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      The effects of HIV self-testing on the uptake of HIV testing, linkage to antiretroviral treatment and social harms among adults in Africa: A systematic review and meta-analysis

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          Abstract

          Introduction

          HIV infection is still a global public health problem. More than 75% of HIV-infected people are in Africa, and up to 54% are unaware of their HIV status, limiting access to antiretroviral treatment.

          Context and purpose of the study

          This review aimed to determine whether HIV self-testing (HIVST) increases the uptake of testing, the yield of new HIV-positive diagnoses, and the linkage to antiretroviral treatment, and social harms among adults in Africa.

          Methods

          PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL), Pan African Clinical Trials Registry, The Cochrane Database of Systematic Reviews (CDSR), Databases of Abstracts of Reviews of Effectiveness (DARE), Social Sciences Citation Index, Web of Science and African Index Medicus databases were searched from 1998 to 2019 (updated in December 2019). Eligible trials employed randomized controlled trials (RCTs), before/after studies, and interrupted time series design comparing HIVST to standard HIV testing services or comparing different approaches to HIVST among adults living in Africa were systematically sought.

          Results

          After searching 2,617 citations eleven trials were identified including 59,119 participants from four (4) African countries. Meta-analysis of seven trials showed a significant increase in the uptake of HIVST compared to standard HIV testing services: Both fixed-effects (Rate Ratio (RR) = 2.64, 95% CI: 2.51 to 2.79), and random-effects (RR) = 3.10, 95% CI: 1.80 to 5.37, and a significant increase in the uptake of couples’ HIVST (RR = 2.50, 95% CI: 2.29 to 2.73 in fixed-effects models; and RR = 2.64, 95% CI: 2.01 to 3.49 in random-effects model). A decrease in linkage to care and ART was observed in HIVST compared to standard HIV testing services (RR = 0.88, 95% CI: 0.88 to 0.95 in fixed-effects models; and RR = 0.78, 95% CI: 0. 56 to 1.08 in random-effects models). Six RCTs measured social harms, with a total of ten reported cases related to HIVST. One RCT comparing two approaches to HIVST showed that offering home-based HIVST with optional home-initiation of antiretroviral treatment increased the reporting of a positive HIV test result (RR: 1.86; 95% CI: 1.16 to 2.98), and linkage to antiretroviral treatment (RR: 2.94; 95% CI: 2.10 to 4.12), compared with facility-based linkage to antiretroviral treatment.

          Conclusions

          HIVST has the potential to increase the uptake of HIV testing compared to standard HIV testing services. Offering HIVST with optional home initiation of HIV care compared to HIVST with facility-based HIV care increases HIV positivity and linkage to antiretroviral treatment. Reported incidences of intimate partner violence related to HIVST were rare. Future research should focus on the potential of HIVST to reach first-time testers, the effect of using different approaches to HIVST, and strategies for linkage to HIV services.

          Systematic review registration

          This systematic review was prospectively registered on the Prospero International Prospective Register of Systematic Review ( CRD42015023935).

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          Most cited references73

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          GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

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            GRADE guidelines: 3. Rating the quality of evidence.

            This article introduces the approach of GRADE to rating quality of evidence. GRADE specifies four categories-high, moderate, low, and very low-that are applied to a body of evidence, not to individual studies. In the context of a systematic review, quality reflects our confidence that the estimates of the effect are correct. In the context of recommendations, quality reflects our confidence that the effect estimates are adequate to support a particular recommendation. Randomized trials begin as high-quality evidence, observational studies as low quality. "Quality" as used in GRADE means more than risk of bias and so may also be compromised by imprecision, inconsistency, indirectness of study results, and publication bias. In addition, several factors can increase our confidence in an estimate of effect. GRADE provides a systematic approach for considering and reporting each of these factors. GRADE separates the process of assessing quality of evidence from the process of making recommendations. Judgments about the strength of a recommendation depend on more than just the quality of evidence. Copyright © 2011 Elsevier Inc. All rights reserved.
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              Basics of meta-analysis: I(2) is not an absolute measure of heterogeneity.

              When we speak about heterogeneity in a meta-analysis, our intent is usually to understand the substantive implications of the heterogeneity. If an intervention yields a mean effect size of 50 points, we want to know if the effect size in different populations varies from 40 to 60, or from 10 to 90, because this speaks to the potential utility of the intervention. While there is a common belief that the I(2) statistic provides this information, it actually does not. In this example, if we are told that I(2) is 50%, we have no way of knowing if the effects range from 40 to 60, or from 10 to 90, or across some other range. Rather, if we want to communicate the predicted range of effects, then we should simply report this range. This gives readers the information they think is being captured by I(2) and does so in a way that is concise and unambiguous. Copyright © 2017 John Wiley & Sons, Ltd.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: MethodologyRole: Writing – original draft
                Role: Methodology
                Role: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                27 January 2021
                2021
                : 16
                : 1
                : e0245498
                Affiliations
                [1 ] School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
                [2 ] Save the Children International SCI, Somalia/Somaliland Country Office, Nairobi, Kenya
                [3 ] Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
                Makerere University School of Public Health, UGANDA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ‡ These authors also contributed equally to this work.

                Author information
                https://orcid.org/0000-0002-7143-8400
                Article
                PONE-D-20-18562
                10.1371/journal.pone.0245498
                7840047
                33503050
                393a6a24-9436-45bf-92f0-81270695dd3d
                © 2021 Njau et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 17 June 2020
                : 31 December 2020
                Page count
                Figures: 6, Tables: 4, Pages: 36
                Funding
                The authors received no specific funding for this work.
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