title: Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches.
abstract: BACKGROUND
  Effective national and global HIV responses require a significant expansion of HIV testing and counselling (HTC) to expand access to prevention and care. Facility-based HTC, while essential, is unlikely to meet national and global targets on its own. This article systematically reviews the evidence for community-based HTC.
  
  
  RESULTS
  PubMed was searched on 4 March 2013, clinical trial registries were searched on 3 September 2012, and Embase and the World Health Organization Global Index Medicus were searched on 10 April 2012 for studies including community-based HTC (i.e., HTC outside of health facilities). Randomised controlled trials, and observational studies were eligible if they included a community-based testing approach and reported one or more of the following outcomes: uptake, proportion receiving their first HIV test, CD4 value at diagnosis, linkage to care, HIV positivity rate, HTC coverage, HIV incidence, or cost per person tested (outcomes are defined fully in the text). The following community-based HTC approaches were reviewed: (1) door-to-door testing (systematically offering HTC to homes in a catchment area), (2) mobile testing for the general population (offering HTC via a mobile HTC service), (3) index testing (offering HTC to household members of people with HIV and persons who may have been exposed to HIV), (4) mobile testing for men who have sex with men, (5) mobile testing for people who inject drugs, (6) mobile testing for female sex workers, (7) mobile testing for adolescents, (8) self-testing, (9) workplace HTC, (10) church-based HTC, and (11) school-based HTC. The Newcastle-Ottawa Quality Assessment Scale and the Cochrane Collaboration's "risk of bias" tool were used to assess the risk of bias in studies with a comparator arm included in pooled estimates. 117 studies, including 864,651 participants completing HTC, met the inclusion criteria. The percentage of people offered community-based HTC who accepted HTC was as follows: index testing, 88% of 12,052 participants; self-testing, 87% of 1,839 participants; mobile testing, 87% of 79,475 participants; door-to-door testing, 80% of 555,267 participants; workplace testing, 67% of 62,406 participants; and school-based testing, 62% of 2,593 participants. Mobile HTC uptake among key populations (men who have sex with men, people who inject drugs, female sex workers, and adolescents) ranged from 9% to 100% (among 41,110 participants across studies), with heterogeneity related to how testing was offered. Community-based approaches increased HTC uptake (relative risk [RR] 10.65, 95% confidence interval [CI] 6.27-18.08), the proportion of first-time testers (RR 1.23, 95% CI 1.06-1.42), and the proportion of participants with CD4 counts above 350 cells/µl (RR 1.42, 95% CI 1.16-1.74), and obtained a lower positivity rate (RR 0.59, 95% CI 0.37-0.96), relative to facility-based approaches. 80% (95% CI 75%-85%) of 5,832 community-based HTC participants obtained a CD4 measurement following HIV diagnosis, and 73% (95% CI 61%-85%) of 527 community-based HTC participants initiated antiretroviral therapy following a CD4 measurement indicating eligibility. The data on linking participants without HIV to prevention services were limited. In low- and middle-income countries, the cost per person tested ranged from US$2-US$126. At the population level, community-based HTC increased HTC coverage (RR 7.07, 95% CI 3.52-14.22) and reduced HIV incidence (RR 0.86, 95% CI 0.73-1.02), although the incidence reduction lacked statistical significance. No studies reported any harm arising as a result of having been tested.
  
  
  CONCLUSIONS
  Community-based HTC achieved high rates of HTC uptake, reached people with high CD4 counts, and linked people to care. It also obtained a lower HIV positivity rate relative to facility-based approaches. Further research is needed to further improve acceptability of community-based HTC for key populations. HIV programmes should offer community-based HTC linked to prevention and care, in addition to facility-based HTC, to support increased access to HIV prevention, care, and treatment.
