Using Community Psychology in NHS Settings… Evolution or Revolution?
Thornton Community Settings Hiv992
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HIV testing in community settings in resource-richcountries: a systematic review of the evidenceAC Thornton, V Delpech, MM Kall and A NardoneHIV STI Department, Health Protection Agency, London, UK
ObjectivesCommunity HIV testing represents an opportunity for diagnosing HIV infection amongindividuals who may not have contact with health services, especially in hard-to-reach groups.The aim of this review was to assess the evidence for feasibility, acceptability and effectivenessof HIV testing strategies in community settings in resource-rich countries.
MethodsThe PubMed database was searched for English language studies of outreach HIV testing inresource-rich countries. Studies were included if they reported one of the following outcomemeasures: uptake of testing; seropositivity; client acceptability; or provider acceptability.
ResultsForty-four studies were identified; the majority took place in the USA and targeted men whohave sex with men. Uptake of HIV testing varied between 9 and 95% (in 14 studies).Seropositivity was � 1% in 30 of 34 studies. In 16 studies the proportion of patients whoreceived their test results varied from 29 to 100% and rapid testing resulted in a higherproportion of clients receiving their results. Overall, client satisfaction with community HIVtesting was high. However, concern remained over confidentiality, professional standards and theneed for post-test counselling. Staff reported positive attitudes towards community testing.
ConclusionsIn the majority of studies, the reported seropositivity was higher than 1/1000, the thresholddeemed to be cost-effective for routinely offering testing. Rapid testing improved the return ofHIV test results to clients. HIV testing in outreach settings may be important in identifyingundiagnosed infections in at-risk populations, but appropriate data to evaluate these initiativesmust be collected.
Keywords: community, diagnosis, HIV, outreach, testing
Accepted 20 December 2011
Introduction
To encourage early diagnosis of HIV infection, to decreasethe proportion of infected people who are undiagnosed andto normalize the process of having a test, there has been arecent policy shift to expand HIV testing into a greatervariety of healthcare and nonclinical community settings[1–6]. Diagnosis of HIV infection allows an individual toaccess treatment and care. The individual patient benefit of
early diagnosis of infection (diagnosis before a point atwhich treatment should have commenced) is decreased riskof short-term morbidity and mortality [7,8]. There is addi-tional public health benefit as HIV treatment lowers anindividual’s viral load, making them less infectious to part-ners [9,10], and knowledge of a positive HIV status allowsindividuals to implement behavioural prevention strategiesto protect their partners [11].
Men who have sex with men (MSM) and individualsfrom Black and minority ethnicity (BME) communitiesremain the population groups most affected by HIV inresource-rich countries [12]. Other populations who may beat increased risk of HIV infection include commercial sex
Correspondence: Dr Anthony Nardone, HIV STI Department, HealthProtection Agency, 61 Colindale Avenue, London NW9 5EQ, UK.Tel: +44 20 8200 4400; fax: +44 20 8200 7868; e-mail:[email protected]
DOI: 10.1111/j.1468-1293.2012.00992.x© 2012 British HIV Association HIV Medicine (2012), 13, 416–426
ORIGINAL RESEARCH
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workers (CSWs) [13], injecting drug users (IDUs) [14] andyoung adults [15]. These populations are often marginal-ized and may not access HIV testing because of a lack ofknowledge about where it is conducted, fears about HIVdisease, fears of disclosure or low self-perception of risk[16]. Community testing initiatives may provide servicesthat would encourage testing in these population groups.
This study aimed to assess the available evidence for thefeasibility, acceptability and effectiveness of carrying outHIV testing in community settings in resource-rich coun-tries and to consider how the community testing strategiesmay be most successfully implemented.
