Cost-Effectiveness of Frequent HIV Testing of High-Risk Populations in the United States

Optimising HIV pre-exposure prophylaxis and testing strategies in men who have sex with men in Australia, Thailand, and China: a modelling study and cost-effectiveness analysis

BACKGROUND

Men who have sex with men (MSM) in the Asia-Pacific region have a disproportionately high burden of HIV infection compared with the general population. Although pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing new HIV infections, the cost-effectiveness of PrEP for MSM in different countries in the Asia-Pacific region with varying PrEP coverage and HIV testing frequencies remains unstudied. We aimed to analyse the economic and health benefits of long-acting injectable cabotegravir (CAB-LA) compared with oral PrEP in high-income countries and low-income and middle-income countries within the Asia-Pacific region.

METHODS

We developed a decision-analytic Markov model to evaluate the population impact and cost-effectiveness of PrEP scale-up among MSM in Australia, Thailand, and China. We assumed a static cohort of 100 000 MSM aged 18 years or older who were at risk of HIV infection, with a monthly cycle length over a 40-year time period. We evaluated hypothetical scenarios with universal PrEP coverage of 80% among 100 000 suitable MSM in each country. We modelled oral PrEP and CAB-LA for MSM with diverse HIV testing frequency strategies. We adopted the health-care system's perspective with a 3% annual discount rate. We calculated the incremental cost-effectiveness ratio (ICER), measured as additional cost per quality-adjusted life-year (QALY) gained, to compare different strategies with the status quo in each country. All costs were reported in 2021 US$. We also performed one-way, two-way, and probabilistic sensitivity analyses to assess the robustness of our findings.

FINDINGS

Compared with the status quo in each country, expanding oral PrEP to 80% of suitable MSM would avert 8·1% of new HIV infections in Australia, 14·5% in Thailand, and 26·4% in China in a 40-year period. Expanding oral PrEP use with 6-monthly HIV testing for both PrEP and non-PrEP users was cost-saving for Australia. Similarly, expanding oral PrEP use remained the most cost-effective strategy in both Thailand and China, but optimal testing frequency varied, with annual testing in Thailand (ICER $4707 per QALY gained) and 3-monthly testing in China (ICER $16 926 per QALY gained) for both PrEP and non-PrEP users. We also found that replacing oral PrEP with CAB-LA for MSM could avert more new HIV infections (12·8% in Australia, 27·6% in Thailand, and 32·8% in China), but implementing CAB-LA was not cost-effective due to its high cost. The cost of CAB-LA would need to be reduced by 50-90% and be used as a complementary strategy to oral PrEP to be cost-effective in these countries.

INTERPRETATION

Expanding oral PrEP use for MSM, with country-specific testing frequency, is cost-effective in Australia, Thailand, and China. Due to the high cost, CAB-LA is currently not affordable as a single-use strategy but might be offered as an additional option to oral PrEP.

FUNDING

Ministry of Science and Technology of the People's Republic of China, the Australian National Health and Medical Research Council, National Key Research and Development Program of China, and National Natural Science Foundation of China.

Impact of voluntary testing on infectious disease epidemiology: A game theoretic approach

The World Health Organization recommends test-and-treat interventions to curb and even eliminate epidemics of HIV, viral hepatitis, and sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis and trichomoniasis). Epidemic models show these goals are achievable, provided the participation of individuals in test-and-treat interventions is sufficiently high. We combine epidemic models and game theoretic models to describe individual's decisions to get tested for infectious diseases within certain epidemiological contexts, and, implicitly, their voluntary participation to test-and-treat interventions. We develop three hybrid models, to discuss interventions against HIV, HCV, and sexually transmitted infections, and the potential behavioral response from the target population. Our findings are similar across diseases. Particularly, individuals use three distinct behavioral patterns relative to testing, based on their perceived costs for testing, besides the payoff for discovering their disease status. Firstly, if the cost of testing is too high, then individuals refrain from voluntary testing and get tested only if they are symptomatic. Secondly, if the cost is moderate, some individuals will test voluntarily, starting treatment if needed. Hence, the spread of the disease declines and the disease epidemiology is mitigated. Thirdly, the most beneficial testing behavior takes place as individuals perceive a per-test payoff that surpasses a certain threshold, every time they get tested. Consequently, individuals achieve high voluntary testing rates, which may result in the elimination of the epidemic, albeit on temporary basis. Trials and studies have attained different levels of participation and testing rates. To increase testing rates, they should provide each eligible individual with a payoff, above a given threshold, each time the individual tests voluntarily.

