Beyond the individual: Addressing structural and intersectional barriers to STBBI testing in Canada

Dear Editor,

Snow et al. offer a commendable exploration of individual and relational factors influencing sexually transmitted and blood-borne infection (STBBI) testing in Canada. ¹ However, despite the study’s diversity of participants, it stops short of critically interrogating the structural and institutional barriers that disproportionately shape testing behaviors particularly among systemically marginalized populations.

One major shortcoming is the limited examination of stigma and discrimination, especially within healthcare settings. Decades of research demonstrate that stigma—whether related to HIV, gender identity, or sexual orientation—is not merely a personal or interpersonal concern, but a structural determinant of health that undermines testing uptake and engagement with care. ² For example, among transgender women and men who have sex with men (MSM) in Jamaica, institutional distrust and fear of exposure were potent barriers to testing. ² These insights, though from a different cultural setting, offer translatable lessons for Canada’s diverse communities and highlight the missed opportunity for Snow et al. to probe stigma’s institutional dimensions more deeply.

The authors also underemphasise intersectionality. While they acknowledge varied identities, they do not meaningfully analyse how race, gender, socioeconomic status, and sexual orientation intersect to compound access barriers. This flattening of identity runs counter to the growing evidence that heteronormative healthcare cultures and clinician bias significantly impact testing behaviors among MSM and other non-dominant identities even within Canadian settings. ³

Moreover, Snow et al. overlook emerging innovations in STBBI testing that address these barriers. Digital self-testing and confidential web-based platforms such as GetCheckedOnline have already demonstrated promising results in British Columbia by improving access, reducing stigma, and enhancing user autonomy. ⁴ The lack of discussion on these evolving modalities limits the study’s applicability to policy or practice.

Finally, although the study captures psychosocial influences, it inadequately addresses macro-level determinants, such as socioeconomic precarity or healthcare infrastructure. A meta-analysis of HIV prevention studies across sub-Saharan Africa revealed how structural vulnerabilities—poverty, limited clinic access, and sociocultural gender norms drive under-testing. ⁵ These dynamics are not geographically bound and warrant contextual adaptation in Canadian settings with similar inequities.

In summary, while Snow et al. offer a valuable contribution, future studies must integrate structural, intersectional, and technological dimensions to inform STBBI testing interventions that are not only equitable but also pragmatically scalable.