Methods
Search strategy
In February 2011, the PubMed database was searched forstudies of HIV testing in community settings conducted inresource-rich countries, after the introduction of highlyactive antiretroviral therapy (post-1996). Broad searchterms were used to maximize the number of results: HIV;testing; screening; community; outreach; voluntary coun-selling; venues; nonclinical; nonhealthcare; mobile healthclinics; community health centres; and needle-exchangeprogrammes were used in various combinations. Wherepossible, medical sub-heading (MESH) terms were includedin the search. Reference lists of those papers retrieved fromthe electronic search were reviewed for additional pertinentreferences.
Inclusion criteria
Community HIV testing facilities were defined as thosethat are based outside pre-existing traditional healthcaresettings. These include both stand-alone HIV testingservices, provided separately from other clinical services,and venues primarily used for other purposes (such associal venues or community centres) where HIV testing isavailable as an additional service. For the purposes of thisreview, established HIV testing provision within hospitals,primary care facilities, antenatal clinics and sexually trans-mitted infection (STI) clinics was excluded.
Studies were included in the final analysis if they wereconducted in a community setting, as defined above, andreported at least one of the following outcome measures:uptake of HIV testing in community settings; HIV serop-ositivity of populations tested in community settings;client attitudes towards HIV testing in community settings;or provider attitudes towards HIV testing in communitysettings. We included studies conducted in resource-richsettings in Western Europe, North America and the Anti-podes which were published from 1996 onwards.
A total of 3107 papers were identified using the searchstrategy. Titles, abstracts and full papers were screenedindependently by two researchers and results from screen-ing by each researcher were compared. After this process,48 papers were found to contain at least one of theoutcome measures of interest and were therefore consid-ered appropriate for data extraction (Fig. 1). These 48papers were examined for evidence of duplication of dataand four papers were excluded on this basis, giving a finaltotal of 44 papers being included in the review (Table 1).Where papers reported on different outcome measures fromthe same location, both papers were included in the finalanalysis.
Analysis
Studies were stratified by the target population and thesetting where HIV testing took place. Acceptability of theHIV testing strategy was examined using uptake of testingand client and staff attitudes to testing. Effectiveness ofHIV testing was examined with regard to new diagnosesmade and transfer of those individuals to appropriate HIV-related care and support services. The use of rapid testingin community settings and its effect on acceptability andeffectiveness were also examined.
Results
Characteristics of included studies
Forty-four studies were included, of which the majoritywere conducted in the USA (38 of 44), nine in Europe (eightin the UK and one in Spain), three in Australia and onein Canada (Table 1). Five studies [17–21] provided non-targeted testing to the general population, while the restaddressed HIV testing in one or more high-risk popula-tions. Eleven studies investigated HIV testing in multiplehigh-risk groups [21–31]. The most commonly targetedgroup for testing was MSM (17 studies, including two thatspecifically targeted BME MSM) [23,27,32–46]. Othergroups included IDUs, youth, homeless individuals andindividuals from Black and minority ethnic groups.
HIV testing was offered at a wide range of sites. Stand-alone HIV testing sites (14 studies [18,20–22,26,34,41,43,47–52]) and mobile clinics (11 studies [17,21,23,24,28–30,36,53–55]) were the most frequently selected sites forcommunity testing. Several studies conducted testing invenues known to be frequented by the target population,for example drug treatment centres for IDUs [25,27,56,57]or gay bars [39,40,40,45] and sex on premises venues[27,33,35,38,44,46] for MSM. Ad hoc testing events wereused as another method of providing HIV testing in thecommunity [37,42,58].
A review of community HIV testing 417
© 2012 British HIV Association HIV Medicine (2012), 13, 416–426
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Accepting an HIV test
Uptake of testing, defined as the proportion of individualsoffered tests who accepted, was reported in 14 studies(for 16 different testing models) [24,27–29,31,38,40,42,45,47,49,50,57,59]. Uptake rates of HIV testing rangedfrom 9 to 95% and are difficult to compare given thediverse settings and offer methods (Fig. 2). For example,the 9% uptake of testing was reported in a study whereevery third man entering a bar in the USA was offered atest [40]. In contrast, the 95% uptake was reported in amobile clinic, although in this model uptake was measuredamong individuals who were either recruited by outreachworkers on the street or who walked into the van of theirown accord [28].
