Abstract
HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.
Highlights
Retroviral therapy (ART) and linking to HIV prevention
For facility HIV testing and counselling (HTC), the target population was defined as people visiting the clinic, and for index partner or family members it was defined as all sexual partners or cohabitating family members listed by index patient
With the exception of HTC targeted to key populations, we excluded HTC studies not related to general population screening, including case reports and studies limited to antenatal or paediatric settings, or to patients with specific diseases
Summary
Retroviral therapy (ART) and linking to HIV prevention. Conventional facility-based HIV testing and counselling (HTC) has not achieved high testing coverage in sub-Saharan Africa and will probably be insufficient to meet UNAIDS ambitious 90–90–90 targets — 90% of HIV-positive individuals knowing their status, 90% of HIV-positive individuals who are aware of their status on ART, and 90% of individuals on ART virally suppressed[4,5]. Community-based HTC (conducted outside of a health facility) has the potential to overcome these barriers, achieve high coverage, and identify asymptomatic HIV-positive individuals at high CD4 counts[8,9]. A large number of studies on HTC have been conducted in sub-Saharan Africa and a previous systematic review was completed in 2012, but facility testing was not included and uptake in men and young adults was not assessed. We evaluate effectiveness in reaching men and young adults (both groups have a disproportionately high risk of HIV acquisition and poorer clinical outcomes once infected22–24) and targeted HTC for key populations (men who have sex with men (MSM), commercial sex workers (CSWs) and people who inject drugs (PWID)) — groups that generally have very high HIV prevalence and low access to health care[25]. Estimates from our analysis can be used as parameters in mathematical models to project the long-term impact of HTC interventions
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