTiwana A, Gale N, Mahay M, Barker T, Hasdell R, Young P, et al. Addressing digital exclusion to improve access to HIV and viral hepatitis care for people who experience criminalization: a mixed methods evaluation of a quality improvement project. Int J Equity Health. 2025 Dec 2;24(1):337. \u003c/li\u003e\n\u003cli\u003eHannigan A, Krishnan N, Singh K, Bytelaar S, Schmitz D, Bartlett S, et al. Scaling up hepatitis C testing and linkage-to-care among people who use drugs: lessons learned from a pilot project implemented at a supervised consumption site. BMC Health Serv Res. 2025 Feb 13;25(1):243. \u003c/li\u003e\n\u003cli\u003ePalis H, Haywood B, McDougall J, Xavier CG, Desai R, Tobias S, et al. Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey. Harm Reduct J. 2024 Jan 6;21(1):5. \u003c/li\u003e\n\u003cli\u003eValencia J, V\u0026aacute;zquez L, Lazarus JV, Cuevas G, Torres-Macho J, Domingorena J, et al. On-site testing and treatment of sexually transmitted infections among female sex workers using molecular point-of-care testing integrated into harm reduction services in Madrid, Spain. Int J Drug Policy. 2024 Jan;123:104281. \u003c/li\u003e\n\u003cli\u003eBaldwin N, Gray R, Goel A, Wood E, Buxton JA, Rieb LM. Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: An observational analysis. Drug Alcohol Depend. 2018 Apr 1;185:322\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKinniburgh B, Liu L, Loewen O, Burgess H, Xavier C, Ge W, et al. Findings from the 2022 Harm Reduction Client Survey related to BC\u0026rsquo;s Decriminalization Policy. [Internet]. BC Centre for Disease Control; 2023. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/HRCS_2022_decriminalization_findings.pdf\u003c/li\u003e\n\u003cli\u003eKaramouzian M, Papamihali K, Graham B, Crabtree A, Mill C, Kuo M, et al. Known fentanyl use among clients of harm reduction sites in British Columbia, Canada. The International journal of drug policy. 2020;77(Journal Article):102665\u0026ndash;102665. \u003c/li\u003e\n\u003cli\u003eMoustaqim-Barrette A, Papamihali K, Crabtree A, Graham B, Karamouzian M, Buxton JA. Correlates of take-home naloxone kit possession among people who use drugs in British Columbia: A cross-sectional analysis. Drug and alcohol dependence. 2019;205(Journal Article):107609\u0026ndash;107609. \u003c/li\u003e\n\u003cli\u003eMap of Participating Harm Reduction Distribution Sites [Internet]. British Columbia Centre for Disease Control; Available from: http://www.bccdc.ca/health-professionals/data-reports/harm-reduction-client-survey\u003c/li\u003e\n\u003cli\u003eHarm Reduction Client Survey [Internet]. 2023. Available from: https://www.bccdc.ca/Health-Professionals-Site/Documents/HRCS%202023%20survey%20final.pdf\u003c/li\u003e\n\u003cli\u003eMartin K, Olaru ID, Buwu N, Bandason T, Marks M, Dauya E, et al. Uptake of and factors associated with testing for sexually transmitted infections in community-based settings among youth in Zimbabwe: a mixed-methods study. The Lancet Child \u0026amp; Adolescent Health. 2021 Feb 1;5(2):122\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eJenkins WD, Williams LD, Pearson WS. STI epidemiology and care in rural areas: a narrative review. Sex Transm Dis. 2021 Dec 1;48(12):e236\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003ePijl EM, Alraja A, Duff E, Cooke C, Dash S, Nayak N, et al. Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review. Substance Abuse Treatment, Prevention, and Policy. 2022 Aug 26;17(1):62. \u003c/li\u003e\n\u003cli\u003eScheidell JD, Chueng T, Ciraldo K, Hervera B, Dakoulas S, Mahachi M, et al. Reaching people who use drugs with sexual and reproductive healthcare through syringe services programs: potential promise and missed opportunities. Harm Reduction Journal. 2024 Nov 14;21(1):198. \u003c/li\u003e\n\u003cli\u003eDisaggregated Demographic Data Collection in British Columbia: The grandmother perspective [Internet]. British Columbia\u0026rsquo;s Office of the Human Rights Commissioner; 2024. Available from: https://bchumanrights.ca/resources/publications/publication/datacollection/\u003c/li\u003e\n\u003cli\u003eAntebi-Gruszka N, Talan AJ, Reisner SL, Rendina HJ. Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men. Sex Transm Infect. 2020 Sep 1;96(6):422\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHwang LY, Ross MW, Zack C, Bull L, Rickman K, Holleman M. Prevalence of Sexually Transmitted Infections and Associated Risk Factors among Populations of Drug Abusers. Clinical Infectious Diseases. 