Abstract
Purpose of Review
HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings.
Recent Findings
Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV.
Summary
Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.
Similar content being viewed by others
Introduction
HIV testing is the crucial first step of the HIV cascade of care [1], and the first of the three goals set by UNAIDS to achieve epidemic control by 2030, where 95% of PLWH will be aware of their status [2]. Accurate and accessible HIV testing is necessary to direct PLWH to treatment and is essential to preventing ongoing transmissions [3]. In addition, being aware of one’s HIV status has been associated with reductions in behaviors with high transmission risk [4], including syringe sharing [5] and inconsistent condom use [6]. Knowing one’s status is also necessary for use of HIV prevention strategies such as pre-exposure (PrEP) [7] and post-exposure prophylaxis (PEP) [8].
In 2021, only 84% of all PLWH were aware of their status [9]. This number is even lower in sub-Saharan Africa, particularly among men and young people [10], as well as globally among certain populations, such as sex workers, men who have sex with men (MSM), people who inject drugs (PWID), and transgender people [11]. Although there are various modalities of HIV testing implemented throughout the world, all have been shown to be cost-effective [12, 13••], even in low-prevalence settings [14]. In this review, we examine recent advancements in HIV testing interventions to improve uptake of HIV testing across global settings.
Facility-Based Strategies
Facility-based interventions are those that offer HIV testing at formal healthcare facilities such as clinics or hospitals. At healthcare facilities, individuals can receive an HIV test via voluntary counseling and testing or through provider-initiated HIV testing, in which healthcare providers recommend HIV testing as part of routine medical care. In sub-Saharan Africa, provider-initiated testing has been the primary means of identifying new HIV infections [15]. Provider-initiated HIV testing often falls into two categories: opt-out or opt-in. Opt-out HIV testing refers to when HIV testing is already a component of receiving healthcare and requires individuals to request not to receive an HIV, whereas opt-in HIV testing refers to the process where patients are offered an HIV test in addition to whatever services they were seeking. Opt-out HIV testing has been implemented in various outpatient and inpatient clinical settings around the world, resulting in increased HIV testing among individuals receiving medical care at clinical facilities [16, 17]. Interestingly, a meta-analysis of studies from high-income countries found no difference in the detection of new HIV infections between the opt-in and opt-out approaches [18]. Despite increasing uptake of HIV testing, these strategies have had suboptimal reach, particularly among men and young people who tend to avoid medical care until they develop advanced symptoms [18,19,20,21,22]. In an analysis of 2019 PEPFAR data from sub-Saharan Africa, men were still only half as likely to receive HIV testing compared with women [23]. As such, additional initiatives have been implemented for patients who present to medical facilities.
Provider Initiated Counseling and HIV Self Testing
Provider-initiated counseling and HIV self-testing provide those who present to medical facilities the opportunity to test via supervised HIV self-testing. In Malawi, offering oral swab Oraquick HIV self-tests while at medical facilities quadrupled HIV testing uptake compared to provider-initiated testing: 51% of participants completed self-testing compared to 13% for provider-initiated testing [24•]. In this study, self-testing uptake was particularly high among men and adolescents. Another study in Kenya demonstrated that over half of pregnant and post-partum women elected to receive an HIV self-test offered at public health facilities as opposed to traditional HIV blood testing [25]. HIV self-testing may be a feasible strategy to expand HIV testing among those who avoid HIV testing due to fear of needles and phlebotomy.
Index Testing
Index testing/partner-assisted notification are facility-based strategies endorsed by the World Health Organization (WHO). Index testing involves offering HIV testing to sexual partners, drug use partners, and biological children of PLWH. Using this approach, family testing for biological children of PLWH has been shown to facilitate rapid identification of children with perinatal HIV across sub-Saharan Africa, including in Zimbabwe where 60% of index-linked children were HIV tested [26]. Unfortunately, these procedures have yet to be routinely integrated into health systems [27]. Partner-assisted notification informs individuals that they may be at risk of HIV acquisition following sexual contact or drug use with a person newly diagnosed with HIV [28]. A study in Kenya found that immediate partner notification was more effective than delayed partner notification, where partners were notified after 6 weeks: 67% of partners who were immediately notified underwent HIV testing compared to 13% in the delayed notification group [29]. Partner-assisted notification has been effective in a variety of contexts, including among Indonesian prison populations and their sexual and drug-use partners [30], as well as among PWID in Kazakhstan, Tajikistan, and the Kyrgyz Republic [31]. One modeling study in Kenya demonstrated that partner-assisted notification is both cost-effective and effective in reducing HIV-related mortality [32]. Results from multiple countries in sub-Saharan Africa revealed that index testing and partner-assisted notification were efficient strategies with high case finding potential [33••], particularly in identifying men living with HIV [23].
Couples Testing
HIV testing among young women has been high in some countries, like Uganda, for example [34], because it has been well-integrated into routine antenatal care. In an effort to improve testing uptake among men and encourage serostatus disclosure between couples, the WHO has recommended couples-based testing, where pregnant women and their partners test for HIV together at prenatal care visits [35]. A study in South Africa found that adding couples-based counseling sessions to couples testing programs improved uptake of HIV testing by 30%, with 42% receiving HIV testing compared to 12% in the control [36]. However, a meta-analysis of studies conducted in sub-Saharan Africa suggested that some couples may be cautious of testing together, preferring the option to test separately [37]. As such, offering home-based HIV testing may provide more acceptable testing circumstances for male partners, as discussed in the section below.