  
  
  BACKGROUND
  International Prospective Register of Systematic Reviews CRD42012002554 Please see later in the article for the Editors' Summary.
authors: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland. amitabh.suthar@gmail.com
authors: Amitabh B
authors: AB
authors: Suthar
authors: Nathan
authors: N
authors: Ford
authors: Pamela J
authors: PJ
authors: Bachanas
authors: Vincent J
authors: VJ
authors: Wong
authors: Jay S
authors: JS
authors: Rajan
authors: Alex K
authors: AK
authors: Saltzman
authors: Olawale
authors: O
authors: Ajose
authors: Ade O
authors: AO
authors: Fakoya
authors: Reuben M
authors: RM
authors: Granich
authors: Eyerusalem K
authors: EK
authors: Negussie
authors: Rachel C
authors: RC
authors: Baggaley
mesh_terms: D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*
references: Am J Public Health. 2010 Apr 1;100 Suppl 1:S146-51
references: 20147689
references: J Public Health Manag Pract. 2010 Sep-Oct;16(5):457-64
references: 20689396
references: J Int AIDS Soc. 2012 Jul 11;15 Suppl 2:17404
references: 22789648
references: BMJ Open. 2012 Apr 01;2(2):e000693
references: 22466158
references: J Acquir Immune Defic Syndr. 2006 Sep;43(1):91-5
references: 16885775
references: Stat Med. 2002 Jun 15;21(11):1539-58
references: 12111919
references: Trop Med Int Health. 2002 Dec;7(12):1064-7
references: 12460398
references: Lancet. 2011 May 21;377(9779):1748
references: 21601710
references: J Public Health Policy. 2013 Jan;34(1):2-16
references: 23191941
references: AIDS Res Hum Retroviruses. 2011 Jun;27(6):593-5
references: 21087196
references: AIDS. 2013 Jan 14;27(2):269-78
references: 23079807
references: Curr HIV Res. 2010 Mar;8(2):179-85
references: 20163349
references: JAMA. 1996 Jan 17;275(3):224-9
references: 8604176
references: Trop Med Int Health. 2012 Apr;17(4):488-96
references: 22296235
references: Health Policy Plan. 2005 Mar;20(2):109-16
references: 15746219
references: AIDS. 2009 Jan 28;23(3):395-401
references: 19114865
references: AIDS. 2013 Feb 20;27(4):617-26
references: 23364442
references: Public Health Rep. 2008 Nov-Dec;123 Suppl 3:78-85
references: 19172705
references: J Clin Epidemiol. 2000 May;53(5):477-84
references: 10812319
references: PLoS Med. 2009 Jul 21;6(7):e1000100
references: 19621070
references: HIV Med. 2007 Jan;8(1):28-31
references: 17305929
references: JAMA. 1988 Jun 24;259(24):3563-6
references: 3131555
references: AIDS Care. 2010 Jan;22(1):81-8
references: 20390484
references: J Acquir Immune Defic Syndr. 2011 Nov 1;58(3):344-52
references: 21836524
references: Cent Afr J Med. 1998 Apr;44(4):98-102
references: 9810402
references: PLoS Med. 2011 Jul;8(7):e1001056
references: 21811403
references: J Acquir Immune Defic Syndr. 2006 Feb 1;41(2):218-24
references: 16394855
references: Curr HIV Res. 2011 Sep;9(6):446-69
references: 21999779
references: AIDS Patient Care STDS. 2006 Oct;20(10):693-700
references: 17052139
references: Sex Transm Dis. 2008 Jun;35(6):631-6
references: 18545142
references: J Acquir Immune Defic Syndr. 2013 Feb 1;62(2):e47-54
references: 23075916
references: J Acquir Immune Defic Syndr. 2012 Mar 1;59(3):e28-34
references: 22173039
references: PLoS One. 2012;7(2):e31316
references: 22347462
references: BMC Public Health. 2006 Nov 10;6:279
references: 17096833
references: J Acquir Immune Defic Syndr. 2013 Jun 1;63(2):e56-63
references: 23403860
references: PLoS Med. 2011 Nov;8(11):e1001128
references: 22140363
references: J Adolesc Health. 2003 Aug;33(2 Suppl):10-22
references: 12888283
references: MMWR Morb Mortal Wkly Rep. 1997 Feb 21;46(7):152-5
references: 9072674
references: J Community Health. 2013 Jun;38(3):427-33
references: 23149569
references: J Acquir Immune Defic Syndr. 2013 Aug 15;63(5):e142-9
references: 23714739
references: Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006493
