Thornton Community Settings Hiv992

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

416

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

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.


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



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

]A

mob

ilecl

inic

prov

idin

gha

rmre

duct

ion

serv

ices

incl

udin

gne

edle

exch

ange

,ST

Ites

ting

and

HIV

test

ing

USA

MSM

who

use

drug

s4

mon

ths

Sero

posi

tivi

ty21

Rece

ipt

ofre

sult

sRo

thm

anet

al.[

56]

Eval

uati

onof

alo

ng-t

erm

prog

ram

me

offe

ring

HIV

serv

ices

co-l

ocat

edw

ith

subs

tanc

eab

use

serv

ices

USA

Dru

gus

ers

13ye

ars

Sero

posi

tivi

ty16

834

0

San

Anto

nio-

Gad

dyet

al.

[20]

Anev

alua

tion

ofra

pid

test

ing

ata

varie

tyof

com

mun

ity

sett

ings

acro

ssN

ewYo

rkSt

ate

USA

Non

spec

ific

6m

onth

sSe

ropo

siti

vity

618

7Re

ceip

tof

resu

lts

Clie

ntat

titu

des

Schu

lden

etal

.[51

]A

sum

mar

yof

com

mun

ity-

base

dte

stin

gat

ava

riety

ofsi

tes

totr

ansg

ende

rin

divi

dual

sin

thre

eci

ties

USA

Tran

sgen

der

com

mun

itie

s2

year

sSe

ropo

siti

vity

559

Rece

ipt

ofre

sult

sSk

olni

ket

al.[

21]

Surv

eys

cond

ucte

dw

ith

clie

nts

ata

stan

d-al

one

test

ing

site

and

am

obile

clin

icU

SAID

Us,

hom

eles

sin

divi

dual

s,an

dno

nspe

cific

4m

onth

sCl

ient

atti

tude

sN

otap

plic

able

Smit

het

al.[

43]

Aco

mpa

rison

betw

een

clie

nts

test

edat

ast

and-

alon

ete

stin

gsi

tean

dse

xual

heal

thcl

inic

sU

SAM

SM26

mon

ths

Sero

posi

tivi

ty1

201

Clie

ntat

titu

des

Spei

lber

get

al.[

27]

Anin

vest

igat

ion

into

clie

ntch

oice

sfo

rra

pid

vs.s

tand

ard

test

ing

ata

bath

hous

ean

da

drug

trea

tmen

tce

ntre

USA

MSM

and

IDU

s7

mon

ths

Upt

ake

ofte

stin

g12

8Re

ceip

tof

resu

lts

214

Spie

lber

get

al.[

44]

Are

port

onth

ede

sign

ofa

test

ing

prog

ram

me

atsa

unas

and

impo

rtan

tlo

gist

ical

cons

ider

atio

nsU

SAM

SMN

otap

plic

able

Clie

ntat

titu

des

Not

appl

icab

leSt

aff

atti

tude

sSt

urro

cket

al.[

26]

Sero

logi

calH

IVte

stin

gco

nduc

ted

acro

ssth

eAu

stra

lian

capi

talt

errit

ory

ata

varie

tyof

venu

es,i

nclu

ding

ast

and-

alon

ete

stin

gsi

te,b

roth

els,

ayo

uth

cent

re,a

univ

ersi

tyan

da

sex

onpr

emis

esve

nue

Aust

ralia

Mul

tipl

ehi

gh-r

isk

grou

ps11

9cl

inic

sov

er3

year

sSe

ropo

siti

vity

Not

stat

ed

Syet

al.[

45]

Anev

alua

tion

ofth

eac

cept

abili

tyof

oral

fluid

test

ing

amon

gm

enin

bars

USA

MSM

2m

onth

s,w

eeke

ndse

rvic

eon

ly(F

riday

and

Satu

rday

nigh

ts)

Upt

ake

ofte

stin

g64

Sero

posi

tivi

tyCl

ient

atti

tude

sW

oods

etal

.[35

]Q

ualit

ativ

est

udy

ofat

titu

des

and

opin

ions

ofst

akeh

olde

rsin

outr

each

ing

test

ing

atsa

unas

and

sex

onpr

emis

esve

nues

USA

MSM

Not

appl

icab

leCl

ient

atti

tude

sN

otap

plic

able

Staf

fat

titu

des

CSW

,com

mer

cial

sex

wor

ker;

IDU

,inj

ecti

ngdr

ugus

er;M

SM,m

enw

hoha

vese

xw

ith

men

;STI

,sex

ually

tran

smit

ted

infe

ctio

n.



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.



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.



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.

