Impact of the COVID-19 pandemic on access to HIV testing and condom use among two-spirit, gay, bisexual, and queer (2SGBQ+) men in Manitoba

ABSTRACT

This cross-sectional online survey (n = 347) examined the impact of the COVID-19 pandemic on access to HIV testing and condom use among Two-Spirit, gay, bisexual, and queer (2SGBQ+) men in Manitoba. Logistic regression assessed the relationship between socio-demographics and the impact of COVID-19 on access to HIV testing and condom use. Among those who answered a question on testing (n = 282), 27.7% reported reduced access to HIV testing. Among those who answered questions on condom use (n = 327), 54.4% reported decreased use of condoms. Compared to living in Winnipeg, living in a medium-sized city (Brandon) and in rural and remote areas were both associated with higher odds of reporting reduced access to HIV testing due to COVID-19. Participants who were dating (vs. married or partnered) were significantly more likely to report reduced access to HIV testing, but less likely to report decreased use of condoms, while younger age was associated with decreased use of condoms. Service providers must be prepared to respond to the impact of COVID-19 on HIV testing and condom use among younger, sexually active 2SGBQ + men, as well as those who live in small, rural, and remote areas in Manitoba.

KEYWORDS:

• 2sgbq + men
• HIV testing
• condom use
• COVID-19
• service disruptions

Introduction

The COVID-19 pandemic is reinforcing health inequities and reducing access to health services among cisgender and transgender Two-Spirit, gay, bisexual, queer (2SGBQ+) men. In Canada, 2SGBQ + men are already at disproportionately high risk for a variety of negative health outcomes (Sandfort et al., 2006; Manitoba HIV Program Report, 2019; Souleymanov et al., 2018). A 2019 study of 2SGBQ + men’s health issues in Manitoba showed that one-fifth (20%) of the total sample (n = 410) of sexually active men had never been tested for HIV, and nearly half were not offered a test by the healthcare provider they saw in the prior 12 months (The Village Lab Community Report, 2021). The study also found that 20% of respondents reported bottoming without using a condom in the last six months with a male partner whose HIV status they did not know, while 16.9% reported this sexual practice with an HIV-positive male partner with an unknown viral load, and 5.9% with an HIV-positive male partner with a detectable viral load (The Village Lab Community Report, 2021).

Canadian and US research showed that during the pandemic many clinics providing testing for sexually transmitted and blood-borne infections (STBBIs) and HIV to 2SGBQ + men stopped providing these services (Braunstein et al., 2021; Brennan et al., 2020; Gilbert et al., 2022). A Canadian survey (n = 1198) completed in August 2020 found that since the pandemic began 52% of the respondents did not access testing services, and 66% had avoided or delayed accessing testing services (Gilbert et al., 2022). Similarly, research on university students in Canada (n = 1504) conducted in January 2021 indicated a decline in access to all sexual health care services (Wood et al., 2021).

This study used a theory-driven socio-ecological systems approach (Lacombe-Duncan et al., 2022; Public Health Agency Summary, 2020), which recognizes the interdependence of people and their environment and provides a framework to examine how different socio-ecological factors (individual age, ethnicity, sexual orientation identity, relationship status, gender identity, geographic location, education) may operate at multiple levels (individual, interpersonal and structural) to impact this population’s access to HIV testing and condom use during the COVID-19 pandemic.

Canadian studies showed that the HIV testing access barriers (insufficient privacy and confidentiality, lack of anonymous testing, stigma) were already profound in small, rural and remote areas even before the COVID-19 pandemic (Laprise & Bolster-Foucault, 2021; Nanditha et al., 2019). With regards to individual age, research also indicated that younger (less than 25 years old) gay and bisexual men may be disproportionately affected by HIV and STBBIs (Sanderson & Jemmott, 1996). Scholars have also highlighted that those who were not in a steady dating relationship reported more consistent condom use and were at less risk for sexual transmission of HIV (Sanderson & Jemmott, 1996). Social exclusion based on ethnicity may also influence access to HIV prevention (Kerrigan et al., 2006). Sexual and gender minority individuals may face additional barriers to accessing healthcare services due to discrimination and lack of culturally competent care (Baral et al., 2013). Overall, the socioecological framework can be utilized to explore the complex interrelationships among different socio-ecological factors that impact access to HIV testing and condom use among 2SGBQ + men in Manitoba during the COVID-19 pandemic.