New diagnoses of HIV infection
The proportion of clients tested who were newly diagnosedwith HIV infection was reported in 34 of the includedstudies (Table 2). Seropositivity ranged from 0 to 12%, withthe highest seropositivity reported from a study that testedtransgender people at a variety of community sites [51]. In
all studies targeting MSM and two of four studies in BMEcommunities, the seropositivity was 2% or higher. In thosestudies where HIV testing was not targeted at high-riskpopulations, lower seropositivity was observed, but was atleast 1% among those tested [17–20].
In all studies where no new diagnoses were made[26,47,49,52], HIV testing was included as part of a bundleof tests for multiple STIs. These studies tested a smallnumber of individuals (between 21 and 116 tests). Three ofthese studies [26,47,49] were conducted in services thattargeted young adults and, although no HIV diagnoses weremade, these services did identify and treat a number ofindividuals with bacterial STIs. Where no new diagnoseswere made, in a project targeting at BME men, the study diddemonstrate the feasibility of integrating HIV preventionand behavioural interventions with health screening [52].
Characteristics of individuals having an HIV testin a community setting
The testing history of those individuals attending commu-nity settings was reported in 15 studies, with 13 of 15
3107 papers identified using the search terms and retrieved for title screening
627 papers retrieved for abstract screening of community HIV testing in resource-rich settings
2480 not relevant or not conducted in resource-rich countries
48 papers contained at least one
113 papers retrieved for full paperscreening
of the specified outcome measures
44 papers included in the final review
4 papers excluded as theycontained duplicate data which were reported in other studies
514 not considered relevant on the basis of abstracts
65 papers excluded as did not contain one of the specified outcome measures
Fig. 1 Selection of papers for inclusion in the review.
418 AC Thornton et al.
© 2012 British HIV Association HIV Medicine (2012), 13, 416–426
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Tabl
e1
Stud
ies
incl
uded
inth
ere
view
Auth
ors
Sum
mar
yof
stud
yCo
untr
yTa
rget
popu
lati
onTe
stin
gpe
riod
(ifap
plic
able
)O
utco
me
mea
sure
s
Tota
lnum
ber
ofte
sts
repo
rted
(ifap
plic
able
)
Arum
aina
yaga
met
al.
[32]
HIV
and
STIs
cree
ning
atou
trea
chse
ssio
nsin
asa
una
UK
MSM
Mon
thly
sess
ions
for
1ye
arSe
ropo
siti
vity
169
Baile
yet
al.[
34]
Aco
mpa
rison
ofm
enw
hote
stat
stan
d-al
one
test
ing
cent
res
wit
hth
ose
who
test
ata
stan
dard
sexu
alhe
alth
clin
icU
KM
SM16
mon
ths
Sero
posi
tivi
ty33
8
Bell
etal
.[53
]Ev
alua
tion
from
four
HIV
coun
selli
ngan
dte
stin
gm
odel
sin
clud
ing
mob
ilecl
inic
s,se
rvic
esfo
rho
mel
ess
and
gay
peop
le,a
nded
ucat
iona
lfac
iliti
esU
SAYo
ung
adul
ts48
mon
ths
Sero
posi
tivi
ty2
654
Rece
ipt
ofre
sult
s1
507 52 267
Blan
ket
al.[
37]
Apr
ogra
mm
eof
nine
even
