Effective national and global HIV responses require a significant expansion of HIV testing and counselling (HTC) to expand access to prevention and care. Facility-based HTC, while essential, is unlikely to meet national and global targets on its own. This article systematically reviews the evidence for community-based HTC.
Methods and Findings
PubMed was searched on 4 March 2013, clinical trial registries were searched on 3 September 2012, and Embase and the World Health Organization Global Index Medicus were searched on 10 April 2012 for studies including community-based HTC (i.e., HTC outside of health facilities). Randomised controlled trials, and observational studies were eligible if they included a community-based testing approach and reported one or more of the following outcomes: uptake, proportion receiving their first HIV test, CD4 value at diagnosis, linkage to care, HIV positivity rate, HTC coverage, HIV incidence, or cost per person tested (outcomes are defined fully in the text). The following community-based HTC approaches were reviewed: (1) door-to-door testing (systematically offering HTC to homes in a catchment area), (2) mobile testing for the general population (offering HTC via a mobile HTC service), (3) index testing (offering HTC to household members of people with HIV and persons who may have been exposed to HIV), (4) mobile testing for men who have sex with men, (5) mobile testing for people who inject drugs, (6) mobile testing for female sex workers, (7) mobile testing for adolescents, (8) self-testing, (9) workplace HTC, (10) church-based HTC, and (11) school-based HTC. The Newcastle-Ottawa Quality Assessment Scale and the Cochrane Collaboration's “risk of bias” tool were used to assess the risk of bias in studies with a comparator arm included in pooled estimates.
117 studies, including 864,651 participants completing HTC, met the inclusion criteria. The percentage of people offered community-based HTC who accepted HTC was as follows: index testing, 88% of 12,052 participants; self-testing, 87% of 1,839 participants; mobile testing, 87% of 79,475 participants; door-to-door testing, 80% of 555,267 participants; workplace testing, 67% of 62,406 participants; and school-based testing, 62% of 2,593 participants. Mobile HTC uptake among key populations (men who have sex with men, people who inject drugs, female sex workers, and adolescents) ranged from 9% to 100% (among 41,110 participants across studies), with heterogeneity related to how testing was offered. Community-based approaches increased HTC uptake (relative risk [RR] 10.65, 95% confidence interval [CI] 6.27–18.08), the proportion of first-time testers (RR 1.23, 95% CI 1.06–1.42), and the proportion of participants with CD4 counts above 350 cells/µl (RR 1.42, 95% CI 1.16–1.74), and obtained a lower positivity rate (RR 0.59, 95% CI 0.37–0.96), relative to facility-based approaches. 80% (95% CI 75%–85%) of 5,832 community-based HTC participants obtained a CD4 measurement following HIV diagnosis, and 73% (95% CI 61%–85%) of 527 community-based HTC participants initiated antiretroviral therapy following a CD4 measurement indicating eligibility. The data on linking participants without HIV to prevention services were limited. In low- and middle-income countries, the cost per person tested ranged from US$2–US$126. At the population level, community-based HTC increased HTC coverage (RR 7.07, 95% CI 3.52–14.22) and reduced HIV incidence (RR 0.86, 95% CI 0.73–1.02), although the incidence reduction lacked statistical significance. No studies reported any harm arising as a result of having been tested.
Community-based HTC achieved high rates of HTC uptake, reached people with high CD4 counts, and linked people to care. It also obtained a lower HIV positivity rate relative to facility-based approaches. Further research is needed to further improve acceptability of community-based HTC for key populations. HIV programmes should offer community-based HTC linked to prevention and care, in addition to facility-based HTC, to support increased access to HIV prevention, care, and treatment.
International Prospective Register of Systematic Reviews CRD42012002554
Please see later in the article for the Editors' Summary
Three decades into the AIDS epidemic, about 34 million people (most living in resource-limited countries) are infected with HIV, the virus that causes AIDS. Every year another 2.2 million people become infected with HIV, usually through unprotected sex with an infected partner, and about 1.7 million people die. Infection with HIV, which gradually destroys the CD4 lymphocytes and other immune system cells that provide protection from life-threatening infections, is usually diagnosed by looking for antibodies to HIV in the blood or saliva. Disease progression is subsequently monitored in HIV-positive individuals by counting the CD4 cells in their blood. Initiation of antiretroviral drug therapy—a combination of drugs that keeps HIV replication in check but that does not cure the infection—is recommended when an individual's CD4 count falls below 500 cells/µl of blood or when he or she develops signs of severe or advanced disease, such as unusual infections.
Why Was This Study Done?
As part of intensified efforts to eliminate HIV/AIDS, United Nations member states recently set several HIV-related targets to be achieved by 2015, including reduced transmission of HIV and increased delivery of antiretroviral therapy. These targets can only be achieved if there is a large expansion in HIV testing and counseling (HTC) and increased access to HIV prevention and care services. The World Health Organization currently recommends that everyone attending a healthcare facility in regions where there is a generalized HIV epidemic (defined as when 1% or more of the general population is HIV-positive) should be offered HTC. However, many people rarely visit healthcare facilities, and others refuse “facility-based” HTC because they fear stigmatization and discrimination. Thus, facility-based HTC alone is unlikely to be sufficient to enable national and global HIV targets to be reached. In this systematic review and meta-analysis, the researchers evaluate the performance of community-based HTC approaches such as index testing (offering HTC to the sexual and injecting partners and household members of people with HIV), mobile testing (offering HTC through a service that visits shopping centers and other public facilities), and door-to-door testing (systematically offering HTC to homes in a catchment area). A systematic review uses predefined criteria to identify all the research on a given topic; meta-analysis combines the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 117 studies (most undertaken in Africa and North America) involving 864,651 participants that evaluated community-based HTC approaches. Among these studies, the percentage of people offered community-based HTC who accepted it (HTC uptake) was 88% for index testing, 87% for self-testing, 80% for door-to-door testing, 67% for workplace testing, and 62% for school-based testing. Compared to facility-based approaches, community-based approaches increased the chances of an individual's CD4 count being above 350 cells/µl at diagnosis (an important observation because early diagnosis improves subsequent outcomes) but had a lower positivity rate, possibly because people with symptoms of HIV are more likely to visit healthcare facilities than healthy individuals. Importantly, 80% of participants in the community-based HTC studies had their CD4 count measured after HIV diagnosis, and 73% of the participants initiated antiretroviral therapy after their CD4 count fell below national eligibility criteria; both these observations suggest that community-based HTC successfully linked people to care. Finally, offering community-based HTC approaches in addition to facility-based approaches increased HTC coverage seven-fold at the population level.
What Do These Findings Mean?
These findings show that community-based HTC can achieve high HTC uptake rates and can reach HIV-positive individuals earlier, when they still have high CD4 counts. Importantly, they also suggest that the level of linkage to care of community-based HTC is similar to that of facility-based HTC. Although the lower positivity rate of community-based HTC approaches means that more people need to be tested with these approaches than with facility-based HTC to identify the same number of HIV-positive individuals, this downside of community-based HTC is likely to be offset by the earlier identification of HIV-positive individuals, which should improve life expectancy and reduce HIV transmission at the population level. Although further studies are needed to evaluate community-based HTC in other regions of the world, these findings suggest that offering community-based HTC in HIV programs in addition to facility-based testing should support the increased access to HIV prevention and care that is required for the intensification of HIV/AIDS elimination efforts.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001496.
- The World Health Organization provides information on all aspects of HIV/AIDS, including information on counseling and testing (in several languages)
- Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
- NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment
- Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on the global HIV/AIDS epidemic, on HIV testing, and on HIV transmission and testing (in English and Spanish)
- The UK National Health Service Choices website provides information (including personal stories) about HIV and AIDS
- The World AIDS Day Report 2012 provides up-to-date information about the AIDS epidemic and efforts to halt it
- Patient stories about living with HIV/AIDS are available through Avert; the nonprofit website Healthtalkonline also provides personal stories about living with HIV, including stories about getting a diagnosis
Citation: Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, et al. (2013) Towards Universal Voluntary HIV Testing and Counselling: A Systematic Review and Meta-Analysis of Community-Based Approaches. PLoS Med 10(8): e1001496. doi:10.1371/journal.pmed.1001496
Academic Editor: Stephanie L. Sansom, Centers for Disease Control and Prevention, United States of America
Received: December 5, 2012; Accepted: June 27, 2013; Published: August 13, 2013
Copyright: © 2013 Suthar et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors were personally salaried by their institutions during the period of writing. No specific funding was received for this study. No funding bodies had any role in the study design, data collection, data analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist. The opinions and statements in this article are those of the authors and do not necessarily represent the official policy, endorsement, or views of their organisations.
Abbreviations: ART, antiretroviral therapy: CI, confidence interval; FSW, female sex workers; HTC, HIV testing and counselling; MSM, men who have sex with men; PWID, people who inject drugs; RR, relative risk; WHO, World Health Organization
HIV is a leading cause of morbidity and mortality globally . Despite considerable progress in controlling the epidemic, there were approximately 2.2 million new HIV infections, 1.7 million HIV-related deaths, and 34.2 million people with HIV worldwide in 2011; 1.5 million of these new HIV infections, 1.2 million of the HIV deaths, and 23.5 million of the people living with HIV were in Africa . Given the urgency to act on the epidemic, all United Nations member states agreed to achieve the following HIV targets by 2015: (1) reduce sexual and parenteral HIV transmission by 50%, (2) eliminate vertical HIV transmission, (3) reduce tuberculosis deaths among people with HIV by 50%, and (4) deliver antiretroviral therapy (ART) to 15 million people . Achieving these targets will require people at risk of HIV to learn their status and link to prevention and care services.
In an effort to expand access to prevention and care services, World Health Organization (WHO) guidelines recommend provider-initiated HIV testing and counselling (HTC) for all people seen in all health facilities in generalised epidemics (i.e., antenatal HIV prevalence ≥1%) and in specific facilities in concentrated epidemics . While provider-initiated HTC programmes have been successful in identifying previously undiagnosed individuals in generalised epidemics, they may not reach all people at risk of HIV acquisition ,. Indeed, the latest Demographic and Health Surveys from 29 sub-Saharan African countries, representing approximately half of the global burden of HIV, indicate that only 15% of adults received results from an HIV test in the previous year . This low coverage is recognised as a critical barrier to scaling up HIV prevention and care interventions. Furthermore, people living with HIV are often diagnosed late in the course of their disease, resulting in avoidable morbidity, mortality, and transmission of the virus. .
The reasons for the current low coverage of HTC are various and include service, patient, and demographic barriers ,. For example, in generalised epidemics women have higher rates of testing than men and adolescents, perhaps because of their contact with reproductive and antenatal health services . Implementation of provider-initiated HTC guidance remains a priority for countries. However, because many people have limited contact with healthcare providers, HTC provision in health facilities alone is insufficient to achieve national and global targets. Although previous research has reviewed home-based HTC ,, the impact of all community-based HTC approaches has not been systematically reviewed. The objective of this study was to systematically review all community-based HTC approaches to inform global and national HIV programming.
