title: Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review.
abstract: BACKGROUND
  Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies.
  
  
  RESULTS
  Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000-30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%-96%), preference (range: 61%-91%), and partner self-testing (range: 80%-97%) were high. A high specificity (range: 99.8%-100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%-100%; one study) versus supervised (range: 97.4%-97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis.
  
  
  CONCLUSIONS
  Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings. Please see later in the article for the Editors' Summary.
authors.affiliation: Division of Clinical Epidemiology, McGill University Health Centre, Department of Medicine, McGill University, Montreal, Canada. nitika.pai@mcgill.ca
authors.forename: Nitika
authors.initials: N
authors.lastname: Pant Pai
authors.forename: Jigyasa
authors.initials: J
authors.lastname: Sharma
authors.forename: Sushmita
authors.initials: S
authors.lastname: Shivkumar
authors.forename: Sabrina
authors.initials: S
authors.lastname: Pillay
authors.forename: Caroline
authors.initials: C
authors.lastname: Vadnais
authors.forename: Lawrence
authors.initials: L
authors.lastname: Joseph
authors.forename: Keertan
authors.initials: K
authors.lastname: Dheda
authors.forename: Rosanna W
authors.initials: RW
authors.lastname: Peeling
mesh_terms: D003376:Counseling; D059026:Diagnostic Self Evaluation; D006678:HIV / Q000302:isolation & purification; D006679:HIV Seropositivity / Q000175:diagnosis*; D006801:Humans; D008403:Mass Screening / Q000379:methods* / Q000458:organization & administration; D010342:Patient Acceptance of Health Care; D012648:Self Care; D012747:Sexual Partners
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