tsin
bars
.Prim
arily
aim
edat
syph
ilis
cont
rolb
utin
clud
ing
ara
nge
ofot
her
heal
thse
rvic
esin
clud
ing
HIV
test
ing
USA
MSM
8m
onth
sSe
ropo
siti
vity
165
Bow
les
etal
.[31
]An
eval
uati
onof
rapi
dH
IVte
stin
gat
ava
riety
ofco
mm
unit
yan
dou
trea
chse
ttin
gsin
eigh
tci
ties
USA
Mul
tipl
ehi
gh-r
isk
grou
ps24
mon
ths
Upt
ake
ofte
stin
g23
900
Sero
posi
tivi
tyBr
adsh
awet
al.[
60]
Stre
etou
trea
chw
asus
edto
recr
uit
clie
nts
for
STIa
ndse
rolo
gica
lHIV
test
ing
Aust
ralia
IDU
s36
mon
ths
Sero
posi
tivi
ty30
9Bu
cher
etal
.[59
]Ra
pid
HIV
test
ing
prov
ided
atce
ntre
sfo
rho
mel
ess
indi
vidu
als
USA
Hom
eles
syo
uth
8m
onth
sU
ptak
eof
test
ing
106
3Se
ropo
siti
vity
Rece
ipt
ofre
sult
sCD
C[4
2]Ra
pid
HIV
test
ing
offe
red
at11
gay
prid
eev
ents
USA
BME
MSM
11on
e-of
fsp
ecia
leve
nts
over
2ye
ars
Upt
ake
ofte
stin
g13
3Se
ropo
siti
vity
Clar
ket
al.[
30]
Asu
rvey
tost
aff
invo
lved
inco
mm
unit
yH
IVte
stin
gin
eigh
tci
ties
USA
Mul
tipl
ehi
gh-r
isk
grou
psN
otap
plic
able
Prov
ider
atti
tude
sN
otap
plic
able
Das
kala
kis
etal
.[33
]A
pilo
tpr
ogra
mm
eof
ferin
gra
pid
test
ing
intw
osa
unas
USA
MSM
4–5
hour
sa
wee
kfo
r20
mon
ths
Sero
posi
tivi
ty49
3Re
ceip
tof
resu
lts
De
laFu
ente
etal
.[17
]Ra
pid
HIV
test
ing
prov
ided
ata
mob
ileva
nSp
ain
Non
spec
ific
14m
onth
sSe
ropo
siti
vity
713
8Re
ceip
tof
resu
lts
DiF
ranc
esis
coet
al.[
19]
Eval
uati
onof
apr
ogra
mm
eof
com
mun
ity
test
ing
atva
rious
outr
each
loca
tion
sU
SAN
onsp
ecifi
c29
mon
ths
Sero
posi
tivi
ty12
171
Elle
net
al.[
24]
Eval
uati
onof
pati
ents
who
rece
ive
post
-tes
tco
unse
lling
ata
mob
ilecl
inic
offe
ring
eith
eror
alor
seru
mH
IVte
stin
gan
dte
stin
gfo
rot
her
STIs
USA
Mul
tipl
ehi
gh-r
isk
grou
ps21
mon
ths
Upt
ake
ofte
stin
g2
242
Sero
posi
tivi
tyRe
ceip
tof
resu
lts
Forb
eset
al.[
47]
Case
note
revi
ewof
aco
mm
unit
ysi
tean
dse
xual
heal
thse
rvic
eU
KYo
ung
BME
com
mun
itie
s5
mon
ths
Upt
ake
ofte
stin
g30
Sero
posi
tivi
tyFr
aze
etal
.[58
]Ev
alua
tion
ofa
cam
paig
nto
prom
ote
HIV
test
ing
and
cond
ucti
ngra
pid
test
ing
atsp
ecia
leve
nts
intw
oci
ties
USA
BME
wom
enA
tota
lof
48on
e-of
fsp
ecia
leve
nts
Sero
posi
tivi
ty1
492
Gal
van
etal
.[40
]A
com
paris
onof
offe
ring
rapi
dH
IVte
sts
alon
eor
bund
led
wit
hot
her
test
sto
men
inba
rsU
SALa
tino
MSM
Not
stat
edU
ptak
eof
test
ing
343
Sero
posi
tivi
tyG
olde
net
al.[
41]
Peer
recr
uite
rsen
rolle
dto
enco
urag
ese
rolo
gica
ltes
ting
for
HIV
asw
ella
ste
stin
gfo
rot
her
STIs
ata
stan
d-al
one
test
ing
site
USA
MSM
17m
onth
sSe
ropo
siti
vity
438
Gue
nter
etal
.[18
]Ev
alua
tion
ofpa
tien
tch
oice
betw
een
rapi
dan
dst
anda
rdte
stin
gat
ast
and-
alon
ete
stin
gsi
teCa
nada
Non
spec
ific
5m
onth
sSe
ropo
siti
vity
161
0Re
ceip
tof
resu
lts
Hue
bner
etal
.[46
]A
com
paris
onof
rapi
dan
dst
anda
rdH
IVte
stin
gin
saun
asU
SAM
SM2
year
sSe
ropo
siti
vity
528
Rece
ipt
ofre
sult
s49
2Jo
nes
etal
.[50
]A
com
paris
onof
atte
ndan
ces
and
test
ing
ata
nurs
e-le
dco
mm
unit
yse
xual
heal
thcl
inic
wit
hth
ose
ata
hosp
