Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis

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Abstract

Introduction: HIV self-testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV-positive persons, linkage to care, social harm, and risk behaviour.

Methods: We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta-analyses of studies reporting comparable outcomes were conducted using a random-effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE.

Results: After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral-fluid rapid tests for HIVST and were among men. Meta-analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta-analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15-month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta-analysis of two RCTs showed HIVST also doubled the likelihood of an HIV-positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk-taking behaviour appeared to be minimal.

Conclusions: HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV-positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.

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Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002-2013: a meta-analysis.

Mark J. Siedner, Courtney K Ng, Ingrid Bassett … (2015)

Both population- and individual-level benefits of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) are contingent on early diagnosis and initiation of therapy. We estimated trends in disease status at presentation to care and at ART initiation in sub-Saharan Africa. We searched PubMed for studies published January 2002-December 2013 that reported CD4 cell count at presentation or ART initiation among adults in sub-Saharan Africa. We abstracted study sample size, year(s), and mean CD4 count. A random-effects meta-regression model was used to obtain pooled estimates during each year of the observation period. We identified 56 articles reporting CD4 count at presentation (N = 295 455) and 71 articles reporting CD4 count at ART initiation (N = 549 702). The mean estimated CD4 count in 2002 was 251 cells/µL at presentation and 152 cells/µL at ART initiation. During 2002-2013, neither CD4 count at presentation (β = 5.8 cells/year; 95% confidence interval [CI], -10.7 to 22.4 cells/year), nor CD4 count at ART initiation (β = -1.1 cells/year; 95% CI, -8.4 to 6.2 cells/year) increased significantly. Excluding studies of opportunistic infections or prevention of mother-to-child transmission did not alter our findings. Among studies conducted in South Africa (N = 14), CD4 count at presentation increased by 39.9 cells/year (95% CI, 9.2-70.2 cells/year; P = .02), but CD4 count at ART initiation did not change. CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Barriers to presentation, diagnosis, and linkage to HIV care remain major challenges that require attention to optimize population-level benefits of ART. © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

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Use of a Rapid HIV Home Test Prevents HIV Exposure in a High Risk Sample of Men Who Have Sex With Men

Alex Carballo-Diéguez, Timothy Frasca, Ivan C Balan … (2012)

The study assessed whether at-risk HIV-uninfected men who have sex with men (MSM) who never or rarely use condoms and have multiple partners would use a rapid, oral fluid, HIV home test (HT) to screen potential sexual partners. Participants received 16 HT kits, were monitored weekly for 3 months, and then interviewed in depth. Twenty-seven ethnically diverse MSM used HT kits before intercourse with approximately 100 partners in private and public spaces. Testing had high acceptability among ethnic minority participants. Ten tested individuals received HIV-antibody positive results. Seven were potential sexual partners, and three were acquaintances of the participants; six of the ten were unaware of their status. No sexual intercourse took place after positive tests. Very few problems occurred. Most participants strongly desired to continue using HT and to buy it freely. HT use results in detection of previously unknown infections. Making HT available within networks where high-risk sexual practices are common may be a cost-efficient and effective prevention method.

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Uptake and Acceptability of Oral HIV Self-Testing among Community Pharmacy Clients in Kenya: A Feasibility Study

Peter M Mugo, Murugi Micheni, Jimmy Shangala … (2017)

Background While HIV testing and counselling is a key entry point for treatment as prevention, over half of HIV-infected adults in Kenya are unaware they are infected. Offering HIV self-testing (HST) at community pharmacies may enhance detection of undiagnosed infections. We assessed the feasibility of pharmacy-based HST in Coastal Kenya. Methods Staff at five pharmacies, supported by on-site research assistants, recruited adult clients (≥18 years) seeking services indicative of HIV risk. Participants were offered oral HST kits (OraQuick®) at US$1 per test. Within one week of buying a test, participants were contacted for post-test data collection and counselling. The primary outcome was test uptake, defined as the proportion of invited clients who bought tests. Views of participating pharmacy staff were solicited in feedback sessions during and after the study. Results Between November 2015 and April 2016, 463 clients were invited to participate; 174 (38%) were enrolled; and 161 (35% [95% Confidence Interval (CI) 31–39%]) bought a test. Uptake was higher among clients seeking HIV testing compared to those seeking other services (84% vs. 11%, adjusted risk ratio 6.9 [95% CI 4.9–9.8]). Only 4% of non-testers (11/302) stated inability to pay as the reason they did not take up the test. All but one tester reported the process was easy (29%) or very easy (70%). Demand for HST kits persisted after the study and participating service providers expressed interest in continuing to offer the service. Conclusions Pharmacy HST is feasible in Kenya and may be in high demand. The uptake pattern observed suggests that a client-initiated approach is more feasible compared to pharmacy-initiated testing. Price is unlikely to be a barrier if set at about US$1 per test. Further implementation research is required to assess uptake, yield, and linkage to care on a larger scale.

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Author and article information

Journal

Journal ID (nlm-ta): J Int AIDS Soc

Journal ID (iso-abbrev): J Int AIDS Soc

Journal ID (archive): ZIAS

Journal ID (publisher-id): zias20

Title: Journal of the International AIDS Society

Publisher: Taylor & Francis

ISSN (Electronic): 1758-2652

Publication date Collection: 2017

Publication date (Electronic): 15 May 2017

Volume: 20

Issue: 1

Electronic Location Identifier: 21594

Affiliations

[ ^a ] Department of HIV, World Health Organization , Geneva, Switzerland

[ ^b ] Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health , Baltimore, MD, USA

[ ^c ] Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina , Charleston, SC, USA

[ ^d ] Independent Clinical Epidemiologist , Cape Town, South Africa

[ ^e ] Department of Essential Medicines and Health Products, World Health Organization , Geneva, Switzerland

Author notes

[ ^§ ]Corresponding author: Cheryl C Johnson, Department of HIV, World Health Organization , 20 Avenue Appia, Geneva 1201, Switzerland. Tel: +41 22 791 4335. ( Johnsonc@ 123456who.int )

Article

Publisher ID: 1324103

DOI: 10.7448/IAS.20.1.21594

PMC ID: 5515051

PubMed ID: 28530049

SO-VID: 8141346b-c075-4e57-985e-b9742d02f860

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License ( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 25 October 2016

Date accepted : 25 April 2017

Page count

Figures: 5, Tables: 3, References: 46, Pages: 11

Funding

Funded by: World Health Organization 10.13039/100004423

This systematic review was supported by UNITAID, the Bill and Melinda Gates Foundation [Grant Number: OPP1134510] and the United States Agency for International Development [Grant Number: GHA-G-00-09-00003] to inform the WHO guidelines on HIV self-testing.

Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis

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Most cited references 14

Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002-2013: a meta-analysis.

Use of a Rapid HIV Home Test Prevents HIV Exposure in a High Risk Sample of Men Who Have Sex With Men

Uptake and Acceptability of Oral HIV Self-Testing among Community Pharmacy Clients in Kenya: A Feasibility Study

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