Conditional Economic Incentives
Conditional economic incentives can include monetary compensation and/or household goods in exchange for receipt of an HIV test. This approach has been used to successfully motivate HIV testing in many global settings. In Zimbabwe, groceries have successfully improved uptake of couples testing, from 10% in the non-incentivized group to 55% in the incentivized group [38]. Monetary incentives have also been successful among adolescents in Zimbabwe, more than doubling rates of facility-based HIV testing [39]. Similar findings were reported from a Kenyan study in which financial incentives increased the odds of adult PLWH bringing their children to facilities for HIV testing.
Community-Based Strategies
Community-based HIV testing interventions aim to overcome well-described barriers to facility-based HIV testing such as anticipated stigma of seeking HIV testing at health facilities [40, 41], and structural barriers, such as poverty and poor health infrastructure that make accessing testing facilities difficult [42,43,44]. Community-based interventions have taken the form of home-based HIV testing, mobile HIV testing campaigns, hybrid approaches, partnerships with trusted community leaders, and social behavior change communication campaigns. Hybrid approaches are those that involve more than one modality of community-based testing and may incorporate both at-home self-testing and mobile HIV clinics.
Home Based and Self Testing Interventions
Door-to-door home-based and self-testing interventions involve delivery of HIV testing to participants’ homes. Intervention strategies vary, with some having community health workers deliver or administer HIV tests, and others relying on family members or partners to deliver HIV self-tests. In a randomized controlled trial in Lesotho, intervention arm participants received HIV self-tests delivered to their homes if they were absent or refused door-to-door testing delivered by a health worker. This strategy improved HIV testing by 21%, with 81% of individual completing an HIV self-test compared with 60% in the referral group [45]. Data have suggested that home-based, self-testing methods may be particularly impactful among men [46, 47]. For example, in Zambia, a home-delivered HIV self-testing intervention resulted in higher testing among men, but not women [48••]. Similar successes were described in another intervention with HIV self-testing targeted to men and young adults in Malawi: 90% of eligible participants accepted HIV testing [49]. A study in rural South Africa found that home-based testing, coupled with financial incentives, improved uptake of HIV testing among men [50].
Other home-based strategies have sought to leverage the potential of women, who are already seeking care at facilities, through partner-delivered HIV self-testing kits. In Malawi, this approach improved uptake of HIV testing among male partners [51]. Similar results were found in randomized trials in Uganda and Kenya where women returning home from antenatal clinics delivered HIV self-testing kits to their male partners, increasing uptake of HIV testing three-fold compared with inviting men for clinic-based testing [52, 53]. Modeling strategies suggest that investing in scale up of home-based, self-testing strategies could expand coverage of HIV testing uptake to over 96% by 2030 in some countries [54].
Mobile HIV Testing
Mobile HIV testing campaigns deliver HIV testing into communities via mobile clinics, reducing geographic barriers to accessing HIV testing services. Mobile campaigns have been shown to effectively reach priority populations, such as MSM and transgender women, in Thailand [55]. In South Africa, a targeted intervention for men coupled mobile testing with peer messaging about HIV treatment as a form of prevention. When compared to referral to mobile testing alone, peer messaging about treatment as prevention increased uptake of HIV testing from 13 to 22% [56•].
Hybrid HIV testing
Hybrid approaches may vary in how they combine HIV testing modalities to maximize HIV testing uptake. Mobile hybrid strategies have been tremendously successful in low-income settings in East Africa, reaching up to 89% coverage of adults in some cases [57]. Hybrid approaches have also been effective at increasing HIV testing among adolescents [58]. One study found that a hybrid HIV testing intervention doubled the number of pediatric HIV infections identified in Kenya and Uganda [59]. Hybrid studies have also incorporated HIV testing as part of multi-disease screening campaigns. A multi-disease campaign in Uganda and Kenya improved HIV testing prevalence in communities from 57 to 90% in 1 year; after 3 years, HIV testing coverage was 98% in intervention communities compared with 96% in control communities [60••]. Another study in Uganda alone reported similar findings with 93% HIV testing uptake using a multi-disease campaign strategy [61].
Partnerships with Trusted Community Leaders
In many parts of the world, traditional and faith healers are an integral part of local health systems. Eighty percent of the population in Africa and Asia rely on traditional medicine for their primary healthcare needs [62, 63], and 35% of Americans report using traditional medicines [64]. It is well-documented that PLWH engage regularly with traditional healers in sub-Saharan Africa [65,66,67], and many have suggested that traditional healers are a largely untapped resource to engage PLWH and improve HIV testing among rural populations [68,69,70]. In rural Mozambique, traditional healers effectively referred their clients to local clinics for HIV testing; however, only 5% of clients who presented to clinics actually received HIV testing [71]. In rural Uganda, a cluster randomized trial demonstrated that healer-facilitated HIV self-testing could quadruple the uptake of HIV testing, from 23% among those referred to facilities to 100% where self-testing was offered at the healer practice [72••]. These interventions are particularly noteworthy as they may be engaging rural populations that might otherwise not engage with biomedical care. In the USA, church-based HIV testing programs have been successful among Black and Latinx populations [73]. This may be a key avenue for improving HIV testing among underrepresented minority populations who bear a disproportionate burden of HIV [74].
Social Behavior Change Communication
Cultural norms often serve as prominent barriers to HIV testing [75]. Consequently, some interventions have focused on social and behavioral change communication strategies as an avenue to improve uptake of HIV testing. In the Ivory Coast, an intervention targeting male gender norms—which included community-based HIV testing, guided group discussions, and male peer navigators—achieved 81% uptake of HIV testing among men [76]. Other programs have developed interventions focused on communication to reduce HIV-related stigma. For example, a stigma reduction intervention with African American and Latinx churches in the USA improved HIV testing [77].