ital
-bas
edcl
inic
UK
Youn
gad
ults
12m
onth
sU
ptak
eof
test
ing
325
Kahn
etal
.[54
]A
mob
ilecl
inic
prov
idin
gST
Iscr
eeni
ngan
dse
rolo
gyfo
rH
IVU
SABM
E41
mon
ths
Sero
posi
tivi
ty2
807
Clie
ntsa
tisf
acti
onKe
enan
&Ke
enan
[25]
Anin
vest
igat
ion
into
the
use
ofra
pid
test
ing
toin
crea
seth
enu
mbe
rof
pati
ents
who
rece
ive
thei
rH
IVte
stre
sult
atce
ntre
sfo
rho
mel
ess
peop
lean
dat
drug
trea
tmen
tce
ntre
s
USA
Hom
eles
sin
divi
dual
san
dID
Us
18m
onth
sSe
ropo
siti
vity
735
Rece
ipt
ofre
sult
s
Kim
brou
ghet
al.[
22]
Nin
eco
mm
unit
y-ba
sed
orga
nisa
tion
sin
seve
nci
ties
enlis
ted
peer
recr
uite
rsto
offe
rH
IVte
stin
gU
SAM
ulti
ple
high
-ris
kgr
oups
26m
onth
sSe
ropo
siti
vity
317
2
Lew
iset
al.[
49]
Anou
trea
chcl
inic
prov
idin
gsc
reen
ing
for
STIs
and
sero
logi
cals
cree
ning
for
HIV
UK
Youn
gad
ults
6m
onth
sU
ptak
eof
test
ing
60Se
ropo
siti
vity
A review of community HIV testing 419
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Tabl
e1
(Con
td.)
Auth
ors
Sum
mar
yof
stud
yCo
untr
yTa
rget
popu
lati
onTe
stin
gpe
riod
(ifap
plic
able
)O
utco
me
mea
sure
s
Tota
lnum
ber
ofte
sts
repo
rted
(ifap
plic
able
)
Lian
get
al.[
28]
Am
obile
clin
icof
ferin
gra
pid
HIV
test
ing
and
STIt
esti
ngU
SAID
Us
and
CSW
s10
mon
ths
Upt
ake
ofte
stin
g43
9Se
ropo
siti
vity
Rece
ipt
ofre
sult
sLi
ebm
anet
al.[
55]
Are
tros
pect
ive
anal
ysis
ofcl
ient
ste
sted
ata
mob
ilecl
inic
offe
ring
STIt
esti
ngan
dse
rolo
gica
ltes
ting
for
HIV
USA
BME
9m
onth
sSe
ropo
siti
vity
247
List
eret
al.[
38]
AnST
Iscr
eeni
ngse
rvic
ein
clud
ing
sero
logi
calH
IVte
stin
gin
asa
una
Aust
ralia
MSM
12m
onth
sU
ptak
eof
test
ing
102
Sero
posi
tivi
tyRe
ceip
tof
resu
lts
O’C
onno
ret
al.[
29]
Are
port
onth
eim
plem
enta
tion
ofa
pilo
tpr
ojec
tof
ferin
gH
IVte
stin
gfr
oma
mob
ilecl
inic
USA
Mul
tipl
ehi
gh-r
isk
grou
psN
otap
plic
able
Upt
ake
ofte
stin
gN
otap
plic
able
Clie
ntat
titu
des
O’D
onne
llet
al.[
52]
Are
port
onth
ede
velo
pmen
tof
ate
stin
gan
dpr
even
tion
prog
ram
me
embe
ddin
gH
IVte
stin
gam
ong
othe
rhe
alth
prom
otio
nat
ast
and-
alon
esi
teU
SABM
Em
en13
sess
ions
Sero
posi
tivi
ty11
6Cl
ient
atti
tude
sPr
ost
etal
.[39
]A
qual
itat
ive
stud
yof
prov
ider
san
dcl
ient
sin
vest
igat
ing
test
ing
inve
nues
such
asba
rsan
dcl
ubs
UK
MSM
Not
appl
icab
leCl
ient
atti
tude
sN
otap
plic
able
Staf
fat
titu
des
Pros
tet
al.[
48]
Qua
litat
ive
stud
yex
amin
ing
clie
ntat
titu
des
tow
ards
aco
mm
unit
yst
and-
alon
ete
stin
gsi
tem
odel
used
inKe
nya
UK
BME
Not
appl
icab
leCl
ient
atti
tude
sN
otap
plic
able
Puga
tch
etal
.[57
]Ev
alua
tion
ofa
sero
logi
cala
ndor
alflu
idH
IVte
stin
gpr
ojec
tat
asu
bsta
nce
mis
use
cent
reU
SAYo
ung
adul
ts15
mon
ths
Upt
ake
ofte
stin
g15
0Re
ceip
tof
resu
lts
Reyn
olds
etal
.[23
]A
com
paris
onbe
twee
nra
pid
and
stan
dard
test
ing
and
HIV
test
ing
alon
eor
inco
mbi
nati
onw
ith
othe
rST
Iand
bloo
dbo
rne
viru
ste
stin
gU
SAID
Us
and
MSM
35m
onth
sSe
ropo
siti
vity
203
1Re
ceip
tof
resu
lts
Rose
etal
.[36
