According to the results from this research, approximately 20% of ACB people have been tested for HIV in the past year. The corresponding proportion for adults in Ontario is about 4.5%.21,22 HIV testing is known to promote behaviour change, which reduces the likelihood of HIV exposure or transmission.23 However, data on the incidence of HIV diagnoses in Ontario show that although ACB people comprise about 4% of Ontario’s population,24,25
they account for about 20% of new HIV diagnoses each year.26,27 Since ACB people are much more likely to be at risk for HIV infection than other adults in Ontario,28,29 it is important for them to be tested much more frequently than other groups of Ontarians.
7.2.4.1. Proximate Determinants of Testing for HIV in the Past Year
In the multivariable model, sexual history factors and HIV knowledge score emerged as the strongest independent proximate determinants of testing for HIV in the past year. The number of sex partners a person had in his/ her lifetime was also a strong predictor of receiving an HIV test in the past year, more so than the number of sex partners that person had in the past year. Several studies had also found that the number of lifetime sex partners impacts HIV testing.30,31 One’s HIV knowledge score was also a strong proximate predictor of HIV testing in the past year. Results from this study showed that people who were more knowledgeable about HIV transmission were more likely to have received an HIV test in the past year. These results were consistent with those from other studies.32 A person’s level proficiency in English approached
significance (p≤0.10) as a proximate determinant of testing for HIV in the past year— people who were more proficient in English appeared to be less likely to have been tested.
The study also found that some factors that were usually associated with HIV testing may not have been important determinants of testing for HIV in the past year in this population. Factors related to one’s sexual history, like past pregnancies, having unprotected sexual intercourse with any kind of partner, and past STI diagnoses, were not
177 significant in the bivariate analyses and were eliminated from the final multivariable model. Similarly, a person’s level of religiosity was not significantly associated with having an HIV test in the past year in the crude or multivariable analyses. Although applying for life insurance was significantly related to HIV testing in the past year in the bivariate analyses, it eliminated from the final model. HIV testing for immigration purposes, health care use, perceptions about HIV risk in the local ACB population, and exposure to HIV prevention messages were not significantly associated with HIV testing in the crude models, and they were also removed from the multivariable model during backward elimination.
7.2.4.2. Gender
Although gender was not significant in the bivariate model, the interaction or intersection of gender with ethnicity was associated with testing for HIV in the past year in the crude three-variable model (p=0.073). The importance of gender as a determinant of HIV testing is documented in other studies,30,31,33 but to date, no quantitative studies have assessed the interaction between/ intersection of gender and ethnicity.
7.2.4.3. Poverty Status/ Income
Like gender, poverty status was not significantly associated with being tested for HIV in the past year in the bivariate model, and its interaction with ethnicity was not significant in the three-variable crude model or any of the adjusted models.
7.2.4.4. Education
Education was not significantly associated with HIV testing in the bivariate model, but it was independently associated with having an HIV test in the past year in the model that only adjusted for markers of SSP and socio-demographic factors. People with no post-secondary education seemed less likely to have tested for HIV in the past year when compared to people whose education exceeded a bachelor’s degree. Other studies have also shown that higher education was associated with HIV testing.30,34–36 Education was not significantly associated with HIV testing in the model including the proximate determinants, however, which indicates that its effect was mediated by the proximate determinants. The mediation models showed that education may have impacted HIV testing in the past year through religiosity and impacting knowledge about HIV
178 transmission. Moreover, the vast majority of the impact of education on HIV testing was mediated by the proximate determinants included in the mediation models.
7.2.4.5. Immigration Experience
Having experience with immigration was strongly related to having had an HIV test in the past year. The amount of time spent in Canada was not associated with HIV testing in the bivariate model, but it was significantly associated with having an HIV test in the multivariable model that included markers of SSP and socio-demographic factors. It was eliminated from the multivariable model including proximate determinants, however, which suggests that much of its impact on having an HIV test in the past year was mediated by the proximate determinants in the model. The effect of the amount of time spent in Canada was mediated by the number of sex partners a person had in her/ his lifetime and a person’s knowledge about HIV. These findings were consistent with those from other studies that showed that the length of time spent in a host country was not associated with HIV testing in multivariable models.34 Immigration class was associated with having an HIV test in the past year in the crude model, and it was also significant in the model that adjusted for other markers of SSP and socio-demographic factors. It was the only dimension of immigration experience that appeared in the multivariable model that included the proximate determinants, but it was not significant. This indicated that much of its effect on HIV testing was mediated by the proximate determinants. The mediators through which it acted were knowledge about HIV and the number of sex partners a person had in her/ his lifetime. While some studies assessed the relationship between immigration status and HIV testing, 34 none was found that assessed
immigration class and HIV testing.
7.2.4.6. Ethnicity
There was no evidence to suggest that ethnicity impacted HIV testing in the past year in the bivariate analyses, and in the multivariable analyses, its effect depended on gender and poverty status. In the crude model, the prevalence of HIV testing was lowest among non-African females, followed by African males, African females, and non- African males. Based on the model that was adjusted for other markers of SSP and socio- demographic factors, compared to non-African females, African females seemed to be
179 680% as likely to have had an HIV test in the past year, non-African males were 359% as likely to have had an HIV test in the past year, and African males may have been 641% as likely to have tested for HIV in the past year. However, none of the comparisons was significant, and only the comparison between non-African females and non-African males approached significance. Based on the mediation analyses, the combined impact of gender and ethnicity was mediated by knowledge about HIV and religiosity. Although the interaction between ethnicity and poverty status was not eliminated from the model that only adjusted for social factors, it was not significant.
7.2.4.7. Employment Status
There was no evidence of an association between employment status and testing for HIV in the past year in the bivariate or multivariable analyses. However, other studies have shown that people who were employed were less likely to get tested than those who were unemployed.37