Barriers to HIV testing in Europe: a systematic review

Prevalence of HIV-related stigma among people with HIV in Switzerland: addressing the elephant in the room

OBJECTIVES

We aimed to determine the prevalence of HIV-related stigma among people with HIV (PWH) in Switzerland.

DESIGN

A cross-sectional multicenter study nested within the Swiss HIV Cohort Study (SHCS).

METHODS

We included adult PWH enrolled in the SHCS, attending follow-up between March 1, 2020, and January 31, 2021. Inability to speak English, French, German, or Italian was the only exclusion criterion. Participants were invited to complete a validated 12-item HIV-stigma questionnaire comprising four stigma subscales (negative self-image, personalized stigma, disclosure concerns, and concerns regarding public attitudes), plus two healthcare-related stigma items. Questionnaire responses were graded using a four-point Likert-type scale, higher scores indicating higher stigma. "Non-applicable," inferring HIV-status non-disclosure, was possible for personalized stigma; stigma scores from participants answering "non-applicable" to at least one item were analyzed separately. Factors associated with HIV-stigma were identified through multivariable linear models.

RESULTS

Of 9643 PWH with a SHCS visit, 5563 participated in the study: 26% were female, 13% Black, and 37% heterosexual; median age was 53 years (interquartile range 44-59); 2067 participants (37%) gave at least one "non-applicable" response. Disclosure concerns had the highest stigma scores and were reported by 4656/5563 (84%). HIV-stigma was reported across all demographic groups. However, being female, Black, and heterosexual were independently associated with higher scores. Higher education and longer follow-up duration were associated with lower scores. Healthcare-related stigma was reported in 37% of participants.

CONCLUSION

HIV-stigma was prevalent across all demographic groups. The association with being female and Black suggests that HIV-stigma accentuates preexisting sex and race inequalities.

Understanding Practical, Robust Implementation and Sustainability of Home-based Comprehensive Sexual Health Care: A Realist Review

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations.

A Statistical Model for Inference of Recent and Incident HIV Infection Using Surveillance Data on Individuals Newly Diagnosed With HIV Infection in Scotland

BACKGROUND

To inform global ambitions to end AIDS, evaluation of progress toward HIV incidence reduction requires robust methods to measure incidence. Although HIV diagnosis date in routine HIV/AIDS surveillance systems are often used as a surrogate marker for incidence, it can be misleading if acquisition of transmission occurred years before testing. Other information present in data such as antibody testing dates, avidity testing result, and CD4 counts can assist, but the degree of missing data is often prohibitive.

METHODS

We constructed a Bayesian statistical model to estimate the annual proportion of first ever HIV diagnoses in Scotland (period 2015-2019) that represent recent HIV infection (ie, occurring within the previous 3-4 months) and incident HIV infection (ie, infection within the previous 12 months), by synthesizing avidity testing results and surveillance data on the interval since last negative HIV test.

RESULTS

Over the 5-year analysis period, the model-estimated proportion of incident infection was 43.9% (95% CI: 40.9 to 47.0), and the proportion of recent HIV infection was 21.6% (95% CI: 19.1 to 24.1). Among the mode of HIV acquisition categories, the highest proportion of recent infection was estimated for people who inject drugs: 27.4% (95% CI: 20.4 to 34.4).

CONCLUSIONS

The Bayesian approach is appropriate for the high prevalence of missing data that can occur in routine surveillance data sets. The proposed model will aid countries in improving their understanding of the number of people who have recently acquired their infection, which is needed to progress toward the goal of HIV transmission elimination.

Point of care HIV testing in dental settings in high-income countries: A mixed-methods systematic review

OBJECTIVES

Expanding HIV testing beyond specialized services has been a key strategic approach to eliminating the transmission of HIV. In recent years, dental settings have been identified as offering an opportunity for delivering point of care HIV testing (POCT) interventions. Intervention components and implementation strategies have varied across studies and there is uncertainty about the prevalence of undiagnosed HIV in the dental patient population. Therefore, this systematic review aimed to synthesize the HIV testing outcomes of intervention studies, identify the core components of POCT interventions implemented in dental settings; and understand the barriers and facilitators to intervention implementation.

METHODS

A mixed-methods systematic review was undertaken. Two authors reviewed abstracts and full papers for inclusion and appraised the studies using the Mixed Methods Appraisal Tool. A convergent integrated mixed methods study design underpinned the synthesis. Outcomes were presented using descriptive statistics. Intervention components were mapped to the Template for Intervention Description and Replication (TIDieR) checklist. Barriers and facilitators were described using a narrative thematic analysis.

RESULTS

POCT was offered to 22 146 dental patients, 62.5% accepted POCT. Intervention studies that reported higher uptake of testing utilized a dedicated dental or researcher staff member to provide testing, integrated testing and provided results within the routine dental appointment and adopted a provider-initiated universal approach to offering testing. Six themes emerged that were pertinent to the barriers and facilitators to HIV testing in dental setting.

CONCLUSIONS

POCT uptake in dental settings was comparable with other non-specialized health settings. Key to the operationalization of the intervention were perceptions about its value and relevance to the dental patient population, attitudes toward the intervention, logistical barriers to its implementation, the risk of HIV testing stigma to the patient-practitioner relationship and maximising the fit of the intervention within the constraints of the dental setting.

Opportunities for improved indicator-based HIV testing in the hospital setting: a structural equation model analysis

Indicator condition (IC)-guided HIV testing, i.e., testing when diagnosing a condition associated with HIV, is a feasible and cost-effective testing strategy to identify undiagnosed individuals. Assessing determinants for IC-guided testing may identify opportunities for improvement. A survey study based on the Theory of Planned Behaviour (TPB) was conducted among 163 hospital physicians from five specialties in Amsterdam, the Netherlands. Structural equation models were used to determine the association between the TPB domains (i.e., attitude, belief, norms, self-efficacy and behavioural control) and (1) the intention to test as a mediator for HIV testing behaviour (intentional model) and (2) actual HIV testing behaviour (direct model). Both models accounted for the effect of guideline recommendations. Behaviour scored lower than intention on a five-point scale (mean score of 2.8, SD = 1.6 versus 3.8, SD = 1.1; p<0.0001). The direct model had a better fit than the intentional model based on fit statistics. Discrepancies between the determinants most important for intention versus those for behaviour led to the following recommendations: interventions to improve IC-guided testing in hospitals should primarily focus on implementation of guideline recommendations, followed by improving physicians' attitude towards IC-guided HIV testing and self-efficacy, as these were the most important correlates of actual HIV testing behaviour.

Missed Opportunities in HIV Testing in Turkiye: Implications for Late Diagnoses

BACKGROUND

Late diagnosis of HIV infection is a major global problem. In Turkiye, only 41%-50% of people living with HIV are diagnosed, suggesting that many opportunities for HIV testing might be missed.

SETTING

The aim of this study was to determine the missed testing opportunities for HIV in healthcare settings in Turkiye and the predictors for missed opportunities (MOs).

METHODS

The study included patients with a new HIV diagnosis, presenting to care between January 2018 and December 2020. They were given a verbal questionnaire face to face, by a telephone call or an online meeting for visits to a health care setting within the year before their diagnosis. Electronic medical records were also examined.

RESULTS

The sample included 198 patients with at least 1 visit to any health care setting, with a total of 1677 visits. Patients had an indication for HIV testing in 51.3% (861/1677) of the visits; an HIV test was not offered in 77.9% (671/861) and was considered a MO. The highest number of MOs was in emergency departments (59.8%) (180/301). The most common reason for visiting was constitutional symptoms and indicator conditions (55.4%) (929/1677). University graduates and those with a CD4+ T-cell count <200/mm 3 were more likely to have a MO.

CONCLUSIONS

Many opportunities to diagnose HIV at an early stage are missed in health care settings in Turkiye. Considering the rapidly increasing number of new diagnoses in the last decade, urgent action needs to be taken.

Missed opportunities for HIV testing and sexual health-related challenges in an individual with intellectual disability: a case report

BACKGROUND

HIV testing remains an important tool in identifying people living with HIV/AIDS (PLWHA). An early diagnosis of HIV can lead to a prolonged life expectancy if treatment is initiated promptly. Indicator conditions can be the first sign of an HIV infection and should therefore be recognised and consequently a HIV test should be carried out. Testing should occur in all individuals as sexuality can be experienced by everyone, and stigma can lead to the exclusion of vulnerable groups, leading to a gap in diagnosis and treatment [1, 2].

CASE PRESENTATION

A 63-year-old man, who identifies as bisexual and has had an intellectual disability since birth, presented at our health care centre for HIV testing. A decade ago, the patient was diagnosed with Stage III Diffuse Large B-cell Non-Hodgkin Lymphoma, an AIDS defining cancer. The patient presented at a Haematology and Oncology department 3 months prior, due to a weight loss of 10 kg over the past 5 months. Oral thrush, an HIV-indicator condition, had been diagnosed by the otolaryngologists shortly before. During this medical evaluation, pancytopenia was identified. Despite the presence of indicator conditions, the patient was never tested for HIV in the past. Staff members from the care facility for intellectually disabled suggested conducting a HIV test in our clinic through the public health department, where HIV positivity was revealed. The AIDS-defining diagnosis, along with a CD4 + cell count of 41/µl, suggests a prolonged period of HIV positivity.