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ths
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ipt
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sult
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thm
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56]
Eval
uati
onof
alo
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erm
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ring
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6m
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het
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al.[
27]
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pid
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port
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26]
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45]
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fluid
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bars
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ly(F
riday
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ake
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ualit
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ing
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mer
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ith
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,sex
ually
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ted
infe
ctio
n.
420 AC Thornton et al.
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showing that the large majority of clients (between 62 and100%) had previously had an HIV test [18,27,31,33,34,36,41,43,47,51,59,60] and only two studies [17,25] report-ing that < 50% of people attending had tested previously.Both of these studies used mobile vans to offer HIV testingand one targeted BME communities in the USA [25], whilethe other, conducted in Spain, did not target any particularhigh-risk group [17].
Only one study compared the testing history of all thosewho tested with the testing history of those who received apositive result. Overall, 14% of attendees had never previ-ously been tested. However, among those who were newlydiagnosed, this proportion was higher, at 24% [59].
Where included studies compared clients who tested incommunity settings with those attending more traditionaltesting services, such as sexual health or STI clinics, therewere conflicting results. Two studies, one among MSMtesting at a stand-alone HIV testing site in the UK [34]and one in Wisconsin, USA [19], showed that individualsattending community settings were less likely to receive apositive result than individuals attending the local STI ortraditional sexual health clinic. By contrast, a Los Angeles,USA study found a higher seropositivity in MSM tested ina community setting (5.3%) than among those tested at anSTI clinic (3.9%) [43]. The fourth study showed that asimilar HIV seropositivity was observed at a mobile clinic
targeting BME populations compared with other testingsites within the same geographical area [55].
