Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis

Abstract

Background: We updated a 2017 systematic review and compared the effects of HIV self-testing (HIVST) to standard HIV testing services to understand effective service delivery models among the general population.

Methods: We included randomized controlled trials (RCTs) comparing testing outcomes with HIVST to standard testing in the general population and published between January 1, 2006 and June 4, 2019. Random effects meta-analysis was conducted and pooled risk ratios (RRs) were reported. The certainty of evidence was determined using the GRADE methodology.

Findings: We identified 14 eligible RCTs, 13 of which were conducted in sub-Saharan Africa. Support provided to self-testers ranged from no/basic support to one-on-one in-person support. HIVST increased testing uptake overall (RR:2.09; 95% confidence interval: 1.69-2.58; p < 0.0001;13 RCTs; moderate certainty evidence) and by service delivery model including facility-based distribution, HIVST use at facilities, secondary distribution to partners, and community-based distribution. The number of persons diagnosed HIV-positive among those tested (RR:0.81, 0.45-1.47; p = 0.50; 8 RCTs; moderate certainty evidence) and number linked to HIV care/treatment among those diagnosed (RR:0.95, 0.79-1.13; p = 0.52; 6 RCTs; moderate certainty evidence) were similar between HIVST and standard testing. Reported harms/adverse events with HIVST were rare and appeared similar to standard testing (RR:2.52: 0.52-12.13; p = 0.25; 4 RCTs; very low certainty evidence).

Interpretation: HIVST appears to be safe and effective among the general population in sub-Saharan Africa with a range of delivery models. It identified and linked additional people with HIV to care. These findings support the wider availability of HIVST to reach those who may not otherwise access testing.

Keywords: HIV self-testing; HIV testing services; Meta-analysis; Systematic Review; general population.

Fig. 1

Study selection.

Fig. 2

Uptake of HIV testing by service delivery model, HIV self-testing compared to standard facility-based HIV testing * Cluster RCTs. Note: Choko 2019b (i): HIVST distribution by HIV-positive (index) clients to their partners; Choko 2019b (ii): HIVST distribution by antenatal women to their male partners. Abbreviations: CI: confidence interval; e: number of events; HIVST: HIV self-testing; n: denominator; RR: risk ratio; SOC: standard of care.

Fig. 3

HIV positivity among those tested, HIV self-testing compared to standard facility-based HIV testing *cluster RCTs. Note: Choko 2019b (i): HIVST distribution by HIV-positive (index) clients to their partners; Choko 2019b (ii): HIVST distribution by antenatal women to their male partners. Abbreviations: CI: confidence interval; e: number of events; HIVST: HIV self-testing; n: denominator; RR: risk ratio; SOC: standard of care.

Fig. 4

Linkage to HIV care or treatment among those diagnosed, HIV self-testing compared to standard facility-based HIV testing, by type of linkage support *cluster RCTs. Note: Choko 2019a(i): HIVST alone; Choko 2019a(ii): HIVST + linkage provider financial incentive arms; Choko 2019a(iii): HIVST + phone reminder arm. Choko 2019b (i): HIVST distribution by HIV-positive (index) clients to their partners; Choko 2019b(ii): HIVST distribution by ANC women to their male partners. Abbreviations: CI: confidence interval; e: number of events; HIVST: HIV self-testing; n: denominator; RR: risk ratio; SOC: standard of care.

Fig. 5

Social harms or adverse events among randomized participants, HIVST compared to SoC Abbreviations: CI: confidence interval; e: number of events; HIVST: HIV self-testing; n: denominator; RR: risk ratio; SOC: Standard of care.