CONCLUSION

Due to the presence of existing indicator conditions, an earlier HIV diagnosis was possible. We contend that most of the recent illnesses could have been prevented if earlier testing had been carried out. Therefore, patients presenting with AIDS indicator conditions, including those with mental disabilities, should be given the opportunity to be tested for HIV. HIV/AIDS trainings should be made available to health care professionals as well as to personnel interacting with vulnerable groups.

The Association Between HIV-Related Stigma and the Uptake of HIV Testing and ART Among Older Adults in Rural South Africa: Findings from the HAALSI Cohort Study

HIV testing and antiretroviral therapy (ART) remain critical for curbing the spread of HIV/AIDS, but stigma can impede access to these services. Using data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI), we used a multivariable logistic regression to examine the correlation between HIV-related stigma, HIV testing and ART uptake in older adults. We used four questions to measure stigma, with three assessing social stigma (reflecting social distancing preferences) and one assessing anticipated stigma (disclosure concern). We combined the three social stigma questions to generate a social stigma score ranging from 0 to 3, with higher scores indicating higher stigma. Anticipated stigma was prevalent 85% (95% CI 0.84-0.86), and social stigma was also frequent 25% (95% CI 0.24-0.27). Higher social stigma scores correlated with decreased HIV testing for all participants with social stigma. Compared to those with a score of 0, odds of testing decreased with higher stigma scores (OR = 0.66, 95% CI 0.53-0.81, p = 0.000) for a score of 1 and (OR = 0.56, 95% CI 0.38-0.83, p = 0.004) for a score of 3. ART uptake also decreased with higher social stigma scores among people living with HIV (PLWH), although it was significant for those with a score of 2 (OR = 0.41, 95% CI 0.19-0.87, p = 0.020). These findings emphasize that HIV-related stigma hampers testing and ART uptake among older adults in rural South Africa. Addressing stigma is crucial for improving testing rates, early diagnosis, and treatment initiation among the older population and achieving UNAIDS 95-95-95 targets.

"I told myself, be bold and go and test": Motivators and barriers to HIV testing among gay, bisexual, and other cis-gender men who have sex with men in Ghana ‒ West Africa

Despite a disproportionately high burden of HIV, GBMSM in Ghana and sub-Saharan Africa often delay testing until the point of illness. However, limited studies examine factors that affect their participation in testing. We used qualitative in-depth interviews (IDIs) and focus group discussions (FGDs) to collect insights into experiences, motivators, and barriers to HIV testing among GBMSM. Two community-based organizations used snowball and convenience sampling to recruit 10 GBMSM for IDIs and 8 to 12 for FGDs. We transcribed, coded, identified, and analyzed the relationship and commonalities between the participants' responses. Under experiences with testing, 1) fear of HIV infection created a stressful HIV testing experience, and 2) a friendly and supportive healthcare environment facilitated a positive experience in healthcare facilities. Motivators or facilitators of testing include 1) the perception or belief that HIV testing is an HIV prevention strategy; 2) encouragement from friends and peers; 3) understanding risk associated with certain sexual behaviors; 4) education or information on HIV; 5) access to free testing and incentives; 6) early symptoms and provider recommendation. Barriers to HIV testing include 1) negative community perceptions of HIV; 2) individual-level low-risk perception or indifference about HIV infection; 3) health system issues; 5) Perceived stigma at healthcare facilities. The findings point to the need to address critical issues around stigma, education, peer support, and healthcare resources through interventions and research to improve HIV testing among GBMSM in the country.

The roles of the general practitioner and sexual health centre in HIV testing: comparative insights and impact on HIV incidence rates in the Rotterdam area, the Netherlands - a cross-sectional population-based study

BACKGROUND

Access to HIV testing is crucial for detection, linkage to treatment, and prevention. In less urbanised areas, reliance on general practitioners (GPs) for HIV testing is probable, as sexual health centres (SHC) are mostly located within urbanised areas. Limited insight into individuals undergoing HIV testing stems from sparse standard registration of demographics at GPs. This cross-sectional study aims (1) to assess and compare HIV testing at the GP and SHC, and (2) to assess population- and provider-specific HIV incidence.

METHODS

Individual HIV testing data of GPs and SHC were linked to population register data (aged ≥ 15 years, Rotterdam area, 2015-2019). We reported the proportion HIV tested, and compared GP and SHC testing rates with negative binomial generalised additive models. Data on new HIV diagnoses (2015-2019) from the Dutch HIV Monitoring Foundation relative to the population were used to assess HIV incidence.

RESULTS

The overall proportion HIV tested was 1.14% for all residents, ranging from 0.41% for ≥ 40-year-olds to 4.70% for Antilleans. The GP testing rate was generally higher than the SHC testing rate with an overall rate ratio (RR) of 1.61 (95% CI: 1.56-1.65), but not for 15-24-year-olds (RR: 0.81, 95% CI: 0.74-0.88). Large differences in HIV testing rate (1.36 to 39.47 per 1,000 residents) and GP-SHC ratio (RR: 0.23 to 7.24) by geographical area were observed. The GPs' contribution in HIV testing was greater for GP in areas further away from the SHC. In general, population groups that are relatively often tested are also the groups with most diagnoses and highest incidence (e.g., men who have sex with men, non-western). The overall incidence was 10.55 per 100,000 residents, varying from 3.09 for heterosexual men/women to 24.04 for 25-29-year-olds.

CONCLUSIONS

GPs have a pivotal role in HIV testing in less urbanised areas further away from the SHC, and among some population groups. A relatively high incidence often follows relatively high testing rates. Opportunities to improve HIV testing have been found for migrants, lower-educated individuals, in areas less urbanised areas and further away from GP/SHC. Strategies include additional targeted testing, via for example SHC branch locations and outreach activities.

Muslim women's perspectives on the barriers to sexually transmitted infections testing and diagnosis in Saudi Arabia

Background

Muslim women are especially vulnerable to sexually transmitted infections (STI) and are at higher risk of under-detection. Evidence on the unique barriers to STI testing and diagnosis among Muslim communities is severely lacking. Understanding the complexity of accessing STI testing and diagnosis in Muslim communities is an area that requires further exploration. We aimed to explore the multilevel barriers to STI testing and diagnosis among Muslim women.

Methods

We conducted qualitative semi-structured interviews informed by the ecological model of health. This study took place in Riyadh Saudi Arabia in 2019 with women aged over 18. Data were analysed using reflexive thematic analysis.

Results

Twenty-eight women were interviewed from different ages, marital status, employment, and educational levels. Muslim women's perceived barriers to STI testing and diagnosis included personal, socio-cultural, and service-level barriers. Lack of knowledge about STIs, denial, and underestimating the seriousness of infection and symptoms were among the many individual barriers to STIs testing and diagnosis. Religious views towards extramarital sex and negative views of people with STIs is a significant barrier to STI testing and diagnosis. Lack of patient confidentiality and providers' judgement and mistreatment were also cited as barriers to seeking healthcare.

Conclusion

Barriers to STI testing and diagnosis exist on many levels including personal, socio-cultural, religious, and healthcare services, and at policy level. Multilevel interventions are needed to reduce the stigma of STIs and facilitate access to sexual health services among Muslims. It is our recommendation that policy and research efforts are directed to enhance trust in the doctor-patient relationship through better clinical training as well as implementing stricter regulations to protect patients' confidentiality in healthcare settings.

Cultural Adaptation and Validation of the Barriers to HIV Testing Scale-Karolinska Version for Brazilian Men Who Have Sex With Men

ABSTRACT

The aim of this study was to perform the cultural adaptation and validation of the Barriers to HIV testing scale-Karolinska version for Brazilian men who have sex with men. A methodological study was conducted for cultural adaptation and validation of the scale. Reliability analyses, exploratory factor analysis, confirmatory factor analysis, and convergent and discriminant validity tests were performed. Four factors were extracted: F1, personal consequences; F2, structural barriers; F3, confidentiality; F4, economic consequences and individual concerns. Good fit indexes were obtained: (χ 2 )/GL (2.71); goodness of fit index (0.94); root-mean-square error of approximation (0.052; 90% CI [0.045-0.059]); Tucker-Lewis index (0.94); normed fit index (0.93); IFI (0.95); comparative fit index (0.95). Convergent validity results were greater than 0.7 for the four factors. The adapted version of the scale showed satisfactory reliability and validity for assessing barriers to HIV testing among men who have sex with men.

