Assessment of an outreach street-based HIV rapid testing programme as a strategy to promote early diagnosis: a comparison with two surveillance systems in Spain, 2008-2011

HIV Testing Strategies, Types of Tests, and Uptake by Men Who have Sex with Men and Transgender Women: A Systematic Review and Meta-analysis

This systematic review and meta-analysis investigated the effectiveness of strategies and types of tests on HIV testing uptake by men who have sex with men (MSM) and transgender women (TGW), and in reaching PLWH. Articles published up to July 2020 were identified from major electronic databases and grey literature. Data were extracted and assessed for risk of bias. Estimates were pooled using random-effect meta-analysis while heterogeneity was evaluated by Cochran's Q test and I². This study is registered with PROSPERO (CRD42020192740). Of 6820 titles, 263 studies (n = 67,288 participants) were included. The testing strategies reported in most studies were community- (71.2%) and facility-based (28.8%). Highest uptake, with facility-based testing, occurred and reached more PLWH while with standard laboratory tests, it occurred with the highest HIV prevalence among MSM. However, urine test showed a highest rate of new HIV infection. Multiple test combinations had the highest uptake and reached more PLWH among TGW. Various testing strategies, considering barriers and regional differences, and different test types, need be considered, to increase uptake among MSM and TGW.

A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade

OBJECTIVE

Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models.

RESULTS

188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively).

CONCLUSION

CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.

Association of Sexualized Drug Use Patterns with HIV/STI Transmission Risk in an Internet Sample of Men Who Have Sex with Men from Seven European Countries

We estimated the prevalence of overall sexualized drug use (SDU) and of chemsex in particular, assessed patterns of drug use, and identified subpopulations of men who have sex with men (MSM) where SDU and chemsex are more frequent. Using data from an online survey of 9407 MSM recruited during 2016 in 7 European countries, we calculated the proportion of participants who reported SDU and chemsex (mephedrone, methamphetamine, and/or GHB/GBL) in the last 12 months. We grouped the different drug-use combinations in patterns and described sexual risk behaviors, sexually transmitted infections (STI), and HIV seropositivity for each one of them. Factors associated with SDU and chemsex were assessed with two logistic regression models. SDU was reported by 17.7% and chemsex by 5.2%. Risk indicators increased through the different SDU patterns but were higher within those including chemsex drugs. In the multivariate analysis, chemsex was independently associated with living in Slovenia. Both SDU and chemsex were independently associated with living in Spain; being < 50 years old; living in cities of > 500,000 inhabitants; being open about their sex life; reporting transactional sex; condomless anal intercourse; having received an STI diagnosis and with being HIV positive or having been tested ≤ 12 months ago. Magnitude of associations was higher in the chemsex model. One in five participants reported SDU, but prevalence of chemsex was notably lower. However, the risk profiles and higher prevalence of HIV/STIs among those involved in chemsex suggest the existence of a subpopulation of MSM that could be playing a relevant role in the HIV and STI epidemics, especially in very large cities of some countries.

HIV testing strategies outside of health care settings in the European Union (EU)/European Economic Area (EEA): a systematic review to inform European Centre for Disease Prevention and Control guidance

OBJECTIVES

In recent years, new technologies and new approaches to scale up HIV testing have emerged. The objective of this paper was to synthesize the body of recent evidence on strategies aimed at increasing the uptake and coverage of HIV testing outside of health care settings in the European Union (EU)/European Economic Area (EEA).

METHODS

Systematic searches to identify studies describing effective HIV testing interventions and barriers to testing were run in five databases (2010-2017) with no language restrictions; the grey literature was searched for similar unpublished studies (2014-2017). Study selection, data extraction and critical appraisal were performed by two independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Eighty studies on HIV testing in non-health care settings were identified, the majority set in Northern Europe. Testing was implemented in 65 studies, with men who have sex with men the risk group most often targeted. Testing coverage and positivity/reactivity rates varied widely by setting and population group. However, testing in community and outreach settings was effective at reaching people who had never previously been tested and acceptability of HIV testing, particularly rapid testing, outside of health care settings was found to be high. Other interventions aimed to increase HIV testing identified were: campaigns (n = 8), communication technologies (n = 2), education (n = 3) and community networking (n = 1).

CONCLUSIONS

This review has identified several strategies with potential to achieve high HIV testing coverage outside of health care settings. However, the geographical spread of studies was limited, and few intervention studies reported before and after data, making it difficult to evaluate the impact of interventions on test coverage.