Very little is currently known about the impact of COVID-19 on access to HIV testing and condom use practices among 2SGBQ + men in Manitoba. This lack of knowledge is worrisome given that Manitoba has the second highest rates of HIV in Canada (Public Health Agency Highlights, 2021). This study examined the impacts of the COVID-19 pandemic on HIV testing and condom use among 2SGBQ + men in Manitoba.

Methodology

Study design

The data were collected through a cross-sectional online survey method (July–October 2021) as part of the quantitative phase of the COVID-19 & Manitoba Two-Spirit, Gay, Bisexual, and Queer Men’s Health Study. The study was a two-part community-based research study designed to examine the impacts of COVID-19 on the health of 2SGBQ + men in Manitoba. The study was conducted in collaboration with a community advisory committee (CAC) and the research team comprised of HIV/health and 2SLGBTQI + community-based organizations (CBO) and academic researchers. These organizations worked hand in hand with our team throughout this research project. The CAC consisted of ten 2SGBQ + men representing diverse 2SGBQ + communities and assisted the research team with the development of the survey, recruitment, and data analysis.

Recruitment, sampling, and eligibility

Participants (n = 366) for the online survey were recruited across Manitoba, using printed flyers (Figure 1) at CBOs, word of mouth, and on Facebook. Eligibility included: 1) identify as a man (cisgender or transgender); 2) report any sex with another man in the previous 12 months or identify as Two-Spirit, gay, bisexual, or queer; 3) be 18 years of age or older; 4) live in Manitoba. Survey participants were compensated $35(CAD). All procedures performed in studies involving human participants were approved in accordance with the ethical standard of the institutional research committee (University of Manitoba Research Ethics Board 1; Protocol # HE2022-0188). Informed written consent was obtained from all participants. All data were kept confidential.

Figure 1. Flyer.

Measures

The online survey included questions on socio-demographics and impact of COVID-19 on access to HIV testing and condom use.

Demographics

Socio-demographics measures included: 1) age; 2) race/ethnicity (Black, African, Caribbean; South Asian; Indigenous; Latin/Latinx, Central American; White–Western European; White– Eastern European); 3) sexual orientation identity (gay, pansexual, bisexual, queer, Two-Spirit, other); 4) gender identity (man, woman, non-binary, trans, gender queer, Two-Spirit); 5) relationship status (married/partnered, dating, not dating/not coupled, separated/divorced/widowed); 6) education (elementary school, high school, college or technical certificate, undergraduate degree, graduate degree); and 7) location (large urban center, medium city/town [Brandon], small city/town, rural or remote).

COVID-19 impact on access to HIV testing (analytic outcome variable 1). To understand the experience, we asked participants: “Is COVID-19 reducing your access to HIV testing?” Answer choices included “yes” and “no”. COVID-19 impact on condom use (Analytic outcome variable 2). We asked participants: “Is your use of condoms decreasing due to COVID-19?” Answer choices included “yes” and “no”.

Data analyses

All data analyses were conducted using SPSS 27 (IBM Corp.). First, descriptive analyses were conducted. Second, bivariate analyses were conducted using Chi-Square tests for categorical variables, as well as t-tests for continuous variables. After significant associations were identified in bivariate tests, multivariable analyses were conducted using binary logistic regression with reported odds ratios, and 95% confidence intervals. Two separate regression analyses were used to examine the relationship between socio-ecological factors (age, ethnicity, sexual orientation identity, gender identity, relationship status, education, location) and: 1) reduced access to HIV testing during the COVID-19 pandemic (outcome/dependent variable); 2) decreased use of condoms during the COVID-19 pandemic.