Assessing the individual benefits of reducing HIV diagnosis delay and increasing adherence to HIV care and treatment

We used an agent-based simulation model (Progression and Transmission of HIV) to follow for 20 years a cohort of persons in the United States infected with HIV in 2015. We assessed the benefits of reducing the delay between HIV infection and diagnosis and increasing adherence to HIV care and treatment on the percent of persons surviving 20 years after infection, average annual HIV transmission rates, and time spent virally suppressed. We examined average diagnosis delays of 1.0-7.0 years, monthly care drop-out rates of 5% to 0.1%, and combinations of these strategies. The percent of the cohort surviving the first 20 years of infection varied from 70.8% to 77.5%, and the annual transmission risk, from 1.5 to 5.2 HIV transmissions per 100 person-years. Thus, individuals can enhance their survival and reduce their risk of transmission to partners by frequent testing for HIV and adhering to care and treatment.

Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City

In-depth qualitative interviews explored the experiences and understandings of men 18-39 years old who have sex with men that could facilitate or prevent HIV testing and routine HIV testing. For many men who tested frequently, testing and routine testing were motivated by awareness of the benefit of prompt treatment; public health and provider encouragement to test periodically; responsibility towards sexual partners; and wanting to share a recent HIV-negative test result when seeking sex online. For some men, any testing was impeded by anxiety around possible HIV diagnosis that made testing a stressful occasion that required time and energy to prepare for. This anxiety was often compounded by stigma related to sex between men, having condomless sex, or having HIV. Routine testing could be further stigmatized as some men felt judged by testing providers or partners if they asked for a test or said they tested frequently. We describe efforts to promote testing and routine testing by countering fear and stigma associated with HIV and testing.

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Factors influencing HIV testing and counselling services among men who have sex with men in Western China: a cross-sectional study based on Andersen’s Behavioral Model

Background

Men who have sex with men (MSM), as a marginal population, has been largely ignored by health service projects. We assessed the utilization of HIV testing and counselling services and its influencing factors based on Andersen’s Behavioral Model, so as to provide a theoretical basis for future infectious disease prevention and control strategies and health services policy formulation for these population.

Method

This was a cross-sectional study. A sample survey was conducted in Western China, and an anonymous self-administered questionnaire survey was conducted among MSM. Based on Andersen’s Behavioral Model, the questionnaire divided the influencing factors into predisposing factor, enabling factor and need factor. Multivariate logistic regression analysis was used to explore the factors influencing the utilization of HIV testing and counselling.

Results

There were 3184 valid questionnaires. In the survey of HIV health services, 82.85% MSM had HIV testing and 64.98% MSM had HIV counselling, respectively. Among the predisposing factor, age 25 years old and over was a facilitator of HIV testing and counselling, and ethnicity was a factor associated with HIV testing. Among the enabling factor, MSM living in urban were more likely to have access to testing and counselling services, and income was also linked to HIV testing. Among the need factor, a high level of HIV knowledge could promote testing and counselling, and a history of sexually transmitted diseases (STD) was a facilitator of testing.

Conclusions

HIV testing is widespread in Western China and higher than counselling service. MSM with high-risk characteristics should be identified as a priority in the future public health services.

Factors related to HIV testing frequency in MSM based on the 2011-2018 survey in Tianjin, China: a hint for risk reduction strategy

BACKGROUND

In recent years, HIV testing has become one of the effective strategies to reduce the risk of the infection. Frequent quarterly HIV testing can be cost effective. Therefore, an in-depth study of factors related to the testing behavior of men who have sex with men (MSM) were analyzed to optimize intervention strategies.

METHODS

From March 2011 to October 2018, the project was implemented in a Tianjin (China) bathhouse, and 5165 MSM were surveyed using snowball sampling. Factors related to HIV testing behavior were analyzed by ordinal logistic regression analysis after grouping according to testing frequency, and comprehensive analysis was performed.

RESULTS

The multivariate logistic analysis showed that 6 variables including young MSM (OR = 0.67, 95% CI: 0.49-0.92, p = 0.01), low-educated MSM (OR = 0.60, 95% CI: 0.48-0.77, p < 0.0001), low HIV/AIDS knowledge (95% CI: 0.57-0.83, p < 0.0001), marital status (OR = 1.30, 95% CI: 1.07-1.57, p = 0.007), acceptance of condom promotion and distribution (OR = 14.52, 95% CI: 12.04-17.51, p < 0.0001), and frequency of condom use (p < 0.05) could link to HIV testing behaviors.

CONCLUSIONS

In order to achieve the 95-95-95 goal, target publicity, HIV/AIDS education and promotion of HIV self-testing kits should be carried out to encourage frequent HIV testing among MSM who are young (especially students), married to women, poorly educated and who are reluctant to always use condoms.