Strategies Targeting Priority Populations
Priority populations include MSM, transgender people, PWID, and people living in prisons/closed settings. Over 60% of new HIV transmissions occur among these priority populations and/or their partners and clients globally [9]. These populations require differentiated approaches for delivery of HIV testing due to stigmatization and/or criminalization [78]. Long distance truck drivers and adolescent girls and young women (AGYW) are also considered priority populations in sub-Saharan Africa. According to one systematic review, HIV self-testing interventions have improved uptake of HIV testing among priority populations by 1.45 times when compared to facility-based testing [79]. Interventions that target priority populations may leverage technological advances, such as mHealth, with delivery of HIV self-testing kits, to provide confidential and convenient HIV testing.
Men Who Have Sex with Men and Transgender Populations
Strategies for improving HIV services uptake among MSM and transgender populations include outreach at venues that are frequented by these populations. In Sweden, rapid HIV tests offered at gay venues resulted in 96% testing uptake; many individuals reported they likely would not have received testing at a health facility [80]. In Thailand, HIV testing delivered at a gay sauna had 41% HIV testing uptake [81]. Peer-led support has also been effective in increasing testing among MSM. In a meta-analysis, interventions led by MSM peers have been shown to double the odds of receiving an HIV test [82]. Mobile health/mHealth interventions involve the use of mobile technologies and typically involve text messages, apps, or social media platforms to encourage HIV testing [83]. In China, mHealth Interventions have successfully linked MSM to HIV self-tests [84••, 85] and improved HIV testing frequency [86, 87]. Pilot studies have also begun to assess the potential for mHealth apps to improve uptake of HIV testing among adolescent MSM [88]. A randomized controlled trial among MSM in India found that 12 weeks of internet-based messaging on avoiding HIV acquisition resulted in higher uptake of HIV testing [89]. Finally, it is important to note that while HIV testing rates among MSM have improved in recent years, data from one meta-analysis among African MSM showed that countries with stricter anti-LGBTQ legislation had lower rates of HIV testing [90].
People Who Inject Drugs
HIV testing rates are extremely low among PWID [91]. For example, despite free access to HIV testing at substance use disorder treatment programs, nearly one-third of PWID in the USA did not receive HIV testing [92]. In India, an integrated intervention among both MSM and PWID improved HIV testing uptake when compared to usual care, from 27 to 40% among MSM and from 25 to 34% among PWID. [93•]. Continued research is needed on novel interventions to improve uptake of HIV testing among PWID.
Female Sex Workers
SMS text messages and peer educators delivering HIV self-testing have been shown to improve uptake of HIV testing among female sex workers. SMS text messages about HIV self-testing kits availability at a nearby wellness center nearly doubled odds of sex workers receiving HIV tests in Kenya [94]. Among Ugandan female sex workers, HIV self-testing coupled with peer-delivered education resulted in 23% more HIV testing where 95% of participants completed an HIV test compared with facility-based testing where 72% received an HIV test [95].
Long Distance Truck Drivers
HIV testing interventions have had limited success among long distance truck drivers due to their mobility. In Kenya, one intervention used text messages to announce availability of HIV self-testing kits. This intervention doubled the uptake of HIV testing in the intervention group, but overall uptake of HIV testing was only 4% [96]. Another study conducted in Mozambique, South Africa, and Zimbabwe employed a similar technique and reported similar results among long distance truck drivers and female sex workers [97].
Adolescent Girls and Young Women
An HIV testing campaign in Haiti that used community health workers to recruit AGYW demonstrated significant success, achieving 98% HIV testing uptake [98]. Delivering HIV testing via youth-friendly providers was also shown to increase the likelihood of receiving an HIV test among AGYW in Malawi [99].
Ongoing Challenges
Men Continue to be Missed by Current HIV Testing Programs
A 2019 study conducted in six sub-Saharan African countries found that approximately twice as many sexually active men had never been tested for HIV, compared with women. However, when offered an HIV test, the vast majority accepted testing for the first time [100]. This work underscores the fact that men in sub-Saharan Africa may be willing to undergo HIV testing if given the opportunity but are missed by existing programs. Future HIV testing interventions must consider factors that have been shown to shape HIV testing preferences—masculinity, economic priorities, and behaviors with risk of HIV acquisition—when developing interventions to effectively reach these populations.
PWID
A recent meta-analysis suggested that PWID with access to needle exchange programs, or involvement in the criminal justice system, have increased likelihood of receiving an HIV test [101]. Outside of these institutional settings, PWID have extremely low uptake of HIV testing, despite very high acquisition risk. A study in the USA showed that PWID in low-income communities have lower HIV testing rates, compared with those living in higher income ones [102]. Targeted interventions are urgently needed to improve HIV testing among this priority population.
PLWH Who Use Alternative Healing Systems
Many PLWH seek care from traditional healers or other informal healthcare providers, in place of or concurrently with biomedical care [103]. Additionally, some are dissuaded from seeking biomedical care due to perceived lapses in confidentiality, poor treatment, and difficulty accessing biomedical care [104,105,106]. Consequently, partnering with traditional health providers may be a key avenue for closing the gap in HIV testing among global populations, particularly among those reticent to engage with biomedical care more generally.