Results

Participant characteristics and descriptive data

Demographics (N = 347) and descriptive data are presented in Table 1. The mean age was 31.3 years (SD = 6.0).

Table 1. Socio-demographic Characteristics & Descriptive Findings.

Characteristic	Frequency (n)	Percentage (%)
Ethnicity
White – Western European	185	51.1
Black, African, Caribbean	66	18.2
White – Eastern European	51	14.1
Indigenous	31	8.6
South Asian	6	1.7
Latino, Latin, Central American	12	3.3
Other	11	3.0
Location
Medium city/town (30,000 - 49,999 people)	152	41.5
Large urban center (100,000 people or more)	118	32.2
Small city/town (1,000 - 29,999 people)	91	24.9
Rural or remote area (less than 1,000 people)	5	1.4
Education
College or technical/vocational certificate	143	39.3
Bachelor’s degree	108	29.7
High school (grades 9–12)	75	20.6
Elementary school (below or up to grade 8)	19	5.2
Graduate degree (i.e., MSc, MBA, MD, PhD)	19	5.2
Sexual Orientation
Gay	254	69.4
Pansexual	43	11.7
Bisexual	42	11.5
Queer	8	2.2
Heterosexual	7	1.9
Two-Spirit	7	1.9
Gender Identity
Man	298	81.6
Non-binary	12	3.3
Trans	11	3.0
Two-Spirit	7	1.9
Gender-queer	7	1.9
Other	30	8.2
Relationship Status
Married or partnered	203	55.5
Dating	91	24.9
Not dating	62	16.9
Separated, divorced or widowed	10	2.7
Access to HIV testing was affected because of COVID-19 pandemic
Yes	78	27.7
No	204	72.3
Condom use decreased because of COVID-19 pandemic
Yes	178	54.4
No	149	45.6

Note. Total numbers vary due to missing data.

Bivariate analyses

COVID-19 impact on access to HIV testing. In the bivariate analysis, medium city/town (Brandon) participants (OR  = 6.41, 95%CI = 3.01–13.69), and those living in rural and remote areas with less than 1,000 people (OR  = 11.55, 95%CI = 1.71–77.73) compared to living in Winnipeg, were both were more likely to report reduced access to HIV testing due to COVID-19. Furthermore, participants who were dating were more likely to report an impact on access to HIV testing (OR  = 4.06, 95%CI = 2.20–7.49).

COVID-19 impact on condom use. In the bivariate analysis, participants who were dating likely to report decreased use of condoms due to the COVID-19 pandemic (OR  = 0.41, 95%CI = 0.24–0.69). Finally, younger age was associated with reduced condom use due to the COVID-19 pandemic (OR  = 0.95, 95%CI = 0.91–0.99).

Multivariable analyses

Logistic regression modeling

COVID-19 impact on access to HIV testing. The results of the logistic analysis revealed a significant logistic regression model for the impact on access to HIV testing during the COVID-19 pandemic for this sample of 2SGBQ + men in Manitoba (χ² = 98.21, p < .00). This model had a very good fit with the sample data (−2 Log Likelihood = 191.29, Hosmer and Lemeshow Chi-Square test of goodness-of-fit, χ² = 3.38, p > .05, Nagelkerke R² = 0.47). The model successfully predicted 82.4% of the cases. The results of the logistic regression analyses are presented in Table 2.

Table 2. Logistic Regression of Socio-demographics and Impact on Reduced HIV testing due to COVID-19 Pandemic among 2SGBQ + Men in Manitoba (N = 282).