2000 Oct 1;31(4):920\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eCai Y, Dai Z, Wen S, Bhandari R. Risk factors associated with infection of blood-borne virus among people who used methamphetamine. BMC Infect Dis. 2020 Oct 9;20:742. \u003c/li\u003e\n\u003cli\u003eMetzger DS, Zhang Y. Drug treatment as HIV prevention: expanding treatment options. Curr HIV/AIDS Rep. 2010 Nov;7(4):220\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eSemaan S, Fleming P, Worrell C, Stolp H, Baack B, Miller M. Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend. 2011 Nov 1;118(2\u0026ndash;3):100\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eDuby Z, Nkosi B, Scheibe A, Brown B, Bekker LG. \u0026lsquo;Scared of going to the clinic\u0026rsquo;: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities. Southern African Journal of HIV Medicine. 2018 Jan 19;19(1):8. \u003c/li\u003e\n\u003cli\u003eMohseni Afshar Z, Goodarzi A, Emadi SN, Miladi R, Shakoei S, Janbakhsh A, et al. A Comprehensive Review on HIV-Associated Dermatologic Manifestations: From Epidemiology to Clinical Management. Int J Microbiol. 2023 Jul 18;2023:6203193. \u003c/li\u003e\n\u003cli\u003eBuuren S van, Groothuis-Oudshoorn K. mice: Multivariate Imputation by Chained Equations in R. Journal of Statistical Software. 2011 Dec 12;45:1\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eFajber K, Palis H, Fraser H, Xavier CG, Desai R, Wall C, et al. Knowledge update: Receipt and access of prescribed alternatives and opioid agonist treatment among respondents from the 2023 Harm Reduction Client Survey [Internet]. BC Centre for Disease Control; 2025. Available from: https://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/KnowledgeUpdate_HRCS2023_PSS%20barriers_FINAL_20250624.pdf\u003c/li\u003e\n\u003cli\u003eZhang Z. Model building strategy for logistic regression: purposeful selection. Ann Transl Med. 2016 Mar;4(6):111. \u003c/li\u003e\n\u003cli\u003eChowdhury MZI, Turin TC. Variable selection strategies and its importance in clinical prediction modelling. Fam Med Com Health [Internet]. 2020 Feb 16 [cited 2025 Sep 5];8(1). Available from: https://fmch.bmj.com/content/8/1/e000262\u003c/li\u003e\n\u003cli\u003eRanganathan P, Aggarwal R, Pramesh CS. Common pitfalls in statistical analysis: Odds versus risk. Perspectives in Clinical Research. 2015 Dec;6(4):222. \u003c/li\u003e\n\u003cli\u003eHottes TS, Farrell J, Bondyra M, Haag D, Shoveller J, Gilbert M. Internet-based HIV and sexually transmitted infection testing in British Columbia, Canada: opinions and expectations of prospective clients. J Med Internet Res. 2012 Mar 6;14(2):e41. \u003c/li\u003e\n\u003cli\u003eFraser M, Fajber K, Kinniburgh B, Liu L, Loewen O, Wall C, et al. Hesitance in accessing services: Harm Reduction Client Survey 2023 [Internet]. BC Centre for Disease Control; 2024. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/HRCS2023_Hesitance_KnowledgeUpdate.pdf\u003c/li\u003e\n\u003cli\u003eSnow ME, Berger MH, Tam AC, Easterbrook A, Okechukwu CE, Mohammadi T, et al. Attributes that influence testing decisions for sexually transmitted and blood-borne infections: A qualitative study among diverse people in Canada. Int J STD AIDS. 2025 Apr 30;09564624251337595. \u003c/li\u003e\n\u003cli\u003eKhumalo F, Passmore JAS, Manhanzva M, Meyer B, Duyver M, Lurie M, et al. Shifting the power: scale-up of access to point-of-care and self-testing for sexually transmitted infections in low-income and middle-income settings. Current Opinion in Infectious Diseases. 2023 Feb;36(1):49. \u003c/li\u003e\n\u003cli\u003eConway A, Stevens A, Murray C, Prain B, Power C, McNulty A, et al. Hepatitis C Treatment Uptake Following Dried Blood Spot Testing for Hepatitis C RNA in New South Wales, Australia: The NSW DBS Pilot Study. Open Forum Infectious Diseases. 2023 Nov 1;10(11):ofad517. \u003c/li\u003e\n\u003cli\u003eYoung J, Ablona A, Klassen BJ, Higgins R, Kim J, Lavoie S, et al. Implementing community-based Dried Blood Spot (DBS) testing for HIV and hepatitis C: a qualitative analysis of key facilitators and ongoing challenges. BMC Public Health. 2022 May 31;22(1):1085. \u003c/li\u003e\n\u003cli\u003eAli F, Russell C, Law J, Imtiaz S, Budau J, Shahin R, et al. Characterizing changes to harm reduction site operations in British Columbia following the implementation of the decriminalization of drugs: Findings from a provincial survey. Harm Reduction Journal. 2025 Jul 18;22(1):122. \u003c/li\u003e\n\u003cli\u003eNyamathi A, Hudson A, Greengold B, Leake B. Characteristics of homeless youth who use cocaine and methamphetamine. Am J Addict. 