Conduct of Systematic Review
This systematic review was conducted in accordance with the PRISMA statement using a pre-defined protocol (International Prospective Register of Systematic Reviews identification number: CRD42012002554; Text S1 and Protocol S1) ,. The PubMed database was searched on 4 March 2013, and Embase and WHO Global Index Medicus were systematically searched on 10 April 2012, without language, geographic, publication, date, or any other restrictions. In addition, the WHO International Clinical Trials Registry Platform, the Cochrane Central Register of Controlled Trials, the International Standard Randomised Controlled Trial Number Register, and ClinicalTrials.gov were systematically searched without language, publication, or date restrictions on 3 September 2012. Experts in the field were contacted to identify unpublished research and ongoing studies, and bibliographies of relevant studies were screened.
Community-based HTC was defined as HTC outside of health facilities. Facility-based HTC approaches were defined as those in healthcare sites (e.g., health facilities, hospitals, and fixed, stand-alone voluntary counselling and testing sites). Eleven different community-based HTC approaches were reviewed in this study: (1) door-to-door testing (systematically offering HTC to homes in a catchment area), (2) mobile testing for the general population (offering HTC via a mobile HTC service in areas visited by the general public, such as shopping centres, transport hubs, or roadside restaurants), (3) index testing (offering HTC to household members of people with HIV and persons who may have been exposed to HIV such as spouses, sexual partners, or children of people with HIV); (4) mobile testing for men who have sex with men (MSM), (5) mobile testing for people who inject drugs (PWID), (6) mobile testing for female sex workers (FSW), (7) mobile testing for adolescents, (8) self-testing, (9) workplace HTC, (10) church-based HTC, and (11) school-based HTC.
Several outcomes were analysed in this study. Uptake was calculated by dividing the number of individuals accepting HTC by the number of individuals offered HTC. The proportion of first-time testers was calculated by dividing the number of people reporting receiving their first HIV test by the total number of people tested. The proportion of participants with a CD4 count greater than 350 cells/µl was calculated among participants with HIV who had their CD4 count measured. Two steps of the retention continuum were assessed: (1) CD4 measurement (among all participants found to have HIV) and (2) initiation of ART (among participants eligible per national guidelines). In studies with a comparator arm, the HIV positivity rate was calculated by dividing the number of individuals found to be HIV positive by the number of individuals tested. HTC coverage was calculated by dividing the number of people tested by the total number of people living in the catchment area for the community-based HTC approach. HIV incidence was calculated by dividing the risk of infection in communities with access to community- and facility-based HTC by the risk of infection in communities with access to only facility-based HTC. Some of the outcomes were not independent. For example, the number of people tested was the denominator for the HIV positivity rate and first-time testers and also the numerator for HTC coverage. Moreover, the number of people living with HIV was the numerator for the HIV positivity rate and also the denominator for calculating the first step of the retention continuum (CD4 measurement). The cost per person tested was approximated by dividing the economic costs incurred during HTC in studies by the total number of people tested. Costs were adjusted for inflation from the year the costs were estimated to 2012 United States dollars using the US Bureau of Labor Statistics' inflation calculator .
Search Strategy and Selection Criteria
The search strategies (Table S1) were designed with the assistance of a librarian to identify studies including community-based HTC. Following recommendations from PRISMA, eligibility criteria were based on key study characteristics: population, intervention, comparator, outcome, and design . Specifically, studies were included when (1) the study population included people in generalised, concentrated, or low-level HIV epidemics; (2) the intervention was community-based HTC offered in combination with a background of facility-based HTC; (3) the comparator was facility-based HTC; (4) the outcome(s) included uptake, proportion of people reporting receiving their first HIV test, CD4 value at diagnosis, rates of linkage to care, HIV positivity rate, HTC coverage, HIV incidence, or cost per person tested; and (5) the study design was a randomised trial or observational cohort study. Given the lack of comparative studies for community-based HTC, studies without a comparator arm were also included if they met the remaining eligibility criteria.
A. B. S., N. F., and O. A. independently screened the abstracts of all articles identified via the literature database searches and then compared the full texts of all articles selected during screening against the inclusion criteria. Disagreements were resolved by discussion. J. S. R. and A. K. S. repeated the same process for the clinical trial registries.
A. B. S., J. S. R., and A. K. S. completed the data extraction of characteristics of study participants, community-based testing approaches, outcomes, and quality assessment using a standardised extraction form.
The Newcastle-Ottawa Quality Assessment Scale was used to assess bias in studies with a comparator arm included in pooled analyses . This scale rates studies based on eight criteria in three sources of bias. We modified this scale to remove one criterion, demonstration that the outcome of interest was not present at the start of study, since a previous HIV test may not affect all the outcomes analysed in this article. The Cochrane Collaboration's “risk of bias” tool was used to assess bias in randomised trials with a comparator arm .
Outcome proportions from studies meeting inclusion criteria were stabilised using the Freeman-Tukey-type arcsine square-root transformation and then pooled to summarise the proportion of participants who (1) accepted different community-based HTC approaches, (2) reported receiving their first HIV test, (3) had CD4 counts measured after diagnosis, (4) were diagnosed with HIV with a CD4 count above 350 cells/µl, and (5) initiated ART after their CD4 count indicated they were eligible for treatment ,. Pooled relative risks (RRs) were used to compare participants of community- and facility-based HTC with respect to uptake, proportion of first-time testers, the HIV positivity rate, proportion with CD4 counts above 350 cells/µl, and HTC coverage. Random-effects models were used for all analyses. Given the differences in HIV epidemiology, sexual mixing patterns, transmission factors, and healthcare utilisation rates for key populations, key population outcome data were reported individually and not pooled. I2 statistics were used to measure heterogeneity . I2 statistics near 25% indicate low heterogeneity, values near 50% indicate moderate heterogeneity, and those above 75% indicate high heterogeneity . All analyses were completed in STATA version 12.0.
108 articles, describing studies conducted from 1987 to 2012 and including 864,651 participants completing HTC, met the eligibility criteria (Table 1; Figure 1). Two articles were randomised trials ,, and the rest were observational in design. Data from one multi-centre cluster-randomised trial were stratified into three studies (based on the country where the testing was offered) , data from three articles were stratified based on the year community-based HTC was offered –, and data from four articles were stratified based on the community-based HTC approach used –. Given that 108 articles provided data from 108 studies and there were nine additional studies after stratification, there were a total of 117 studies included (Table S4). 76 studies were from Africa, 28 were from North America (excluding Central America), six were from Asia, four were from Central and South America, three were from Europe, and one was from Australia. The clinical trial registers identified ten ongoing trials: one on index testing , one on mobile testing , five on door-to-door testing –, one on self-testing , and two on community-based testing for key populations ,.
Figure 1. Flow of information through different phases of the review.doi:10.1371/journal.pmed.1001496.g001
Table 1. Summary of study participants and methods.doi:10.1371/journal.pmed.1001496.t001
The percentage of participants who were male was 45.3% for index testing, 45.9% for door-to-door testing, 44.9% for mobile testing, 62.6% for self-testing, 67.0% for workplace testing, and 42.2% for school-based testing (Table 1). Excluding studies including only MSM or only FSW, 62.9% of testers were male in mobile testing for key populations (Table 1). Population-level HTC efforts found that implementation of community-based HTC increases the number of couples receiving testing (Table 2).
Table 2. Percentage of clients received as couples in community-wide testing efforts.doi:10.1371/journal.pmed.1001496.t002
61 studies reported uptake of different community-based testing approaches among 713,632 participants: seven studies evaluated index testing among 12,052 participants ,,–, three evaluated self-testing among 1,839 participants –, 14 evaluated mobile HTC among 79,475 participants ,,–, 28 evaluated door-to-door testing among 555,267 participants ,,,,–, six evaluated workplace HTC among 62,406 participants ,–, and three evaluated school-based HTC among 2,593 participants – (Figure 2). The percentage of participants accepting HTC was 88.2% for index testing (95% confidence interval [CI] 80.5%–95.9%; I2 99.7%, 95% CI 99.7%–99.8%; Figure 3), 87.1% for self-testing (95% CI 85.1%–89.0%; I2 28.8%, 95% CI 0%–92.6%; Figure 4), 86.8% for mobile HTC (95% CI 85.6%–88.1%; I2 99.9%, 95% CI 99.9%–99.9%; Figure 5), 80.0% for door-to-door HTC (95% CI 76.9%–83.1%; I2 99.9%, 95% CI 99.9%–99.9%; Figure 6), 67.4% for workplace HTC (95% CI 32.8%–100.0%; I2 100%, 100.0%–100.0%; Figure 7), and 62.1% for school-based HTC (95% CI 39.6%–84.5%; I2 99.0%, 95% CI 98.5%–99.4%; Figure 8). Uptake was higher in community-based HTC compared to providing vouchers to participants for facility-based HTC (RR 10.65, 95% CI 6.27–18.08; I2 96.1%; Figure 9) ,.
Figure 2. Pooled uptake of community-based HTC approaches.
Bars indicate 95% CIs.doi:10.1371/journal.pmed.1001496.g002
Figure 3. Uptake of index HTC.doi:10.1371/journal.pmed.1001496.g003
Figure 4. Uptake of self-testing.doi:10.1371/journal.pmed.1001496.g004
Figure 5. Uptake of mobile HTC.doi:10.1371/journal.pmed.1001496.g005
Figure 6. Uptake of door-to-door HTC.
Asterisk: data reported were exclusively from children aged 18 mo.–13 y.doi:10.1371/journal.pmed.1001496.g006
Figure 7. Uptake of workplace HTC.
Asterisk: data reported were from the Democratic Republic of Congo, Rwanda, Burundi, Congo, and Nigeria.doi:10.1371/journal.pmed.1001496.g007
Figure 8. Uptake of school-based HTC.doi:10.1371/journal.pmed.1001496.g008
Figure 9. Pooled relative risks of community-based HTC versus facility-based HTC.
The numerator for all RRs was the risk of an outcome in community-based testing, while the denominator was the risk of an outcome in facility-based testing.doi:10.1371/journal.pmed.1001496.g009
19 studies reported uptake among 41,110 participants in key populations, including 16,725 MSM –, 4,681 PWID ,–, 81 FSW , 13,240 adolescents ,, and 6,383 individuals from combinations of key populations. The percentage accepting HTC was 99.7% among FSW, ranged from 13.7% to 94.5% among PWID, ranged from 9.4% to 95.0% among MSM, and ranged from 33.9% to 96.6% among adolescents (Figure 10). One study reported an uptake percentage of 95.2% among PWID and FSW , another reported an uptake percentage of 75.1% among PWID, FSW, and MSM , and another reported an uptake percentage of 60.0% among PWID and MSM . Uptake was higher for community-based testing than for facility-based testing among FSW (RR 1.10, 95% CI 1.03–1.17)  and MSM (RR 1.53, 95% CI 1.42–1.65)  (Figure 11).