	Univariate			Multivariate
	OR	95% CI	Sig.	AOR	95% CI	Sig.
Socio-Demographic
Variables
Age	0.99	[0.94, 1.04]	0.67	1.03	[0.94, 1.12]	0.46
Location (ref = Large urban center)
Medium city/town	6.41**	[3.01, 13.69]	0.00	11.58**	[3.48, 38.48]	0.00
Small city/town	1.77	[0.75, 4.22]	0.19	2.96	[0.78, 11.19]	0.11
Rural or remote area	11.55*	[1.71, 77.73]	0.01	25.18*	[1.98, 32.11]	0.01
Relationship Status (ref = married/partnered)
Dating	4.06**	[2.20, 7.49]	0.00	6.07**	[2.46, 14.95]	0.00
Not dating	1.82	[0.85, 3.92]	0.12	2.27	[0.74, 6.89]	0.15
Separated, divorced, or widowed	1.85	[0.34, 10.05]	0.47	4.87	[0.37, 63.44]	0.23
Education (ref = Elementary school)
High school (grades 9–12)	0.44	[0.07, 2.71]	0.37	0.17	[0.01, 4.12]	0.28
College or technical/vocational certificate	0.55	[0.09, 3.21]	0.51	0.20	[0.01, 4.49]	0.31
Bachelor’s degree	1.76	[0.30, 10.19]	0.52	0.81	[0.03, 17.54]	0.89
Graduate degree	0.12	[0.01, 1.75]	0.12	0.01	[0.02, 0.05]	1.00
Ethnicity (ref = White/Western European)
White/Eastern European	0.79	[0.32, 1.95]	0.61	0.45	[0.11, 1.77]	0.25
South Asian	0.78	[0.01, 0.08]	0.99	0.00	[0.01, 0.05]	1.00
Black-African-Caribbean	2.62	[1.29, 5.30]	0.01	2.29	[0.83, 6.27]	0.11
Indigenous	0.83	[0.29, 2.38]	0.74	2.07	[0.46, 9.21]	0.34
Latino-Latin-Central American	0.03	[0.45, 0.87]	1.00	0.00	[0.01, 0.02]	1.00
Other	4.23	[0.91, 19.72]	0.06	8.85	[0.51, 152.7]	0.13
Gender Identity (ref = Man)
Gender-queer	1.23	[0.22, 6.88]	0.81	0.09	[0.00, 2.28]	0.15
Non-binary	1.23	[0.11, 13.81]	0.86	0.03	[0.00, 7.98]	1.00
Two-Spirit	0.40	[0.10, 0.97]	0.99	0.07	[0.78, 65.89]	1.00
Other	0.09	[0.56, 0.86]	0.99	24.04	[0.02, 3.14]	1.00
Trans	0.70	[0.14, 3.47]	0.66	0.20	[0.30, 7.19]	1.00
Sexual orientation (ref = gay/homosexual)
Bisexual	0.49	[0.18, 1.34]	0.16	0.58	[0.11, 3.01]	0.51
Heterosexual	0.82	[0.08, 8.01]	0.86	0.00	[0.00, 0.05]	1.00
Queer	1.22	[0.22, 6.86]	0.82	5.63	[0.19, 162.3]	0.31
Pansexual	0.95	[0.38, 2.39]	0.92	0.34	[0.07, 1.55]	0.16
Two-Spirit	2.45	[0.15, 39.81]	0.53	0.26	[0.01, 0.25]	1.00

Note. SE = standard error; AOR = adjusted odds ratio; CI = confidence interval; Ref. = reference group. *p < .05, **p < =  .001.

Among those who answered the question on testing (n = 282), 27.7% reported that COVID-19 affected their access to HIV testing in Manitoba. In multivariate analyses, living in Brandon, a medium-sized city of 30,000–49,000 people (AOR = 11.58, 95%CI = 3.48–38.48) and living in rural and remote areas with less than 1,000 people (AOR = 25.19, 95%CI = 1.98–32.01) compared to living in Winnipeg, were both associated with higher odds of reporting a reduced access to HIV testing during the COVID-19 pandemic. Participants who were dating (compared to those who were married or partnered) were also significantly more likely to report reduced access to HIV testing (AOR = 6.07, 95%CI:2.06–14.95).