2012;21(3):243\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCepeda JA, Vickerman P, Bruneau J, Zang G, Borquez A, Farrell M, et al. Estimating the contribution of stimulant injection to HIV and HCV epidemics among people who inject drugs and implications for harm reduction: A modeling analysis. Drug and Alcohol Dependence. 2020 Aug 1;213:108135. \u003c/li\u003e\n\u003cli\u003eBroady TR, Brener L, Caruana T, Cama E, Treloar C. Factors associated with sharing equipment among people who inject drugs: The role of community attachment in harm reduction and health promotion. Drug and Alcohol Review. 2023;42(3):561\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGrant JE, Redden SA, Lust K, Chamberlain SR. Nonmedical Use of Stimulants Is Associated With Riskier Sexual Practices and Other Forms of Impulsivity. J Addict Med. 2018;12(6):474\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eTarasuk J, Zhang J, Lemyre A, Cholette F, Bryson M, Paquette D. National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, 2017-2019. Can Commun Dis Rep. 2020 May 7;46(5):138\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eUnlinked anonymous monitoring (UAM) survey of HIV and viral hepatitis among people who inject drugs (PWID): 2024 report [Internet]. UK Health Security Agency; 2024. Available from: https://www.gov.uk/government/publications/people-who-inject-drugs-hiv-and-viral-hepatitis-monitoring/unlinked-anonymous-monitoring-uam-survey-of-hiv-and-viral-hepatitis-among-people-who-inject-drugs-pwid-2024-report\u003c/li\u003e\n\u003cli\u003eHIV, Syphilis, and Sexually Transmitted and Blood-Borne Infections (STBBI) Awareness and Perceptions Survey Executive Summary [Internet]. Health Canada; 2024. Available from: https://publications.gc.ca/site/archivee-archived.html?url=https://publications.gc.ca/collections/collection_2024/sc-hc/HP40-361-2024-1-eng.pdf\u003c/li\u003e\n\u003cli\u003eBC Syphilis Action Plan, 2023-2025 [Internet]. BC Centre for Disease Control (BCCDC); 2023. Available from: http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/STI/Syphilis_Action_Plan_Refresh_2023.pdf\u003c/li\u003e\n\u003cli\u003eWasserheit JN. Epidemiological Synergy: Interrelationships between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases. Sexually Transmitted Diseases. 1992 Apr;19(2):61. \u003c/li\u003e\n\u003cli\u003eNusbaum MRH, Wallace RR, Slatt LM, Kondrad EC. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. 2004 Dec;104(12):527\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eLyons MS, Lindsell CJ, Ruffner AH, Trott AT, Fichtenbaum CJ. Relationship of Self-Reported Prior Testing History to Undiagnosed HIV Positivity and HIV Risk. Curr HIV Res. 2009 Nov;7(6):580\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBigio J, Butler M, Sood S, Cox J, Jackson B, Marshall Z, et al. Sexually transmitted and blood-borne infections in transgender and non-binary people in Canada: A scoping review. PLOS ONE. 2025 May 20;20(5):e0322521. \u003c/li\u003e\n\u003cli\u003eKrementz DH, Macklin C, King A, Fleming T, Kafeety A, Lambert S, et al. Connections with the Land: A Scoping Review on Cultural Wellness Retreats as Health Interventions for Indigenous Peoples Living with HIV, Hepatitis C, or Both. ab-Original. 2018 Oct 1;2(1):23\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eRyan C, Ali A, Sabourin H. A Culturally Safe and Trauma-Informed Sexually Transmitted Blood Borne Infection (STBBI) Intervention Designed by and for Incarcerated Indigenous Women and Gender-Diverse People. IJIH. 2020 Nov 5;15(1):108\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eToxic Drug Crisis Data [Internet]. First Nations Health Authority; Available from: https://www.fnha.ca/what-we-do/mental-wellness-and-substance-use/harm-reduction-and-the-toxic-drug-crisis/toxic-drug-crisis-data\u003c/li\u003e\n\u003cli\u003eUrbanoski KA. Need for equity in treatment of substance use among Indigenous people in Canada. CMAJ. 2017 Nov 6;189(44):E1350\u0026ndash;1. \u003c/li\u003e\n\u003cli\u003ePotier C, Lapr\u0026eacute;vote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014 Dec 1;145:48\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez ST, Morgan JW, Bond L, Kumari S, Martinchek K. Increasing the Rigor of Quantitative Research with Participatory and Community-Engaged Methods: A Participatory and Quantitative Methods Guidebook [Internet]. Urban Institute; 2023 Oct [cited 2025 Jun 24]. Available from: https://www.urban.org/research/publication/increasing-rigor-quantitative-research-participatory-and-community-engaged\u003c/li\u003e\n\u003cli\u003eLavalley J, Steinhauer L, Bundy D (Boomer), Kerr T, McNeil R. \u003cem\u003e\u0026ldquo;They talk about it like it\u0026rsquo;s an overdose crisis when in fact it\u0026rsquo;s basically genocide\u0026rdquo;\u003c/em\u003e: The experiences of Indigenous peoples who use illicit drugs in Vancouver\u0026rsquo;s Downtown Eastside neighbourhood. International Journal of Drug Policy. 