Abstract
Purpose Community-based HIV testing and counselling (HTC) has been recommended for improving access to prevention, care, and treatment services in at-risk populations. Earlier systematic reviews and meta-analyses have been undertaken, but due to some methodological limitations, their findings do not yet provide a practical significance. The purpose of this paper is to re-examine the recent evidence of the efficacy of community-based HTC approaches on the uptake of HTC in at-risk populations. Design/methodology/approach The database of PubMed online, Science Direct, the Lancet Global Health, the Cochrane Central Register of Controlled Trials, and Google Scholar were systematically searched using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to obtain empirical papers published between March 2013 and December 2015. Findings Of 600 collected papers, there were 6 cluster randomized trials papers which met the inclusion criteria. Compared to the health facilities-based HTC, community-based HTC approaches have been shown to improve the uptake of HIV testing from 5.8 to 37 per cent, and improve HIV testing in men and their partners together from 6.8 to 34 per cent. The community approaches also detected lower HIV-positive cases (0.29 per cent as compared to 4 per cent), improved access to treatment services from 0.3 to 25 per cent, demonstrated higher cluster differentiation 4 count in newly diagnosed patients (median of 400-438 cells/µl), and increased the rate of first-time HIV testing from 9 to 11.8 per cent. With respect to social and behavioural outcomes, community-based HTC increased social norms for HIV testing by 6 per cent (95 per cent CI 3-9), decreased multiple sex partners by 55 per cent (95 per cent CI 42-73), lowered casual sex by 45 per cent (95 per cent CI 33-62), increased knowledge about HIV (83.2 vs 28.9 per cent), improved positive attitudes towards HIV patients (73.0 vs 34.3 per cent), and increased the use of condoms (28.0 vs 12.3 per cent). Originality/value Community-based HTC combined with behavioural interventions have been found to be more effective in increasing the uptake of HIV testing as well as other outcomes as compared to the conventional health facilities-based testing and counselling approaches.
Highlights
The 90-90-90 target set by UNAIDS for achieving the vision of “Ending the AIDS Endemic by 2030” provides a new perspective in the control of transmission of human immunodeficiency virus (HIV ) with a main key strategy being early diagnosis[1]
Studies were included when: the study population included general populations in generalised HIV epidemics or populations at risk in concentrated or low-level HIV epidemics; the intervention was community-based HIV testing and counselling (HTC) services offered in combination with a facility-based HTC as background; the comparator was facility-based HTC or other types of community-based HTC services; the outcome(s) included either uptake of HIV testing, cluster differentiation 4 (CD4) count at diagnosis, access to treatment services, HIV-positive rate, or coverage of HIV testing; the study design was randomized controlled trials or observational cohort study; and English or Indonesian empirical papers published after the latest systematic review and meta-analysis publication[10], i.e. between March 2013 and December 2015
A total of 93 full text papers were reviewed separately based on the inclusion criteria by two reviewers with the results: 11 papers were not community-based HTC, 26 papers having irrelevant data, 23 papers were not randomized controlled trials or observational cohort studies, 19 papers were published before March 2013, 7 full text papers were inaccessible, and 1 paper was a research protocol (Figure 1)
Summary
The 90-90-90 target set by UNAIDS for achieving the vision of “Ending the AIDS Endemic by 2030” provides a new perspective in the control of transmission of human immunodeficiency virus (HIV ) with a main key strategy being early diagnosis[1]. Lack of knowledge about HIV, low perceived risk of HIV infection, misperception of benefits, and lack of social support have been identified as possible factors preventing the populations at risk to utilise facility-based HTC services[6]. The World Health Organization (WHO) has issued a strong recommendation for community-based HTC (i.e. HTC conducted outside of health facilities) approaches to improve access to HIV prevention, care, and treatment services for populations at risk[7, 8]. The effectiveness and efficacy of community-based HTC has been piloted through various studies around the world It is considered as an effective HTC approach with high acceptance and utilisation, helping reduce stigma and discrimination, especially for hard to reach populations, and contributing to the removal of the structural, logistical, and social barriers to HTC[9]
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