The Potential Epidemiological Impact of Coronavirus Disease 2019 (COVID-19) on the Human Immunodeficiency Virus (HIV) Epidemic and the Cost-effectiveness of Linked, Opt-out HIV Testing: A Modeling Study in 6 US Cities

Background

Widespread viral and serological testing for SARS-CoV-2 may present a unique opportunity to also test for HIV infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on HIV incidence and the cost-effectiveness of this strategy in six US cities.

Methods

Using a previously-calibrated dynamic HIV transmission model, we constructed three sets of scenarios for each city: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviours at discrete levels between 0%-50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%-90% of the adult population in addition to scenario (2). We estimated cumulative HIV infections between 2020-2025 and incremental cost-effectiveness ratios of linked HIV testing over 20 years.

Results

In the absence of linked, opt-out HIV testing, we estimated a total of 16.5% decrease in HIV infections between 2020-2025 in the best-case scenario (50% reduction in risk behaviours and no service disruptions), and 9.0% increase in the worst-case scenario (no behavioural change and 50% reduction in service access). We estimated that HIV testing (offered at 10%-90% levels) could avert a total of 576-7,225 (1.6%-17.2%) new infections. The intervention would require an initial investment of $20.6M-$220.7M across cities; however, the intervention would ultimately result in savings in health care costs in each city.

Conclusions

A campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce HIV incidence and reduce direct and indirect health care costs attributable to HIV.

Cost-Effectiveness of Peer-Delivered HIV Self-Tests for MSM in Uganda

Introduction: Distribution of HIV self-testing (HIVST) kits through MSM peer networks is a novel and effective strategy to increase HIV testing coverage in this high-risk population. No study has evaluated the cost or cost effectiveness of peer distribution of HIVST strategies among MSM in sub-Saharan Africa. Methods: From June to August 2018, we conducted a pilot study of secondary MSM peer HIVST kit distribution at The AIDS Support Organization at Entebbe and Masaka. We used an ingredients approach to estimate the cost of MSM peer HIVST kit distribution relative to standard-of-care (SOC) hotspot testing using programme expenditure data reported in US dollars. The provider perspective was used to estimate incremental cost-effective ratios per HIV infection averted using the difference in HIV annual transmission rates between MSM with HIV who knew their status and were not virologically suppressed and MSM with HIV who did not know their status. Results: We enrolled 297 participants of whom 150 received MSM peer HIVST kit distribution (intervention group) and 147 received TASO standard of care HIV testing (control group). Provider cost for the intervention was $2,276 compared with $1,827 for SOC during the 3-month study period. Overall, the intervention resulted in higher HIV positivity yield (4.9 vs. 1.4%) and averted more HIV infections per quarter (0.364 vs. 0.104) compared with SOC. The cost per person tested was higher for the intervention compared to SOC ($15.90 vs. $12.40). Importantly, the cost per new HIV diagnosis ($325 vs. $914) and cost per transmission averted ($6,253 vs. $ 17,567) were lower for the intervention approach relative to SOC. The incremental cost per HIV transmission averted by the self-testing program was $1,727. The incremental cost to providers per additional HIV-positive person identified by the intervention was $147.30. Conclusion: The intervention strategy was cost-effective, and identified more undiagnosed HIV infections than SOC hotspot testing at a cost-effectiveness threshold of US $2,129. Secondary distribution of HIVST kits through peers should further be evaluated with longer duration aimed at diagnosing 95% of all persons with HIV by 2030; the first UNAIDS 95-95-95 target.

2021 European guideline on HIV testing in genito-urinary medicine settings

Testing for HIV is critical for early diagnosis of HIV infection, providing long-term good health for the individual and prevention of onward transmission if antiretroviral treatment is initiated early. The main purpose of the 2021 European Guideline on HIV Testing in Genito-Urinary Settings is to provide advice on testing for HIV infection in individuals aged 16 years and older who present to sexually transmitted infection, genito-urinary or dermato-venereology clinics across Europe. The guideline presents the details of best practice and offers practical guidance to clinicians and laboratories to identify and offer HIV testing to appropriate patient groups.

Economic evaluation of alternative testing regimes and settings to detect undiagnosed HIV in Australia

Background

The study aimed to estimate the comparative costs per positive diagnosis of previously undetected HIV in three testing regimes: conventional; parallel and point of care (POC) testing. The regimes are analysed in six testing settings in Australia where infection is concentrated but with low prevalence.