references: 17943913
references: J Acquir Immune Defic Syndr. 2012 Oct 1;61(2):e13-7
references: 22659650
references: J Acquir Immune Defic Syndr Hum Retrovirol. 1998 Nov 1;19(3):282-8
references: 9803971
references: S Afr Med J. 2010 Oct 01;100(10):671-4
references: 21080998
references: Trop Med Int Health. 2012 Aug;17(8):e38-48
references: 22943378
references: BMC Health Serv Res. 2011 Dec 21;11:346
references: 22189090
references: Soc Sci Med. 2009 Jun;68(12):2263-70
references: 19375208
references: PLoS Med. 2013;10(4):e1001414
references: 23565066
references: AIDS Educ Prev. 2011 Jun;23(3 Suppl):110-6
references: 21689041
references: Stat Med. 1998 Apr 30;17(8):873-90
references: 9595617
references: J Acquir Immune Defic Syndr. 2011 Oct 1;58(2):e29-36
references: 21725247
references: AIDS Patient Care STDS. 2010 Nov;24(11):735-41
references: 21067357
references: Trop Med Int Health. 2012 Jan;17(1):59-70
references: 22032300
references: BMC Infect Dis. 2012 Aug 21;12:196
references: 22909128
references: PLoS One. 2011 Jan 31;6(1):e16488
references: 21304973
references: J Acquir Immune Defic Syndr. 2012 Mar 1;59(3):e43-6
references: 22107821
references: Health Aff (Millwood). 2012 Jul;31(7):1459-69
references: 22778335
references: Public Health Rep. 2012 Jul-Aug;127(4):407-21
references: 22753984
references: Lancet. 2011 Jun 11;377(9782):2031-41
references: 21641026
references: J Int AIDS Soc. 2012 Jun 04;15(2):17423
references: 22713257
references: Annu Rev Public Health. 1992;13:239-52
references: 1599587
references: J Urban Health. 2006 Sep;83(5):849-59
references: 16755390
references: Arch Intern Med. 1997 Feb 10;157(3):309-14
references: 9040298
references: Lancet. 2009 Jan 3;373(9657):48-57
references: 19038438
references: Trop Med Int Health. 2008 Nov;13(11):1341-50
references: 18983282
references: AIDS. 2000 Aug 18;14(12):1819-28
references: 10985320
references: Lancet. 2003 May 3;361(9368):1569
references: 12737909
references: HIV Med. 2012 Nov;13(10):581-8
references: 22500780
references: PLoS One. 2012;7(4):e34101
references: 22514619
references: PLoS Med. 2011 Oct;8(10):e1001102
references: 21990966
references: AIDS Behav. 2007 Sep;11(5):770-7
references: 17503171
references: Lancet. 2012 Dec 15;380(9859):2197-223
references: 23245608
references: AIDS Behav. 2012 Oct;16(7):1902-16
references: 22814569
references: AIDS. 1998 Jul 9;12(10):1211-25
references: 9677171
references: PLoS One. 2010 Aug 26;5(8):e12435
references: 20865049
references: AIDS Educ Prev. 2001 Dec;13(6):541-50
references: 11791785
references: PLoS Med. 2012;9(12):e1001351
references: 23226107
references: PLoS One. 2013;8(3):e59906
references: 23527284
references: Arch Ophthalmol. 1994 Jul;112(7):987-93
references: 8031283
references: Lancet. 2009 Dec 19;374(9707):2080-2089
references: 19939445
references: AIDS Educ Prev. 2011 Jun;23(3 Suppl):49-57
references: 21689036
references: J Acquir Immune Defic Syndr. 2010 Oct;55(2):e3-10
references: 20714272
references: PLoS One. 2012;7(8):e43400
references: 22916256
references: Public Health Rep. 2008 Nov-Dec;123 Suppl 3:94-100
references: 19166093
references: Health Promot Pract. 2013 Mar;14(2):247-55
references: 22885289
references: Southeast Asian J Trop Med Public Health. 2010 Jan;41(1):153-62
references: 20578494
references: Int J STD AIDS. 2010 Jul;21(7):489-96
references: 20852199
references: AIDS Care. 2010 Feb;22(2):195-205
references: 20390498
references: MMWR Morb Mortal Wkly Rep. 2007 Jun 22;56(24):602-4
references: 17585289
references: AIDS Behav. 2013 Jul;17(6):2100-8
references: 23180155
references: AIDS Care. 2013;25(1):85-94
references: 22709242
references: Science. 2013 Feb 22;339(6122):961-5
references: 23430655
references: AIDS Behav. 2013 Jan;17(1):224-34
references: 23076720
