Abstract
IntroductionLearning one’s HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. HTS may impact subsequent sexual behaviour, but the degree to which this varies by population or is true in the setting of contemporary HIV prevention activities is largely unknown. As part of the 2019 World Health Organization Consolidated Guidelines on HTS, we undertook a systematic review and meta‐analysis to determine the effect of HTS on sexual behaviour.MethodsWe searched nine electronic databases for studies published between July 2010 and December 2019. We included studies that reported on at least one outcome (condom use [defined as the frequency of condom use or condom‐protected sex], number of sex partners, HIV incidence, STI incidence/prevalence). We included studies that prospectively assessed outcomes and that fit into one of three categories: (1) those evaluating more versus less‐intensive HTS, (2) those of populations receiving HTS versus not and (3) those evaluating outcomes after versus before HTS. We conducted meta‐analyses using random‐effects models.Results and discussionOf 29 980 studies screened, 76 studies were included. Thirty‐eight studies were randomized controlled trials, 36 were cohort studies, one was quasi‐experimental and one was a serial cross‐sectional study. There was no significant difference in condom use among individuals receiving more‐intensive HTS compared to less‐intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Condom use was significantly higher after receiving HTS compared to before HTS for individuals newly diagnosed with HIV (RR = 1.65; 95% CI: 1.36 to 1.99) and marginally significantly higher for individuals receiving an HIV‐negative diagnosis (RR = 1.63; 95% CI: 1.01 to 2.62). Individuals receiving more‐intensive HTS reported fewer sex partners at follow‐up than those receiving less‐intensive HTS, but the finding was not statistically significant (mean difference = −0.28; 95% CI: −3.66, 3.10).ConclusionsOur findings highlight the importance of using limited resources towards HTS strategies that focus on early HIV diagnosis, treatment and prevention services rather than resources dedicated to supplementing or enhancing HTS with additional counselling or other interventions.
Highlights
Learning one’s HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk
Seventeen studies examined enhanced counselling or education sessions compared to standard HTS [16,18,25,26,29,30,33,35,36,38,39,40,42,45,49,50,91], two studies examined the distribution of HIV self-testing kits relative to standard HTS [31,32], two studies from the same cluster-randomized controlled trials (RCT) examined community-based HTS [17,20] along with two other studies [22,34], one study included couple HTS relative to standard HTS [37], one study examined counsellor-delivered home-based HTS versus clinic-based HTS [21] and one study examined abbreviated HTS compared to standard HTS [48]
When stratifying by HTS outcome, we found that among individuals newly diagnosed HIV positive, condom use was significantly higher after receiving HTS compared to before receiving HTS (RR = 1.65; 95% CI = 1.36 to 1.99) (Table 5)
Summary
Learning one’s HIV status through HIV testing services (HTS) is an essential step toward accessing treatment and linking to preventive services for those at high HIV risk. There was no significant difference in condom use among individuals receiving more-intensive HTS compared to less-intensive HTS (relative risk [RR]=1.03; 95% CI: 0.99 to 1.07). Counselling and messaging delivered through HIV testing services (HTS) may offer an opportunity to influence subsequent sexual behaviour and thereby affect HIV acquisition and transmission [9]. These changes in behaviour may be attributable to counselling received as part of HTS, the act of testing, or knowledge of one’s HIV serostatus.
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