Methods

A cost model was developed to highlight the trade-offs between test and economic efficiency from a provider perspective. First, an estimate of the number of tests needed to find a true (previously undiagnosed) positive diagnosis was made. Second, estimates of the average cost per positive diagnosis in whole of population (WoP) and men who have sex with men (MSM) was made, then third, aggregated to the total cost for diagnosis of all undetected infections.

Results

Parallel testing is as effective as conventional testing, but more economically efficient. POC testing provide two significant advantages over conventional testing: they screen out negatives effectively at comparatively lower cost and, with confirmatory testing of reactive results, there is no loss in efficiency. The average and total costs per detection in WoP are prohibitive, except for Home Self Testing. The diagnosis in MSM is cost effective in all settings, but especially using Home Self Testing when the individual assumes the cost of testing.

Conclusions

This study illustrates the trade-offs between economic and test efficiency and their interactions with population(s) prevalence. The efficient testing regimes and settings are presently under or not funded in Australia. Home Self Testing has the potential to dramatically increase testing rates at very little cost.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06040-5.

Trends and differences in sexual practices and sexually transmitted infections in men who have sex with men only (MSMO) and men who have sex with men and women (MSMW): a repeated cross-sectional study in Melbourne, Australia

OBJECTIVES

In the 2010s, there has been an increase in sexually transmitted infections (STI) in men who have sex with men (MSM) in Australia, and since 2015 also in urban heterosexuals. Men who have sex with both men and women (MSMW) have characteristics that may differ from both men who have sex with men only (MSMO) and heterosexual men. We aimed to compare the sexual practices and the trends in HIV/STI positivity between MSMO and MSMW.

DESIGN

Repeated cross-sectional study.

SETTING

A sexual health centre in Melbourne, Australia.

PARTICIPANTS

MSM aged 18 years and above who attended the Melbourne Sexual Health Centre for the first time between 2011 and 2018. This includes 12 795 MSMO and 1979 MSMW.

PRIMARY OUTCOME MEASURES

Demographic characterics, sexual practices and HIV/STI positivity.

RESULTS

Compared with MSMW, MSMO were more likely to practice anal sex and to have condomless receptive anal sex with casual male partners, and less likely to have a current regular relationship. Over the 8-year period, there was an increase in condomless receptive anal sex with casual male partners for both groups (MSMO: from 46.2% to 63.3%, ptrend <0.001; MSMW: from 41.3% to 57.9%, ptrend=0.011). Syphilis positivity increased in MSMO (from 5.5% to 7.9%, ptrend=0.012) and MSMW (from 0.9% to 6.4%, ptrend=0.004) and HIV remained stable. Gonorrhoea increased among MSMO from 2011 to 2014 (from 6.7% to 9.6%, ptrend=0.002), and remained stable from 2015 to 2018. MSMO had higher odds of testing positive for gonorrhoea (adjusted OR (aOR) 1.36, 95% CI 1.13 to 1.64), chlamydia (aOR 1.39, 95% CI 1.16 to 1.67), syphilis (aOR 1.74, 95% CI 1.37 to 2.22) and HIV (aOR 4.60, 95% CI 2.43 to 8.70) than MSMW.

CONCLUSIONS

MSMW have overall lower condomless sex and lower HIV/STI positivity. In the last years, changes in sexual practices in MSM have affected both MSMW and MSMO leading to an increased STI risk.

The impact of localized implementation: determining the cost-effectiveness of HIV prevention and care interventions across six United States cities

OBJECTIVE

Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics.

DESIGN

Dynamic HIV transmission model-based cost-effectiveness analysis.

METHODS

We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDC's Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon.

RESULTS

Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city.

CONCLUSION

Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.

Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review

BACKGROUND

As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change.

OBJECTIVES

To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers.

METHODS

A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management.

RESULTS

22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996.

CONCLUSIONS

This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses.

DISCLOSURES

This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.

Psychosocial Correlates of HIV Testing Frequency Among Men Who Have Sex with Men in Guangzhou, China

We examined sociodemographic and psychosocial factors associated with HIV testing patterns in the past 2 years among 492 HIV-negative men who have sex men (MSM) at an HIV testing center in Guangzhou, China. MSM who tested for HIV frequently were more likely to be older, reside in Guangzhou, and have higher monthly income. Compared with MSM who tested frequently, MSM who never tested were less likely to report that their sexual partner(s) had ever received HIV tests or that their good friends had ever received HIV tests, and were less likely to report having an HIV-positive gay friend or ever discussing HIV with sexual partners; they were more likely to report perceiving barriers to HIV testing. Compared with MSM who tested frequently, those who tested irregularly were less likely to report having HIV-positive gay friends or to disclose their sexual orientation to non-gay friends; reported greater barriers to HIV testing; and higher internalized homophobia.

