Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis

Abstract

Background We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. Methods We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. Results After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. Conclusions HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

Impact and acceptability of HIV self-testing for trans men and trans women: A mixed-methods subgroup analysis of the SELPHI randomised controlled trial and process evaluation in England and Wales

“…Previous studies have investigated the experiences of trans people with HIVST in other (non-European) settings; this work adds weight to the conclusion that HIVST is highly acceptable to this group in a range of settings [18,20,32]. We also demonstrate significant unmet testing need; 31% of trans men and women had not previously tested for HIV, this is more than double the 15% of MSM (cis and trans combined) from the wider trial who had not previously tested [33].…”

“…Analysis combined framework and thematic approaches [26,27]. Our framework drew from emerging themes identified during data generation, the wider literature around trans peoples' experiences of HIVST / sexual health services, theorised key components of intervention acceptability from formative and RCT acceptability work and systematic reviews [18,23,[28][29][30]. The analysis framework can be found in additional file 3.…”

“…RCT evidence regarding HIVST for trans people is scarce. Small numbers of trans people (mostly trans women) (n = 72) have been included in two RCTs recruiting cisgender MSM; but their data were not reported separately [16,17,18]. Pilot and demonstration projects including trans women in the US show that HIVST is an acceptable and feasible method for delivering HIV testing both through clinic distribution and for onward distribution to their sexual partners [19,20].…”

HIV self-testing: finding its way in the prevention tool box

“…HIVST may be especially well-suited for key populations, including men who have sex with men (MSM) and female sex workers (FSWs), by addressing additional barriers these populations face to facility-based testing (e.g., stigma, discrimination, and inconvenient clinic hours). In this study, Dr. Witzel and colleagues conducted a systematic review and meta-analysis to understand the effect of HIVST versus standard facility-based HIV testing for key populations [4]. Overall, the authors found that HIVST increased testing uptake, frequency, and yield of positive results for cisgender MSM and transgender persons but not for FSWs.…”

Opinions towards Key Operational Aspects for the Implementation of HIV Self-Testing in Spain: A Comparison between Stakeholders and Potential Users

“…We also compare their positions to those expressed by MSM who are one of the most relevant groups of PUs. HIV self-testing has proven to be a reliable testing option [17] and has shown its capacity to increase testing uptake under experimental conditions [18]. According to the European Centre for Disease Prevention and Control (ECDC), it needs to be made available to MSM in order to increase testing uptake and frequency of testing [19].…”