Figure 10. Uptake of community-based HTC approaches among key populations.doi:10.1371/journal.pmed.1001496.g010
Figure 11. Relative risks of community-based HTC versus facility-based HTC among key populations.
The numerator for all RRs was the risk of an outcome in community-based testing, while the denominator was the risk of an outcome in facility-based testing.doi:10.1371/journal.pmed.1001496.g011
33 studies reported the HTC history among 597,016 participants in community-based HTC approaches ,,–,,,,–,–,,,,,,,,–. 62.2% (95% CI 58.0%–66.4%; I2 99.9%, 95% CI 99.9%–99.9%; Figure 12) of participants at community-based HTC sites reported receiving their first HIV test. In the nine studies with a facility-based comparator arm, a larger proportion of participants reported receiving their first HIV test at community-based HTC than at facility-based HTC (RR 1.23, 95% CI 1.06–1.42; I2 99.8%, 95% CI 99.8%–99.9%; Figure 9) ,,,,,.
Figure 12. First-time testers in community-based testing approaches.doi:10.1371/journal.pmed.1001496.g012
17 studies reported the HTC history of 25,311 participants from key populations receiving community-based HTC ,,,,,,,,–. 9% to 79% of participants reported receiving their first HIV test (Figure 13). Five of these studies included a facility-based comparator arm (Figure 11). There were more first-time testers in community-based HTC than facility-based HTC for two study populations of MSM (RR 2.24, 95% CI 1.27–3.93  and RR 1.37, 95% CI 1.18–1.59 ); however, there were fewer first-time testers in community-based HTC for a different study population of MSM (RR 0.33, 95% CI 0.26–0.43 ). There were more first-time testers in community-based HTC than facility-based HTC for a study population including PWID and MSM (RR 1.10, 95% CI 1.08–1.13 ); however, there was no difference in the proportion of first-time testers for a study population of FSW (RR 0.97, 95% CI 0.72–1.30 ).
Figure 13. First time testers in community-based testing approaches for key populations.doi:10.1371/journal.pmed.1001496.g013
HIV Positivity Rate
14 studies included data on the HIV positivity rate among people testing in community-based approaches relative to people testing in facility-based approaches ,,,,,,,,–. Overall, the HIV positivity rate was lower in community-based approaches relative to facility-based approaches (RR 0.59, 95% CI 0.37–0.96; I2 99.6%, 95% CI 99.6%–99.7%; Figure 9). The median number needed to screen to identify one person with HIV in community- and facility-based HTC was 17 (range 3–86) and 6 (range 4–154), respectively (Table 3). The number needed to screen with community-based testing was highest in settings with a low national HIV prevalence: 54 in Thailand and 86 in Guatemala ,.
Table 3. Number needed to screen to identify a person with HIV in studies offering community- and facility-based HTC.doi:10.1371/journal.pmed.1001496.t003
Six community-based testing studies for key populations included a facility-based comparator arm (Figure 11). Studies including FSW and a combination of PWID and MSM found no difference in the positivity rate for community- versus facility-based approaches (FSW, RR 0.62, 95% CI 0.29–1.34  and RR 1.39, 95% CI 0.85–2.29 ; PWID and MSM, RR 1.13, 95% CI 0.91–1.39 ). There was a lower positivity rate among a study population of MSM (RR 0.09, 95% CI 0.03–0.33 ) and among a study population including PWID, FSW, and MSM (RR 0.51, 95% CI 0.28–0.94 ). There was also a higher positivity rate among a study population of MSM (RR 2.37, 95% CI 1.35–4.15 ). The number needed to screen to identify one person with HIV varied depending on the key population and study setting (Table 4).
Table 4. Number needed to screen to identify a person with HIV in studies offering community- and facility-based HTC to key populations.doi:10.1371/journal.pmed.1001496.t004
18 studies reported the CD4 counts of 8,993 participants found to be HIV-positive using point-of-care or standard lab diagnostics ,,,,,,,,,,,,–. 56.7% (95% CI 49.6%–63.9%; I2 97.6%, 95% CI 97.0%–98.1%; Figure 14) of participants testing positive had CD4 counts above 350 cells/µl. In the five studies with a facility-based HTC comparator arm, more participants in community-based HTC approaches had CD4 counts above 350 cells/µl than in facility-based approaches (RR 1.42, 95% CI 1.16–1.74; I2 94.8%, 95% CI 90.5%–97.1%; Figure 9) ,,,.
Figure 14. Pooled percentage of community-based HTC participants with CD4 counts above 350 cells/µl.doi:10.1371/journal.pmed.1001496.g014
Two studies reported the CD4 counts of participants found to be HIV-positive in a key population. Using standard lab diagnostics these studies reported a median CD4 count of 550 cells/µl among MSM  and 385 cells/µl among MSM, PWID, and FSW .
Linkage to Care
17 studies, including 5,852 participants with HIV, reported linkage to care from HIV diagnosis to CD4 measurement ,,,,,,,,,,–,,. Overall, 80.1% of participants had their CD4 count measured after HIV diagnosis (95% CI 74.8%–85.4%; I2 99.5%, 95% CI 99.4%–99.5%; Figure 15). Nine studies with 527 participants reported linkage to care from being eligible to ART to initiating ART ,,,,,,. Overall, 73.1% of participants initiated ART after their CD4 count indicated that they were eligible (95% CI 61.3%–84.9%; I2 96.9%, 95% CI 95.6%–97.9%; Figure 15).
Figure 15. Linkage to care with community-based approaches to HTC.
Asterisk: study included 14 workplace sites in the Democratic Republic of Congo, Rwanda, Burundi, Congo, and Nigeria.doi:10.1371/journal.pmed.1001496.g015
Two studies, including 52 participants with HIV, reported linkage to care from HIV diagnosis to CD4 measurement in key populations. 12 of 15 MSM had their CD4 count measured after HIV diagnosis . 26 of 37 MSM and/or PWID had their CD4 count measured after HIV diagnosis . No studies reported linkage to care from being eligible for ART to initiating ART in key populations.
14 studies summarised HTC coverage among all people living in the testing site's catchment area ,,,,,,,. Coverage of HTC ranged from 5% to 93% depending on the type of approach used (Table 5). Mobile HTC available as part of multi-disease health campaigns achieved high coverage in the shortest period of time. Community-based HTC increased coverage of HTC relative to facility-based approaches (RR 7.07, 95% CI 3.52–14.22; I2 99.7%, 95% CI 99.7%–99.8%; Figure 9).
Table 5. Community coverage of voluntary HTC.doi:10.1371/journal.pmed.1001496.t005
One study reported HIV incidence . There was a decreased risk of HIV infection in communities randomised to community-based testing relative to communities randomised to facility-based testing, although this estimate lacked statistical significance (RR 0.86, 95% CI 0.73–1.02; Figure 9).
Cost per Person Tested
The cost per person tested ranged from US$2.45 to US$881.63 using different community-based testing approaches (Table 6) ,,,,,,,–. The cost per person tested was US$2.45 to US$14.37 for door-to-door testing, US$3.26 to US$33.54 for mobile testing, US$12.91 for hospital testing, US$15.30 to US$203.04 for index testing, US$21.28 to US$29.56 for testing at a fixed HTC site, US$126.48 for church-based testing, US$92.83 to US$881.63 for community-based testing for key populations, and US$93.73 for testing at an HIV clinic. Due to the heterogeneity in health systems and HIV prevalence within and between countries, the cost per person identified with HIV was not included.
Table 6. Cost per person tested using different community-based testing approaches.doi:10.1371/journal.pmed.1001496.t006
No studies reported harm arising as a result of having been tested. 18 studies gave a description of the testers' experiences or listed reasons for tester refusal –,,,,,,,,,,,,–. The studies discussed both the clients' positive testing experiences and their fears. Eight studies (including one targeting key populations) reported instances where participants refused HTC because of fear of status disclosure or stigma ,,,,,,,. In contrast, 12 studies (including three studies targeting key populations) specifically reported either no evidence of harm –,,,, or benefit through improved privacy or reduced stigma and fear ,,–.
There was concern of selection bias in nine of the studies included in pooled analyses ,,,,,, concern of confounding in five studies ,,,,, and concern of measurement bias in five studies ,,,, (Table S2). The randomised trials appeared to have limited selection, attrition, and reporting bias; however, their lack of blinding made them susceptible to performance and detection bias , (Table S3).
While there was high uptake for community-based approaches in most studies, there were several outliers with low uptake. To gauge whether these outliers influenced pooled uptake estimates and increased heterogeneity we conducted sensitivity analyses without them (Table 7). Although the pooled estimates increased and the CIs tightened without the outliers, there was still high heterogeneity using the I2 statistic. There was potential for selection bias, confounding, and measurement bias in several of the observational studies identified (Table S2). To determine whether these studies introduced bias into our results we ran sensitivity analyses without them and found the results to be similar (Table 8).
Table 7. Pooled relative risks of community- versus facility-based HTC sensitivity analyses.doi:10.1371/journal.pmed.1001496.t007
This systematic review found that community-based HTC approaches were successful in reaching populations early in the course of HIV infection. The studies with facility-based comparator arms further suggest that community-based HTC reached populations earlier in the course of HIV infection than facility-based HTC. Earlier HIV diagnosis supports timely access to ART, which could improve life expectancy and reduce HIV transmission 140–142. Earlier HIV diagnosis linked to ART may also have important socioeconomic effects at the population level, including (1) reducing the number of orphans , (2) improving education and employment outcomes ,, and (3) increasing the size of workforces ,.
The HIV positivity rate among participants in community-based HTC approaches was generally lower than that among participants in facility-based HTC. This could be because (1) symptomatic people with HIV are more likely to visit health facilities, (2) healthcare workers are more likely to offer HTC to patients with symptoms that might be associated with HIV, and (3) the positivity rate of participants in community-based HTC is more likely to be representative of the general population. While obtaining a lower positivity rate may immediately be associated with increased numbers needing to be tested to identify people with HIV, community-based HTC increased the number of newly diagnosed people with HIV 4-fold in a randomised controlled trial, has the potential to decrease HIV stigma by normalising HIV testing, and is an opportunity to provide prevention interventions for HIV and other diseases to asymptomatic populations ,,,–. The HIV positivity rate among key populations utilising community-based testing varied relative to the HIV positivity rate among key populations utilising facility-based HTC and requires further examination within different epidemiological contexts. Although few comparative cost data exist on the various HTC approaches, the reported estimates indicate that several community-based testing approaches are cheaper or similarly priced compared to facility-based HTC (Table 6).
Because many settings lack universal health coverage, other disease control strategies—such as the guinea worm eradication campaign , eradication campaigns against polio and measles ,, and efforts to eliminate preventable blindness —are built upon community-based elements for broader reach. Since community outreach efforts for these disease control strategies have largely been vertical in nature, some have suggested leveraging community-based HTC as a conduit for delivering other public health activities based on national burden of disease . Multi-disease approaches may include the provision of vaccines, water filters, and malaria bed nets and screening for cardiovascular disease, diabetes, and pulmonary disease . Settings implementing recent WHO guidance on community-based screening for tuberculosis and malaria could also consider multi-disease frameworks to improve efficiency ,. Including other public health activities based on national epidemiology, such as family planning and viral hepatitis screening and treatment, may also be appropriate. Indeed, 40 of the 117 studies meeting this review's eligibility criteria (34%) had a multi-disease component. Broadening community-based HTC to include preventive interventions and screening for other diseases could further improve cost-effectiveness .