Community-based HIV testing through a general health check event in a high HIV-prevalent multicultural area in Rotterdam, The Netherlands: a pilot study on feasibility and acceptance

BACKGROUND

HIV testing is crucial for finding the remaining cases in a declining HIV epidemic in The Netherlands; providing HIV testing in non-traditional settings may be warranted. We conducted a pilot study to determine the feasibility and acceptability of a community-based HIV testing (CBHT) approach with general health checks to improve HIV test uptake.

METHODS

CBHT's main conditions were low-threshold, free-of-charge, general health check, and HIV education. We interviewed 6 community leaders, 25 residents, and 12 professionals/volunteers from local organizations to outline these main conditions. Walk-in test events were piloted at community organizations, providing HIV testing along with body mass index (BMI), blood pressure, blood glucose screening, and HIV education (October 2019 to February 2020). Demographics, HIV testing history, risk perception, and sexual contact were collected via questionnaires. To evaluate the pilots' feasibility and acceptance, we utilized the RE-AIM framework and predefined goals, incorporating quantitative data from the test events and qualitative input from participants, organizations, and staff.

RESULTS

A total of 140 individuals participated (74% women, 85% non-Western, median age 49 years old). The number of participants during the seven 4-h test events ranged from 10 to 31. We tested 134 participants for HIV, and one was found positive (positivity 0.75%). Almost 90% of the participants were never tested or > 1 year ago, and 90% perceived no HIV risk. One-third of the participants had one or more abnormal test results on BMI, blood pressure, or blood glucose. The pilot was well-rated and accepted by all parties. The staff had concerns about waiting time, language problems, and privacy. Participants hardly indicated these concerns.

CONCLUSIONS

This CBHT approach is feasible, acceptable, and well-suited for testing not (recently) tested individuals and detecting new cases. Besides reducing HIV-associated stigma and increasing HIV test acceptance, offering multiple health tests may be appropriate as we frequently observed multiple health problems. Whether this laborious approach is sustainable in the micro-elimination of HIV and should be deployed on a large scale is questionable. CBHT like ours may be suitable as a supplement to more sustainable and cost-effective methods, e.g., proactive HIV testing by general practitioners and partner notification.

An application of social marketing for promoting HIV testing in Iran

BACKGROUND

It has been estimated that 60,000 Iranians have been infected with HIV/AIDS and only 36% of them are aware of their status. This study aimed to design, implement and evaluate a social marketing campaign to promote HIV testing in Boyer-Ahmad County, Kohgiluyeh, and Boyer-Ahmad Province, southwest of Iran.

MATERIALS AND METHODS

This study was a quasi-experimental pretest-posttest without a control group, developed based on a social marketing assessment and response tool. To design the intervention formative research was conducted, comprised of four focus group discussion sessions with 42 participants of the target community along with seven in-depth semi-structured personal interviews with health care providers involved in the HIV/AIDS Program. Data analysis was done manually using content analysis and the main content was formulated for the campaign. Afterward, the slogan and messages of the campaign were developed. The campaign's materials including banners, posters, pamphlets, referral forms, and short messages were designed, pretested, and revised. Ultimately, the campaign was conducted for one month in October 2019. To determine the effectiveness of the campaign, the rate of referrals to the Center for Behavioral Health Counseling Services (CBHCS), for three months before and after the campaign, was compared.

RESULTS

Qualitative findings identified that the majority of the interviewees mentioned that the main reasons for the low rate of referrals to get tested for HIV were lack of awareness and information about HIV/AIDS and its diagnosis as well as the free and confidential tests available from the CBHCS. Moreover, the stigma associated with HIV/AIDS was another important reason for low referrals for testing. The rate of referrals for HIV testing in the three months leading up to the campaign was 18, 32, and 23 people, and three months after the campaign was 64, 81, and 44 individuals; respectively. The results of the multivariate analysis demonstrated that the campaign had increased the rates of referrals for HIV testing through its significant influence on females, and individuals with academic degrees.

CONCLUSION

It can be concluded that the social marketing campaign was successful in persuading people to get tested for HIV.

Factors associated with HIV testing in people aged ⩾50 years: an integrated qualitative analysis of patients and healthcare providers

Background

Older people continue to be disproportionately affected by late HIV diagnosis, which results in increased morbidity and mortality. Despite high acceptance of HIV testing generally, older people are less likely to undergo testing than younger people. Two previous studies have been conducted, one focussing on patient-related and one focussing on clinician-related factors associated with HIV testing in older age (⩾50 years).

Objective

This study is an integrated analysis from two linked studies - one focussed on patients, and one focussed on clinicians - to understand overlap in views and experiences of HIV testing in older age, to outline the clinical implications of the findings, and to highlight potential interventions to improve testing in this group.

Methods

This qualitative study utilised semi-structured interviews conducted with 20 clinicians who were not HIV care specialists, but who had recently seen an older person prior to their HIV diagnosis, and 20 people who had been diagnosed late with HIV aged 50+. Interviews were audio recorded, transcribed verbatim and thematically analysed. The combined synthesis reported here was planned a priori as part of a sequential design.

Results

Seven clinician- and seven patient-related themes were associated with undergoing HIV testing in older age. This article discusses the four themes that were common to both groups: poor knowledge, incorrect symptom attribution, inaccurate perception of risk, and stigma.

Conclusion

Both clinician and patient factors associated with testing will have to be addressed in order to increase HIV testing in older people, and reduce the likelihood of late diagnosis. Findings from overlapping themes suggest several areas for intervention: (1) routine screening as part of existing clinical contacts aimed at older people to eliminate the need to attribute symptoms to HIV or assess risk; (2) specific and tailored education materials for clinicians and older people which utilise appropriate modalities; (3) tailored HIV testing services: either specific clinics for older people at existing sexual health services, or dedicated services in primary care.

Interventions to enhance testing and linkage to treatment for hepatitis C infection for people who inject drugs: A systematic review and meta-analysis

BACKGROUND

With the advent of direct acting antiviral (DAA) therapies for the treatment of hepatitis C virus (HCV), the World Health Organization recommended a goal to eliminate HCV as a public health threat globally by 2030. With the majority of new and existing infections in high income countries occurring among people who inject drugs, achieving this goal will require the design and implementation of interventions which address the unique barriers to HCV care faced by this population.

METHODS

In this systematic review and meta-analysis, we searched bibliographic databases and conference abstracts to July 21, 2020 for studies assessing interventions to improve the following study outcomes: HCV antibody testing, HCV RNA testing, linkage to care, and treatment initiation. We included both randomised and non-randomised studies which included a comparator arm. We excluded studies which enrolled only paediatric populations (<18 years old) and studies where the intervention was conducted in a different healthcare setting than the control or comparator. This analysis was restricted to studies conducted among people who inject drugs. Data were extracted from the identified records and meta-analysis was used to pool the effect of interventions on study outcomes. This study was registered in PROSPERO (CRD42020178035).

FINDINGS

Of 15,342 unique records, 45 studies described the implementation of an intervention to improve HCV testing, linkage to care and treatment initiation among people who inject drugs. These included 27 randomised trials and 18 non-randomised studies with the risk of bias rated as "critical" for most non-randomised studies. Patient education and patient navigation to address patient-level barriers to HCV care were shown to improve antibody testing uptake and linkage to HCV care respectively although patient education did not improve antibody testing when restricted to randomised studies. Provider care coordination to address provider level barriers to HCV care was effective at improving antibody testing uptake. Three different interventions to address systems-level barriers to HCV care were effective across different stages of HCV care: point-of-care antibody testing (linkage to care); dried blood-spot testing (antibody testing uptake); and integrated care (linkage to care and treatment initiation).

INTERPRETATION

Multiple interventions are available that can address the barriers to HCV care for people who inject drugs at the patient-, provider-, and systems-level. The design of models of care to improve HCV testing and treatment among people who inject drugs must consider the unique barriers to care that this population faces. Further research, including high-quality randomised controlled trials, are needed to robustly assess the impact these interventions can have in varied populations and settings.

Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines

BACKGROUND

New HIV infections in the Philippines are increasing at an alarming rate. However, over three quarters of men who have sex with men (MSM) have never been tested for HIV. HIV self-testing (HIVST) may increase overall testing rates by removing barriers, particularly fear of stigmatization and mistrust of providers. This study aimed to determine if these factors are associated with preference for HIVST among Filipino cisgender MSM (cis-MSM), and whether there is an interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST.

METHODS

We conducted secondary analysis of a one-time survey of 803 cis-MSM who were recruited using purposive sampling from online MSM dating sites and MSM-themed bar locations in Metro Manila, Philippines. Summary statistics were computed to describe participant characteristics. Multivariable modified Poisson regression analyses were conducted to determine if anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST among cis-MSM. Other variables such as age, education, monthly income, relationship status, HIV serostatus, and knowing where to get HIV testing were the minimal sufficient adjustment set in the analyses.