COVID-19 impact on condom use. The results of the logistic analysis revealed a significant logistic regression model for decreased use of condoms during COVID-19 pandemic for this sample of 2SGBQ + men in Manitoba (χ² = 73.15, p < .00). This model had a very good fit with the sample data (−2 Log Likelihood = 321.63, Hosmer and Lemeshow Chi-Square test of goodness-of-fit, χ² = 3.63, p > .05, Nagelkerke R2 = 0.30). The model successfully predicted 67.5% of the cases. The results of the logistic regression analyses are presented in Table 3.

Table 3. Logistic Regression of Socio-demographics and Decreased Use of Condoms due to COVID-19 Pandemic among 2SGBQ + Men in Manitoba (N = 327).

	Univariate			Multivariate
	OR	95% CI	Sig.	AOR	95% CI	Sig.
Socio-Demographic
Variables
Age	0.95*	[0.91, 0.99]	0.03	0.93*	[0.88, 0.99]	0.02
Location (ref = Large urban center)
Medium city/town	0.71	[0.42, 1.18]	0.19	0.89	[0.43, 1.81]	0.75
Small city/town	1.41	[0.78, 2.56]	0.25	2.23	[0.99, 5.02]	0.05
Rural or remote area	0.19	[0.02, 1.78]	0.15	0.27	[0.02, 3.16]	0.30
Relationship Status (ref = married/partnered)
Dating	0.41**	[0.24, 0.69]	0.00	0.27**	[0.13, 0.54]	0.00
Not dating	0.50	[0.26, 0.95]	0.33	0.48	[0.19, 1.17]	0.11
Separated, divorced, or widowed	0.59	[0.16, 2.11]	0.42	0.83	[0.16, 4.29]	0.83
Education (ref = Elementary school)
High school (grades 9–12)	1.24	[0.38, 4.06]	0.72	0.36	[0.02, 4.87]	0.44
College or technical/vocational certificate	1.69	[0.54, 5.32]	0.36	0.49	[0.03, 6.22]	0.58
Bachelor’s degree	0.93	[0.29, 2.98]	0.91	0.33	[0.02, 4.25]	0.40
Graduate degree	17.50	[1.75, 174.42]	0.01	16.42	[0.50, 14.23]	1.00
Ethnicity (ref = White/Western European)
White/Eastern European	0.99	[0.51, 1.91]	0.98	1.56	[0.68, 3.56]	0.29
South Asian	1.25	[0.20, 7.69]	0.81	0.78	[0.06, 9.81]	0.85
Black-African-Caribbean	0.78	[0.44, 1.40]	0.41	1.03	[0.47, 2.21]	0.94
Indigenous	1.48	[0.62, 3.55]	0.37	1.93	[0.62, 5.98]	0.25
Latino-Latin-Central American	7.51	[0.93, 60.67]	0.06	4.55	[0.47, 43.7]	0.19
Other	0.67	[0.17, 2.57]	0.56	0.57	[0.08, 3.96]	0.57
Gender Identity (ref = Man)
Gender-queer	0.17	[0.02, 1.47]	0.11	2.98	[0.08, 109.9]	0.55
Non-binary	0.64	[0.14, 2.90]	0.56	0.90	[0.10, 26.21]	1.00
Two-Spirit	4.24	[0.49, 36.83]	0.19	26.17	[0.08, 0.39]	1.00
Other	0.42	[0.04, 4.74]	0.49	1.34	[0.05, 31.08]	0.86
Trans	0.09	[0.12, 0.75]	0.32	0.08	[0.09, 0.97]	0.44
Sexual orientation (ref = gay/homosexual)
Bisexual	1.23	[0.60, 2.53]	0.31	1.11	[0.38, 3.25]	0.84
Heterosexual	0.31	[0.06, 1.65]	0.56	0.49	[0.06, 3.86]	0.50
Queer	0.13	[0.01, 1.10]	0.55	0.00	[0.80, 0.97]	1.00
Pansexual	0.74	[0.36, 1.51]	0.29	1.59	[0.58, 4.37]	0.36
Two-Spirit	1.56	[0.28, 8.74]	0.23	0.60	[0.60, 0.67]	1.00

Note. SE = standard error; AOR = adjusted odds ratio; CI = confidence interval; Ref. = reference group. *p < .05, **p < =  .001.