Subsequent Steps of the HIV Continuum of Care
HIV testing is only the first step in the HIV continuum of care. Timely ART initiation is imperative for achieving viral suppression and preventing ongoing HIV transmissions. While community-based HIV testing programs have markedly increased uptake of HIV testing, entry into HIV care has been suboptimal following testing. In one home-based HIV testing strategy in Uganda and South Africa, only 50% of PLWH linked to care within 1 month [107]. In another South African study, large-scale HIV testing was not shown to reduce HIV incidence, likely due to poor linkage to care [108••]. It is therefore critical that future HIV testing interventions consider subsequent barriers to PLWH entering care once they are aware of their HIV status.
Conclusions
Innovations in facility- and community-based HIV testing have brought us steps closer to achieving UNAIDS goal of epidemic control, starting with 95% of all PLWH being aware of their status. Despite this, current HIV testing programs are still missing hard-to-reach populations such as men in sub-Saharan Africa, people who inject drugs, and those who use alternative healing systems. In addition, interventions that have been shown to be effective in one setting may not be generalizable to a different cultural and social contexts; formative work is necessary to determine if interventions can be successfully adapted to other settings. Finally, it is critical that HIV testing programs consider effective approaches for linking those newly identified as living with HIV to care to prevent ongoing transmission.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Kapadia F, Landers S. Ending the HIV epidemic: getting to zero and staying at zero. Am J Public Health. 2020;110(1):15–6.
Fast-track commitments to end AIDS by 2030. Available from: https://www.unaids.org/en/resources/documents/2016/fast-track-commitments. Accessed 24 Jan 2022
Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–9.
Rosenberg MS, Gómez-Olivé FX, Rohr JK, Houle BC, Kabudula CW, Wagner RG, et al. Sexual behaviors and HIV status: a population-based study among older adults in rural South Africa. J Acquir Immune Defic Syndr 1999. 2017;74(1):e9-17.
Pavlopoulou ID, Dikalioti SK, Gountas I, Sypsa V, Malliori M, Pantavou K, et al. High-risk behaviors and their association with awareness of HIV status among participants of a large-scale prevention intervention in Athens, Greece. BMC Public Health. 2020;20(1):105.
Ortblad KF, Chanda MM, Mwale M, Haberer JE, McConnell M, Oldenburg CE, et al. Perceived knowledge of HIV-negative status increases condom use among female sex workers in Zambian transit towns. AIDS Patient Care STDs. 2020;34(4):184–92.
McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet Lond Engl. 2016;387(10013):53–60.
World Health Organization. Guidelines on post-exposure prophylaxis for HIV and the use of co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children: recommendations for a public health approach: December 2014 supplement to the 2013 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. 42 p. Available from: https://apps.who.int/iris/handle/10665/145719. Accessed 26 Jan 2022
Global HIV & AIDS statistics — fact sheet. Available from: https://www.unaids.org/en/resources/fact-sheet. Accessed 20 Jan 2022
Staveteig S, Croft TN, Kampa KT, Head SK. Reaching the ‘first 90’: gaps in coverage of HIV testing among people living with HIV in 16 African countries. Graham SM, editor. PLOS ONE. 2017;12(10):e0186316.
UNAIDS - Key populations atlas. Available from: https://kpatlas.unaids.org/dashboard. Accessed 11 Jan 2022
Thomas R, Probert WJM, Sauter R, Mwenge L, Singh S, Kanema S, et al. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial. Lancet Glob Health. 2021;9(5):e668–80.
•• Cambiano V, Johnson CC, Hatzold K, Terris-Prestholt F, Maheswaran H, Thirumurthy H, et al. The impact and cost-effectiveness of community-based HIV self-testing in sub-Saharan Africa: a health economic and modelling analysis. J Int AIDS Soc. 2019;22 Suppl 1(S1):e25243. This modeling study showed that community-based HIV self-testing could have greatest impact in averting new HIV infections among men, and would have highest cost-effectiveness among female sex workers
Bert F, Gualano MR, Biancone P, Brescia V, Camussi E, Martorana M, et al. Cost-effectiveness of HIV screening in high-income countries: a systematic review. Health Policy. 2018;122(5):533–47.
De Cock KM, Barker JL, Baggaley R, El-Sadr WM. Where are the positives? HIV testing in sub-Saharan Africa in the era of test and treat. AIDS Lond Engl. 2019;33(2):349–52.
Bartholomew TS, Tookes HE, Serota DP, Behrends CN, Forrest DW, Feaster DJ. Impact of routine opt-out HIV/HCV screening on testing uptake at a syringe services program: an interrupted time series analysis. Int J Drug Policy. 2020;84:102875.
Gebrezgi MT, Mauck DE, Sheehan DM, Fennie KP, Cyrus E, Degarege A, et al. Acceptance of opt-out HIV screening in outpatient settings in the United States: a systematic review and meta-analysis. Public Health Rep. 2019;134(5):484–92.
Henriquez-Camacho C, Villafuerte-Gutierrez P, Pérez-Molina J, Losa J, Gotuzzo E, Cheyne N. Opt-out screening strategy for HIV infection among patients attending emergency departments: systematic review and meta-analysis. HIV Med. 2017;18(6):419–29.
Lightfoot M, Dunbar M, Weiser SD. Reducing undiagnosed HIV infection among adolescents in sub-Saharan Africa: provider-initiated and opt-out testing are not enough. PLOS Med. 2017;14(7):e1002361.
Wise JM, Ott C, Azuero A, Lanzi RG, Davies S, Gardner A, et al. Barriers to HIV testing: patient and provider perspectives in the deep south. AIDS Behav. 2019;23(4):1062–72.
Meng XJ, Grulich A, Wang XW, Yin HL, Gu J, Zhang X, et al. Repeat HIV testing and incident rates among individuals attending voluntary counseling and testing clinics in Wuxi, China: a retrospective study. Biomed Environ Sci. 2018;31(1):37–47.