RESULTS

Average age of participants was 28.6 years (SD = 8.0); most had received college degrees (73%) and were employed (80%). Most respondents (81%) preferred facility-based testing, while 19% preferred HIVST. A high percentage of participants reported anticipated HIV testing stigma (66%) and provider mistrust (44%). Anticipated HIV testing stigma (aPR = 1.51; 95% CI = 1.01-2.25, p = 0.046) and provider mistrust (aPR = 1.49; 95% CI = 1.07-2.09, p = 0.020) were independently associated with a preference for HIVST. There was a positive, additive interaction between provider mistrust and anticipated HIV testing stigma on preference for HIVST (RERI = 1.13, 95% CI: 0.20-2.06; p = 0.017), indicating that the association between anticipated HIV testing stigma and preference for HIVST is greater among those with provider mistrust compared to those without provider mistrust.

CONCLUSIONS

HIVST should be offered as a supplement to traditional facility-based HIV testing services in the Philippines to expand testing and reach individuals who may not undergo testing due to anticipated HIV testing stigma and provider mistrust.

Opt-in HIV testing in construction workplaces: an exploration of its suitability, using the socioecological framework

Background

Late diagnosis of HIV remains a challenge, despite improved testing and treatment. Testing is often targeted at high-risk groups; workplace events might normalise testing and allow access to a wider population. The construction workforce has a number of risk factors for HIV. In the Test@Work study, HIV tests were delivered within general health checks to construction employees, with high uptake and acceptability. This paper reports on the experiences of construction managers and health professionals involved in Test@Work and explores the suitability of construction worksites as a venue for opt-in HIV testing.

Methods

Qualitative interviews (n = 24) were conducted with construction managers who had facilitated health check/HIV testing (n = 13), and delivery partners (n = 11) including i) healthcare volunteers who had delivered general health checks (n = 7) and, ii) HIV professionals who had conducted HIV testing (n = 4) at 21 Test@Work events held on construction sites. Interviews explored their experiences of these events and views towards HIV testing in the workplace. Exit questionnaires (n = 107) were completed by delivery partners after every event, providing qualitative data identifying facilitators and barriers to effective delivery. Thematic analysis identified themes that were mapped against a socioecological framework.

Results

Delivery partners reported high engagement of construction workers with workplace HIV testing, peer-to-peer encouragement for uptake, and value for accessibility of onsite testing. HIV professionals valued the opportunity to reach an untested population, many of whom had a poor understanding of their exposure to HIV risk. Managers valued the opportunity to offer workplace health checks to employees but some identified challenges with event planning, or provision of private facilities.

Conclusions

The construction sector is complex with a largely male workforce. Providing worksite HIV testing and education to an untested population who have poor knowledge about HIV risk helped to normalise testing, encourage uptake and reduce HIV-related stigma. However, there are practical barriers to testing in the construction environment. Rapid testing may not be the most suitable approach given the challenges of maintaining confidentiality on construction worksites and alternatives should be explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13787-5.

Increasing HIV early diagnosis by implementing an automated screening strategy in emergency departments

INTRODUCTION

Late HIV diagnosis is associated with increased morbidity, mortality and risk of onward transmission. Increasing HIV early diagnosis is still a priority. In this observational study with historical control, we determined the impact of an opportunistic HIV screening strategy in the reduction of late diagnosis and missed opportunities for earlier diagnosis.

METHODS

The screening programme was implemented in the emergency department (ED) of the Hospital de Cascais between September 2018 and September 2021. Eligible patients were aged 18-64 years, with no known HIV diagnosis or antibody testing performed in the previous year, and who required blood work for any reason. Out of the 252 153 emergency visits to the ED, we identified 43 153 (17.1%) patients eligible for HIV testing. Among the total population eligible for the screening, 38 357 (88.9%) patients were ultimately tested for HIV. Impact of the ED screening was determined by analysing late diagnosis in the ED and missed opportunities at different healthcare settings 3 years before and 3 years after the start of the ED screening.

RESULTS

After 3 years of automated HIV ED testing, we found 69 newly diagnosed HIV cases (54% male, 39% Portuguese nationals, mean age 40.5 years). When comparing the characteristics of HIV diagnoses made in the ED, we observed a significant reduction in the number of people with late HIV diagnosis before and after implementation of the screening programme (78.4% vs. 39.1%, respectively; p = 0.0291). The mean number of missed opportunities for diagnosis also fell (2.6 vs. 1.5 annual encounters with the healthcare system per patient, p = 0.0997).

CONCLUSIONS

People living with HIV in Cascais and their providers miss several opportunities for earlier diagnosis. Opportunistic screening strategies in settings previously deemed to be unconventional, such as EDs, are feasible and effective in mitigating missed opportunities for timely HIV diagnosis.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Investigating pathways for predisposing, enabling and need factors in predicting the use of STI/HIV-testing services among Syrian and Iraqi migrants in Scania, Sweden - a cross-sectional study with directed acyclic graphs for modelling pathways to testing

BACKGROUND

Some groups of migrants have increased vulnerability to Sexually Transmitted Infections (STI) and Human Immunodeficiency Virus (HIV) transmission partly due to a lower uptake of disease preventive activities targeting the general population in receiving country. Limited access to economic and social resources and poor language skills may exacerbate exposure to sexual risks and utilization of health services.

AIM

To explore general and migrant specific predictors for STI/HIV-testing among Syrian and Iraqi migrants in Sweden and to investigate potential pathways that link predisposing, enabling and need- factors to STI/HIV-testing.

METHOD

Cross-sectional study design based on a migration specific framework for health care utilization. Directed acyclic graphs (DAGs) were used to model assumptions about factors associated with the uptake of STI/HIV-testing services. Bi-variable and multivariable logistic regression analyses assessed individual predictors while adjusting for covariates. The magnitude of the indirect effect of mediating variables were estimated with bootstrap analyses and a method for decomposing the total effect.

RESULT

The pathways between younger age, unmarried, and self-identifying as bi- or homosexual and testing were mainly indirect, mediated by experiences of sexual coercion and other risk behaviours. One third of the indirect mediating effect of the pathway between higher education and testing could be attributed to Swedish language skills.

CONCLUSION

Utilization of STI/HIV-testing services among Syrian and Iraqi migrants seemed to be motivated by sexual risk exposure and risk awareness. Interventions should focus on language-adapted information about available screening services and where to go for advice on sexual wellbeing and sexual rights. Such activities should be implemented within an integration promoting framework, addressing structures that increase STI/HIV risk exposure, specifically targeting vulnerable subgroups of migrants.

Determinants of therapy failure among adults on first-line antiretroviral therapy in Asmara, Eritrea: a multicenter retrospective matched case-control study

BACKGROUND

Information on treatment failure (TF) in People living with HIV in a data-poor setting is necessary to counter the epidemic of TF with first-line combined antiretroviral therapies (cART) in sub-Saharan Africa (SSA). In this study, we examined the risk factors associated with TF in Asmara, Eritrea from 2001 to 2020.

METHODS

A multicenter, retrospective 1:2 matched (by age and gender) case-control study was conducted in four major hospitals in Asmara, Eritrea on adults aged ≥ 18 years who were on treatment for at least 6 months. Cases were patients who fulfills at least one of the WHO therapy failure criterion during the study period. Controls were randomly selected patients on first-line treatment and plasma viral load < 1000 copies/ml in their latest follow-up measurement. Multivariable logistic regression analysis was conducted to identify risk factors for TF. All P-values were 2-sided and the level of significance was set at P < 0.05 for all analyses.

RESULTS

Of the 1068 participants (356 cases; 712 controls), 585 (54.7%) were females. The median age at treatment initiation was 46 years [interquartile range (IQR): 39-51]. Median time to combined antiretroviral therapy (cART) failure was 37 months (IQR = 24-47). In the multivariate analysis, factors associated with increased likelihood of TF included initial nucleoside reverse transcriptase inhibitors (NRTI) backbone (Zidovudine + Lamivudine (AZT + 3TC): adjusted odds ratio (aOR) = 2.70, 95% Confidence interval (CI): 1.65-4.41, P-value < 0.001), (Abacavir + lamivudine (ABC + 3TC): aOR = 4.73, 95%CI: 1.18-18.92, P-value = 0.028], and (Stavudine + Lamivudine (D4T + 3TC): aOR = 5.00; 95% CI: 3.03-8.20, P-value < 0.001) in comparison to Emtricitabine and Tenofovir diproxil fumarate (FTC + TDF). Additional associations included prior exposure to cART (aOR = 2.28, 95%CI: 1.35-3.86; P- value = 0.002), record of sub-optimal drug adherence (aOR = 3.08, 95%CI: 2.22-4.28; P < 0.001), ambulatory/bedridden at presentation (aOR = 1.61, 95%CI: 1.12-4.28; P-value = 0.010), presence of comorbidities (aOR = 2.37; 95%CI: 1.36-4.10, P-value = 0.002), duration of cART (< 5 years: aOR: 5.90; 95% CI: 3.95-8.73, P-value < 0.001), and use of SMX-TMP prophylaxis (aOR = 2.00, 95%CI, 1.44-2.78, P-value < 0.001).