References

1 Branson BM, Handsfield HH, Lampe MA et al. Revised

recommendations for HIV testing of adults, adolescents, and

pregnant women in health-care settings. MMWR Recomm

Rep 2006; 22: 1–17.

2 British HIV Association, British Association for Sexual

Health and HIV, British Infection Society. UK national

guidelines for HIV testing. 2008.

3 National Institue for Health and Clinical Excellence.

Increasing the uptake of HIV testing to reduce undiagnosed

infection and prevent transmission among black African

communities living in England. 2011.

4 National Institue for Health and Clinical Excellence.

Increasing the uptake of HIV testing to reduce undiagnosed



infection and prevent transmission among men who have

sex with men. 2011.

5 World Health Organisation. Guidance on provider-initiated

HIV testing and counselling in healthcare facilities. 2007.

6 European Centre for Disease Control and Prevention. HIV

testing: increasing uptake and effectiveness in the European

Union. 2010.

7 Chadborn TR, Baster K, Delpech VC et al. No time to wait:

how many HIV-infected homosexual men are diagnosed late

and consequently die? (England and Wales, 1993–2002).

AIDS 2005; 19: 513–520.

8 Chadborn TR, Delpech VC, Sabin CA, Sinka K, Evans BG.

The late diagnosis and consequent short-term mortality of

HIV-infected heterosexuals (England and Wales, 2000–2004).

AIDS 2006; 20: 2371–2379.

9 Reynolds SJ, Makumbi F, Nakigozi G et al. HIV-1

transmission among HIV-1 discordant couples before and

after the introduction of antiretroviral therapy. AIDS 2011;

25: 473–477.

10 Cohen M, Chen Y, McCauley M et al. Antiretroviral

treatment to prevent the sexual transmission of HIV-1:

results from the HPTN 052 multinational randomized

controlled trial. 6th Annual Conference of the International

AIDS Society. Rome, Italy, July 2011 [Abstract MOAX0102].

11 Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis

of high-risk sexual behavior in persons aware and unaware

they are infected with HIV in the United States: implications

for HIV prevention programs. J Acquir Immune Defic Syndr

2005; 39: 446–453.

12 UNAIDS. Report on the global AIDS epidemic. 2010.

13 Cwikel JG, Lazer T, Press F, Lazer S. Sexually transmissible

infections among female sex workers: an international

review with an emphasis on hard-to-access populations. Sex

Health 2008; 5: 9–16.

14 Mathers BM, Degenhardt L, Phillips B et al. Global

epidemiology of injecting drug use and HIV among people

who inject drugs: a systematic review. Lancet 2008; 372:

1733–1745.

15 Centers for Disease Control and Prevention. HIV surveillance

– United States, 1981–2008. MMWR 2011; 61: 689–693.

16 Deblonde J, De Koker P, Hamers FF, Fontaine J, Luchters S,

Temmerman M. Barriers to HIV testing in Europe: a

systematic review. Eur J Public Health 2010; 20: 422–432.

17 de la Fuente L, Delgado J, Hoyos J et al. Increasing early

diagnosis of HIV through rapid testing in a street outreach

program in Spain. AIDS Patient Care STDS 2009; 23:

625–629.

18 Guenter D, Greer J, Barbara A, Robinson G, Roberts J,

Browne G. Rapid point-of-care HIV testing in community-

based anonymous testing program: a valuable alternative to

conventional testing. AIDS Patient Care STDS 2008; 22:

195–204.

19 DiFranceisco W, Holtgrave DR, Hoxie N et al. HIV

seropositivity rates in outreach-based counseling and testing

services: program evaluation. J Acquir Immune Defic Syndr

Hum Retrovirol 1998; 19: 282–288.

20 Antonio-Gaddy M, Richardson-Moore A, Burstein GR,

Newman DR, Branson BM, Birkhead GS. Rapid HIV antibody

testing in the New York State Anonymous HIV Counseling

and Testing Program: experience from the field. J Acquir

Immune Defic Syndr 2006; 43: 446–450.

21 Skolnik HS, Phillips KA, Binson D, Dilley JW. Deciding

where and how to be tested for HIV: what matters most?

J Acquir Immune Defic Syndr 2001; 27: 292–300.

22 Kimbrough LW, Fisher HE, Jones KT, Johnson W,

Thadiparthi S, Dooley S. Accessing social networks with

high rates of undiagnosed HIV infection: the social networks

demonstration project. Am J Public Health 2009; 99:

1093–1099.

23 Reynolds GL, Fisher DG, Napper LE, Marsh KA, Willey C,

Brooks R. Results from a multiple morbidities testing

program offering rapid HIV testing bundled with hepatitis

and sexually transmitted infection testing. Public Health Rep

2008; 123 (Suppl 3): 63–69.