Cost-effectiveness of increased HIV testing among MSM in The Netherlands

OBJECTIVES

To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands.

METHODS

Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective.

RESULTS

A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27 900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36 700/QALY gained. Both were not cost-effective, with a &OV0556;20 000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving.

CONCLUSION

Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.

Structural Design and Data Requirements for Simulation Modelling in HIV/AIDS: A Narrative Review

Born out of a necessity for fiscal sustainability, simulation modeling is playing an increasingly prominent role in setting priorities for combination implementation strategies for HIV treatment and prevention globally. The design of a model and the data inputted into it are central factors in ensuring credible inferences. We executed a narrative review of a set of dynamic HIV transmission models to comprehensively synthesize and compare the structural design and the quality of evidence used to support each model. We included 19 models representing both generalized and concentrated epidemics, classified as compartmental, agent-based, individual-based microsimulation or hybrid in our review. We focused on four structural components (population construction; model entry, exit and HIV care engagement; HIV disease progression; and the force of HIV infection), and two analytical components (model calibration/validation; and health economic evaluation, including uncertainty analysis). While the models we reviewed focused on a variety of individual interventions and their combinations, their structural designs were relatively homogenous across three of the four focal components, with key structural elements influenced by model type and epidemiological context. In contrast, model entry, exit and HIV care engagement tended to differ most across models, with some health system interactions-particularly HIV testing-not modeled explicitly in many contexts. The quality of data used in the models and the transparency with which the data was presented differed substantially across model components. Representative and high-quality data on health service delivery were most commonly not accessed or were unavailable. The structure of an HIV model should ideally fit its epidemiological context and be able to capture all efficacious treatment and prevention services relevant to a robust combination implementation strategy. Developing standardized guidelines on evidence syntheses for health economic evaluation would improve transparency and help prioritize data collection to reduce decision uncertainty.

Assessing frontline HIV service provider efficiency using data envelopment analysis: a case study of Philippine social hygiene clinics (SHCs)

BACKGROUND

Globally, local and frontline HIV service delivery units have been deployed to halt the HIV epidemic. However, with the limited resources, there is a need to understand how these units can deliver their optimum outputs/outcomes efficiently given the inputs. This study aims to determine the efficiency of the social hygiene clinics (SHC) in the Philippines as well as to determine the association of the meta-predictor to the efficiencies.

METHODS

In determining efficiency, we used the variables from two data sources namely the 2012 Philippine HIV Costing study and 2011 Integrated HIV Behavioral and Serologic Surveillance, as inputs and outputs, respectively. Various data management protocols and initial assumptions in data matching, imputation and variable selection, were used to create the final dataset with 9 SHCs. We used data envelopment analysis (DEA) to analyse the efficiency, while variations in efficiencies were analysed using Tobit regression with area-specific meta-predictors.

RESULTS

There were potentially inefficient use of limited resources among sampled SHC in both aggregate and key populations. Tobit regression results indicated that income was positively associated with efficiency, while HIV prevalence was negatively associated with the efficiency variations among the SHCs.

CONCLUSIONS

We were able to determine the inefficiently performing SHCs in the Philippines. Though currently inefficient, these SHCs may adjust their inputs and outputs to become efficient in the future. While there were indications of income and HIV prevalence to be associated with the efficiency variations, the results of this case study may only be limited in generalisability, thus further studies are warranted.

Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Untreated HIV infection can result in significant morbidity, mortality, and HIV transmission. A 2012 review for the US Preventive Services Task Force (USPSTF) found antiretroviral therapy (ART) associated with improved clinical outcomes and decreased transmission risk in persons with CD4 cell counts less than 500/mm3.

OBJECTIVE

To update the 2012 review on HIV screening to inform the USPSTF.

DATA SOURCES

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2012 to June 2018, with surveillance through January 2019.

STUDY SELECTION

Nonpregnant individuals 12 years and older; randomized clinical trials (RCTs) and controlled observational studies of screening vs no screening, alternative screening strategies, earlier vs later initiation of ART, and long-term harms of ART.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

MAIN OUTCOMES AND MEASURES

Mortality, AIDS events, quality of life, function, and HIV transmission; harms of screening and long-term (≥2 years) harms of ART; screening yield.

