Acute and early HIV infection screening among men who have sex with men, a systematic review and meta-analysis

Abstract

Introduction: Screening for acute and early HIV infections (AEHI) among men who have sex with men (MSM) remains uncommon in sub-Saharan Africa (SSA). Yet, undiagnosed AEHI among MSM and subsequent failure to link to care are important drivers of the HIV epidemic. We conducted a systematic review and meta-analysis of AEHI yield among MSM mobilized for AEHI testing; and assessed which risk factors and/or symptoms could increase AEHI yield in MSM.

Methods: We systematically searched four databases from their inception through May 2020 for studies reporting strategies of mobilizing MSM for testing and their AEHI yield, or risk and/or symptom scores targeting AEHI screening. AEHI yield was defined as the proportion of AEHI cases among the total number of visits. Study estimates for AEHI yield were pooled using random effects models. Predictive ability of risk and/or symptom scores was expressed as the area under the receiver operator curve (AUC).

Results: Twenty-two studies were identified and included a variety of mobilization strategies (eight studies) and risk and/or symptom scores (fourteen studies). The overall pooled AEHI yield was 6.3% (95% CI, 2.1 to 12.4; I² = 94.9%; five studies); yield varied between studies using targeted strategies (11.1%; 95% CI, 5.9 to 17.6; I² = 83.8%; three studies) versus universal testing (1.6%; 95% CI, 0.8 to 2.4; two studies). The AUC of risk and/or symptom scores ranged from 0.69 to 0.89 in development study samples, and from 0.51 to 0.88 in validation study samples. AUC was the highest for scores including symptoms, such as diarrhoea, fever and fatigue. Key risk score variables were age, number of sexual partners, condomless receptive anal intercourse, sexual intercourse with a person living with HIV, a sexually transmitted infection, and illicit drug use. No studies were identified that assessed AEHI yield among MSM in SSA and risk and/or symptom scores developed among MSM in SSA lacked validation.

Conclusions: Strategies mobilizing MSM for targeted AEHI testing resulted in substantially higher AEHI yields than universal AEHI testing. Targeted AEHI testing may be optimized using risk and/or symptom scores, especially if scores include symptoms. Studies assessing AEHI yield and validation of risk and/or symptom scores among MSM in SSA are urgently needed.

Keywords: acute HIV infection; early HIV infection; men who have sex with men; mobilization; risk score; systematic review; targeted screening.

Figure 1

Study selection. AEHI, acute and early HIV infection; ERIC, Education Resources Information Center; MSM, men who have sex with men.

Figure 2

Forest plots of acute HIV infection yield and acute and early HIV infection yield among men who have sex with men. Study estimates and their 95% CIs, and pooled estimates and their 95% CIs for AEHI yield, overall and stratified by testing strategy: targeted testing and universal testing. (A) Displays AEHI yield, (B) displays AHI yield. Yield was defined as the proportion of AEHI cases among the number of visits during which AEHI was assessed. The size of the grey boxes represents a study’s weight in the meta‐analysis. *The study population was men who have sex with men in all studies, with the exception of Silvera et al. In this study, heterosexual men, women and men who have sex with men were included, however, they predominantly targeted MSM during recruitment. AHI, acute HIV infection; AEHI, acute and early HIV infection; CI, confidence interval; ES, effect size; N/A, not accessible; NL, the Netherlands; USA, United States of America.

Figure 3

Area under receiver operator curves of published risk and/or symptom scores to assist screening for acute and early HIV infection among men who have sex with men. The black dots represent point estimates, the coloured lines 95% confidence intervals. If no coloured lines are displayed, the study did not report 95% confidence intervals. For each risk and/or symptom score, the first point estimate represents the area under receiver operator curve of the development study sample, the latter point estimate(s) represents the area under receiver operator curve of the validation study sample(s). The development outcomes of scores Facente, UMRSS, CDC and Gilead have not been included in this review, therefore, only validation outcomes are represented. CDC, Center for Disease Control and Prevention; CDRSS, Cohort Derived Risk Screening Score; D, Development study sample; HIRI‐MSM, HIV Incidence Risk Index for MSM; MSM, men who have sex with men; NL, the Netherlands; NS, not specified; SDET, San Diego Early Test; SDSS, San Diego Symptom Score; UMRSS, University of North Carolina Malawi Risk Screening Score; USA, United States of America; V, Validation study sample.