In the studies reviewed, HTC uptake exceeded 80% in the mobile, index, self, and door-to-door testing approaches. While workplace and school-based testing could be an important approach in some settings, the uptake of these approaches was lower than that of other community-based approaches. Further research may improve their acceptability and could evaluate their impact on employment and education outcomes. Although there was no evidence of any harm resulting from being tested in community-based HTC approaches, there were reports of fear of status disclosure or stigma. Moreover, a recent report highlights the possibility of false positive diagnoses in settings (1) lacking a confirmation HIV test, (2) with poor training and supervision of community health workers, and (3) with insufficient quality control procedures . These findings highlight the continuing need to adhere to validated testing algorithms and to address legal and human rights issues, and for the 5 Cs of good testing practices—informed consent, confidentiality, counselling, correct test results, and connection to prevention and care—to always be present .
There was variable uptake for community-based testing among key populations. The heterogeneity between studies likely relates to differences in the way HTC was offered. For example, the studies with the lowest uptake among key populations offered HTC only in combination with extensive behavioural surveys ,. The findings from this small number of studies cannot be generalised widely. Moreover, there were limited CD4 count and ART linkage data from these studies, indicating that caution may be needed when providing HTC to key populations in settings where they remain marginalised and stigmatised and where there are inadequate linkages to prevention and care services. It is also important to safeguard confidentiality and prevent possible coercion, discrimination, and other adverse consequences for key populations being offered HTC in community settings. Further operational research on community-based testing for key populations, including mobile peer-based models ,,,, within this human rights framework is needed.
One of the benefits of community-based testing, especially door-to-door testing, is allowing couples and families to be counselled about their HIV status, behaviour change, ART, and prevention interventions together ,. Review of population-level HTC efforts suggest that implementation of community-based HTC could increase the number of couples receiving testing (Table 2). There were relatively limited data on HTC approaches for infants, children and adolescents. The door-to-door, mobile, school, and index community-based approaches have promise for these young populations, but further research could improve their operationalisation ,. In addition to implementing provider-initiated HTC in all health facilities in generalised epidemics, introducing HIV testing at scheduled immunisation visits may facilitate earlier diagnosis linked to care .
Offering community-based HTC in addition to facility-based HTC increased knowledge of HIV status approximately 7-fold at the population level. Providing near universal knowledge of HIV status linked to prevention and care may impact HIV transmission networks through increased coverage of ART, increased male circumcision prevalence, increased utilisation of needle exchange programmes, increased utilisation of condoms, increased utilisation of pre-exposure prophylaxis, behavioural change, and increased coverage of opiate substitution therapy. A cluster-randomised trial detected a statistically non-significant 14% reduction in population incidence in communities where community-based HTC was available . Since community-based HTC wasn't directly linked to prevention and care services in this trial, achieving and maintaining high levels of HTC coverage and maximising linkage to ART and other components of combination prevention could lead to more substantial reductions in population incidence –.
Incidence reductions depend on high coverage of repeat testing among people at risk of HIV infection. WHO recommends that HIV-negative individuals with ongoing sexual behaviour and/or who inject drugs with partners of positive or unknown HIV status should be tested at least annually . A high percentage of people reported being first-time testers with community-based approaches, and overall there was a higher proportion of first-time testers in community-based approaches than in facility-based approaches. In effective HTC programmes, the proportion of people reporting receiving their first test should decrease over time as a result of implementing WHO repeat testing recommendations . Several studies assessed uptake in the context of repeat testing. In several generalised epidemic settings, uptake remained high among the general population ,. Conversely, uptake decreased among the general population in a concentrated epidemic, suggesting that HTC may need to be targeted to key populations on an ongoing basis in these settings .
This review found that 80% of participants in the community-based HTC studies where CD4 measurement was offered had their CD4 count measured after HIV diagnosis. CD4 measurement was facilitated by (1) point-of-care CD4 diagnostics, (2) collection of blood samples at the time of diagnosis, and (3) workplace programmes that had regular contact with participants because of their work schedules. This percentage was similar to the percentages reported in two systematic reviews evaluating CD4 measurement from facility-based testing (59%–72%) ,, and supports the notion that high uptake of CD4 measurement can be achieved outside of health facilities when it is offered in combination with testing results. This review also found that 73% of participants initiated ART after their CD4 counts indicated that they were eligible. This proportion was comparable to previous estimates from two systematic reviews evaluating ART initiation rates from healthcare facilities (62%–68%) ,. Linkage from community-based HTC approaches to community-based treatment programmes could improve ART access and uptake and merits further exploration –. The data on linkage to prevention services, including linking men with negative results to male circumcision , were very limited. These linkages will be required to maximise the population benefits of community-based testing. Additional data on linkage to prevention services are urgently needed. Because self-testing achieves anonymous knowledge of status, no studies have been able to provide data on rates of linkage to care or prevention for people using this testing approach . Nonetheless, self-testing may provide programmatic advantages in some settings and requires further research .
There are some methodological limitations that need to be considered when evaluating the impact of community-based HTC. One of the outcomes, first-time tester proportion, has potential for recall bias since it relies on participants to recall their history of HIV testing. Since all of the studies that included a facility-based HTC comparator arm did not indicate whether HTC was provider- or client-initiated, comparisons were made to facility-based HTC approaches irrespective of who initiated the interaction. Therefore, this review may not provide conclusive evidence of community-based HTC relative to provider-initiated HTC. While 73% of participants initiated ART after their CD4 count indicated they were eligible, all of the studies providing these data did not provide information on the timing of this outcome. Understanding how soon after diagnosis participants were able to initiate ART could help establish the efficiency of linkage systems. While this review summarises information from different community-based testing approaches globally, only six of the 117 studies identified were from Asia, indicating a need to expand community-based HTC research efforts in this region. Finally, given the complexity and expense of conducting cluster-randomised controlled trials, most of the studies meeting the eligibility criteria were observational. Although our analyses included data from randomised controlled trials, the potential for unmeasured confounding in observational studies makes attempts to establish causal effect more difficult.
The meta-analyses may have limitations in the statistical methodology used. Using the I2 statistic, there was high heterogeneity for most meta-analyses. All analyses should be interpreted with respect to local epidemiology, social and cultural context, and the health systems organisation of the studies contributing data. Publication bias was not formally assessed, as analytical methods to test for publication bias, such as funnel plots and funnel plot asymmetry tests, may not be appropriate for observational data . Multiple study estimates and standardised variable definitions are required to explore the contributors of heterogeneity for pooled estimates. Given that the same variables were not collected systematically in all studies, this assessment was not undertaken for this review.
In conclusion, many community-based approaches achieved high uptake of HTC. Costs and linkage to care appeared similar to those of facility-based HTC approaches. The lower yield of people with HIV relative to facility-based HTC approaches appears to be offset by increasing knowledge of status at the population level, which, combined with timely linkage to treatment and prevention services, could have population effects on life expectancy and HIV transmission. As countries develop their new national strategic plans and investment cases based on WHO and Joint United Nations Programme on HIV/AIDS strategic guidance , consideration should be given to increasing the proportion of people with HIV who know their status, with linkages to prevention and care, by offering community-based testing in addition to facility-based testing .
Systematic review protocol.
Search strategy for all databases.
Newcastle-Ottawa Quality Assessment Scale. *Given that the distribution of possible confounders in randomised controlled trials is related to chance alone, randomised controlled trials were not assessed for confounding.
Bias assessment for randomised controlled trials.
Characteristics of studies meeting inclusion criteria. CE model, cost-effectiveness model; N/A, not applicable (e.g., gender data was not calculated for community-based testing only for MSM or FSW); N/R, not reported; OS, observational study; RCT, randomised controlled trial; STD, sexually transmitted disease; TB, tuberculosis; VCT, voluntary counselling and testing.
We thank Elizabeth Marum for helpful advice, investigators from several studies for providing additional data, and members of the Operational and Service Delivery Guideline Development Group for discussing critical issues.
Conceived and designed the experiments: ABS NF EKN RCB. Performed the experiments: ABS NF JSR AKS OA. Analyzed the data: ABS NF. Wrote the first draft of the manuscript: ABS. Contributed to the writing of the manuscript: ABS NF PJB VJW JSR AKS OA AOF RMG EKN RCB. ICMJE criteria for authorship read and met: ABS NF PJB VJW JSR AKS OA AOF RMG EKN RCB. Agree with manuscript results and conclusions: ABS NF PJB VJW JSR AKS OA AOF RMG EKN RCB.
- 1. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2197–2223.
- 2. Joint United Nations Programme on HIV/AIDS (2012) UNAIDS report on the global AIDS epidemic. Available: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdf. Accessed 25 July 2013.
- 3. United Nations General Assembly (2011) Political declaration on HIV/AIDS: intensifying our efforts to eliminate HIV/AIDS. Available: http://www.unaids.org/en/media/unaids/contentassets/documents/document/2011/06/20110610_un_a-res-65-277_en.pdf. Accessed 1 July 2013.
- 4. World Health Organization (2007) Guidance on provider-initiated HIV testing and counselling in health facilities. Available: http://whqlibdoc.who.int/publications/2007/9789241595568_eng.pdf. Accessed 1 July 2013.
- 5. Roura M, Watson-Jones D, Kahawita TM, Ferguson L, Ross DA (2013) Provider-initiated testing and counselling programmes in sub-Saharan Africa: a systematic review of their operational implementation. AIDS 27: 617–626. doi: 10.1097/qad.0b013e32835b7048
- 6. Hensen B, Baggaley R, Wong VJ, Grabbe KL, Shaffer N, et al. (2012) Universal voluntary HIV testing in antenatal care settings: a review of the contribution of provider-initiated testing & counselling. Trop Med Int Health 17: 59–70. doi: 10.1111/j.1365-3156.2011.02893.x
- 7. Staveteig S, Wang S, Head SK, Bradley SEK, Nybro E (2013) Demographic patterns of HIV testing uptake in Sub-Saharan Africa. Available: http://www.measuredhs.com/pubs/pdf/CR30/CR30.pdf. Accessed 1 July 2013.
- 8. Egger M, The IDEA and ART cohort collaborations (2013) Immunodeficiency at the start of combination antiretroviral therapy in low-, middle- and high-income countries. J Acquir Immune Defic Syndr. E-pub ahead of print.
- 9. Matovu JK, Makumbi FE (2007) Expanding access to voluntary HIV counselling and testing in sub-Saharan Africa: alternative approaches for improving uptake, 2001–2007. Trop Med Int Health 12: 1315–1322. doi: 10.1111/j.1365-3156.2007.01923.x
- 10. World Health Organization (2012) Service delivery approaches to HIV testing and counselling (HTC): a strategic policy framework. Available: http://apps.who.int/iris/bitstream/10665/75206/1/9789241593877_eng.pdf. Accessed 1 July 2013.