Among those who answered questions on condom use (n = 327), 54.4% reported that they decreased their use of condoms due to the COVID-19 pandemic. In multivariate analyses, younger age was associated with reduced condom use due to the COVID-19 pandemic (AOR  = 0.93, 95%CI = 0.88–0.99). As compared to participants who were married or partnered, participants who were dating were significantly less likely to report decreased use of condoms (AOR  = 0.27, 95%CI = 0.13–0.54).

Discussion

This research examined the impacts of COVID-19 on access to HIV testing and condom use among 2SGBQ + men in Manitoba, an under-studied and marginalized community in a prairie province in Canada with a population of approximately 1.3 million people (Canada Population, 2022). The findings from this study add to existing knowledge about the impacts of the COVID-19 pandemic on access to HIV testing and condom use among 2SGBQ + men in Manitoba. The study found that 27.7% of participants in this sample reported decreased access to HIV testing, and 54.4% reported decreasing their use of condoms due to the COVID-19 pandemic. Our findings are consistent with literature which indicates that there has been an overall decline in access to all health services (Wood et al., 2021), especially in rural areas (Public Health Agency Summary, 2020), as many services were either reduced or closed during the pandemic (Brennan et al., 2020).

While HIV testing emerged as a significant finding in this research, before the pandemic, research conducted in Manitoba already suggested that 2SGBQ + men were having significant issues with healthcare access (Souleymanov et al., 2022). Some of these barriers include health care professionals’ lack of competence and knowledge of 2SGBQ + men’s health care needs, negative attitudes towards 2SGBQ + men’s communities, and 2SGBQ + men’s reluctance to disclose their sexual orientation, which can then lead to inadequate care (Souleymanov et al., 2022).

The findings from our study suggested that during the COVID-19 pandemic, individuals living in a medium-sized city (e.g., Brandon) and rural/remote areas reported reduced access to HIV testing. In addition, people who were dating (compared to those who were married or partnered) were significantly more likely to report reduced access to HIV testing but less likely to report decreased use of condoms. Finally, the findings also showed that younger people were more likely to report decreased use of condoms during the COVID-19 pandemic.

With regards to geographic location of medium sized cities as well as rural and remote areas, our findings are consistent with previous research that highlighted healthcare access barriers for 2SGBQ + men in Brandon, as well as in rural and remote areas in Manitoba (Souleymanov et al., 2022). Given that most studies of 2SGBQ + men have historically been conducted in urban centers, this study supplements this gap in knowledge by elucidating access barriers among 2SGBQ + men who live in smaller towns, remote/rural areas, as well as those who live in geographically isolated areas. Several aspects might influence access to HIV testing among 2SGBQ + men living in Brandon, or those living in rural and remote areas. These findings can be partially explained due to increased stigma and social isolation that 2SGBQ + men experience in smaller, isolated, and rural areas. The results are consistent with the research which suggests that rural areas may be less hospitable to 2SLGBTQIA + people (Swank et al., 2013). These findings are also consistent with previous research, which suggests that stigma and social isolation in smaller, remote and rural areas may be at play when it comes to individuals’ access to healthcare (Swank et al., 2013; Whitehead et al., 2016). However, even before the COVID-19 pandemic, social exclusion, stigma, and marginalization reinforced 2SGBQ + men’s invisibility in smaller, rural, and remote areas and affected the access to, and availability of, HIV/STBBI testing, as well as health and social care services that address these men’s unique sexual health needs (Souleymanov et al., 2022).