RESULTS

Eighteen new studies (5 RCTs, 11 cohort studies, and 2 systematic reviews; N = 266 563) were included, and 11 studies (2 RCTs and 9 cohort studies; N = 218 542) were carried forward from the prior USPSTF report. No study directly evaluated effects of HIV screening vs no screening on clinical outcomes or harms, or the yield of alternative screening strategies. Two newly identified RCTs conducted completely or partially in low-resource settings found ART initiation at CD4 cell counts greater than 500/mm3 associated with lower risk of a composite outcome of mortality, AIDS-defining events, or serious non-AIDS events (relative risk [RR], 0.44 [95% CI, 0.31-0.63] and RR, 0.57 [95% CI, 0.35-0.95]); results were consistent with those from a large observational study. Early ART was not associated with increased risk of cardiovascular events. Early ART initiation was associated with sustained reduction in risk of HIV transmission at 5.5 years (RR, 0.07 [95% CI, 0.02-0.22] for linked transmission). New evidence regarding the association between abacavir use and risk of cardiovascular events was inconsistent. Certain antiretroviral regimens were associated with increased risk of long-term neuropsychiatric, renal, hepatic, and bone adverse events.

CONCLUSIONS AND RELEVANCE

In nonpregnant adolescents and adults there was no direct evidence on the clinical benefits and harms of screening for HIV infections vs no screening, or the yield of repeat or alternative screening strategies. New evidence extends effectiveness of ART to asymptomatic individuals with CD4 cell counts greater than 500/mm3 and shows sustained reduction in risk of HIV transmission at longer-term follow-up, although certain ART regimens may be associated with increased risk of long-term harms.

Evidence for optimal HIV screening and testing intervals in HIV-negative individuals from various risk groups: A systematic review

Background

Human immunodeficiency virus (HIV) testing plays a crucial role in Canada's HIV prevention and treatment efforts and is the first step to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; however, how often Canadians, including populations at increased risk of HIV exposure, should be tested is unclear. We conducted a systematic literature review to determine the optimal HIV screening and testing intervals.

Objective

To examine the current evidence on HIV testing intervals in HIV-negative individuals from various risk groups and to assess the potential harms and patients' values and preferences associated with different testing frequencies.

Methods

We searched MEDLINE/PubMed, Scopus, Embase, the Cochrane Library, PsychINFO and EconLit for studies on different frequencies of HIV testing published between January 2000 and September 2016. An additional search was conducted for grey literature published between January 2000 and October 2016. Data extraction included study characteristics, participants, exposure, outcomes and economic variables. The quality of the studies was assessed and results summarized.

Results

Of the 2,702 articles identified from the searches, 27 met the inclusion criteria for review. This included assessments of HIV testing intervals among the general population, men who have sex with men, people who use injection drugs and sex workers. Optimal testing intervals across risk groups ranged from one-time testing to every three months. Data from modelling studies may not be representative of the Canadian context. Few studies identified potential harms of increased screening, specifically an increase in both false positive and false negative results. There were only two studies that addressed patient values and preferences concerning HIV screening, which suggested that the majority of participants were amenable to routine screening through their primary care provider.

Conclusion

There was insufficient evidence to support optimal HIV screening and testing intervals for different populations. Context-specific factors, such as budget allocation, human resources, local epidemiology, socioeconomic factors and risk behaviours, along with clinical judgement, inform whom and how often to screen, suggesting the need for research specific to Canada. Research on patient preferences as well as the benefits and harms of more frequent screening are also indicated.

Sensitivity of joint contagiousness and susceptibility-based dynamic optimal control strategies for HIV prevention

Predicting the population-level effects of an infectious disease intervention that incorporate multiple modes of intervention is complicated by the joint non-linear dynamics of both infection transmission and the intervention itself. In this paper, we consider the sensitivity of Dynamic Optimal Control Profiles (DOCPs) for the optimal joint investment in both a contagiousness and susceptibility-based control of HIV to bio-behavioral, economic, and programmatic assumptions. The DOCP is calculated using recently developed numerical algorithms that allow controls to be represented by a set of piecewise constant functions that maintain a constant yearly budget. Our transmission model assumes multiple stages of HIV infection corresponding to acute and chronic infection and both within- and between-individual behavioral heterogeneity. We parameterize a baseline scenario from a longitudinal study of sexual behavior in MSM and consider sensitivity of the DOCPs to deviations from that baseline scenario. In the baseline scenario, the primary determinant of the dominant control were programmatic factors, regardless of budget. In sensitivity analyses, the qualitative aspects of the optimal control policy were often robust to significant deviation in assumptions regarding transmission dynamics. In addition, we found several conditions in which long-term joint investment in both interventions was optimal. Our results suggest that modeling in the service of decision support for intervention design can improve population-level effects of a limited set of economic resources. We found that economic and programmatic factors were as important as the inherent transmission dynamics in determining population-level intervention effects. Given our finding that the DOCPs were robust to alternative biological and behavioral assumptions it may be possible to identify DOCPs even when the data are not sufficient to identify a transmission model.