Nsirim R, Ugochukwu G, Onuoha M, Okoroezi I, Ani C, Peters E. Effectiveness of provider-initiated testing and counseling in increasing HIV testing and counselling utilization and HIV detection rates in Ebonyi State, South-Eastern Nigeria. Int J STD AIDS. 2018;29(14):1362–7.
Drammeh B, Medley A, Dale H, De AK, Diekman S, Yee R, et al. Sex differences in HIV testing — 20 PEPFAR-supported sub-Saharan African countries, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(48):1801–6.
• Dovel K, Shaba F, Offorjebe OA, Balakasi K, Nyirenda M, Phiri K, et al. Effect of facility-based HIV self-testing on uptake of testing among outpatients in Malawi: a cluster-randomised trial. Lancet Glob Health. 2020;8(2):e276–87. This facility-based study that showed offering HIV self-tests at facilities can quadruple same-day HIV testing uptake.
Oyaro P, Kwena Z, Bukusi EA, Baeten JM. Is HIV self-testing a strategy to increase repeat testing among pregnant and postpartum women? A pilot mixed methods study. JAIDS J Acquir Immune Defic Syndr. 2020;84(4):365–71.
Dziva Chikwari C, Simms V, Kranzer K, Dringus S, Chikodzore R, Sibanda E, et al. Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP study. Lancet HIV. 2021;8(3):e138–48.
Simon KR, Flick RJ, Kim MH, Sabelli RA, Tembo T, Phelps BR, et al. Family Testing: an index case finding strategy to close the gaps in pediatric HIV diagnosis. JAIDS J Acquir Immune Defic Syndr. 2018;78(2):S88-97.
HIV Partner Notification Services. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. World Health Organization; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK401676/. Accessed 26 Jan 2022
Cherutich P, Golden MR, Wamuti B, Richardson BA, Ásbjörnsdóttir KH, Otieno FA, et al. Assisted partner services for HIV in Kenya: a cluster randomised controlled trial. Lancet HIV. 2017;4(2):e74-82.
Culbert GJ, Waluyo A, Earnshaw VA. Exploring the acceptability of HIV partner notification in prisons: findings from a survey of incarcerated people living with HIV in Indonesia. PLOS ONE. 2020;15(6):e0234697.
Little KM, Kan M, Samoylova O, Rsaldinova A, Saliev D, Ishokov F, et al. Implementation experiences and insights from the scale-up of an HIV assisted partner notification intervention in Central Asia. J Int AIDS Soc. 2019;22(S3):e25313.
Sharma M, Smith JA, Farquhar C, Ying R, Cherutich P, Golden M, et al. Assisted partner notification services are cost-effective for decreasing HIV burden in western Kenya. AIDS Lond Engl. 2018;32(2):233–41.
•• Mahachi N, Muchedzi A, Tafuma TA, Mawora P, Kariuki L, Semo B, et al. Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe. J Int AIDS Soc. 2019;22(S3):e25321. HIV testing done through targeted index and partner notification programs had nearly 10-times the positivity rates compared with routine HIV testing offered at facilities in Zimbabwe.
Gunn JKL, Asaolu IO, Center KE, Gibson SJ, Wightman P, Ezeanolue EE, et al. Antenatal care and uptake of HIV testing among pregnant women in sub-Saharan Africa: a cross-sectional study. J Int AIDS Soc. 2016;19(1):20605.
Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. Geneva: World Health Organization; 2012. Available from: http://www.ncbi.nlm.nih.gov/books/NBK138278/. Accessed 23 Jan 2022
Darbes LA, McGrath NM, Hosegood V, Johnson MO, Fritz K, Ngubane T, et al. Results of a couples-based randomized controlled trial aimed to increase testing for HIV. J Acquir Immune Defic Syndr 1999. 2019;80(4):404–13.
Hailemariam TG, Nathan S, Seifu CN, Rawstorne P. Uptake of couples HIV testing and counselling among heterosexual couples in Sub-Saharan Africa: a systematic review and meta-analysis. AIDS Care. 2020;32(2):137–47.
Krishnamoorthy Y, Rehman T, Sakthivel M. Effectiveness of financial incentives in achieving UNAID fast-track 90–90-90 and 95–95-95 target of HIV care continuum: a systematic review and meta-analysis of randomized controlled trials. AIDS Behav. 2021;25(3):814–25.
Kranzer K, Simms V, Bandason T, Dauya E, McHugh G, Munyati S, et al. Economic incentives for HIV testing by adolescents in Zimbabwe: a randomised controlled trial. Lancet HIV. 2018;5(2):e79-86.
Sullivan MC, Rosen AO, Allen A, Benbella D, Camacho G, Cortopassi AC, et al. Falling short of the first 90: HIV stigma and HIV testing research in the 90–90–90 era. AIDS Behav. 2020;24(2):357–62.
Wulandari LPL, Ruddick A, Guy R, Kaldor J. “Self-testing sounds more private, rather than going to the clinic and everybody will find out”: facilitators and barriers regarding HIV testing among men who purchase sex in Bali, Indonesia. PLOS ONE. 2019;14(4):e0214987.
Palk L, Okano JT, Dullie L, Blower S. Travel time to health-care facilities, mode of transportation, and HIV elimination in Malawi: a geospatial modelling analysis. Lancet Glob Health. 2020;8(12):e1555–64.
Mayer CM, Owaraganise A, Kabami J, Kwarisiima D, Koss CA, Charlebois ED, et al. Distance to clinic is a barrier to PrEP uptake and visit attendance in a community in rural Uganda. J Int AIDS Soc. 2019;22(4):e25276.