CONCLUSION

Our findings underscore the importance of optimizing cART adherence, diversification of cART regimens, and interventions directed at enhancing early HIV diagnosis, prompt initiations of treatment, and improved patient-focused monitoring of treatment response.

Late diagnosis of HIV infection and its associated factors in Shiraz, Southern Iran: a retrospective study

Late diagnosis (LD) of HIV infection can give rise to suboptimal responses to antiretroviral treatment. The current study aimed to determine the prevalence and associated factors of HIV LD in Shiraz, Southern Iran. This retrospective cohort study was conducted from August 1997 to May 2018. Medical records were examined to extract required data. Individuals with time period less than three months from HIV diagnosis to an advanced phase of AIDS on CD4 < 350 were considered as LD. Multivariable logistic regression used to investigate the associated factors of late HIV diagnosis and adjusted odds ratios were reported. Of 1385 individuals, 1043 (75.3%) were considered as LD. The following factors were identified as the associated factors of LD: age at diagnosis (OR = 1.72, 95% CI: 1.22, 2.41), HCV co-infection (OR = 1.65, 95% CI: 1.23, 2.21), not living in Shiraz (OR = 1.36, 95% CI: 1.02, 1.82), increased likelihood of LD and being housewife (OR = 0.67, 95% CI: 0.47, 0.95) which decreased the likelihood of LD. Our results showed delayed diagnosis of a large proportion of individuals with HIV. It is critical to improve the HIV testing guidelines in Iran to identify individuals with HIV without delays in order to provide them with timely HIV medical care and treatment.

PrEP in the Context of Other HIV Risk Reduction Strategies Among Men Who Have Sex with Men: Results from the Flash! PrEP in Europe Survey

Combination HIV prevention covers a range of biomedical, behavioral, and socio-structural interventions. Despite the growing availability of pre-exposure prophylaxis (PrEP), it is not always accessible in European Centre for Disease Prevention and Control reporting countries and may not meet the needs of all at-risk populations. Based on the Flash! PrEP in Europe data, multiple correspondence analysis and hierarchical clustering were used to identify patterns in HIV prevention strategies among 9980 men who have sex with men (MSM). PrEP interest was evaluated among four identified clusters: (A) "high condom use, sometimes Treatment as Prevention (TasP)"; (B) "mix of methods, infrequent condom use"; (C) "high condom use, tendency to choose partners based on serological status" and (D) "moderate use of condoms mixed with other prevention strategies". Clusters B and D had higher PrEP interest. These results suggest that MSM use a range of behavioral and biomedical risk reduction strategies that are often combined. On-demand PrEP may meet the needs of MSM who infrequently use condoms and other prevention methods.

Electronic medical record alert increases HIV screening rates: the Foch hospital pilot POP-up project

Background

Despite significant national human immunodeficiency virus (HIV) screening activity, there are persistent delays in screening, and many missed diagnostic opportunities. To facilitate targeted screening, an electronic medical record (EMR) alert reminder was applied in the Foch hospital. Screening rates after implementation were reported.

Methods

A prospective cohort analysis was performed in Foch Hospital between 24 April 2018 and 4 October 2019 among hospitalized patients born in high HIV prevalence countries and/or having social vulnerability criteria (universal health coverage). From the admissions software, when specific low health coverage was provided and/or high-prevalence country of birth was registered, an electronic alert (EMR alert) appeared on the ward where the patient was hospitalized. The EMR alert database was examined for HIV screening and activity responses from each service of the Hospital.

Results

Eight thousand one hundred eighty-one alerts were recovered during the period for 1448 patients. 27 services used the EMR alert. Most of the alerts were directly closed (74.4%), 14.5% of the alerts were closed due to doctors declaring that they did not have time to respond. 297 (3.6%) of the 8181 alerts resulted in a prescription of HIV serology corresponding for 20.5% of the patients.

Conclusion

EMR alert can help to increase the rate of HIV screening in hospital care practice. Through this EMR alert system, HIV screening can be implemented as a common practice like any other medical alternative. Future research should examine the factors influencing physicians’ attitudes to this alert system to improve the HIV screening rate.

Barriers and Facilitators to Participation in Health Screening: an Umbrella Review Across Conditions

Screening is an essential prevention practice for a number of health conditions. However, screening coverage remains generally low. Studies that investigate determinants of screening participation are becoming more common, but oftentimes investigate screening for health conditions in an individualized rather than integrated fashion. In routine clinical practice, however, healthcare professionals are often confronted with situations in which several screening procedures are recommended for the same patient. The consideration of their common determinants may support a more integrated screening approach. The objectives of this umbrella review were therefore to examine: 1) the determinants (barriers and facilitators) that have been identified in relation to recommended health screening procedures; and 2) the modifiable determinants (in primary care) common across health conditions or specific to individual procedures. Results were presented through a narrative synthesis. PubMed, PsycInfo and Cochrane were searched up to January 2022. Systematic reviews reporting determinants of participation in health screening procedures with grade A or B recommendation according to the US Preventive Services Task Force were included. A total of 85 systematic reviews were included, most which contained both qualitative and quantitative studies on determinants that describe individual factors (961 occurrences), social factors (113 occurrences, healthcare professional factors (149 occurrences), health system factors (105 occurrences) and screening procedure factors (99 occurrences). The most studied screening procedures concerned cervical cancer/human papillomavirus (n = 33), breast cancer (n = 28), colorectal cancer (n = 25) and the human immunodeficiency virus (n = 12). Other conditions have been under-studied (e.g. cardiovascular problems, lung cancer, syphilis). The individual domain, including determinants such as knowledge, beliefs and emotions, was the most covered across health conditions. Healthcare professional's recommendations and the quality of patient-provider communication were identified to have a strong influence on screening participation in most conditions. The other three domains included determinants which were more specific to a condition or a population. Various determinants modifiable in primary care were found in the individual domain and in the health system, healthcare professional and screening procedure domains. Quality was assessed as low for most systematic reviews included. The identification of various modifiable determinants common across conditions highlights the potential of an integrated screening participation approach. Interventions may address common determinants in a broader person-centred framework within which tailoring to specific procedures or populations can be considered. This approach needs to be explored in intervention studies. The systematic review registration is PROSPERO CRD42019126709.

Acceptability and perceptions of HIV oral self-testing across settings: A comparative qualitative study among Dominican and Tanzanian female sex workers

Rapid oral HIV self-tests (HIVST) have potential to increase the proportion of people who know their HIV status, especially among stigmatised populations. This study was embedded in two cohorts of female sex workers (FSW) in the Dominican Republic (DR) and Tanzania. Qualitative interviews with 40 FSW were conducted to explore perceived acceptability of HIVST. Interviews were analysed using inductive and deductive thematic coding. Emergent themes were organised by socio-ecological framework levels. FSW in both settings responded positively to the ease of use of HIVST but questioned test accuracy due to the use of saliva rather than blood. FSW in the DR had a more cautious response, while women in Tanzania had favourable perceptions expressing eagerness to use it. At the individual level, themes shaping participants' interest included autonomy, HIV risk perception, and emotional well-being for those with reactive test results, and self-efficacy. At the interpersonal level, privacy, confidentiality, sex work and HIV stigma and social support were salient. Structural level themes focused on health systems including linkages to HIV treatment, provider roles, and access (cost, travel, distribution). Understanding FSW's perceptions and acceptability of HIVST is essential to its integration into health systems and programmes using a community-driven approach.

Interventions to enhance testing, linkage to care, and treatment initiation for hepatitis C virus infection: a systematic review and meta-analysis

BACKGROUND

Despite the goal set by WHO to eliminate hepatitis C virus (HCV) as a public health threat, uptake of HCV testing and treatment remains low. To achieve this target, evidence-based interventions are needed to address the barriers to care for people with, or at risk of, HCV infection. We aimed to assess the efficacy of interventions to improve HCV antibody testing, HCV RNA testing, linkage to HCV care, and treatment initiation.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE (PubMed), Scopus, Web of Science, the Cochrane Central Register of Controlled Trials, and PsycINFO without language restrictions for reports published between database inception and July 21, 2020, assessing the following primary outcomes: HCV antibody testing; HCV RNA testing; linkage to HCV care; and direct-acting antiviral treatment initiation. We also searched key conference abstracts. We included randomised and non-randomised studies assessing non-pharmaceutical interventions that included a comparator or control group. Studies were excluded if they enrolled only paediatric populations (aged <18 years) or if they conducted the intervention in a different health-care setting to that of the control or comparator. Authors were contacted to clarify study details and to obtain additional population-level data. Data were extracted from the records identified into a pre-piloted and standardised data extraction form and a random-effects meta-analysis was used to pool the effects of the interventions on study outcomes. This study is registered in PROSPERO, CRD42020178035.