Factors Associated with Recent HIV Testing among Men Who Have Sex with Men in Philadelphia: a Cross-Sectional Analysis of the National Behavioral Surveillance System Survey

The main objective of this study was to determine the demographic, geographic and socioeconomic characteristics of men who have sex with men (MSM) in Philadelphia that were associated with having a recent HIV test. We used data from the National HIV Behavioral Surveillance System (NHBS) surveys from 2011 and 2014 among MSM in Philadelphia, with the outcome of interest of having received an HIV test in the past twelve months. Of 1043 HIV-negative MSM, 70.2% had an HIV test. Multivariable analysis showed that seeing a medical provider (aOR: 1.73; p = .0039) or having heard of PrEP (aOR: 2.24; p < .0001) was associated with recent HIV testing. Those participants forty-five years of age or older (aOR 0.40, p = .0001) and those with Medicaid had lower rates of HIV testing (aOR 0.48, p = .002). Although over 80% of participants had seen a medical provider in the past year, only 50% had been offered an HIV test by a provider. Optimizing HIV testing through the expansion and increased awareness of PrEP, especially among older MSM, is critical. Further research is needed to delineate barriers that prevent MSM from utilizing medical providers for HIV testing and for those with Medicaid from receiving HIV testing.

p24 revisited: a landscape review of antigen detection for early HIV diagnosis

: Despite major advances in HIV testing, early detection of infection at the point of care (PoC) remains a key challenge. Although rapid antibody PoC and laboratory-based nucleic acid amplification tests dominate the diagnostics market, the viral capsid protein p24 is recognized as an alternative early virological biomarker of infection. However, the detection of ultra-low levels of p24 at the PoC has proven challenging. Here we review the landscape of p24 diagnostics to identify knowledge gaps and barriers and help shape future research agendas. Five hundred and seventy-four research articles to May 2018 that propose or evaluate diagnostic assays for p24 were identified and reviewed. We give a brief history of diagnostic development, and the utility of p24 as a biomarker in different populations such as infants, the newly infected, those on preexposure prophylaxis and self-testers. We review the performance of commercial p24 assays and consider elements such as immune complex disruption, resource-poor settings, prevalence, and assay antibodies. Emerging and ultrasensitive assays are reviewed and show a number of promising approaches but further translation has been limited. We summarize studies on the health economic benefits of using antigen testing. Finally, we speculate on the future uses of high-performance p24 assays, particularly, if available in self-test format.

Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems

Substance use disorders are highly prevalent and are a large driver of costly inpatient medical care; however, historically the substance use disorder has gone unaddressed during an inpatient stay. Inpatient addiction consult services are an important intervention to use the reachable moment of hospitalization to engage patients and initiate addiction treatment. Addiction consultation involves taking an addiction-specific history, motivational interviewing, withdrawal symptom management, and initiation of long-term pharmacotherapy. Addiction consult services have the potential to decrease readmissions and utilization costs for medical systems and improve substance-related outcomes for patients.

Understanding the Targeting and Uptake of HIV Testing Among Gay and Bisexual Men Attending Sexual Health Clinics

We assessed trends in HIV testing outcomes during a period of clinic-based initiatives introduced to increase HIV testing among gay and bisexual men (GBM) attending sexual health clinics (SHCs) in New South Wales (NSW). A cohort of 25,487 HIV-negative GBM attending 32 SHCs in NSW (2009-2015) was classified into six sub-groups each year based on client-type (new/existing), risk-status (low/high-risk), and any recent HIV testing. Poisson regression methods were used to assess HIV testing outcomes in sub-groups of GBM. HIV testing outcomes and the sub-groups with greatest statistically significant annual increases were: individuals attending (26% in high-risk existing clients with recent testing); testing uptake (4% in low-risk existing clients with no recent testing); testing frequency (6% in low-risk existing clients with no recent testing and 5% in high-risk existing clients with recent testing); and total tests (31% in high-risk existing clients with recent testing). High-risk existing clients with recent testing had a 13% annual increase in the proportional contribution to total tests. Our findings show improved targeting of testing to high-risk GBM at NSW SHCs. The clinic-based initiatives should be considered for translation to other similar settings.

Evaluating the Evidence for More Frequent Than Annual HIV Screening of Gay, Bisexual, and Other Men Who Have Sex With Men in the United States: Results From a Systematic Review and CDC Expert Consultation

The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC's current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.

The role of frequent HIV testing in diagnosing HIV in men who have sex with men

OBJECTIVES

In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing.

METHODS

Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported.

RESULTS

Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17).

CONCLUSIONS

The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM.