Receiving an HIV test result and transfer to care
The proportions of patients who received their HIV testresult ranged from 29 to 100% (data available for 16studies) [17,18,20,23–25,27,28,33,36,38,46,51,53,57,59].Three studies, which conducted testing from mobile vans,had < 50% return rates (using oral fluid [36,53] or sero-logical testing [24,53]). The use of rapid tests consistentlyresulted in higher proportions of individuals receiving theirresults (>80%) compared to when laboratory blood or sali-vary tests were used (five studies) [18,20,23,27,46]. Onlythree studies reported the proportion of those patients whoreceived a positive HIV test result who were successfullylinked to care, and this was 75% [33] and 100% [34,38].
Client attitudes to HIV testing in community settings
Overall, where reported, client satisfaction with communitytesting services was high (Table 3). Choice of test type [20],use of a noninvasive test [52], anonymous testing [21,44],confidentiality and the test being free of charge [21] werecited as important factors by clients in choosing to test forHIV. Three studies showed that rapid testing was preferredby clients [18,20,27].
0
10
20
30
40
50
60
70
80
90
100
MSMgroups
Other
Upt
ake
of H
IV te
stin
g (%
)
37
19
27
49
38
32
46
29
48
10
37
42
53
45
31
Various high-riskIDUsYoung adults
Sex on premises venue + Drug treatment centre x Mobile clinic
Bar/club - Stand-alone HIV testing sites
References shown as numbers next to the data points
Other
Fig. 2 Uptake of HIV testing in community settings. IDU, injecting drug user; MSM, men who have sex with men.
A review of community HIV testing 421
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Qualitative work in MSM and BME communities, assess-ing client attitudes towards HIV testing in communitysettings [39,48], found concerns about possible breaches inconfidentiality, as well as stigma and the ability of com-
munity services to provide a high professional standard ofcare [48]. Among MSM there was concern that providingadequate post-test counselling would be difficult in com-munity settings such as bars and clubs [39].
Table 2 New HIV diagnoses in community HIV testing projects
Target population Venue for HIV testing Number tested Positivity (%) Reference
MSM Stand-alone site 280 3 [9]438 5 [34]
1 201 5 [39]Bar/club 165 4 [18]
64 6 [49]343 4 [32]
Sex on premises venue 169 4 [2]493 4 [6]102 2 [27]528 2 [50]492 4 [50]
Mobile clinics 21 10 [17]Other* 133 6 [38]
BME communities Mobile clinics 2 807 2 [21]247 3 [22]
Stand-alone site 116 0 [54]Other* 1 492 1 [3]
Young adults Stand-alone site 60 0 [29]30 0 [10]
Mobile clinics 1 507 3 [20]52 6 [20]
Drug treatment centre 150 1 [46]Various community sites 2 654 1 [20]Other* 21 0 [35]
53 0 [35]IDUs Drug treatment centre 168 340 9 [16]
428 1 [24]Other* 309 1 [40]
Other† Various sites 559 12 [51]Other* 102 3 [24]
1 063 3 [31]Multiple specified high-risk groups Mobile clinics 2 031 5 [12]
439 2 [42]2 242 7 [19]
Stand-alone site 2 172 6 [7]Various community sites 23 900 1 [53]
Nonspecific Mobile clinics 7 126 1 [1]Stand-alone site 1 610 1 [13]
6 187 1 [43]Various community sites 12 171 1 [41]
BME, Black and minority ethnicity; IDU, injecting drug user; MSM, men who have sex with men.*Includes gay pride events, street outreach, educational institutions, youth centres and homeless centres. †Includes commercial sex workers, homelessindividuals and transgender individuals.