Kimmel AD, Masiano SP, Bono RS, Martin EG, Belgrave FZ, Adimora AA, et al. Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South. AIDS Care. 2018;30(11):1459–68.
Amstutz A, Lejone TI, Khesa L, Muhairwe J, Bresser M, Vanobberghen F, et al. Home-based oral self-testing for absent and declining individuals during a door-to-door HIV testing campaign in rural Lesotho (HOSENG): a cluster-randomised trial. Lancet HIV. 2020;7(11):e752–61.
Tsai AC, Siedner MJ. The missing men: HIV treatment scale-up and life expectancy in sub-Saharan Africa. PLoS Med. 2015;12(11):e1001906.
Grimsrud A, Ameyan W, Ayieko J, Shewchuk T. Shifting the narrative: from “the missing men” to “we are missing the men.” J Int AIDS Soc. 2020: 23(Suppl 2).
•• Mulubwa C, Hensen B, Phiri MM, Shanaube K, Schaap AJ, Floyd S, et al. Community based distribution of oral HIV self-testing kits in Zambia: a cluster-randomised trial nested in four HPTN 071 (PopART) intervention communities. Lancet HIV. 2019;6(2):e81-92. This cluster randomized trial in Zambia successfully improved HIV testing uptake among hard-to-reach men via community distribution of HIV self-testing kits.
Geoffroy E, Schell E, Jere J, Khozomba N. Going door-to-door to reach men and young people with HIV testing services to achieve the 90–90–90 treatment targets. Public Health Action. 2017;7(2):95–9.
Tanser FC, Kim H-Y, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, et al. Home-based intervention to test and start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa. J Int AIDS Soc. 2021;24(2):e25665.
Choko AT, Fielding K, Johnson CC, Kumwenda MK, Chilongosi R, Baggaley RC, et al. Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial. Lancet Glob Health. 2021;9(7):e977–88.
Korte JE, Kisa R, Vrana-Diaz CJ, Malek AM, Buregyeya E, Matovu JKB, et al. HIV oral self-testing for male partners of women attending antenatal care in central Uganda: uptake of testing and linkage to care in a randomized trial. JAIDS J Acquir Immune Defic Syndr. 2020;84(3):271–9.
Krakowiak D, Kinuthia J, Osoti AO, Asila V, Gone MA, Mark J, et al. Home-based HIV testing among pregnant couples increases partner testing and identification of serodiscordant partnerships. JAIDS J Acquir Immune Defic Syndr. 2016;72(2):S167–73.
Johnson LF, van Rensburg C, Govathson C, Meyer-Rath G. Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness. Sci Rep. 2019;9(1):12621.
Wasantioopapokakorn M, Manopaiboon C, Phoorisri T, Sukkul A, Lertpiriyasuwat C, Ongwandee S, et al. Implementation and assessment of a model to increase HIV testing among men who have sex with men and transgender women in Thailand, 2011–2016. AIDS Care. 2018;30(10):1239–45.
• Smith P, Buttenheim A, Schmucker L, Bekker L-G, Thirumurthy H, Davey DLJ. Undetectable = Untransmittable (U = U) Messaging increases uptake of HIV testing among men: results from a pilot cluster randomized trial. AIDS Behav. 2021;25(10):3128–36. This cluster randomized trial in South Africa found that peer-delivered messaging on "U=U" (explaining the benefit of HIV treatment in reducing HIV transmission) increased the number of men presenting to a mobile clinic for HIV testing.
Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, et al. A hybrid mobile HIV testing approach for population-wide HIV testing in rural East Africa: an observational study. Lancet HIV. 2016;3(3):e111–9.
Kadede K, Ruel T, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, et al. Increased adolescent HIV testing with a hybrid mobile strategy in Uganda and Kenya. AIDS Lond Engl. 2016;30(14):2121–6.
Ayieko J, Chamie G, Balzer L, Kwarisiima D, Kabami J, Sang N, et al. Mobile, Population-wide, hybrid HIV testing strategy increases number of children tested in rural Kenya and Uganda. Pediatr Infect Dis J. 2018;37(12):1279–81.
•• Havlir DV, Balzer LB, Charlebois ED, Clark TD, Kwarisiima D, Ayieko J, et al. HIV testing and treatment with the use of a community health approach in rural Africa. N Engl J Med. 2019;381(3):219–29. This cluster randomized trial leveraged community health workers and mobile clinics to improve HIV testing rates in rural African communities, exceeding the UNAIDS 95% benchmark.
SEARCH Collaboration. Evaluating the feasibility and uptake of a community-led HIV testing and multi-disease health campaign in rural Uganda. J Int AIDS Soc. 2017;20(1):21514.
Oyebode O, Kandala N-B, Chilton PJ, Lilford RJ. Use of traditional medicine in middle-income countries: a WHO-SAGE study. Health Policy Plan. 2016;31(8):984–91.
World Health Organization. WHO traditional medicine strategy. 2014–2023. Geneva: World Health Organization; 2013. p. 76.
Rashrash M, Schommer JC, Brown LM. Prevalence and predictors of herbal medicine use among adults in the United States. J Patient Exp. 2017;4(3):108–13.
Wanyama JN, Tsui S, Kwok C, Wanyenze RK, Denison JA, Koole O, et al. Persons living with HIV infection on antiretroviral therapy also consulting traditional healers: a study in three African countries. Int J STD AIDS. 2017;28(10):1018–27.
Moshabela M, Bukenya D, Darong G, Wamoyi J, McLean E, Skovdal M, et al. Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa. Sex Transm Infect. 2017;93(Suppl 3):e052974.
