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Results
Characteristics of Included Studies
Forty-four studies were included, of which the majority were conducted in the USA (38 of 44), nine in Europe (eight in the UK and one in Spain), three in Australia and one in Canada (Table 1). Five studies provided nontargeted testing to the general population, while the rest addressed HIV testing in one or more high-risk populations. Eleven studies investigated HIV testing in multiple high-risk groups. The most commonly targeted group for testing was MSM (17 studies, including two that specifically targeted BME MSM). Other groups included IDUs, youth, homeless individuals and individuals from Black and minority ethnic groups.
HIV testing was offered at a wide range of sites. Stand-alone HIV testing sites (14 studies) and mobile clinics (11 studies) were the most frequently selected sites for community testing. Several studies conducted testing in venues known to be frequented by the target population, for example drug treatment centres for IDUs or gay bars and sex on premises venues for MSM. Ad hoc testing events were used as another method of providing HIV testing in the community.
Accepting an HIV Test
Uptake of testing, defined as the proportion of individuals offered tests who accepted, was reported in 14 studies (for 16 different testing models). Uptake rates of HIV testing ranged from 9 to 95% and are difficult to compare given the diverse settings and offer methods (Fig. 2). For example, the 9% uptake of testing was reported in a study where every third man entering a bar in the USA was offered a test. In contrast, the 95% uptake was reported in a mobile clinic, although in this model uptake was measured among individuals who were either recruited by outreach workers on the street or who walked into the van of their own accord.
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Figure 2.
Uptake of HIV testing in community settings. IDU, injecting drug user; MSM, men who have sex with men.
New Diagnoses of HIV Infection
The proportion of clients tested who were newly diagnosed with HIV infection was reported in 34 of the included studies (Table 2). Seropositivity ranged from 0 to 12%, with the highest seropositivity reported from a study that tested transgender people at a variety of community sites. In all studies targeting MSM and two of four studies in BME communities, the seropositivity was 2% or higher. In those studies where HIV testing was not targeted at high-risk populations, lower seropositivity was observed, but was at least 1% among those tested.
In all studies where no new diagnoses were made, HIV testing was included as part of a bundle of tests for multiple STIs. These studies tested a small number of individuals (between 21 and 116 tests). Three of these studies [26, 47, 49] were conducted in services that targeted young adults and, although no HIV diagnoses were made, these services did identify and treat a number of individuals with bacterial STIs. Where no new diagnoses were made, in a project targeting at BME men, the study did demonstrate the feasibility of integrating HIV prevention and behavioural interventions with health screening.
Characteristics of Individuals Having an HIV Test in a Community Setting
The testing history of those individuals attending community settings was reported in 15 studies, with 13 of 15 showing that the large majority of clients (between 62 and 100%) had previously had an HIV test and only two studies reporting that < 50% of people attending had tested previously. Both of these studies used mobile vans to offer HIV testing and one targeted BME communities in the USA, while the other, conducted in Spain, did not target any particular high-risk group.
Only one study compared the testing history of all those who tested with the testing history of those who received a positive result. Overall, 14% of attendees had never previously been tested. However, among those who were newly diagnosed, this proportion was higher, at 24%.
Where included studies compared clients who tested in community settings with those attending more traditional testing services, such as sexual health or STI clinics, there were conflicting results. Two studies, one among MSM testing at a stand-alone HIV testing site in the UK and one in Wisconsin, USA, showed that individuals attending community settings were less likely to receive a positive result than individuals attending the local STI or traditional sexual health clinic. By contrast, a Los Angeles, USA study found a higher seropositivity in MSM tested in a community setting (5.3%) than among those tested at an STI clinic (3.9%). The fourth study showed that a similar HIV seropositivity was observed at a mobile clinic targeting BME populations compared with other testing sites within the same geographical area.
Receiving an HIV Test Result and Transfer to Care
The proportions of patients who received their HIV test result ranged from 29 to 100% (data available for 16 studies). Three studies, which conducted testing from mobile vans, had < 50% return rates (using oral fluid [36, 53] or serological testing [24, 53]). The use of rapid tests consistently resulted in higher proportions of individuals receiving their results (>80%) compared to when laboratory blood or salivary tests were used (five studies). Only three studies reported the proportion of those patients who received a positive HIV test result who were successfully linked to care, and this was 75% and 100%.
Client Attitudes to HIV Testing in Community Settings
Overall, where reported, client satisfaction with community testing services was high (Table 3). Choice of test type, use of a noninvasive test, anonymous testing, confidentiality and the test being free of charge were cited as important factors by clients in choosing to test for HIV. Three studies showed that rapid testing was preferred by clients.
Qualitative work in MSM and BME communities, assessing client attitudes towards HIV testing in community settings, found concerns about possible breaches in confidentiality, as well as stigma and the ability of community services to provide a high professional standard of care. Among MSM there was concern that providing adequate post-test counselling would be difficult in community settings such as bars and clubs.
Providers' Attitudes to HIV Testing in Community Settings
Researchers reported overall positive attitudes of staff towards community testing. Staff training was highlighted as an important component of community testing as it increased the levels of comfort about both the testing and the provision of results in this setting. Developing strong relationships and building trust between venue owners and testing staff was also seen as important. In one study examining the attitudes to introducing HIV testing in bars and saunas frequented by MSM, although venue owners were supportive overall, they did express some concerns that the service may be a deterrent to potential customers.
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