Table 3 Quantitative measures of client satisfaction with community HIV testing
Target population Venue for HIV testing Client satisfaction measure Reference
MSM Stand-alone site 97% of clients would recommend rapid testing to a friend [39]MSM Bar/club 91% of clients felt comfortable with testing in this setting [49]BME Mobile clinics 97% of clients reported that neighbourhood-based HIV testing was a good idea [21]Various high-risk groups Various community settings 98% of clients reported that they felt the venue that they were attending was an
appropriate setting for HIV testing[53]
Nonspecific Stand-alone site Among those testing negative, 99% were satisfied with the experience, although42% reported that the experience had made them feel anxious
[13]
BME, Black and minority ethnicity; MSM, men who have sex with men.
422 AC Thornton et al.
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Providers’ attitudes to HIV testing incommunity settings
Researchers reported overall positive attitudes of stafftowards community testing [18,20,30,35,39,44]. Stafftraining was highlighted as an important component ofcommunity testing as it increased the levels of comfortabout both the testing and the provision of results in thissetting [20,44]. Developing strong relationships and build-ing trust between venue owners and testing staff was alsoseen as important [35]. In one study examining the atti-tudes to introducing HIV testing in bars and saunas fre-quented by MSM, although venue owners were supportiveoverall, they did express some concerns that the servicemay be a deterrent to potential customers [39].
Discussion
The results of the studies included in this review indicatethat community testing initiatives are successful in diag-nosing previously undiagnosed HIV infections amongMSM communities [32–34,37,38,41,43,45,46] and peoplefrom BME [54,55] communities and are acceptable to bothclients and staff. Rapid testing technologies increased thelikelihood of a person receiving their test result and areacceptable to clients [18,20,23,27,46].
The proportions of patients testing in community set-tings who had never previously tested were generally small[17,18,27,31,34,36,41,43,47,51,59]. In addition, compari-sons of seropositivity among clients attending communitytesting settings and those attending more traditional set-tings were conflicting [19,34,43,55]. Therefore, although itis clear that community testing services are providing animportant choice for individuals regarding where they havean HIV test, whether the services are diagnosing individu-als who would otherwise not test until they are unwell isless clear.
Evidence from the studies included in this review dem-onstrates the importance of selecting appropriate venues,building relationships with venue owners and choosingsuitable locations within those venues [35,39]. The locationshould be conducive to providing a confidential testingservice of equal professional standard to those services inhealthcare facilities. In addition, training of staff conduct-ing the tests as well as of staff working in the venues willincrease confidence and acceptability [20,44].
There are some limitations to our review. Studies wereonly included if they had been published in peer-reviewedjournals and were written in English. Given that a largenumber of community testing projects may be conductedby small nongovernmental, nonacademic organizations,much of the information that exists on projects may only
be published in grey literature or in local languages.Almost all studies were observational and only five had acomparison group, making the true effect of communitytesting on the outcome measures more difficult to measurecompared with more traditional strategies [20,34,43,55,56].Information on the stage at which people are diagnosed(CD4 cell count at diagnosis) is lacking and therefore it isnot possible to assess whether patients are diagnosedearlier as a result of community testing initiatives.
In evaluating HIV testing strategies it is importantthat feasibility, acceptability, effectiveness and cost-effectiveness are considered and, to allow meaningful com-parisons of studies, there is a need for use of comparablemeasures [61]. This review highlights the range of outcomemeasures that are used to evaluate these testing strategies.For example, in the studies included in this review, ser-positivity was not always reported [21,27,29,50,57] andtransfer to care of newly diagnosed individuals was rarelyreported [33,34,38].
Our review did not consider the costs associated withcommunity HIV testing. This will be an important factorin implementing these strategies and to date there havebeen few studies, none of which have compared the costof testing in the community with that of testing in moretraditional services [41,62–64]. The cost-effectiveness ofcommunity HIV testing for MSM has been consideredin a recent review, which also found limited evidence[65].
This review has shown that community HIV testing strat-egies provide an acceptable alternative to HIV testing inhealthcare settings and are feasible to implement. However,these strategies require careful planning to ensure that theyreach the population most at need of alternative testingvenues and are able to transfer any individuals newlydiagnosed with HIV into appropriate treatment and carepathways.
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