Risk-Based Screening Tools to Optimise HIV Testing Services: A Systematic Review

Abstract

Background: Effective ways to diagnose the remaining people living with HIV who do not know their status with limited resources is a global priority. This study aims to evaluate the use of risk-based tools, a set of criteria to either identify high-risk individuals for HIV testing who would not otherwise be offered a test (screen in) or exclude people from a routine offer of a test (screen out). Methods: The study was two parts: (1) systematic literature review and (2) global survey of implementers. We searched four databases July 2020 and assessed the accuracy of tools diagnosing HIV (using AUC: area under a receiver operating characteristic curve). The systematic review protocol is registered PROSPERO (CRD42020187838). From August to September 2020, we invited 68 implementers to complete a survey of their experiences using these tools within programmes. Results: We identified 18,238 citations, and 71 were included the final analysis. Tools identified were most commonly from high-income (51%) and low HIV (<5%) prevalence countries (73%); and used primary care settings (24%), for men who have sex with men (MSM, 21%) and paediatric populations (20%). The majority were for screening in (70%), with the highest performance tools related to identifying MSM with acute HIV (AUC 0.85-0.89). Data from implementers revealed that tools were mainly used middle-income countries (68%), from high HIV prevalence countries (68%) and hospitals (36%). Less than half stated the tools were evaluated (43%) and were used to screen (20/80, 25%), screen out (7/80, 9%) or unknown (53/80, 66%). Conclusion: There is potential for risk-based tools to improve the efficiency of HIV testing services. Screening tools may be helpful settings where it is not feasible or recommended to offer testing routinely. Caution is needed for out tools, where there is a trade-off between reducing costs of testing with missing cases of people living with HIV. Tools must be locally evaluated for accuracy and feasibility of implementation. Country programmes should be cautious implementing such tools and ensure consistent monitoring and regular re-validation to not undermine progress toward the 95-95-95 targets. Registration Details: The systematic review protocol is registered PROSPERO (CRD42020187838). Funding Information: This research was supported by funding from the World Health Organization through the following grants: USAID GHA‐G‐00‐09‐00003, and the Bill and Melinda Gates Foundation OPP1177903. JJO is supported by an Australian National Health and Medical Research Council Emerging Leadership Fellowship (GNT1193955). Declaration of Interests: The authors declare they do not have any competing interests.