Community HIV Screening Among MSM in Three Indonesian Cities

BACKGROUND

Indonesia lags behind its peers with regard to ART coverage of PLHIV. Insufficient HIV testing among MSM and other key affected populations remains a barrier to increasing ART coverage.

OBJECTIVE

This report presents the results of the first government-endorsed implementation research study of a community screening approach to increasing the rate of HIV testing among MSM in three cities.

METHODS

All new MSM outreach contacts meeting eligibility criteria during March-June 2017 were included in the study. HIV testing at a government health facility, which is required to qualify for government-supported ART, was advised for all new contacts. Men refusing formal testing were offered an HIV screening test in a community setting using a saliva-based rapid test and advised to get a confirmatory test at a health facility. All outreach contacts and testing activities were recorded on individual client records.

RESULTS

Of 1,149 eligible MSM, 27% were willing to be referred to receive HIV testing at a health facility, among which 83% were confirmed to have been tested. Of the 838 study subjects refusing health facility testing, 38% accepted community screening. The screening positivity rate was 14.8%. Only 38% of men with reactive screening tests received a confirmatory test at a health facility, along with 8% of those with non-reactive tests.

CONCLUSION

While community screening resulted in more MSM knowing their HIV status, reluctance to avail government health facility-based services, or indeed to be tested at all, must be addressed if community screening is to accelerate progress in getting HIV-positive MSM onto treatment.

Strategies to Increase HIV Testing Among MSM: A Synthesis of the Literature

More than 30 years into the HIV epidemic, men who have sex with men (MSM) continue to be disproportionately impacted. It is estimated that worldwide nearly half of MSM infected with HIV are unaware of their status, making HIV testing along with early linkage to care crucial to HIV prevention efforts. However, there remain significant barriers to HIV testing among MSM, due largely to complex issues of layered stigma that deter MSM from accessing traditional, clinic-based testing. We conducted a review and synthesis of the literature on strategies to increase uptake of HIV testing among MSM. We found that social network-based strategies, community-based testing, HIV self-testing, and modifications to the traditional clinic-based model can effectively reach a subset of MSM, but success was often context-specific and there are significant gaps in evidence. We provide recommendations for increasing HIV testing rates and status awareness among MSM.

Economic and public health consequences of delayed access to medical care for migrants living with HIV in France

In 2013, migrants accounted for 46% of newly diagnosed cases of HIV (human immunodeficiency virus) infection in France. These populations meet with specific obstacles leading to late diagnosis and access to medical care. Delayed access to care (ATC) for HIV-infected migrants reduces their life expectancy and quality of life. Given the reduction of infectivity under antiretroviral (ARV) treatment, delayed ATC for HIV-infected migrants may also hinder the control of the HIV epidemic. The objective of this study is to measure the public health and economic consequences of delayed ATC for migrants living with HIV in France. Using a healthcare payer perspective, our model compares the lifetime averted infections and costs of early vs. late ATC for migrants living with HIV in France. Early and late ATC are defined by an entry into care with a CD4 cell count of 350 and 100/mm³, respectively. Our results show that an early ATC is dominant, even in the worst-case scenario. In the most favorable scenario, early ATC generates an average net saving of €198,000 per patient, and prevents 0.542 secondary infection. In the worst-case scenario, early ATC generates an average net saving of €32,000 per patient, and prevents 0.299 secondary infection. These results are robust to various adverse changes in key parameters and to a definition of late ATC as an access to care at a CD4 level of 200/mm³. In addition to individual health benefits, improving ATC for migrants living with HIV proves efficient in terms of public health and economics. These results stress the benefit of ensuring early ATC for all individuals living with HIV in France.

HIV Linkage to Care and Retention in Care Rate Among MSM in Guangzhou, China

Quantifying HIV service provision along the HIV care continuum is increasingly important for monitoring and evaluating HIV interventions. We examined factors associated with linkage and retention in care longitudinally among MSM (n = 1974, 4933 person-years) diagnosed and living in Guangzhou, China, in 2008-2014. We measured longitudinal change of retention in care (≥2 CD4 tests per year) from linkage and antiretroviral therapy initiation (ART). We examined factors associated with linkage using logistic regression and with retention using generalized estimating equations. The rate of linkage to care was 89% in 2014. ART retention rate dropped from 71% (year 1) to 46% (year 2), suggesting that first-year retention measures likely overestimate retention over longer periods. Lower CD4 levels and older age predicted retention in ART care. These data can inform interventions to improve retention about some subgroups.