Wringe A, Renju J, Seeley J, Moshabela M, Skovdal M. Bottlenecks to HIV care and treatment in sub-Saharan Africa: a multi-country qualitative study. Sex Transm Infect. 2017;93(Suppl 3):e053172.
Boum Y, Kwedi-Nolna S, Haberer JE, Leke RRG. Traditional healers to improve access to quality health care in Africa. Lancet Glob Health. 2021;9(11):e1487–8.
King R, Balaba D, Kaboru B. The role of traditional healers in comprehensive HIV/AIDS AIDS AIDS AIDS prevention and care in Africa: untapped opportunities. In: From The Ground Up. Washington D.C.: Elizabeth Glaser Pediatric AIDS Foundation; 2009. p. 301–32.
Audet CM, Clemens EM, Ngobeni S, Mkansi M, Sack DE, Wagner RG. Throwing the bones to diagnose HIV: views of rural South African traditional healers on undertaking HIV counselling and testing. AIDS Care. 2020;1(1):1–5.
Audet CM, Salato J, Blevins M, Amsalem D, Vermund SH, Gaspar F. Educational intervention increased referrals to allopathic care by traditional healers in three high HIV-prevalence rural districts in Mozambique. PLoS ONE. 2013;8(8):e70326–8.
•• Sundararajan R, Ponticiello M, Lee MH, Strathdee SA, Muyindike W, Nansera D, et al. Traditional healer-delivered point-of-care HIV testing versus referral to clinical facilities for adults of unknown serostatus in rural Uganda: a mixed-methods, cluster-randomised trial. Lancet Glob Health. 2021;9(11):e1579–88. This cluster randomized trial in rural Uganda achieved 100% testing uptake when HIV self-tests were offered by traditional healers to clients of unknown serostatus.
Berkley-Patton JY, Thompson CB, Moore E, Hawes S, Berman M, Allsworth J, et al. Feasibility and outcomes of an HIV testing intervention in African American churches. AIDS Behav. 2019;23(1):76–90.
Murdock CJ, Laurencin L, Christensen DM, Laurencin CT. HIV/AIDS and the African-American community 2018: a decade call to action. J Racial Ethn Health Disparities. 2018;5(3):449–58.
Nyblade L, Mingkwan P, Stockton MA. Stigma reduction: an essential ingredient to ending AIDS by 2030. Lancet HIV. 2021;8(2):e106–13.
Naugle DA, Dosso A, Tibbels NJ, Van Lith LM, Hendrickson ZM, Kouadio AM, et al. Addressing uptake of HIV testing and linkage to care among men in Côte d’Ivoire: an evaluation of the brothers for life program implementation. J Acquir Immune Defic Syndr 1999. 2020;84(5):480–7.
Derose KP, Griffin BA, Kanouse DE, Bogart LM, Williams MV, Haas AC, et al. Effects of a pilot church-based intervention to reduce HIV stigma and promote HIV testing among African Americans and Latinos. AIDS Behav. 2016;20(8):1692–705.
Macdonald V, Verster A, Baggaley R. A call for differentiated approaches to delivering HIV services to key populations. J Int AIDS Soc. 2017;20(S4):21658.
Witzel TC, Eshun-Wilson I, Jamil MS, Tilouche N, Figueroa C, Johnson CC, et al. Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis. BMC Med. 2020;18(1):381.
Strömdahl S, Hoijer J, Eriksen J. Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey. Sex Transm Infect. 2019;95(8):575–9.
Khawcharoenporn T, Apisarnthanarak A, Phanuphak N. Active targeted HIV testing and linkage to care among men who have sex with men attending a gay sauna in Thailand. AIDS Care. 2017;29(3):355–64.
Shangani S, Escudero D, Kirwa K, Harrison A, Marshall B, Operario D. Effectiveness of peer-led interventions to increase HIV testing among men who have sex with men: a systematic review and meta-analysis. AIDS Care. 2017;29(8):1003–13.
Ko JS, Stafylis C, Klausner JD. Mobile health promotion of human immunodeficiency virus self-testing in the United States. mHealth. 2020;6:10–10.
•• Zhu X, Zhang W, Operario D, Zhao Y, Shi A, Zhang Z, et al. Effects of a mobile health intervention to promote HIV self-testing with MSM in China: a randomized controlled trial. AIDS Behav. 2019;23(11):3129–39. This randomized controlled trial demonstrated increased uptake of HIV self-testing among MSM who used a mobile app in addition to home delivery of self-test kits.
Wang Z, Lau JTF, Ip M, Ho SPY, Mo PKH, Latkin C, et al. A randomized controlled trial evaluating efficacy of promoting a home-based HIV self-testing with online counseling on increasing HIV testing among men who have sex with men. AIDS Behav. 2018;22(1):190–201.
Katz DA, Golden MR, Hughes JP, Farquhar C, Stekler JD. HIV self-testing increases hiv testing frequency in high risk men who have sex with men: a randomized controlled trial. J Acquir Immune Defic Syndr 1999. 2018;78(5):505–12.
Jamil MS, Prestage G, Fairley CK, Grulich AE, Smith KS, Chen M, et al. Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial. Lancet HIV. 2017;4(6):e241–50.
Ybarra ML, Prescott TL, Phillips GL, Bull SS, Parsons JT, Mustanski B. Pilot RCT results of an mHealth HIV prevention program for sexual minority male adolescents. Pediatrics. 2017;140(1):e20162999.
Patel VV, Rawat S, Dange A, Lelutiu-Weinberger C, Golub SA. An internet-based, peer-delivered messaging intervention for hiv testing and condom use among men who have sex with men in India (CHALO!): pilot randomized comparative trial. JMIR Public Health Surveill. 2020;6(2):e16494.
