While the I’m Ready program is a valuable service for people who want to take steps to know their status through HIV self-testing, it’s also an implementation science research program.
“Implementation science” can be defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services.” The main objective of implementation science is to identify barriers and facilitators that affect program uptake and to be responsive to the health access and service needs of key populations in a variety of contexts.
Why we used an implementation science approach for the I’m Ready program
At REACH Nexus, we are committed to ensuring we implement HIV self-testing in a way that will have the biggest impact and the most benefits for people living in Canada. Implementation science helps us to move what we know—through past research, investigations or policies—into what we do and how we do it.
In this case, we know that HIV self-testing has been shown to be effective for individual use, and has now been approved for use in Canada. What we’re doing is making sure HIV self-testing is thoughtfully implemented through the I’m Ready research program, all while we’re collecting data about participants and program use to increase what we know about HIV self-testing and connecting to care.
Learning how to implement and evaluate is also important so we can make sure everyone has equal access to the testing and services they need for their health and well-being. We know that one size doesn’t fit all.
I’m Ready’s intended outcomes
The main goal of the I’m Ready research program is to implement and evaluate how well we are able to reach and support people who are undiagnosed with HIV across Canada to get access to testing, care and treatment. We are also aiming to significantly improve health equity—both geographically and for key populations—regarding testing, care, and for access to appropriate services.
Additionally, we are exploring the scalability and sustainability of the program, including evaluating whether the program is cost-effective and if it provides “value for money.” This information will be valuable for program managers and government decision-makers.
We anticipate that what we learn through this process will be used to create sustainable HIV self-testing programs and better connections to care and prevention across the country.
How we used implementation science to develop the I’m Ready program
HIV self-testing is a new testing method for Canadians, only available in Canada as of Nov. 3, 2020, in part thanks to research efforts led by REACH Nexus. This means that we needed to understand many different factors to plan and launch this program. Among these:
- Who would use I’m Ready, Test (the testing and surveys app) and I’m Ready, Talk (our peer navigator telehealth service)?
- How would users move through the steps in the process, from preparing to test, to responding to surveys, to taking the test, to engaging with health and social services after a test?
- What other information and resources would have to be readily accessible to ensure an integrated user journey across the digital products that together form the I’m Ready platform? This component led to us building the I’m Ready to Know website.
- Which mobile application, survey, web and other technologies would best support our service delivery model, create the least friction for our users, and be manageable for us to maintain and improve over time?
- How does access to HIV self-testing impact people’s health and wellness?
Our previous research helped us consider some of these questions. We will more fully understand each of these components throughout the program’s duration as we collect information and evaluation data to refine the program, and ultimately, improve HIV testing and care in Canada.
Our implementation science framework: RE-AIM
In order to provide a framework to examine these programming questions, we chose the RE-AIM implementation science framework as a guidepost for the research and evaluation activities of the I’m Ready program.
These are the five domains of RE-AIM, as we defined them for this research program:
- Reach: The absolute number, proportion, and representativeness of individuals who participate in the program who are undiagnosed from key populations.
- Effectiveness: The impact of the program on important outcomes. This includes comparative effectiveness between participants who use I’m Ready, Talk and I’m Ready, Test compared to those who only use I’m Ready, Test. This also includes how clinical and knowledge-based outcomes vary by key population, equity and geography.
- Adoption: Absolute number, proportion, and representativeness of settings and intervention agents who are initiating the I’m Ready research program. This includes study participants, distribution sites, and staff/peers/front-line implementers.
- Implementation: Fidelity to the various elements of the program. This includes consistency of delivery as intended as well as the program costs.
- Maintenance: The extent to which the I’m Ready research program becomes a part of routine organizational practice and policies, and how can we make this type of program work in other settings.
Learning and evaluation through the I’m Ready program
The I’m Ready research program supports learning and evaluation about HIV self-testing use in Canada in a number of ways:
- through the collection of anonymized survey data from program participants;
- by engaging key service providers, like peer navigators, in answering key questions; and
- by evaluating implementation decisions that impact how the program is rolled out.
We are also collecting information on:
We are collecting data to understand how low-barrier access to free HIV self-testing kits through the I’m Ready, Test app, combined with the peer navigator support through the I’m Ready, Talk secure telehealth service, may together help reach those who are undiagnosed with HIV.
We’re especially interested in understanding if this makes a difference for people who may not be coming forward for testing in the healthcare system because of structural barriers like racism, homophobia and stigma.
We know that some people may need peer support for their testing or to navigate connections to care, while others may be more comfortable with a “do-it-yourself” approach. This is why we developed both our I’m Ready, Test mobile app and our I’m Ready, Talk secure telehealth service as companion products.
We are collecting data to better understand what supports people need (from one of our peers through I’m Ready, Talk) when accessing their first HIV self-test, but also how this may change during subsequent instances of self-testing if and when people become more comfortable with testing at home.
We know from our work so far that 95% of people who use an HIV self-test for the 1st time would use it again, and over 95% would recommend it to a sexual partner or friend. In the I’m Ready program, we are offering participants up to 3 free HIV self-test kits to use themselves or to share with a partner or friend.
We will be evaluating how well this works to reach others who are undiagnosed and need access to testing to confirm their status and get supported with care.
After months of planning and preparation, we’re ecstatic to have the I’m Ready research program up and running, and we eagerly look forward to sharing our findings with community members, our peers in science and research, policymakers, and anyone who’s interested in improving HIV testing and care in Canada.
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