FINDINGS

Of 15 342 unique records identified, 142 were included, which reported on 148 unique studies (47 randomised controlled trials and 101 non-randomised studies). Medical chart reminders, provider education, and point-of-care antibody testing significantly improved at least three study outcomes compared with a comparator or control. Interventions that simplified HCV testing, including dried blood spot testing, point-of-care antibody testing, reflex RNA testing, and opt-out screening, significantly improved testing outcomes compared with a comparator or control. Enhanced patient and provider support through patient education, provider care coordination, and provider education also significantly improved testing outcomes compared with a comparator or control. Integrated care and patient navigation or care coordination significantly improved linkage to care and the uptake of direct-acting antiviral treatment compared with a comparator or control.

INTERPRETATION

Several interventions to improve HCV care that address several key barriers to HCV care were identified. New models of HCV care must be designed and implemented to address the barriers faced by the population of interest. Further high-quality research, including rigorously designed randomised studies, is still needed in key populations.

FUNDING

None.

Financial Incentives, Not Behavioral Nudges, Led to Optimized HIV Testing among Pregnant Women in a High-Burden Urban Population in Ecuador

Behavioral economic principles are increasingly being used in the fight against HIV, including improving voluntary testing in sub-Saharan Africa and South America. However, behavioral nudges have not been widely tested as a strategy to optimize HIV testing in pregnant women. Here, we assessed whether behavioral nudges or financial incentives were effective in optimizing HIV testing among pregnant women in a high-HIV burden setting. A randomized clinical trial was conducted between May 21 and Oct 5, 2018, to allocate pregnant women in Ecuador into three study arms: information only, soft commitment (i.e., a behavioral nudge), and financial incentives. All participants received an informational flyer, including the address of a testing location. Participants in the soft-commitment arm signed and kept a form on which they committed to get tested for HIV. Those in the financial incentive arm received a $10 incentive when tested for HIV. A stepwise logistic regression analysis estimated the effect of the study arms on HIV testing rate. Participants in the financial-incentive arm had higher odds of getting an HIV test (adjusted odds ratio 17.06, P < 0.001) as compared with information-only participants. Soft-commitment had the opposite effect (adjusted odds ratio 0.14, P = 0.014). Financial incentives might be useful in improving HIV testing among pregnant women, especially among those who might be at higher risk but who have not completed an HIV test.

Barriers and facilitators to engagement with artificial intelligence (AI)-based chatbots for sexual and reproductive health advice: a qualitative analysis

Background The emergence of artificial intelligence (AI) provides opportunities for demand management of sexual and reproductive health services. Conversational agents/chatbots are increasingly common, although little is known about how this technology could aid services. This study aimed to identify barriers and facilitators for engagement with sexual health chatbots to advise service developers and related health professionals. Methods In January-June 2020, we conducted face-to-face, semi-structured and online interviews to explore views on sexual health chatbots. Participants were asked to interact with a chatbot, offering advice on sexually transmitted infections (STIs) and relevant services. Participants were UK-based and recruited via social media. Data were recorded, transcribed verbatim and analysed thematically. Results Forty participants (aged 18-50 years; 64% women, 77% heterosexual, 58% white) took part. Many thought chatbots could aid sex education, providing useful information about STIs and sign-posting to sexual health services in a convenient, anonymous and non-judgemental way. Some compared chatbots to health professionals or Internet search engines and perceived this technology as inferior, offering constrained content and interactivity, limiting disclosure of personal information, trust and perceived accuracy of chatbot responses. Conclusions Despite mixed attitudes towards chatbots, this technology was seen as useful for anonymous sex education but less suitable for matters requiring empathy. Chatbots may increase access to clinical services but their effectiveness and safety need to be established. Future research should identify which chatbots designs and functions lead to optimal engagement with this innovation.

Predictors of late presentation and advanced HIV disease among people living with HIV in Oman (2000-2019)

Background

The aim of this study was to determine the proportions and predictors of late presentation (LP) and advanced HIV disease (AD) in Oman. LP and AD were defined as presenting with a baseline CD4 count of < 350 and < 200 cells/mm3, respectively.

Methods

We conducted a retrospective database analysis of the National HIV Surveillance System to identify Omani people (≥ 13 years old) who were diagnosed with HIV in the period between January 2000 and December 2019 and had a documented baseline CD4 cell count. We calculated the rates and trend over time of LP and AD. A logistic regression was carried out to determine the predictors of LP and AD.

Results

A total of 1418 patients, who were diagnosed with HIV in the period from January 2000 to December 2019, were included; 71% were male and 66% were heterosexuals. The median (IQR) age at diagnosis was 33 (25–39) years. Overall, 71% (95% CI: 68–73) and 46% (95% CI: 44–49) of patients had LP and AD at presentation, respectively. The LP percentage decreased from 76% in 2000–2004 to 69% in 2015–2019; AD percentage decreased from 57 to 46% over the same period. The proportions of men with LP and AD were higher than women (74% vs. 62 and 50% vs. 36%, respectively). The percentages of persons with LP among people aged 13–24, 25–49, and ≥ 50 years were 65, 71, and 84%, respectively. The proportions of persons with AD among people aged 13–24, 25–49, and ≥ 50 years were 39, 46, and 65%, respectively. Logistic regression showed that male sex, older age, having an “unknown” HIV risk factor, and living outside Muscat were independent predictors of AD. Male sex also independently predicted LP.

Conclusions

This analysis indicates that a significant proportion of new HIV cases in Oman continue to present late. This study identified patient subgroups at greatest risk of late HIV diagnosis such as men and older people. Targeted interventions and greater efforts to scale up HIV testing services in Oman are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12048-1.

Acceptability and facilitators of and barriers to point-of-care HIV testing in a homeless-focused service in Gloucestershire: a qualitative evaluation

OBJECTIVES

Late HIV diagnosis increases the risks of onward transmission, morbidity and mortality. Rapid point-of-care testing (POCT) reaches people who have never been tested and people living with HIV who are undiagnosed. This study explored the acceptability and feasibility of HIV POCT from the perspectives of service providers and users.

METHODS

A pilot study introduced HIV POCT to one service in Gloucestershire, England. Eleven semi-structured interviews with service users and a focus group with three service providers were conducted. The Theoretical Framework of Acceptability and the Theoretical Domains Framework were used to design the topic guide and analysis.

RESULTS

Acceptability of HIV POCT was high. Seven facilitators were identified (e.g. understanding the test purpose and process), alongside two potential barriers, one relevant to service providers and users (anxiety) and the other to service users (stigma).

CONCLUSIONS

To maximize the benefits of implementation of HIV POCT, health care providers require appropriate training and supervision to offer and administer POCT.

HIV testing in secondary care: a multicentre longitudinal mixed methods electronic survey of non-HIV specialist hospital physicians in South-East Scotland and Northern England

BACKGROUND

Increasing the uptake of HIV testing in people who may have undiagnosed HIV is essential to reduce the morbidity associated with late HIV diagnosis.

METHODS

We conducted a multicentre, longitudinal, mixed-methods study, surveying the attitudes, knowledge and practice of non-HIV specialist hospital physicians in South-East Scotland and North-East England with respect to HIV testing.

RESULTS

We found that although awareness of indications for HIV testing had improved over time, only 13% of clinicians recognised all of the surveyed HIV indicator conditions. Physicians were better at recognising the indicator conditions relevant to their specialty. The perception of working with a low-risk patient population was the most frequently cited barrier to offering an HIV test. Only a third of study respondents had requested more than 10 HIV tests in the preceding year.

CONCLUSIONS

Our study supports a need for targeted and sustained educational initiatives to increase rates of HIV testing in secondary care.

Acceptability of Nurse-Driven HIV Screening for Key Populations in Emergency Departments: A Mixed-Methods Study

BACKGROUND

Optimizing care continuum entry interventions is key to ending the HIV epidemic. Offering HIV screening to key populations in emergency departments (EDs) is a strategy that has been demonstrated to be effective. Analyzing patient and provider perceptions of such screening can help identify implementation facilitators and barriers.

OBJECTIVES

The aim of this study was to investigate the acceptability of offering nurse-driven HIV screening to key populations based on data collected from patients, nurses, and other service providers.

METHODS

This convergent mixed-methods study was a substudy of a cluster-randomized two-period crossover trial conducted in eight EDs to evaluate the effectiveness of the screening strategy. During the DICI-VIH (Dépistage Infirmier CIblé du VIH) trial, questionnaires were distributed to patients aged 18-64 years. Based on their responses, nurses offered screening to members of key populations.Over 5 days during the intervention period in four EDs, 218 patients were secondarily questioned about the acceptability of screening. Nurses completed 271 questionnaires pre- and posttrial regarding acceptability in all eight EDs. Descriptive analyses were conducted on these quantitative data. Convenience and purposeful sampling was used to recruit 53 providers to be interviewed posttrial. Two coders conducted a directed qualitative content analysis of the interview transcripts independently.