2024 Dec 1;134:104631. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"epidemiology, harm reduction, people who use substances, HIV, Hepatitis C, syphilis, self-testing","lastPublishedDoi":"10.21203/rs.3.rs-8436044/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8436044/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeople who use substances (PWUS) experience disproportionately higher burden of sexually transmitted and bloodborne infections (STBBIs) compared to the general population. Harm reduction supply distribution sites are recognized as potential access points for STBBI testing among PWUS. However, little is known about the uptake of STBBI testing among PWUS who access these sites. This study aimed to identify factors associated with recent STBBI testing among PWUS accessing harm reduction sites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analyzed cross-sectional data from the 2023 Harm Reduction Client Survey in British Columbia, Canada, which included 433 respondents across 23 sites. Sociodemographic, substance use, and harm reduction-related factors associated with recent testing (previous 12 months) for HIV, hepatitis C virus (HCV), or syphilis were examined. Adjusted risk ratios (aRRs) and corresponding 95% confidence intervals (CIs) were estimated using Poisson regression with robust standard errors. Analysis and interpretation were guided by people with lived or living experience of substance use and/or STBBIs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOver one-third of respondents (38%) had not been tested for an STBBI in the previous 12 months. Those participating in smaller communities (aRR = 0.7; 95% CI: 0.48, 1.03), from health regions outside Vancouver Coastal (Fraser Health aRR = 0.66; 95% CI: 0.43–1.02), and women (aRR = 0.85; 95% CI = 0.64, 1.12) were less likely to have been recently tested. Participants prescribed alternatives to the toxic drug supply (aRR = 1.21; 95% CI: 0.93, 1.59) were more likely to report recent testing. Among those who reported a previous STBBI test, either within the previous 12 months or earlier (n = 281), HIV testing was the most common (93%), followed by syphilis (88%) and HCV (83%). Nearly one-quarter (23%) of respondents did not know their test results. The majority of respondents (73%) expressed interest in accessing STBBI self-testing kits through harm reduction sites.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany PWUS accessing harm reduction sites reported no recent STBBI testing, particularly women and those outside large urban centres. Distributing self-testing kits through these sites could potentially help reduce the disproportionate burden of STBBIs among PWUS and contribute to progress toward eliminating STBBIs as a public health threat.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Sexually transmitted and bloodborne infections testing among people who use substances: findings from the 2023 British Columbia Harm Reduction Client Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 08:11:00","doi":"10.21203/rs.3.rs-8436044/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-22T19:09:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T23:44:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T17:03:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167542947077749514031414877681044785445","date":"2026-01-09T19:30:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296456178052455796444233488758492526598","date":"2026-01-09T18:43:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T17:42:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-26T05:59:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T05:58:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-12-23T16:59:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d58dafd2-e072-4f3d-aeed-c3b8e86c31e0","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:02:20+00:00","versionOfRecord":{"articleIdentity":"rs-8436044","link":"https://doi.org/10.1186/s12879-026-12924-4","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-02-23 15:58:09","publishedOnDateReadable":"February 23rd, 2026"},"versionCreatedAt":"2026-01-12 08:11:00","video":"","vorDoi":"10.1186/s12879-026-12924-4","vorDoiUrl":"https://doi.org/10.1186/s12879-026-12924-4","workflowStages":[]},"version":"v1","identity":"rs-8436044","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8436044","identity":"rs-8436044","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}