- 11. Bateganya MH, Abdulwadud OA, Kiene SM (2007) Home-based HIV voluntary counseling and testing in developing countries. Cochrane Database Syst Rev 2007: CD006493. doi: 10.1002/14651858.cd006493
- 12. Sabapathy K, Van den Bergh R, Fidler S, Hayes R, Ford N (2012) Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis. PLoS Med 9: e1001351 doi:10.1371/journal.pmed.1001351.
- 13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, et al. (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6: e1000100 doi:10.1371/journal.pmed.1000100.
- 14. Suthar AB (2012) Towards universal voluntary HIV testing and counselling: a systematic review of community-based approaches. Available: http://www.crd.york.ac.uk/PROSPEROFILES/2554_PROTOCOL_20120527.pdf. Accessed 1 July 2013.
- 15. United States Department of Labor Bureau of Labor Statistics (2012) CPI inflation calculator [database]. Available: http://www.bls.gov/data/inflation_calculator.htm. Accessed 1 July 2013.
- 16. Wells G, Shea B, O'Connell D, Peterson J, Welch V, et al.. (2011) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 July 2013.
- 17. The Cochrane Collaboration (2011) Cochrane handbook for systematic reviews of interventions, version 5.1.0. Available: http://www.cochrane-handbook.org/. Accessed 1 July 2013.
- 18. Freeman M, Tukey J (1950) Transformations related to the angular and the square root. Ann Math Stat 21: 607–611. doi: 10.1214/aoms/1177729756
- 19. Newcombe RG (1998) Interval estimation for the difference between independent proportions: comparison of eleven methods. Stat Med 17: 873–890. doi: 10.1002/(sici)1097-0258(19980430)17:8<873::aid-sim779>3.0.co;2-i
- 20. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21: 1539–1558. doi: 10.1002/sim.1186
- 21. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327: 557–560. doi: 10.1136/bmj.327.7414.557
- 22. Corbett EL, Dauya E, Matambo R, Cheung YB, Makamure B, et al. (2006) Uptake of workplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe. PLoS Med 3: e238 doi:10.1371/journal.pmed.0030238.
- 23. Sweat M, Morin S, Celentano D, Mulawa M, Singh B, et al. (2011) Community-based intervention to increase HIV testing and case detection in people aged 16-32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. Lancet Infect Dis 11: 525–532. doi: 10.1016/s1473-3099(11)70060-3
- 24. Angotti N, Bula A, Gaydosh L, Kimchi EZ, Thornton RL, et al. (2009) Increasing the acceptability of HIV counseling and testing with three C's: convenience, confidentiality and credibility. Soc Sci Med 68: 2263–2270. doi: 10.1016/j.socscimed.2009.02.041
- 25. Helleringer S, Mkandawire J, Reniers G, Kalilani-Phiri L, Kohler HP (2012) Should home-based HIV testing and counseling services be offered periodically in programs of ARV treatment as prevention? A case study in Likoma (Malawi). AIDS Behav 17: 2100–2108. doi: 10.1007/s10461-012-0365-0
- 26. Slesak G, Inthalad S, Kim JH, Manhpadit S, Somsavad S, et al. (2012) High HIV vulnerability of ethnic minorities after a trans-Asian highway construction in remote northern Laos. Int J STD AIDS 23: 570–575. doi: 10.1258/ijsa.2012.011416
- 27. Ahmed S, Delaney K, Villalba-Diebold P, Aliyu G, Constantine N, et al. (2013) HIV counseling and testing and access-to-care needs of populations most-at-risk for HIV in Nigeria. AIDS Care 25: 85–94. doi: 10.1080/09540121.2012.686597
- 28. Maheswaran H, Thulare H, Stanistreet D, Tanser F, Newell ML (2012) Starting a home and mobile HIV testing service in a rural area of South Africa. J Acquir Immune Defic Syndr 59: e43–e46. doi: 10.1097/qai.0b013e3182414ed7
- 29. Menzies N, Abang B, Wanyenze R, Nuwaha F, Mugisha B, et al. (2009) The costs and effectiveness of four HIV counseling and testing strategies in Uganda. AIDS 23: 395–401. doi: 10.1097/qad.0b013e328321e40b
- 30. Shapiro AE, Variava E, Rakgokong MH, Moodley N, Luke B, et al. (2012) Community-based targeted case finding for tuberculosis and HIV in household contacts of patients with tuberculosis in South Africa. Am J Respir Crit Care Med 185: 1110–1116. doi: 10.1164/rccm.201111-1941oc
- 31. University of Washington (2012) Home-based versus partner-friendly clinic testing to enhance male partner HIV-1 testing during pregnancy. Available: http://clinicaltrials.gov/ct2/show/NCT01620073. Accessed 1 July 2013.
- 32. National Institute of Allergy and Infectious Diseases (2010) A pilot semi-factorial cluster-randomized trial to estimate the effect size of community mobilization and VCT vans on the adoption of voluntary counseling and testing (VCT) services in Andhra Pradesh, India: the MCVCT Study. Available: http://clinicaltrials.gov/ct2/show/NCT01160575. Accessed 1 July 2013.
- 33. Liverpool School of Tropical Medicine (2011) Home assessment and initiation of antiretroviral therapy for HIV in Malawi (CONDA-YAPA). Available: http://clinicaltrials.gov/ct2/show/NCT01414413. Accessed 1 July 2013.
- 34. SolidarMed (2011) Comparison of door-to-door versus community gathering to provide HIV counseling and testing services in rural Lesotho (DoDoPi). Available: http://clinicaltrials.gov/ct2/show/record/NCT01459120. Accessed 1 July 2013.
- 35. University of Zambia (2009) Home-based voluntary human immunodeficiency virus (HIV) counselling and testing in Zambia. Available: http://www.controlled-trials.com/ISRCTN53353725. Accessed 1 July 2013.
- 36. Stellenbosch University (2008) Is it possible to develop a home based package of interventions delivered by community based women that will improve levels of maternal, newborn, child and HIV care in a disadvantaged community in South Africa? Available: http://www.controlled-trials.com/ISRCTN41046462. Accessed 1 July 2013.
- 37. London School of Hygiene and Tropical Medicine (2012) Intensified HIV/TB prevention linking home-based HIV testing, including the option of self-testing, with HIV care: a cluster-randomised trial in Blantyre, Malawi. Available: http://www.controlled-trials.com/ISRCTN02004005. Accessed 1 July 2013.
- 38. University of Washington (2010) Home self-testing for HIV to increase HIV testing frequency in men who have sex with men (the iTest Study). Available: http://clinicaltrials.gov/ct2/show/study/NCT01161446. Accessed 1 July 2013.
- 39. New York University (2012) Testing and linkage to care for injecting drug users in Kenya (TLC-IDU Kenya). Available: http://clinicaltrials.gov/ct2/show/NCT01557998. Accessed 1 July 2013.
- 40. University of California at Los Angeles (2010) Using incentives to improve parolee participation and attendance in community treatment (PIP). Available: http://clinicaltrials.gov/ct2/show/NCT01090245. Accessed 1 July 2013.
- 41. Armbruster B, Helleringer S, Kalilani-Phiri L, Mkandawire J, Kohler HP (2011) Exploring the relative costs of contact tracing for increasing HIV case finding in sub-Saharan countries. J Acquir Immune Defic Syndr 58: e29–e36. doi: 10.1097/qai.0b013e31822a9fa8
- 42. Colindres P, Mermin J, Ezati E, Kambabazi S, Buyungo P, et al. (2008) Utilization of a basic care and prevention package by HIV-infected persons in Uganda. AIDS Care 20: 139–145. doi: 10.1080/09540120701506804
- 43. Lugada E, Levin J, Abang B, Mermin J, Mugalanzi E, et al. (2010) Comparison of home and clinic-based HIV testing among household members of persons taking antiretroviral therapy in Uganda: results from a randomized trial. J Acquir Immune Defic Syndr 55: 245–252. doi: 10.1097/qai.0b013e3181e9e069
- 44. Were WA, Mermin JH, Wamai N, Awor AC, Bechange S, et al. (2006) Undiagnosed HIV infection and couple HIV discordance among household members of HIV-infected people receiving antiretroviral therapy in Uganda. J Acquir Immune Defic Syndr 43: 91–95. doi: 10.1097/01.qai.0000225021.81384.28
- 45. Wykoff RF, Heath CW Jr, Hollis SL, Leonard ST, Quiller CB, et al. (1988) Contact tracing to identify human immunodeficiency virus infection in a rural community. JAMA 259: 3563–3566. doi: 10.1001/jama.259.24.3563
- 46. Nelson AK, Caldas A, Sebastian JL, Munoz M, Bonilla C, et al. (2012) Community-based rapid oral human immunodeficiency virus testing for tuberculosis patients in Lima, Peru. Am J Trop Med Hyg 87: 399–406. doi: 10.4269/ajtmh.2012.12-0036
- 47. Choko AT, Desmond N, Webb EL, Chavula K, Napierala-Mavedzenge S, et al. (2011) The uptake and accuracy of oral kits for HIV self-testing in high HIV prevalence setting: a cross-sectional feasibility study in Blantyre, Malawi. PLoS Med 8: e1001102 doi:10.1371/journal.pmed.1001102.
- 48. Frank AP, Wandell MG, Headings MD, Conant MA, Woody GE, et al. (1997) Anonymous HIV testing using home collection and telemedicine counseling. A multicenter evaluation. Arch Intern Med 157: 309–314. doi: 10.1001/archinte.1997.00440240073011
- 49. Spielberg F, Critchlow C, Vittinghoff E, Coletti AS, Sheppard H, et al. (2000) Home collection for frequent HIV testing: acceptability of oral fluids, dried blood spots and telephone results. HIV Early Detection Study Group. AIDS 14: 1819–1828. doi: 10.1097/00002030-200008180-00018
- 50. Bahwere P, Piwoz E, Joshua MC, Sadler K, Grobler-Tanner CH, et al. (2008) Uptake of HIV testing and outcomes within a community-based therapeutic care (CTC) programme to treat severe acute malnutrition in Malawi: a descriptive study. BMC Infect Dis 8: 106. doi: 10.1186/1471-2334-8-106
- 51. Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, et al. (2012) Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda. PLoS ONE 7: e43400 doi:10.1371/journal.pone.0043400.