RESULTS

The vast majority of patients (95%) were comfortable with questions asked to determine membership in key populations and agreed (89%) that screening should be offered to key populations in EDs. Nurses mostly agreed that offering screening to key populations was well accepted by patients (62.2% pretrial and 71.4% posttrial), was easy to implement, and fell within the nursing sphere of competence. Pretrial, 73% of the nurses felt that such screening could be implemented in EDs. Posttrial, the proportion was 41%. Three themes emerged from the interviews: preference for targeted screening and a written questionnaire to identify key populations, facilitators of long-term implementation, and implementation barriers. Nurses were favorable to such screening provided specific conditions were met regarding training, support, collective involvement, and flexibility of application to overcome organizational and individual barriers.

DISCUSSION

Screening for key populations was perceived as acceptable and beneficial by patients and providers. Addressing the identified facilitators and barriers would help increase screening implementation in EDs.

Socio-economic differences in the uptake of HIV testing and associated factors in South Africa

BACKGROUND

Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90-90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa.

METHODS

This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households.

RESULTS

HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households.

CONCLUSIONS

HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing.

Prophylaxie préexposition au VIH (PrEP) en médecine générale : existe-t-il des freins ?

OBJECTIVES

Pre-exposure chemoprophylaxis &#8220;PrEP&#8221;, a new prevention tool against HIV for high-risk populations, has been available in France since 2016 in France. The first prescription should occur in CeGIDD or hospital and, its renewal and follow-up can be made by the GP. The analysis of barriers to prescribing PrEP and its follow-up by GP is essential to guide public health actions in order to reach the objectives necessary to observe an inflection of new HIV contaminations.

METHODS

In this descriptive study, on general practitioners who were surveyed about their opinions and current practices of PrEP on the French territory from August to October 2018.

RESULTS

351&#160;responded to the survey, with an estimated response rate of 11%. Most clinicians (88.9%) supported PrEP but only 6.3% had provided it and 12.8% of them did PrEP monitoring. The non-providers self-assessed for 97% of them, as their knowledge of PrEP was low or very low. The significant barriers to providing PrEP among non-adopters were the lack of training received (90.6% vs 59,1% for adopters, P&#160;&lt;&#160;0.001), the assessment of patient as &#8220;not at risk for HIV&#8221; (29.8% vs 0%, P&#160;=&#160;0.003), not having a private health assurance (34.7% vs 13.6%, P&#160;=&#160;0.04), the&#160;lack of knowledge about patient sexuality (27.1% vs 4.5%, P&#160;=&#160;0.02). The absence of a first prescription was a barrier only for PrEP follow-up and was over-represented in this group (33.3% vs 18.3% for non-adopters, P&#160;=&#160;0.02).

CONCLUSION

This study shows that GPs are interested in providing PrEP despite their barriers. The management of PrEP in general practice must be improved, particularly through the training of general practitioners in the context of continuing medical education and by an institutional evolution in the extension of provide PrEP to increase the interest in global health management to overcome these barriers.

Community-based HIV testing in The Netherlands: experiences of lay providers and end users at a rapid HIV test checkpoint

BACKGROUND

The AIDS Healthcare Foundation (AHF-Checkpoint) in The Netherlands offers rapid HIV testing for key populations by lay providers. We explored the experiences and needs of lay providers and end users of HIV testing at AHF-Checkpoint, taking into account the WHO 5C-(consent, confidentiality, counselling, correct-results, connection-to-care) criteria for HIV test services.

METHODS

Qualitative evaluation with 15 semi-structured interviews conducted during 2020 with ten lay providers and five gay or bisexual end users. Recorded interviews were thematically analysed, taking data triangulation into account.

RESULTS

Four domains were identified: (1) accessibility of HIV testing, (2) quality of test procedures, (3) bridging (transitional care), and (4) future strategies for service delivery. AHF-Checkpoint fills a gap for key populations including LGBTQ and refugees, who experience HIV testing barriers at sexual health centres or general practices. The level of trust between lay providers and end users was highly valued by end users. They appreciated the low threshold to test at no costs, and the absence of waiting lists or triaging. Needs expressed by lay providers included more preparedness for emotionally charged situations, and extra training to improve STI knowledge. End users expressed a need for a full STI test package. Of the 5Cs, consent, counselling, and correct results were realised but confidentiality was sometimes difficult to achieve at pop-up locations, and referral barriers for confirmation testing (connection-to-care) were occasionally experienced by lay providers during weekends.

CONCLUSION

AHF-Checkpoint was described as a convenient and easily accessible service by end users and lay providers. Of the WHO 5Cs, connection-to-care could be optimised to ensure HIV confirmation and STI testing through a liaison approach with professionals from the regular healthcare sector.

Promoting HIV indicator condition-guided testing in hospital settings (PROTEST 2.0): study protocol for a multicentre interventional study

Background

Late presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting.

Methods

We designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC.

Discussion

This protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands.

Trial registration

Dutch trial registry: NL7521. Registered 14 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06183-8.

The Rhythm of Risk: Sexual Behaviour, PrEP Use and HIV Risk Perception Between 1999 and 2018 Among Men Who Have Sex with Men in Amsterdam, The Netherlands

HIV risk perception plays a crucial role in the uptake of preventive strategies. We investigated how risk perception and its determinants changed between 1999 and 2018 in an open, prospective cohort of 1323 HIV-negative men who have sex with men (MSM). Risk perception, defined as the perceived likelihood of acquiring HIV in the past 6 months, changed over time: being relatively lower in 2008–2011, higher in 2012–2016, and again lower in 2017–2018. Irrespective of calendar year, condomless anal intercourse (AI) with casual partners and high numbers of partners were associated with higher risk perception. In 2017–2018, condomless receptive AI with a partner living with HIV was no longer associated with risk perception, while PrEP use and condomless AI with a steady partner were associated with lower risk perception. We showed that risk perception has fluctuated among MSM in the past 20 years. The Undetectable equals Untransmittable statement and PrEP coincided with lower perceived risk.

HIV self-testing: A review and analysis to guide HIV prevention policy

HIV self-testing is a relatively new approach to HIV testing that, with increasing licensure in many countries, is an impending intervention. Considering such current or near-future implementation, it is important for HIV prevention policymakers to reflect on if and how to incorporate HIV self-testing. In this paper, using the Impact Fraction Model and the Anderson-May equation, I discuss how HIV self-testing should be an efficacious prevention approach when targeted appropriately. I then review the potential impacts of self-testing on HIV surveillance and discuss possible ethical concerns about such testing. The outcome of this analysis is that, while some issues may arise related to surveillance, and while some ethical concerns can be raised, no empirical evidence substantiates either, suggesting that HIV self-testing is an important strategy if it can be focused on and used by the persons most affected by HIV.

Social network distribution of syphilis self-testing among men who have sex with men in China: study protocol for a cluster randomized control trial

BACKGROUND

Syphilis is a common sexually transmitted infection (STI) among men who have sex with men (MSM). Increasing syphilis testing is important to syphilis control. However, in low- and middle-income countries like China, syphilis testing rates remain low among MSM. We describe a randomized controlled trial protocol to examine the effectiveness of social network distribution approaches of syphilis self-testing among MSM in China.

METHODS

We will recruit index and alter MSM. Indexes will be eligible if they: are born biologically male; aged 18 years or above; ever had sex with another man; are willing to distribute syphilis testing packages or referral links to their alters; and willing to provide personal contact information for future follow-up. Three hundred MSM will be recruited and randomly assigned in a 1:1:1 ratio into three arms: standard of care (control arm); standard syphilis self-testing (SST) delivery arm; and referral link SST delivery arm. Indexes will distribute SST packages or referral links to encourage alters to receive syphilis testing. All indexes will complete a baseline survey and a 3-month follow-up survey. Syphilis self-test results will be determined by photo verification via a digital platform. The primary outcome is the mean number of alters who returned verified syphilis testing results per index in each arm.

DISCUSSION

The trial findings will provide practical implications in strengthening syphilis self-testing distribution and increasing syphilis testing uptake among MSM in China. This study also empowers MSM community in expanding syphilis testing by using their own social network.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000036988 . Registered 26 August 2020 - Retrospectively registered.

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework

BACKGROUND

Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.

METHODS

In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.

RESULTS

Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).

CONCLUSION

Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Clinician Barriers and Facilitators to Routine HIV Testing: A Systematic Review of the Literature

Background:

Routine HIV screening rates are suboptimal.

Objectives:

This systematic review identified barriers to/facilitators of routine HIV testing, categorized them using the socioecological model (SEM), and provided recommendations for interventions to increase screening.

Data Sources:

Included articles were indexed in PubMed, EBSCO CINAHL, Scopus, Web of Science, and the Cochrane Library between 2006 and October 2018.

Eligibility Criteria:

Included studies were published in English or Spanish and directly assessed providers’ barriers/facilitators to routine screening.