Stannah J, Dale E, Elmes J, Staunton R, Beyrer C, Mitchell KM, et al. HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis. Lancet HIV. 2019;6(11):e769–87.
Guidance on testing and counselling for HIV in settings attended by people who inject drugs: improving access to treatment, care and prevention. Geneva: World Health Organization; 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK305379/. Accessed 16 Jan 2022
Kyle TL, Horigian VE, Tross S, Gruber VA, Pereyra M, Mandler RN, et al. Uptake of HIV testing in substance use disorder treatment programs that offer on-site testing. AIDS Behav. 2015;19(3):536–42.
• Solomon SS, Solomon S, McFall AM, Srikrishnan AK, Anand S, Verma V, et al. Integrated HIV testing, prevention, and treatment intervention for key populations in India: a cluster-randomised trial. Lancet HIV. 2019;6(5):e283–96. HIV testing integrated into opiate treatment centers and MSM health centers increased testing among PWID and MSM in India.
Kelvin EA, George G, Mwai E, Kinyanjui S, Romo ML, Odhiambo JO, et al. A randomized controlled trial to increase hiv testing demand among female sex workers in Kenya through announcing the availability of HIV self-testing via text message. AIDS Behav. 2019;23(1):116–25.
Ortblad K, Musoke DK, Ngabirano T, Nakitende A, Magoola J, Kayiira P, et al. Direct provision versus facility collection of HIV self-tests among female sex workers in Uganda: a cluster-randomized controlled health systems trial. PLOS Med. 2017;14(11):e1002458.
Kelvin EA, George G, Kinyanjui S, Mwai E, Romo ML, Oruko F, et al. Announcing the availability of oral HIV self-test kits via text message to increase HIV testing among hard-to-reach truckers in Kenya: a randomized controlled trial. BMC Public Health. 2019;19(1):7.
Govender K, Beckett S, Masebo W, Braga C, Zambezi P, Manhique M, et al. Effects of a short message service (SMS) intervention on reduction of HIV risk behaviours and improving HIV testing rates among populations located near roadside wellness clinics: a cluster randomised controlled trial in South Africa, Zimbabwe and Mozambique. AIDS Behav. 2019;23(11):3119–28.
Reif LK, Rivera V, Louis B, Bertrand R, Peck M, Anglade B, et al. Community-based HIV and health testing for high-risk adolescents and youth. AIDS Patient Care STDs. 2016;30(8):371–8.
Rosenberg NE, Bhushan NL, Vansia D, Phanga T, Maseko B, Nthani T, et al. Comparing youth friendly health services to the standard of care through “girl power-Malawi”: a quasi-experimental cohort study. J Acquir Immune Defic Syndr 1999. 2018;79(4):458–66.
Quinn C, Kadengye DT, Johnson CC, Baggaley R, Dalal S. Who are the missing men? Characterising men who never tested for HIV from population-based surveys in six sub-Saharan African countries. J Int AIDS Soc. 2019;22(10):e25398.
Bayani A, Ghiasvand H, Rezaei O, Fattah Moghaddam L, Noroozi A, Ahounbar E, et al. Factors associated with HIV testing among people who inject drugs: a meta-analysis. J Addict Dis. 2020;38(3):361–74.
for the National HIV Behavioral Surveillance Study Group, Tempalski B, Cooper HLF, Kelley ME, Linton SL, Wolfe ME, et al. Identifying which place characteristics are associated with the odds of recent HIV testing in a large sample of people who inject drugs in 19 US metropolitan areas. AIDS Behav. 2019;23(2):318–35.
Nabukalu D, Ponticiello M, Bennett T, Clark S, King R, Mwanga-Amumpaire J, et al. Factors associated with HIV testing among traditional healers and their clients in rural Uganda: results from a cross-sectional study. Int J STD AIDS. 2021;31(11):1043–51.
Layer EH, Brahmbhatt H, Beckham SW, Ntogwisangu J, Mwampashi A, Davis WW, et al. “I pray that they accept me without scolding:” experiences with disengagement and re-engagement in HIV care and treatment services in Tanzania. AIDS Patient Care STDs. 2014;28(9):483–8.
Ware NC, Wyatt MA, Geng EH, Kaaya SF, Agbaji OO, Muyindike WR, et al. Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study. PLoS Med. 2013;10(1):e1001369.
Mwamba C, Sharma A, Mukamba N, Beres L, Geng E, Holmes CB, et al. ‘They care rudely!’: resourcing and relational health system factors that influence retention in care for people living with HIV in Zambia. BMJ Glob Health. 2018;3(5):e001007.
Barnabas RV, van Rooyen H, Tumwesigye E, Murnane PM, Baeten JM, Humphries H, et al. Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study. Lancet HIV. 2014;1(2):e68-76.
•• Iwuji CC, Orne-Gliemann J, Larmarange J, Balestre E, Thiebaut R, Tanser F, et al. Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial. Lancet HIV. 2018;5(3):e116–25. Universal HIV testing and treatment did not reduce population HIV incidence in rural South Africa, likely due to poor linkage to care after being newly diagnosed with HIV
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no competing interests.
Human and Animal Rights
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Behavioral-Bio-Medical Interface
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Sundararajan, R., Ponticiello, M., Nansera, D. et al. Interventions to Increase HIV Testing Uptake in Global Settings. Curr HIV/AIDS Rep 19, 184–193 (2022). https://doi.org/10.1007/s11904-022-00602-4
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11904-022-00602-4