- 52. Chirawu P, Langhaug L, Mavhu W, Pascoe S, Dirawo J, et al. (2010) Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project. AIDS Care 22: 81–88. doi: 10.1080/09540120903012577
- 53. Darling KE, Diserens EA, N'Garambe C, Ansermet-Pagot A, Masserey E, et al. (2012) A cross-sectional survey of attitudes to HIV risk and rapid HIV testing among clients of sex workers in Switzerland. Sex Transm Infect 88: 462–464. doi: 10.1136/sextrans-2012-050489
- 54. Kawichai S, Celentano DD, Chariyalertsak S, Visrutaratna S, Short O, et al. (2007) Community-based voluntary counseling and testing services in rural communities of Chiang Mai Province, Northern Thailand. AIDS Behav 11: 770–777. doi: 10.1007/s10461-007-9242-7
- 55. Kranzer K, Govindasamy D, van Schaik N, Thebus E, Davies N, et al. (2012) Incentivized recruitment of a population sample to a mobile HIV testing service increases the yield of newly diagnosed cases, including those in need of antiretroviral therapy. HIV Med 13: 132–137. doi: 10.1111/j.1468-1293.2011.00947.x
- 56. Lugada E, Millar D, Haskew J, Grabowsky M, Garg N, et al. (2010) Rapid implementation of an integrated large-scale HIV counseling and testing, malaria, and diarrhea prevention campaign in rural Kenya. PLoS ONE 5: e12435 doi:10.1371/journal.pone.0012435.
- 57. Mahler HR, Kileo B, Curran K, Plotkin M, Adamu T, et al. (2011) Voluntary medical male circumcision: matching demand and supply with quality and efficiency in a high-volume campaign in Iringa Region, Tanzania. PLoS Med 8: e1001131 doi:10.1371/journal.pmed.1001131.
- 58. Ostermann J, Reddy EA, Shorter MM, Muiruri C, Mtalo A, et al. (2011) Who tests, who doesn't, and why? Uptake of mobile HIV counseling and testing in the Kilimanjaro Region of Tanzania. PLoS ONE 6: e16488 doi:10.1371/journal.pone.0016488.
- 59. van Rooyen H, McGrath N, Chirowodza A, Joseph P, Fiamma A, et al. (2012) Mobile VCT: reaching men and young people in urban and rural South African pilot studies (NIMH Project Accept, HPTN 043). AIDS Behav E-pub ahead of print. doi:10.1007/s10461-012-0368-x.
- 60. Cherutich P, Kaiser R, Galbraith J, Williamson J, Shiraishi RW, et al. (2012) Lack of knowledge of HIV status a major barrier to HIV prevention, care and treatment efforts in Kenya: results from a nationally representative study. PLoS ONE 7: e36797 doi:10.1371/journal.pone.0036797.
- 61. Dalal W, Feikin DR, Amolloh M, Ransom R, Burke H, et al. (2013) Home-based HIV testing and counseling in rural and urban Kenyan communities. J Acquir Immune Defic Syndr 62: e47–e54. doi: 10.1097/qai.0b013e318276bea0
- 62. Gonzalez R, Munguambe K, Aponte J, Bavo C, Nhalungo D, et al. (2012) High HIV prevalence in a southern semi-rural area of Mozambique: a community-based survey. HIV Med 13: 581–588. doi: 10.1111/j.1468-1293.2012.01018.x
- 63. Kimaiyo S, Were MC, Shen C, Ndege S, Braitstein P, et al. (2010) Home-based HIV counselling and testing in western Kenya. East Afr Med J 87: 100–108. doi: 10.4314/eamj.v87i3.62195
- 64. Kranzer K, McGrath N, Saul J, Crampin AC, Jahn A, et al. (2008) Individual, household and community factors associated with HIV test refusal in rural Malawi. Trop Med Int Health 13: 1341–1350. doi: 10.1111/j.1365-3156.2008.02148.x
- 65. Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH (2002) The Rakai Project counselling programme experience. Trop Med Int Health 7: 1064–1067. doi: 10.1046/j.1365-3156.2002.00964.x
- 66. Medley A, Ackers M, Amolloh M, Owuor P, Muttai H, et al. (2013) Early uptake of HIV clinical care after testing HIV-positive during home-based testing and counseling in western Kenya. AIDS Behav 17: 224–234. doi: 10.1007/s10461-012-0344-5
- 67. Michelo C, Sandoy IF, Dzekedzeke K, Siziya S, Fylkesnes K (2006) Steep HIV prevalence declines among young people in selected Zambian communities: population-based observations (1995–2003). BMC Public Health 6: 279. doi: 10.1186/1471-2458-6-279
- 68. Molesworth AM, Ndhlovu R, Banda E, Saul J, Ngwira B, et al. (2010) High accuracy of home-based community rapid HIV testing in rural Malawi. J Acquir Immune Defic Syndr 55: 625–630. doi: 10.1097/qai.0b013e3181f98628
- 69. Mutale W, Michelo C, Jurgensen M, Fylkesnes K (2010) Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities. BMC Public Health 10: 347. doi: 10.1186/1471-2458-10-347
- 70. Naik R, Tabana H, Doherty T, Zembe W, Jackson D (2012) Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa. BMC Public Health 12: 824. doi: 10.1186/1471-2458-12-824
- 71. Negin J, Wariero J, Mutuo P, Jan S, Pronyk P (2009) Feasibility, acceptability and cost of home-based HIV testing in rural Kenya. Trop Med Int Health 14: 849–855. doi: 10.1111/j.1365-3156.2009.02304.x
- 72. Sekandi JN, Sempeera H, List J, Mugerwa MA, Asiimwe S, et al. (2011) High acceptance of home-based HIV counseling and testing in an urban community setting in Uganda. BMC Public Health 11: 730. doi: 10.1186/1471-2458-11-730
- 73. Shisana O, Stoker D, Simbayi LC, Orkin M, Bezuidenhout F, et al. (2004) South African national household survey of HIV/AIDS prevalence, behavioural risks and mass media impact—detailed methodology and response rate results. S Afr Med J 94: 283–288.
- 74. Tumwesigye E, Wana G, Kasasa S, Muganzi E, Nuwaha F (2010) High uptake of home-based, district-wide, HIV counseling and testing in Uganda. AIDS Patient Care STDS 24: 735–741. doi: 10.1089/apc.2010.0096
- 75. Uwimana J, Zarowsky C, Hausler H, Jackson D (2012) Training community care workers to provide comprehensive TB/HIV/PMTCT integrated care in KwaZulu-Natal: lessons learnt. Trop Med Int Health 17: 488–496. doi: 10.1111/j.1365-3156.2011.02951.x
- 76. van Rooyen H, Phakathi Z, Krows M, Hong T, Barnabas R, et al.. (2012) High testing uptake and linkages to HIV treatment through home-based HIV counseling and testing and facilitated referral: KwaZulu-Natal, South Africa [abstract]. 19th Conference on Retroviruses and Opportunistic Infections; 5–8 March 2012; Seattle, Washington, US.
- 77. Vreeman RC, Nyandiko WM, Braitstein P, Were MC, Ayaya SO, et al. (2010) Acceptance of HIV testing for children ages 18 months to 13 years identified through voluntary, home-based HIV counseling and testing in western Kenya. J Acquir Immune Defic Syndr 55: e3–e10. doi: 10.1097/qai.0b013e3181f0758f
- 78. Wawer MJ, Gray RH, Sewankambo NK, Serwadda D, Paxton L, et al. (1998) A randomized, community trial of intensive sexually transmitted disease control for AIDS prevention, Rakai, Uganda. AIDS 12: 1211–1225. doi: 10.1097/00002030-199810000-00014
- 79. Welz T, Hosegood V, Jaffar S, Batzing-Feigenbaum J, Herbst K, et al. (2007) Continued very high prevalence of HIV infection in rural KwaZulu-Natal, South Africa: a population-based longitudinal study. AIDS 21: 1467–1472. doi: 10.1097/qad.0b013e3280ef6af2
- 80. Were W, Mermin J, Bunnell R, Ekwaru JP, Kaharuza F (2003) Home-based model for HIV voluntary counselling and testing. Lancet 361: 1569. doi: 10.1016/s0140-6736(03)13212-6
- 81. Wolff B, Nyanzi B, Katongole G, Ssesanga D, Ruberantwari A, et al. (2005) Evaluation of a home-based voluntary counselling and testing intervention in rural Uganda. Health Policy Plan 20: 109–116. doi: 10.1093/heapol/czi013
- 82. Feeley FG, Collier AC, Richards SC, Van der Borght SF, Rinke de Wit T (2007) A successful workplace program for voluntary counseling and testing and treatment of HIV/AIDS at Heineken, Rwanda. Int J Occup Environ Health 13: 99–106. doi: 10.1179/107735207800244910
- 83. Kwena ZA, Camlin CS, Shisanya CA, Mwanzo I, Bukusi EA (2013) Short-term mobility and the risk of HIV infection among married couples in the fishing communities along Lake Victoria, Kenya. PLoS ONE 8: e54523 doi:10.1371/journal.pone.0054523.
- 84. Machekano R, McFarland W, Mbizvo MT, Bassett MT, Katzenstein D, et al. (1998) Impact of HIV counselling and testing on HIV seroconversion and reported STD incidence among male factory workers in Harare, Zimbabwe. Cent Afr J Med 44: 98–102. doi: 10.1097/00002030-199607000-00013
- 85. Todd CS, Nasir A, Mansoor GF, Sahibzada SM, Jagodzinski LL, et al. (2012) Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits. BMC Infect Dis 12: 196. doi: 10.1186/1471-2334-12-196
- 86. Van der Borght SF, Schim van der Loeff MF, Clevenbergh P, Kabarega JP, Kamo E, et al. (2010) Long-term voluntary counseling and testing (VCT) uptake dynamics in a multicountry HIV workplace program in sub-Saharan Africa. AIDS Care 22: 195–205. doi: 10.1080/09540120903111486
- 87. Henry-Reid LM, Rodriguez F, Bell MA, Martinez J, Peera A (1998) Youth counseled for HIV testing at school- and hospital-based clinics. J Natl Med Assoc 90: 287–292. doi: 10.1016/1054-139x(96)81212-2
- 88. Kharsany AB, Mlotshwa M, Frohlich JA, Yende Zuma N, Samsunder N, et al. (2012) HIV prevalence among high school learners—opportunities for schools-based HIV testing programmes and sexual reproductive health services. BMC Public Health 12: 231. doi: 10.1186/1471-2458-12-231
- 89. Patel D, Matyanga P, Nyamundaya T, Chimedza D, Webb K, et al. (2012) Facilitating HIV testing, care and treatment for orphans and vulnerable children aged five years and younger through community-based early childhood development playcentres in rural Zimbabwe. J Int AIDS Soc 15 (Suppl 2) 17404. doi: 10.7448/ias.15.4.17404
- 90. Lister NA, Smith A, Tabrizi SN, Garland S, Hayes P, et al. (2005) Comprehensive clinical care on-site in men-only saunas: confidential STI/HIV screening outreach clinic. Int J STD AIDS 16: 794–798. doi: 10.1258/095646205774988163
- 91. Outlaw AY, Naar-King S, Parsons JT, Green-Jones M, Janisse H, et al. (2010) Using motivational interviewing in HIV field outreach with young African American men who have sex with men: a randomized clinical trial. Am J Public Health 100 (Suppl 1) S146–S151. doi: 10.2105/ajph.2009.166991
- 92. Spielberg F, Branson BM, Goldbaum GM, Lockhart D, Kurth A, et al. (2005) Choosing HIV counseling and testing strategies for outreach settings: a randomized trial. J Acquir Immune Defic Syndr 38: 348–355.