Services in these areas may also be culturally insensitive toward the needs of 2SGBQ + men (Souleymanov et al., 2022). Given the geographic isolation of remote communities in Manitoba, 2SGBQ + men may also face a complex set of barriers to HIV testing that includes geography, lack of trust, lack of transportation, as well as lower number of HIV testing providers in these areas.

Findings with regards to relationship status are mixed. Some previous research showed that people who were dating used condoms less consistently (Sanderson & Jemmott, 1996). Recent work among heterosexually identified people showed that both coupled and non-coupled individuals reported less frequent condom use due to the COVID-19 pandemic (Dacosta et al., 2021) (even when controlling for a decline in sexual frequency). Our findings showed a picture where individuals who were dating were experiencing two things at the same time–reduced access to HIV testing, but not reduced condom use. These findings may indicate high levels of HIV/STBBI literacy among people who are dating. Future studies are needed to probe for potential explanations for condom use. Future research will need to be contextualized within the current biomedical HIV advances such as pre-exposure prophylaxis, treatment as prevention, and undetectable viral loads.

With regards to an association between younger age with reduced condom use during COVID-19 pandemic, our findings were contrary to existing research which suggested that the percentage of individuals aged 15–44 old who use condoms during sex decreases with older age (Copen, 2017). However, our findings may be explained by other lines of research which suggest that pleasure and fear of partner reactions upon initiating condom use may be important factors in explaining reduced condom use among younger people (Brown et al., 2008).

Limitations

First, the study relied on cross-section survey design, which presents issues with establishing directionality of findings. Secondly, the study also relied on self-reported data and are subject to social desirability, recall and information bias. Furthermore, it is important to point out that there are other factors (economic, social support, pre-existing health inequities) not measured here that may be critical in understanding the impacts of COVID-19 on 2SGBQ + men’s access to HIV testing, or their use of condoms during the pandemic. Nevertheless, the findings from this research are consistent with other literature on this topic and expand our understanding in relation to key demographic and geographic variables.

Recommendations and conclusions

Our findings contribute to a socio-ecological understanding of barriers to HIV testing and condom use and underscore the importance of attending to sociodemographic factors. Future research could explore how the social context toward 2SGBQ + men decreases HIV testing access in smaller towns, as well as remote and rural areas and reserves. Social context, including attitudes, beliefs, practices, and discrimination towards 2SGBQ + men could impact their access to HIV testing services. Research can evaluate interventions to reduce stigma and discrimination towards 2SGBQ + men. To increase access to HIV testing and condom use, it may be important to develop outreach programs to provide HIV testing and condom distribution in smaller towns, remote and rural areas. Additionally, it is important to advocate for the creation of more healthcare facilities and resources in rural and remote areas that specifically cater to sexual and gender minority individuals. Improving the capacity of mainstream services and health care providers to provide inclusive and culturally sensitive HIV prevention and care for 2SGBQ + men could reduce stigma and discrimination and improve access to HIV testing. Health and social care service providers who work in HIV prevention may also require training and opportunities to increase information and skills to prepare them to adequately support 2SGBQ + men in rural and remote areas. Additionally, creating a network or community of health care providers who are either 2SGBQ + men themselves or specialize in providing care to 2SGBQ + individuals, to share knowledge and best practices may prove to be beneficial. It is also important that future research and programs also consider how relationship status affects HIV testing and access to condom use among a diverse group of 2SGBQ + men. Furthermore, the government could provide additional funding towards HIV testing and sexual health initiatives in Manitoba and help create programs and sexual health education targeted at younger people in urban and rural communities. Local governments and public health offices can also develop public health campaigns that target younger 2SGBQ + men in urban and rural communities. These campaigns can utilize social media and other digital platforms to increase awareness and provide easy access to information about HIV testing and prevention.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Institute of Health Services and Policy Research: [Grant Number 448647].