references: J Acquir Immune Defic Syndr. 2005 Mar 1;38(3):348-55
references: 15735456
references: Emerg Infect Dis. 1998 Jul-Sep;4(3):414-5
references: 9716960
references: AIDS Behav. 2011 May;15(4):743-50
references: 20945158
references: PLoS Med. 2013 Aug;10(8):e1001496
references: 23966838
references: Sex Transm Infect. 2011 Mar;87(2):136-40
references: 21071565
references: PLoS One. 2012;7(11):e42909
references: 23173030
references: J Acquir Immune Defic Syndr. 2010 Dec;55(4):483-90
references: 20683336
references: Science. 2013 Feb 22;339(6122):966-71
references: 23430656
references: AIDS Behav. 2013 Nov;17(9):2946-53
references: 23142856
references: Sex Transm Infect. 2012 Oct;88(6):462-4
references: 22628660
references: S Afr Med J. 2005 Dec;95(12):968-71
references: 16465359
references: AIDS. 2013 Feb 20;27(4):627-34
references: 23169332
references: PLoS One. 2013;8(1):e54523
references: 23336005
references: Clin Infect Dis. 2012 Jan 15;54(2):275-81
references: 22156847
references: BMC Public Health. 2011 Sep 26;11:730
references: 21943164
references: Am J Respir Crit Care Med. 2012 May 15;185(10):1110-6
references: 22427532
references: S Afr Med J. 2004 Apr;94(4):283-8
references: 15150943
references: AIDS. 2007 Jul 11;21(11):1467-72
references: 17589193
references: AIDS Patient Care STDS. 1998 Dec;12(12):931-7
references: 11362065
references: PLoS One. 2012;7(5):e36797
references: 22574226
references: AIDS Patient Care STDS. 2005 Apr;19(4):253-7
references: 15857197
references: Sex Transm Dis. 2006 Oct;33(10 Suppl):S111-6
references: 16505738
references: Trop Med Int Health. 2007 Nov;12(11):1315-22
references: 17949401
references: Sex Transm Dis. 1998 Apr;25(4):211-5
references: 9564724
references: BMC Public Health. 2012 Sep 25;12:824
references: 23009202
references: Int J Occup Environ Health. 2007 Jan-Mar;13(1):99-106
references: 17427354
references: BMC Public Health. 2012 Nov 12;12:966
references: 23146071
references: Soc Sci Med. 2013 Mar;81:18-25
references: 23422056
references: BMC Public Health. 2010 Jun 17;10:347
references: 20553631
references: Cochrane Database Syst Rev. 2012 Sep 12;(9):CD001224
references: 22972050
references: J Acquir Immune Defic Syndr. 2010 Oct;55(2):245-52
references: 20714273
references: J Natl Med Assoc. 1998 May;90(5):287-92
references: 9617069
references: AIDS Care. 2008 Feb;20(2):139-45
references: 17896196
references: Trop Med Int Health. 2009 Aug;14(8):849-55
references: 19552646
references: Int J STD AIDS. 2012 Aug;23(8):570-5
references: 22930294
references: J Acquir Immune Defic Syndr. 2010 Jul;54(3):317-23
references: 20453819
references: Int J Tuberc Lung Dis. 2012 Apr;16(4):430-6
references: 22640510
references: PLoS Med. 2011 Nov;8(11):e1001131
references: 22140366
references: Am J Trop Med Hyg. 2012 Sep;87(3):399-406
references: 22826481
references: Int J STD AIDS. 2005 Dec;16(12):794-8
references: 16336760
references: AIDS Res Ther. 2011 Mar 07;8:13
references: 21385370
references: PLoS Med. 2006 Jul;3(7):e238
references: 16796402
references: East Afr Med J. 2010 Mar;87(3):100-8
references: 23057305
references: HIV Med. 2012 Feb;13(2):132-7
references: 22103326
references: BMC Infect Dis. 2008 Jul 31;8:106
references: 18671876
references: AIDS Res Treat. 2012;2012:412643
references: 22611485
references: Am J Public Health. 2009 Jun;99(6):1093-9
references: 19372521
references: Trop Med Int Health. 2012 Dec;17(12):1509-20
references: 22994151
references: Sex Transm Dis. 2012 May;39(5):354-8
references: 22504598
references: Lancet Infect Dis. 2011 Jul;11(7):525-32
references: 21546309
references: BMC Public Health. 2012 Mar 22;12:231
references: 22439635
references: J Acquir Immune Defic Syndr. 2010 Dec 15;55(5):625-30
references: 21934554
references: BMJ. 2003 Sep 6;327(7414):557-60
references: 12958120