- 93. Centers for Disease Control and Prevention (2007) Rapid HIV testing among racial/ethnic minority men at gay pride events—nine U.S. cities, 2004-2006. MMWR Morb Mortal Wkly Rep 56: 602–604. doi: 10.1001/jama.298.6.621
- 94. Balaji AB, Bowles KE, Le BC, Paz-Bailey G, Oster AM (2013) High HIV incidence and prevalence and associated factors among young MSM, 2008. AIDS 27: 269–278. doi: 10.1097/qad.0b013e32835ad489
- 95. Galvan FH, Bluthenthal RN, Ani C, Bing EG (2006) Increasing HIV testing among latinos by bundling HIV testing with other tests. J Urban Health 83: 849–859. doi: 10.1007/s11524-006-9072-3
- 96. Smith LV, Rudy ET, Javanbakht M, Uniyal A, Sy LS, et al. (2006) Client satisfaction with rapid HIV testing: comparison between an urban sexually transmitted disease clinic and a community-based testing center. AIDS Patient Care STDS 20: 693–700. doi: 10.1089/apc.2006.20.693
- 97. Sy FS, Rhodes SD, Choi ST, Drociuk D, Laurent AA, et al. (1998) The acceptability of oral fluid testing for HIV antibodies. A pilot study in gay bars in a predominantly rural state. Sex Transm Dis 25: 211–215. doi: 10.1097/00007435-199804000-00006
- 98. Centers for Disease Control and Prevention (1997) Community-based HIV prevention in presumably underserved populations—Colorado Springs, Colorado, July-September 1995. MMWR Morb Mortal Wkly Rep 46: 152–155.
- 99. Gelberg L, Robertson MJ, Arangua L, Leake BD, Sumner G, et al. (2012) Prevalence, distribution, and correlates of hepatitis C virus infection among homeless adults in Los Angeles. Public Health Rep 127: 407–421.
- 100. O'Connor CA, Patsdaughter CA, Grindel CG, Taveira PF, Steinberg JL (1998) A mobile HIV education and testing program: bringing services to hard-to-reach populations. AIDS Patient Care STDS 12: 931–937. doi: 10.1089/apc.1998.12.931
- 101. Nhurod P, Bollen LJ, Smutraprapoot P, Suksripanich O, Siangphoe U, et al. (2010) Access to HIV testing for sex workers in Bangkok, Thailand: a high prevalence of HIV among street-based sex workers. Southeast Asian J Trop Med Public Health 41: 153–162.
- 102. Bell DN, Martinez J, Botwinick G, Shaw K, Walker LE, et al. (2003) Case finding for HIV-positive youth: a special type of hidden population. J Adolesc Health 33: 10–22. doi: 10.1016/s1054-139x(03)00160-5
- 103. Robbins CL, Zapata L, Kissin DM, Shevchenko N, Yorick R, et al. (2010) Multicity HIV seroprevalence in street youth, Ukraine. Int J STD AIDS 21: 489–496. doi: 10.1258/ijsa.2010.010097
- 104. Liang TS, Erbelding E, Jacob CA, Wicker H, Christmyer C, et al. (2005) Rapid HIV testing of clients of a mobile STD/HIV clinic. AIDS Patient Care STDS 19: 253–257. doi: 10.1089/apc.2005.19.253
- 105. Bucher JB, Thomas KM, Guzman D, Riley E, Dela Cruz N, et al. (2007) Community-based rapid HIV testing in homeless and marginally housed adults in San Francisco. HIV Med 8: 28–31. doi: 10.1111/j.1468-1293.2007.00423.x
- 106. Bowles KE, Clark HA, Tai E, Sullivan PS, Song B, et al. (2008) 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 123 (Suppl 3) 78–85.
- 107. Grabbe KL, Menzies N, Taegtmeyer M, Emukule G, Angala P, et al. (2010) Increasing access to HIV counseling and testing through mobile services in Kenya: strategies, utilization, and cost-effectiveness. J Acquir Immune Defic Syndr 54: 317–323. doi: 10.1097/qai.0b013e3181ced126
- 108. Lahuerta M, Sabido M, Giardina F, Hernandez G, Palacios JF, et al. (2011) Comparison of users of an HIV/syphilis screening community-based mobile van and traditional voluntary counselling and testing sites in Guatemala. Sex Transm Infect 87: 136–140. doi: 10.1136/sti.2010.043067
- 109. Morin SF, Khumalo-Sakutukwa G, Charlebois ED, Routh J, Fritz K, et al. (2006) Removing barriers to knowing HIV status: same-day mobile HIV testing in Zimbabwe. J Acquir Immune Defic Syndr 41: 218–224. doi: 10.1097/01.qai.0000179455.01068.ab
- 110. Nglazi MD, van Schaik N, Kranzer K, Lawn SD, Wood R, et al. (2012) An incentivized HIV counseling and testing program targeting hard-to-reach unemployed men in Cape Town, South Africa. J Acquir Immune Defic Syndr 59: e28–e34. doi: 10.1097/qai.0b013e31824445f0
- 111. Spielberg F, Kurth A, Reidy W, McKnight T, Dikobe W, et al. (2011) Iterative evaluation in a mobile counseling and testing program to reach people of color at risk for HIV—new strategies improve program acceptability, effectiveness, and evaluation capabilities. AIDS Educ Prev 23: 110–116. doi: 10.1521/aeap.2011.23.3_supp.110
- 112. Truong HM, Fritz K, McFarland W, Hartogensis W, Fiamma A, et al. (2011) Recent HIV type 1 infection among participants in a same-day mobile testing pilot study in Zimbabwe. AIDS Res Hum Retroviruses 27: 593–595. doi: 10.1089/aid.2010.0249
- 113. Bingham TA, Secura GM, Behel SK, Bunch JG, Simon PA, et al. (2008) HIV risk factors reported by two samples of male bathhouse attendees in Los Angeles, California, 2001–2002. Sex Transm Dis 35: 631–636. doi: 10.1097/olq.0b013e31816b475a
- 114. Bungay V, Kolar K, Thindal S, Remple VP, Johnston CL, et al. (2013) Community-based HIV and STI prevention in women working in indoor sex markets. Health Promot Pract 14: 247–255. doi: 10.1177/1524839912447189
- 115. Champenois K, Le Gall JM, Jacquemin C, Jean S, Martin C, et al. (2012) ANRS-COM'TEST: description of a community-based HIV testing intervention in non-medical settings for men who have sex with men. BMJ Open 2: e000693. doi: 10.1136/bmjopen-2011-000693
- 116. DiFranceisco W, Holtgrave DR, Hoxie N, Reiser WJ, Resenhoeft R, et al. (1998) HIV seropositivity rates in outreach-based counseling and testing services: program evaluation. J Acquir Immune Defic Syndr Hum Retrovirol 19: 282–288. doi: 10.1097/00042560-199811010-00011
- 117. Keenan PA, Keenan JM (2001) Rapid HIV testing in urban outreach: a strategy for improving posttest counseling rates. AIDS Educ Prev 13: 541–550. doi: 10.1521/aeap.13.6.541.21439
- 118. Stein R, Green K, Bell K, Toledo CA, Uhl G, et al. (2011) Provision of HIV counseling and testing services at five community-based organizations among young men of color who have sex with men. AIDS Behav 15: 743–750. doi: 10.1007/s10461-010-9821-x
- 119. Hood JE, MacKellar D, Spaulding A, Nelson R, Mosiakgabo B, et al. (2012) Client characteristics and gender-specific correlates of testing HIV positive: a comparison of standalone center versus mobile outreach HIV testing and counseling in Botswana. AIDS Behav 16: 1902–1916. doi: 10.1007/s10461-012-0253-7
- 120. McCoy SI, Shiu K, Martz TE, Smith CD, Mattox L, et al. (2013) Improving the efficiency of HIV testing with peer recruitment, financial incentives, and the involvement of persons living with HIV infection. J Acquir Immune Defic Syndr 63: e56–e63. doi: 10.1097/qai.0b013e31828a7629
- 121. van Schaik N, Kranzer K, Wood R, Bekker LG (2010) Earlier HIV diagnosis—are mobile services the answer? S Afr Med J 100: 671–674.
- 122. Shrestha RK, Clark HA, Sansom SL, Song B, Buckendahl H, et al. (2008) Cost-effectiveness of finding new HIV diagnoses using rapid HIV testing in community-based organizations. Public Health Rep 123 (Suppl 3) 94–100.
- 123. Yin YP, Chen SC, Wang HC, Wei WH, Wang QQ, et al. (2012) Prevalence and risk factors of HSV-2 infection and HSV-2/HIV coinfection in men who have sex with men in China: a multisite cross-sectional study. Sex Transm Dis 39: 354–358. doi: 10.1097/olq.0b013e318244aef0
- 124. Govindasamy D, van Schaik N, Kranzer K, Wood R, Mathews C, et al. (2011) Linkage to HIV care from a mobile testing unit in South Africa by different CD4 count strata. J Acquir Immune Defic Syndr 58: 344–352. doi: 10.1097/qai.0b013e31822e0c4c
- 125. Granich R, Muraguri N, Doyen A, Garg N, Williams BG (2012) Achieving universal access for human immunodeficiency virus and tuberculosis: potential prevention impact of an integrated multi-disease prevention campaign in kenya. AIDS Res Treat 2012: 412643. doi: 10.1155/2012/412643
- 126. Larson BA, Schnippel K, Ndibongo B, Xulu T, Brennan A, et al. (2012) Rapid point-of-care CD4 testing at mobile HIV testing sites to increase linkage to care: an evaluation of a pilot program in South Africa. J Acquir Immune Defic Syndr 61: e13–e17. doi: 10.1097/qai.0b013e31825eec60
- 127. Wachira J, Kimaiyo S, Ndege S, Mamlin J, Braitstein P (2012) What is the impact of home-based HIV counseling and testing on the clinical status of newly enrolled adults in a large HIV care program in western Kenya? Clin Infect Dis 54: 275–281. doi: 10.1093/cid/cir789
- 128. Naughton J, Hughes H, Wilkinson L, Boyles T (2011) HIV counselling and testing in South African schools. Lancet 377: 1748. doi: 10.1016/s0140-6736(11)60735-6
- 129. Wringe A, Floyd S, Kazooba P, Mushati P, Baisley K, et al. (2012) Antiretroviral therapy uptake and coverage in four HIV community cohort studies in sub-Saharan Africa. Trop Med Int Health 17: e38–e48. doi: 10.1111/j.1365-3156.2011.02925.x
- 130. Coates T, Eshleman S, Chariyalertsak S, Chingono A, Gray G, et al.. (2013) Community-level reductions in estimated HIV incidence: HIV Prevention Trials Network 043, Project Accept [abstract]. 20th Conference on Retroviruses and Opportunistic Infections; 3–6 March 2013; Atlanta, Georgia, US.