24 Ellen JM, Liang TS, Jacob CA, Erbelding E, Christmyer C.

Post-HIV test counselling of clients of a mobile STD/HIV

clinic. Int J STD AIDS 2004; 15: 728–731.

25 Keenan PA, Keenan JM. Rapid hiv testing in urban outreach:

a strategy for improving posttest counseling rates. AIDS

Educ Prev 2001; 13: 541–550.

26 Sturrock CJ, Currie MJ, Vally H et al. Community-based

sexual health care works: a review of the ACT outreach

program. Sex Health 2007; 4: 201–204.

27 Spielberg F, Branson BM, Goldbaum GM et al. Choosing HIV

counseling and testing strategies for outreach settings: a

randomized trial. J Acquir Immune Defic Syndr 2005; 38:

348–355.

28 Liang TS, Erbelding E, Jacob CA et al. Rapid HIV testing of

clients of a mobile STD/HIV clinic. AIDS Patient Care STDS

2005; 19: 253–257.

29 O’Connor CA, Patsdaughter CA, Grindel CG, Taveira PF,

Steinberg JL. A mobile HIV education and testing program:

bringing services to hard-to-reach populations. AIDS Patient

Care STDS 1998; 12: 931–937.

30 Clark HA, Bowles KE, Song B, Heffelfinger JD.

Implementation of rapid HIV testing programs in community

and outreach settings: perspectives from staff at eight

community-based organizations in seven U.S. cities. Public

Health Rep 2008; 123 (Suppl 3): 86–93.

31 Bowles KE, Clark HA, Tai E et al. Implementing rapid HIV

testing in outreach and community settings: results from an

advancing HIV prevention demonstration project conducted

in seven U.S. cities. Public Health Rep 2008; 123 (Suppl 3):

78–85.



32 Arumainayagam J, Grimshaw R, Acharya S, Chandramani S,

Morrall IA, Pugh RN. Value of targeting at-risk populations

at outreach venues: findings from a local sauna. Int J STD

AIDS 2009; 20: 642–643.

33 Daskalakis D, Silvera R, Bernstein K et al. Implementation of

HIV testing at 2 New York City bathhouses: from pilot to

clinical service. Clin Infect Dis 2009; 48: 1609–1616.

34 Bailey AC, Roberts J, Weatherburn P et al. Community HIV

testing for men who have sex with men: results of a pilot

project and comparison of service users with those testing in

genitourinary medicine clinics. Sex Transm Infect 2009; 85:

145–147.

35 Woods WJ, Erwin K, Lazarus M, Serice H, Grinstead O,

Binson D. Building stakeholder partnerships for an on-site

HIV testing programme. Cult Health Sex 2008; 10: 249–262.

36 Rose VJ, Raymond HF, Kellogg TA, McFarland W. Assessing

the feasibility of harm reduction services for MSM: the late

night breakfast buffet study. Harm Reduct J 2006; 3: 29–36.

37 Blank S, Gallagher K, Washburn K, Rogers M. Reaching out

to boys at bars: utilizing community partnerships to employ

a wellness strategy for syphilis control among men who

have sex with men in New York City. Sex Transm Dis 2005;

32 (Suppl 10): S65–S72.

38 Lister NA, Smith A, Tabrizi SN, Garland S, Hayes P, Fairley

CK. Comprehensive clinical care on-site in men-only saunas:

confidential STI/HIV screening outreach clinic. Int J STD

AIDS 2005; 16: 794–798.

39 Prost A, Chopin M, McOwan A et al. ‘There is such a thing

as asking for trouble’: taking rapid HIV testing to gay

venues is fraught with challenges. Sex Transm Infect 2007;

83: 185–188.

40 Galvan FH, Bluthenthal RN, Ani C, Bing EG. Increasing HIV

testing among latinos by bundling HIV testing with other

tests. J Urban Health 2006; 83: 849–859.

41 Golden MR, Gift TL, Brewer DD et al. Peer referral for HIV

case-finding among men who have sex with men. AIDS

2006; 20: 1961–1968.

42 Centers for Disease Control and Prevention. Rapid HIV

testing among racial/ethnic minority men at gay pride

events – nine U.S. cities, 2004–2006. MMWR 2007; 56:

602–604.

43 Smith LV, Rudy ET, Javanbakht M et al. Client satisfaction

with rapid HIV testing: comparison between an urban

sexually transmitted disease clinic and a community-based

testing center. AIDS Patient Care STDS 2006; 20:

693–700.

44 Spielberg F, Branson BM, Goldbaum GM, Kurth A, Wood

RW. Designing an HIV counseling and testing program for

bathhouses: the Seattle experience with strategies to improve

acceptability. J Homosex 2003; 44: 203–220.

