HIV self-testing with digital supports as the new paradigm: A systematic review of global evidence (2010-2021)

Abstract

Background: HIV self-testing (HIVST) is recommended by the WHO as an innovative strategy to reach UNAIDS targets to end HIV by 2030. HIVST with digital supports is defined as the use of digital interventions (e.g., website-based, social media, mobile HIVST applications (apps), text messaging (SMS), digital vending machines (digital VMs)) to improve the efficiency and impact of HIVST. HIVST deployment and integration in health services is an emerging priority. We conducted a systematic review aiming to close the gap in evidence that summarizes the impact of digitally supported HIVST and to inform policy recommendations.

Methods: We searched PubMed and Embase for articles and abstracts on HIVST with digital supports published during the period February 1st, 2010 to June 15th, 2021, following Cochrane guidelines and PRISMA methodology. We assessed feasibility, acceptability, preference, and impact outcomes across all populations and study designs. Metrics reported were willingness to use HIVST, preferences for HIVST delivery, proportion of first-time testers, HIVST uptake, HIVST kit return rate, and linkage to care. Heterogeneity of the interventions and reported metrics precluded us from conducting a meta-analysis.

Findings: 46 studies were narratively synthesized, of which 72% were observational and 28% were RCTs. Half of all studies (54%, 25/46) assessed web-based innovations (e.g., study websites, videos, chatbots), followed by social media (26%, 12/46), HIVST-specific apps (7%, 3/46), SMS (9%, 4/46), and digital VMs (4%, 2/46). Web-based innovations were found to be acceptable (77-97%), preferred over in-person and hybrid options by more first-time testers (47-48%), highly feasible (93-95%), and were overall effective in supporting linkage to care (53-100%). Social media and app-based innovations also had high acceptability (87-95%) and linkage to care proportions (80-100%). SMS innovations increased kit return rates (54-94%) and HIVST uptake among hard-to-reach groups. Finally, digital VMs were highly acceptable (54-93%), and HIVST uptake was six times greater when using digital VMs compared to distribution by community workers.

Interpretation: HIVST with digital supports was deemed feasible, acceptable, preferable, and was shown to increase uptake, engage first-time testers and hard-to-reach populations, and successfully link participants to treatment. Findings pave the way for greater use of HIVST interventions with digital supports globally.

Keywords: Digital; HIV; Intervention; Mhealth; Online; Self-testing.

Fig. 1

Study Selection. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.

Fig. 2

Distribution of HIVST with digital supports innovations. Dark blue indicates web-based innovations (25/46, 54%), orange indicates social media-based innovations (12/46, 25%). gray indicates SMS-based innovations (4/46, 9%), yellow indicates mobile HIVST-specific apps (3/46, 7%), and light blue indicates digital VM-based innovations (2/46, 4%).

Fig. 3

Risk of bias assessment for observational studies. The Newcastle-Ottawa Scale was used to assess potential sources of bias in included observational studies, rating each as low, high, or unclear risk of bias.

Fig. 4

Risk of bias assessment for RCTs. The Cochrane Risk of Bias tool was used to assess potential sources of bias in included RCTs, rating each as low, high, or unclear risk of bias. ‘Yes’ indicates the Cochrane RoB domain is satisfied, and presents a low risk of bias; ‘No’ indicates the Cochrane RoB domain is not satisfied and may present a high risk of bias; ‘Unclear’ indicates that insufficient information was presented to determine risk of bias.