- 131. Kahn JG, Harris B, Mermin JH, Clasen T, Lugada E, et al. (2011) Cost of community integrated prevention campaign for malaria, HIV, and diarrhea in rural Kenya. BMC Health Serv Res 11: 346. doi: 10.1186/1472-6963-11-346
- 132. McConnel CE, Stanley N, du Plessis JA, Pitter CS, Abdulla F, et al. (2005) The cost of a rapid-test VCT clinic in South Africa. S Afr Med J 95: 968–971.
- 133. Shrestha RK, Sansom SL, Kimbrough L, Hutchinson AB, Daltry D, et al. (2010) Cost-effectiveness of using social networks to identify undiagnosed HIV infection among minority populations. J Public Health Manag Pract 16: 457–464. doi: 10.1097/phh.0b013e3181cb433b
- 134. Shrestha RK, Sansom SL, Schulden JD, Song B, Smith LC, et al. (2011) Costs and effectiveness of finding new HIV diagnoses by using rapid testing in transgender communities. AIDS Educ Prev 23: 49–57. doi: 10.1521/aeap.2011.23.3_supp.49
- 135. Terris-Prestholt F, Kumaranayake L, Foster S, Kamali A, Kinsman J, et al. (2006) The role of community acceptance over time for costs of HIV and STI prevention interventions: analysis of the Masaka Intervention Trial, Uganda, 1996–1999. Sex Transm Dis 33: S111–S116. doi: 10.1097/01.olq.0000175389.10289.ba
- 136. Edgil D, Stankard P, Forsythe S, Rech D, Chrouser K, et al. (2011) Voluntary medical male circumcision: logistics, commodities, and waste management requirements for scale-up of services. PLoS Med 8: e1001128 doi:10.1371/journal.pmed.1001128.
- 137. Jurgensen M, Sandoy IF, Michelo C, Fylkesnes K (2013) Effects of home-based voluntary counselling and testing on HIV-related stigma: findings from a cluster-randomized trial in Zambia. Soc Sci Med 81: 18–25. doi: 10.1016/j.socscimed.2013.01.011
- 138. Kyaddondo D, Wanyenze RK, Kinsman J, Hardon A (2012) Home-based HIV counseling and testing: client experiences and perceptions in Eastern Uganda. BMC Public Health 12: 966. doi: 10.1186/1471-2458-12-966
- 139. Nuwaha F, Kasasa S, Wana G, Muganzi E, Tumwesigye E (2012) Effect of home-based HIV counselling and testing on stigma and risky sexual behaviours: serial cross-sectional studies in Uganda. J Int AIDS Soc 15: 17423. doi: 10.7448/ias.15.2.17423
- 140. Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML (2013) High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science 339: 966–971. doi: 10.1126/science.1228160
- 141. Fonner VA, Denison J, Kennedy CE, O'Reilly K, Sweat M (2012) Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. Cochrane Database Syst Rev: CD001224. doi: 10.1002/14651858.cd001224.pub4
- 142. Bor J, Herbst AJ, Newell ML, Bärnighausen T, et al. (2013) Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science 339: 961–965. doi: 10.1126/science.1230413
- 143. Anema A, Au-Yeung CG, Joffres M, Kaida A, Vasarhelyi K, et al. (2011) Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009–2020. AIDS Res Ther 8: 13. doi: 10.1186/1742-6405-8-13
- 144. Thirumurthy H, Chamie G, Jain V, Kabami J, Kwarisiima D, et al. (2013) Improved employment and education outcomes in households of HIV-infected adults with high CD4 cell counts: evidence from a community health campaign in Uganda. AIDS 27: 627–634. doi: 10.1097/qad.0b013e32835c54d8
- 145. Bor J, Tanser F, Newell ML, Barnighausen T (2012) In a study of a population cohort in South Africa, HIV patients on antiretrovirals had nearly full recovery of employment. Health Aff (Millwood) 31: 1459–1469. doi: 10.1377/hlthaff.2012.0407
- 146. Risley CL, Drake LJ, Bundy DA (2012) Economic impact of HIV and antiretroviral therapy on education supply in high prevalence regions. PLoS ONE 7: e42909 doi:10.1371/journal.pone.0042909.
- 147. Ventelou B, Arrighi Y, Greener R, Lamontagne E, Carrieri P, et al. (2012) The macroeconomic consequences of renouncing to universal access to antiretroviral treatment for HIV in Africa: a micro-simulation model. PLoS ONE 7: e34101 doi:10.1371/journal.pone.0034101.
- 148. Hopkins DR (1998) The Guinea worm eradication effort: lessons for the future. Emerg Infect Dis 4: 414–415. doi: 10.3201/eid0403.980319
- 149. de Quadros CA, Andrus JK, Olive JM, Guerra de Macedo C, Henderson DA (1992) Polio eradication from the Western Hemisphere. Annu Rev Public Health 13: 239–252. doi: 10.1146/annurev.pu.13.050192.001323
- 150. de Quadros CA, Olive JM, Hersh BS, Strassburg MA, Henderson DA, et al. (1996) Measles elimination in the Americas. Evolving strategies. JAMA 275: 224–229. doi: 10.1001/jama.1996.03530270064033
- 151. Natchiar G, Robin AL, Thulasiraj RD, Krishnaswamy S (1994) Attacking the backlog of India's curable blind. The Aravind Eye Hospital model. Arch Ophthalmol 112: 987–993. doi: 10.1001/archopht.1994.01090190135035
- 152. Suthar AB, Klinkenberg E, Ramsay A, Garg N, Bennett R, et al. (2012) Community-based multi-disease prevention campaigns for controlling human immunodeficiency virus-associated tuberculosis. Int J Tuberc Lung Dis 16: 430–436. doi: 10.5588/ijtld.11.0480
- 153. World Health Organization (2012) Prevention and control of NCDs: guidelines for primary health care in low-resource settings. Available: http://apps.who.int/iris/bitstream/10665/76173/1/9789241548397_eng.pdf. Accessed 1 July 2013.
- 154. World Health Organization (2012) Disease surveillance for malaria elimination: an operational manual. Available: http://whqlibdoc.who.int/publications/2012/9789241503334_eng.pdf. Accessed 1 July 2013.
- 155. World Health Organization (2013) Systematic screening for active tuberculosis: principles and recommendations. Available: http://www.who.int/tb/publications/Final_TB_Screening_guidelines.pdf. Accessed 1 July 2013.
- 156. Kahn JG, Muraguri N, Harris B, Lugada E, Clasen T, et al. (2012) Integrated HIV testing, malaria, and diarrhea prevention campaign in Kenya: modeled health impact and cost-effectiveness. PLoS ONE 7: e31316 doi:10.1371/journal.pone.0031316.
- 157. Shanks L, Klarkowski D, O'Brien DP (2013) False positive HIV diagnoses in resource limited settings: operational lessons learned for HIV programmes. PLoS ONE 8: e59906 doi:10.1371/journal.pone.0059906.
- 158. Kimbrough LW, Fisher HE, Jones KT, Johnson W, Thadiparthi S, et al. (2009) Accessing social networks with high rates of undiagnosed HIV infection: the social networks demonstration project. Am J Public Health 99: 1093–1099. doi: 10.2105/ajph.2008.139329
- 159. Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, et al. (2013) Willingness to access peer-delivered HIV testing and counseling among people who inject drugs in Bangkok, Thailand. J Community Health 38: 427–433. doi: 10.1007/s10900-012-9635-z
- 160. World Health Organization (2012) Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. Available: http://whqlibdoc.who.int/publications/2012/9789241501972_eng.pdf. Accessed 1 July 2013.
- 161. World Health Organization (2012) Planning, implementing and monitoring home-based HIV testing. Available: http://apps.who.int/iris/bitstream/10665/75366/1/9789241504317_eng.pdf. Accessed 1 July 2013.
- 162. Binagwaho A, Mugwaneza P, Irakoze AA, Nsanzimana S, Agbonyitor M, et al.. (2013) Scaling up early infant diagnosis of HIV in Rwanda, 2008-2010. J Public Health Policy 34: : 2–16.
- 163. Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG (2009) Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 373: 48–57. doi: 10.1016/s0140-6736(08)61697-9
- 164. Kato M, Granich R, Duc Bui D, Vu Tran H, Nadol P, et al. (2013) The potential impact of expanding antiretroviral therapy and combination prevention in Vietnam: towards elimination of HIV transmission. J Acquir Immune Defic Syndr E-pub ahead of print. doi: 10.1097/QAI.0b013e31829b535b.
- 165. Granich R, Gupta S, Suthar AB, Smyth C, Hoos D, et al. (2011) Antiretroviral therapy in prevention of HIV and TB: update on current research efforts. Curr HIV Res 9: 446–469. doi: 10.2174/157016211798038597
- 166. World Health Organization (2010) Delivering HIV test results and messages for re-testing and counseling in adults. Available: http://whqlibdoc.who.int/publications/2010/9789241599115_eng.pdf. Accessed 1 July 2013.
- 167. Mugglin C, Estill J, Wandeler G, Bender N, Egger M, et al.. (2012) Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health. E-pub ahead of print. doi: 10.1111/j.1365-3156.2012.03089.x.
- 168. Rosen S, Fox MP (2011) Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 8: e1001056 doi:10.1371/journal.pmed.1001056.
- 169. Jaffar S, Amuron B, Foster S, Birungi J, Levin J, et al. (2009) Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial. Lancet 374: 2080–2089. doi: 10.1016/s0140-6736(09)61674-3
- 170. Kipp W, Konde-Lule J, Saunders LD, Alibhai A, Houston S, et al. (2010) Results of a community-based antiretroviral treatment program for HIV-1 infection in Western Uganda. Curr HIV Res 8: 179–185. doi: 10.2174/157016210790442722
- 171. Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, et al. (2010) Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. J Acquir Immune Defic Syndr 55: 483–490. doi: 10.1097/qai.0b013e3181eb5edb
- 172. Pant Pai N, Sharma J, Shivkumar S, Pillay S, Vadnais C, et al. (2013) Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review. PLoS Med 10: e1001414 doi:10.1371/journal.pmed.1001414.
- 173. World Health Organization (2013) Report on the first international symposium on self-testing for HIV: the legal, ethical, gender, human rights and public health implication of HIV self-testing scale-up. Available: http://apps.who.int/iris/bitstream/10665/85267/1/9789241505628_eng.pdf. Accessed 1 July 2013.
- 174. Tang JL, Liu JL (2000) Misleading funnel plot for detection of bias in meta-analysis. J Clin Epidemiol 53: 477–484. doi: 10.1016/s0895-4356(99)00204-8
- 175. Schwartlander B, Stover J, Hallett T, Atun R, Avila C, et al. (2011) Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 377: 2031–2041. doi: 10.1016/s0140-6736(11)60702-2
- 176. World Health Organization (2013) Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. Available: http://www.who.int/hiv/pub/guidelines/arv2013/. Accessed 1 July 2013.