45 Sy FS, Rhodes SD, Choi ST et al. The acceptability of oral

fluid testing for HIV antibodies. A pilot study in gay bars in

a predominantly rural state. Sex Transm Dis 1998; 25:

211–215.

46 Huebner DM, Binson D, Dilworth SE, Neilands TB,

Grinstead O, Woods WJ. Rapid vs. standard HIV testing in

bathhouses: what is gained and lost? AIDS Behav 2010; 14:

688–696.

47 Forbes KM, Rahman N, McCrae S, Reeves I. Integrated

community-based sexual health services for young people in

urban areas: are we meeting the needs of the local

community? Int J STD AIDS 2008; 19: 713–714.

48 Prost A, Sseruma WS, Fakoya I et al. HIV voluntary

counselling and testing for African communities in London:

learning from experiences in Kenya. Sex Transm Infect 2007;

83: 547–551.

49 Lewis DA, McDonald A, Thompson G, Bingham JS. The 374

clinic: an outreach sexual health clinic for young men. Sex

Transm Infect 2004; 80: 480–483.

50 Jones KE, Beeching BA, Roberts P et al. Success of a nurse

led community based genitourinary medicine clinic for

young people in Liverpool: review of the first year. Sex

Transm Infect 2006; 82: 318–320.

51 Schulden JD, Song B, Barros A et al. Rapid HIV testing in

transgender communities by community-based organizations

in three cities. Public Health Rep 2008; 123 (Suppl 3):

101–114.

52 O’Donnell L, Bonaparte B, Joseph H et al. Keep it up:

development of a community-based health screening and

HIV prevention strategy for reaching young African

American men. AIDS Educ Prev 2009; 21: 299–313.

53 Bell DN, Martinez J, Botwinick G et al. Case finding for

HIV-positive youth: a special type of hidden population.

J Adolesc Health 2003; 33 (Suppl): 10–22.

54 Kahn RH, Moseley KE, Thilges JN, Johnson G, Farley TA.

Community-based screening and treatment for STDs: results

from a mobile clinic initiative. Sex Transm Dis 2003; 30:

654–658.

55 Liebman J, Pat LM, Altice F. Effectiveness of a mobile

medical van in providing screening services for STDs and

HIV. Public Health Nurs 2002; 19: 345–353.

56 Rothman J, Rudnick D, Slifer M, Agins B, Heiner K,

Birkhead G. Co-located substance use treatment and HIV

prevention and primary care services, New York State,

1990–2002: a model for effective service delivery to a

high-risk population. J Urban Health 2007; 84: 226–242.

57 Pugatch DL, Levesque BG, Lally MA et al. HIV testing

among young adults and older adolescents in the setting of

acute substance abuse treatment. J Acquir Immune Defic

Syndr 2001; 27: 135–142.

58 Fraze JL, Uhrig JD, Davis KC et al. Applying core principles

to the design and evaluation of the ‘Take Charge. Take the

Test’ campaign: what worked and lessons learned. Public

Health 2009; 123 (Suppl 1): e23–e30.



59 Bucher JB, Thomas KM, Guzman D, Riley E, Dela CN,

Bangsberg DR. Community-based rapid HIV testing in

homeless and marginally housed adults in San Francisco.

HIV Med 2007; 8: 28–31.

60 Bradshaw CS, Pierce LI, Tabrizi SN, Fairley CK, Garland SM.

Screening injecting drug users for sexually transmitted

infections and blood borne viruses using street outreach

and self collected sampling. Sex Transm Infect 2005; 81:

53–58.

61 Health Protection Agency. Time to test for HIV: expanding

HIV testing in healthcare and community services in

England. 2011.

62 Pinkerton SD, Bogart LM, Howerton D, Snyder S, Becker K,

Asch SM. Cost of OraQuick oral fluid rapid HIV testing at 35

community clinics and community-based organizations in

the USA. AIDS Care 2009; 21: 1157–1162.

63 Shrestha RK, Sansom SL, Kimbrough L et al. Cost-

effectiveness of using social networks to identify

undiagnosed HIV infection among minority populations.

J Public Health Manag Pract 2010; 16: 457–464.

64 Shrestha RK, Clark HA, Sansom SL et al. Cost-effectiveness

of finding new HIV diagnoses using rapid HIV testing in

community-based organizations. Public Health Rep 2008;

123 (Suppl 3): 94–100.

65 Lorenc T, Marrero-Guillamon I, Aggleton P et al. Promoting

the uptake of HIV testing among men who have sex with

men: systematic review of effectiveness and cost-

effectiveness. Sex Transm Infect 2011; 87: 272–278.



Thornton Community Settings Hiv992

Documents

Transcript of Thornton Community Settings Hiv992