title: Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa.
abstract: HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.
authors.affiliation: Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Seattle, Washington 98195, USA.
authors.forename: Monisha
authors.initials: M
authors.lastname: Sharma
authors.affiliation: Department of Global Health, University of Washington, 1510 San Juan Road 310e, Seattle, Washington 98195, USA.
authors.forename: Roger
authors.initials: R
authors.lastname: Ying
authors.affiliation: Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Seattle, Washington 98195, USA.
authors.forename: Gillian
authors.initials: G
authors.lastname: Tarr
authors.affiliation: Department of Epidemiology, University of Washington, 1959 NE Pacific Street, Seattle, Washington 98195, USA.|Department of Global Health, University of Washington, 1510 San Juan Road 310e, Seattle, Washington 98195, USA.|School of Medicine, University of Washington, 4333 Brooklyn Avenue NE, Seattle, Washington 98105, USA.|Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N., Seattle, Washington 98109, USA.
authors.forename: Ruanne
authors.initials: R
authors.lastname: Barnabas
mesh_terms: D017954:Africa South of the Sahara; D018791:CD4 Lymphocyte Count; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics / Q000821:virology; D006301:Health Services Needs and Demand / Q000191:economics; D006801:Humans; D017678:Sex Distribution; D019562:Viral Load / Q000187:drug effects