Data Extraction:

We used a standardized Excel template to extract barriers/facilitators and identify levels in the SEM.

Data Synthesis:

Intrapersonal factors predominated as barriers, while facilitators were directed at the institutional level.

Limitations:

Policy barriers are not universal across countries. Meta-analysis was not possible. We could not quantify frequency of any given barrier/facilitator.

Conclusions:

Increasing reimbursement and adding screening as a quality measure may incentivize HIV testing; however, many interventions would require little resource investment.

HIV testing and its associated factors among street-based female sex workers in Iran: results of a national rapid assessment and response survey

Background

Female sex workers (FSWs) are at a disproportionate risk of sexually transmitted infections and they may face significant barriers to HIV testing. This study aimed to examine HIV testing prevalence and its associated factors among street-based FSWs in Iran.

Method

A total of 898 FSWs were recruited from 414 venues across 19 major cities in Iran between October 2016 and March 2017. Eligible FSWs were women aged 18 years of age who had at least one commercial sexual intercourse in the previous year. HIV testing was defined as having tested for HIV in the lifetime. Bivariable and multivariable logistic regression were used to examine the correlates of HIV testing. We report adjusted odds ratios (aOR) and their 95% confidence intervals (CI).

Result

Overall, 57.8% (95%CI: 20.0, 88.0) of participants reported having tested for HIV, and HIV prevalence among FSWs who tested for HIV was 10.3% (95%CI: 7.5, 13.0). The multivariable model showed that unstable housing (aOR: 8.86, 95%CI: 2.68, 29.32) and drug use (aOR: 3.47, 95%CI: 1.33, 9.06) were associated with increased likelihood of HIV testing. However, FSWs with a higher level of income were less likely to be tested for HIV (aOR: 0.09, 95%CI: 0.02, 0.43).

Conclusion

Almost one in ten street-based FSWs had never tested for HIV. These findings suggest the need for evidence-based strategies such as outreach support and HIV self-testing to improve HIV testing in this marginalized population.

Systematic Development of an Intervention to Promote Self-Sampling for HIV and Sexually Transmitted Infections for Men Who Have Sex With Men: An Intervention Mapping Approach

Sexual healthcare aims to reduce HIV and sexually transmitted infections (STIs) by promoting testing and prevention. To better reach men who have sex with men (MSM), additional strategies are needed. Here, we describe development of an intervention, which is part of a broader HIV/STI home-care program, targeted to reach MSM and motivate them to use self-sampling tests. Self-sampling includes blood sampling (finger prick) for HIV, hepatitis B, and syphilis, and a urine sample and oral and anorectal swab samples for chlamydia and gonorrhea. Intervention mapping, a systematic six-step approach, was used to guide the development process: (1) needs assessment including interviews with MSM, (2) create a matrix of change, (3) selection of theory-based methods and practical strategies, (4) intervention development, (5) implementation plan, and (6) evaluation (not included in this paper). Stakeholders were involved to increase program support and feasibility. The needs assessment revealed that testing barriers among MSM related to stigma, time, and privacy concerns. Barriers among healthcare providers related to time, competing priorities, lack of expertise, and guideline restrictions. Included intervention components are designed to overcome these barriers, e.g., engaging role models, with a website with a role model story, and providing tailored information. Methods to reach MSM were a variety of information channels (posters, flyers, and audio-visual displays) and delivery modes, such as advertisements on websites and invitational cards (online and paper) distributed by healthcare providers and MSM themselves (social network testing/peer testing). Our intervention aims to encourage MSM to engage in testing, re-testing, and providing a test to peer MSM. Evidence-based methods to overcome barriers were included to reach and motivate an increased number of MSM. Using intervention mapping stimulated systematic evidence-based decision making and adapting the intervention to the target audience and setting. The next step (step 6) is to implement and evaluate the intervention.

Using a machine learning approach to explore predictors of healthcare visits as missed opportunities for HIV diagnosis

OBJECTIVES

A significant number of individuals with a new HIV diagnosis are still late presenters despite numerous healthcare encounters prior to HIV diagnosis. We employed a machine learning approach to identify the predictors for the missed opportunities for earlier HIV diagnosis.

METHODS

The cohort comprised of individuals who were diagnosed with HIV in South Carolina from January 2008 to December 2016. Late presenters (LPs) (initial CD4 ≤200 cells/mm3 within one month of HIV diagnosis) with any healthcare visit during three years prior to HIV diagnosis were defined as patients with a missed opportunity. Using least absolute shrinkage and selection operator (LASSO) regression, two prediction models were developed to capture the impact of facility type (model 1) and physician specialty (model 2) of healthcare visits on missed opportunities.

RESULTS

Among 4,725 eligible participants, 72.2% had at least one healthcare visit prior to their HIV diagnosis, with most of the healthcare visits (78.5%) happening in the emergency departments (ED). A total of 1,148 individuals were LPs, resulting in an overall prevalence of 24.3% for the missed opportunities for earlier HIV diagnosis. Common predictors in both models included ED visit, older age, male gender, and alcohol use.

CONCLUSIONS

The findings underscored the need to reinforce the universal HIV testing strategy ED remains an important venue for HIV screening, especially for medically underserved or elder population. An improved and timely HIV screening strategy in clinical settings can be a key for early HIV diagnosis and play an increasingly important role in ending HIV epidemic.

Social support, perceived risk and the likelihood of COVID-19 testing and vaccination: cross-sectional data from the United Kingdom

Two samples of 227 and 214 adults completed surveys of social support, perceived risk of COVID-19 and COVID-19 preventive activity - in Study 1 likelihood of testing was examined and in Study 2 likelihood of both testing and vaccination were examined during the COVID-19 pandemic in the United Kingdom. Path analysis showed, in Study 1, that access to help (as an indicator of social support) had a direct effect on likelihood of testing and indirect effects through self-efficacy, perceived risk and preventive behavior; and, in Study 2, that neighborhood identification (as an indicator of social support) had a direct effect on likelihood of testing and indirect effects on likelihood of both testing and vaccination through the mediators of strength of social network, loneliness, perceived risk of COVID-19, and preventive activity. Both studies suggest that level of social support (conceptualized in different ways) is an important determinant of COVID-19 testing and Study 2 shows it is also a determinant of likelihood of vaccination. As resurgences of COVID-19 occur, it will be necessary to monitor the likelihood of COVID-19 testing and vaccination behaviors and, especially, to promote confidence in the latter in individuals with decreased access to social support.

Psychometric testing of a set of patient-reported instruments to assess healthcare interventions for autistic adults

LAY ABSTRACT

Interventions to improve healthcare for autistic adults are greatly needed. To evaluate such interventions, researchers often use surveys to collect data from autistic adults (or sometimes, their supporters), but few survey measures have been tested for use with autistic adults. Our objective was to create and test a set of patient- or proxy-reported survey measures for use in studies that evaluate healthcare interventions. We used a community-based participatory research (CBPR) approach, in partnership with autistic adults, healthcare providers, and supporters. We worked together to create or adapt survey measures. Three survey measures focus on things that interventions may try to change directly: (1) how prepared patients are for visits; (2) how confident they feel in managing their health and healthcare; and (3) how well the healthcare system is making the accommodations patients feel they need. The other measures focus on the outcomes that interventions may hope to achieve: (4) improved patient-provider communication; (5) reduced barriers to care; and (6) reduced unmet healthcare needs. We then tested these measures in a survey of 244 autistic adults recruited from 12 primary care clinics in Oregon and California, USA (with 194 participating directly and 50 participating via a proxy reporter). Community partners made sure items were easy to understand and captured what was important about the underlying idea. We found the survey measures worked well in this sample. These measures may help researchers evaluate new healthcare interventions. Future research needs to assess whether interventions improve healthcare outcomes in autistic adults.

Understanding barriers and facilitators to HIV testing in Canada from 2009-2019: A systematic mixed studies review

BACKGROUND

HIV testing is a core pillar of Canada's approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed.

OBJECTIVE

To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada.

METHODS

A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized.

RESULTS

Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices.

CONCLUSION

Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations.

Understanding the Barriers of HIV Testing Services for Men Who Have Sex With Men and Transgender Women in Bangladesh: A Qualitative Study

Coverage of HIV testing services (HTS) is generally low among men who have sex with men (MSM) and transgender women (hijra) in Bangladesh, thus impeding the national goal of attaining the 90-90-90 target. In this context, this article delineates HTS uptake barriers among these populations. This qualitative study entailed 30 in-depth interviews, six focus groups and seven key-informant interviews with purposively selected MSM and hijra, alongside service providers. Participants cited individual and interpersonal barriers such as low risk perception and misconceptions about HIV testing, programmatic barriers such as knowledge gaps among peer service providers, as well as community and structural barriers such as the criminalization and stigmatization of male-to-male sex. Considering these contexts, it is essential for stakeholders to improve the HTS modality using multipronged approaches to address the multifaceted barriers of HTS uptake.