HIV Rapid Testing Programs in Non-Clinical Settings have the Potential to Constitute a Major Diagnostic Option for MSM in Spain

We analyze the impact of HIV rapid testing (RT) programs in non-clinical settings (NCS) by evaluating their contribution to new diagnoses reported to the Spanish HIV Surveillance System (SINIVIH) from 2007 to 2012. We estimate the proportion of new diagnoses reported to SINIVIH attributable to them and the maximum annual contribution (MAC). Of 95.575 rapid tests conducted, 2061 were reactive; 1582 in men who have sex with men (MSM). The contribution of RT in NCS increased from 3.4% in 2007 to 11.0% in 2012 (8.1%-16.6% in MSM). RT programs contributed 25.3% of the new diagnoses reported in Catalonia (MAC:30.6%), 15% in the Canary Islands (MAC:16.2%) and 13.7% in the Basque Country (MAC:21.0%). Among MSM, contribution was of 45.2% in Catalonia (MAC:60.7%), 20.2% in the Canary Islands (MAC:21.3%) and 16.6% in the Basque country (MAC:20.9%). Especially among MSM, RT in NCS contributed a large proportion of the new HIV cases diagnosed in regions with a very high HIV incidence.

Factors Associated to a Reactive Result of Rapid-HIV Test in Socio-culturally Adapted Services in Primary Care in Spain

The Services of Prevention and Early diagnosis of HIV in Madrid (Spain) are set in selected primary care centers. Cultural mediators targeted to vulnerable groups (economic immigrants, MSM, sex workers…) perform risk assessment and counselling. Between 2010 and 2014 they performed 6 039 rapid-HIV test, 27.8 % in MSM, 41.2 % in men who have sex exclusively with women (MSW) and 31.0 % in women; 35.7 % in immigrants, mainly from Latin America. A reactive result was more common among MSM (6.0 %) compared to women (0.6 %) and MSW (0.5 %). In MSM it was associated to being immigrant and to antecedents of sexually transmitted infections (STI). Among MSW the factors associated to a reactive result were: seropositivity of sexual partner and heroine consumption, and in women: infrequent use of condoms, seropositivity of sexual partner and antecedents of STI. Preventive interventions to reduce risk of HIV transmission and for early detection should be adapted and targeted to high risk population.

Widening the Access to HIV Testing: The Contribution of Three In-Pharmacy Testing Programmes in Spain

BACKGROUND AND OBJECTIVE

Spain has implemented several in-pharmacy HIV testing programmes performed by pharmacists as part of their everyday routine. We aim to assess the feasibility and the main outcomes of three programmes implemented in three Spanish regions with different sociological profiles and also different epidemiology for HIV.

METHODS

The characteristics of the 24151 people tested between 2009 and 2013 at 74 urban pharmacies are studied. We compare the main outcomes of the programmes with those of each Regional HIV Surveillance System (RHSS) assessing the contribution to the total new diagnosis in each region and if priority groups are being reached.

RESULTS

45.7% were heterosexual men (MSW), 14.4% men who have sex with men (MSM), and 27% women. The 35% were younger than 30 and 9.6% foreigners. The 52% were previously untested, and women were the most likely to be untested. The three programmes altogether diagnosed 226 people, resulting in a global prevalence of 0.9% (95%CI: 0.8-1.1); 3.4% in MSM (95%CI: 2.8-4.0). The prevalence among Spaniards was 0.8% (0.7-1.0) vs. 2.2 (1.6-2.9) among foreigners. The percentages of MSM diagnosed by all three programmes were higher than the one reported by their respective RHSS. Thirty four percent of the reactive MSM and the 71.4% of the reactive MSW did not have a previous HIV test although big testing history differences were observed across the programmes. Altogether, these services contributed with the 10.6% of all HIV diagnoses in these regions.

CONCLUSIONS

In-pharmacy HIV testing programmes are a valuable testing option, having been able to uncover 1 out of 10 the new diagnoses reported in each region. They showed a good capacity of reaching and diagnosing previously untested populations, not only a priority population such as MSM but also heterosexual population who are more affected by delayed diagnosis. They seem to be particularly suitable for regions without large cities and specific HIV diagnostic services.