Characteristics of HIV-infected U.S. Army soldiers linked in molecular transmission clusters, 2001-2012

Objective

Recent surveillance data suggests the United States (U.S.) Army HIV epidemic is concentrated among men who have sex with men. To identify potential targets for HIV prevention strategies, the relationship between demographic and clinical factors and membership within transmission clusters based on baseline pol sequences of HIV-infected Soldiers from 2001 through 2012 were analyzed.

Methods

We conducted a retrospective analysis of baseline partial pol sequences, demographic and clinical characteristics available for all Soldiers in active service and newly-diagnosed with HIV-1 infection from January 1, 2001 through December 31, 2012. HIV-1 subtype designations and transmission clusters were identified from phylogenetic analysis of sequences. Univariate and multivariate logistic regression models were used to evaluate and adjust for the association between characteristics and cluster membership.

Results

Among 518 of 995 HIV-infected Soldiers with available partial pol sequences, 29% were members of a transmission cluster. Assignment to a southern U.S. region at diagnosis and year of diagnosis were independently associated with cluster membership after adjustment for other significant characteristics (p<0.10) of age, race, year of diagnosis, region of duty assignment, sexually transmitted infections, last negative HIV test, antiretroviral therapy, and transmitted drug resistance. Subtyping of the pol fragment indicated HIV-1 subtype B infection predominated (94%) among HIV-infected Soldiers.

Conclusion

These findings identify areas to explore as HIV prevention targets in the U.S. Army. An increased frequency of current force testing may be justified, especially among Soldiers assigned to duty in installations with high local HIV prevalence such as southern U.S. states.

Increasing HIV testing among hard-to-reach groups: examination of RAPID, a community-based testing service in Queensland, Australia

Background

The success of ‘treatment as prevention’ (TasP) to control HIV relies on the uptake of testing across priority population groups. Innovative strategies including; rapid HIV testing (RHT) in community and outreach settings, engaging peer service providers, and not requiring disclosure of sexual history have been designed to increase access. This paper reports on the implementation of ‘RAPID’, a community-based testing program in Queensland, Australia that employs these strategies to increase access to testing.

Methods

Service data, including client registration forms and a satisfaction survey from all clients attending RAPID between August 2014 and July 2015 were analysed.

Results

In 2014/2015 1,199 people attended RAPID to receive a free HIV test. The majority were urban-based gay men. 17.1% were first-time testers and 20.1% of participants were not eligible to access Medicare, Australia’s universal health care scheme.

Conclusions

RAPID’s evidence-based strategies appear to facilitate access to HIV testing, particularly among those who have never tested before; however the implications for the ongoing treatment and care of people ineligible for Medicare, who test positive to HIV warrants careful consideration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2249-5) contains supplementary material, which is available to authorized users.

HIV Trends in the United States: Diagnoses and Estimated Incidence

Background

The best indicator of the impact of human immunodeficiency virus (HIV) prevention programs is the incidence of infection; however, HIV is a chronic infection and HIV diagnoses may include infections that occurred years before diagnosis. Alternative methods to estimate incidence use diagnoses, stage of disease, and laboratory assays of infection recency. Using a consistent, accurate method would allow for timely interpretation of HIV trends.

Objective

The objective of our study was to assess the recent progress toward reducing HIV infections in the United States overall and among selected population segments with available incidence estimation methods.

Methods

Data on cases of HIV infection reported to national surveillance for 2008-2013 were used to compare trends in HIV diagnoses, unadjusted and adjusted for reporting delay, and model-based incidence for the US population aged ≥13 years. Incidence was estimated using a biomarker for recency of infection (stratified extrapolation approach) and 2 back-calculation models (CD4 and Bayesian hierarchical models). HIV testing trends were determined from behavioral surveys for persons aged ≥18 years. Analyses were stratified by sex, race or ethnicity (black, Hispanic or Latino, and white), and transmission category (men who have sex with men, MSM).

Results

On average, HIV diagnoses decreased 4.0% per year from 48,309 in 2008 to 39,270 in 2013 (P<.001). Adjusting for reporting delays, diagnoses decreased 3.1% per year (P<.001). The CD4 model estimated an annual decrease in incidence of 4.6% (P<.001) and the Bayesian hierarchical model 2.6% (P<.001); the stratified extrapolation approach estimated a stable incidence. During these years, overall, the percentage of persons who ever had received an HIV test or had had a test within the past year remained stable; among MSM testing increased. For women, all 3 incidence models corroborated the decreasing trend in HIV diagnoses, and HIV diagnoses and 2 incidence models indicated decreases among blacks and whites. The CD4 and Bayesian hierarchical models, but not the stratified extrapolation approach, indicated decreases in incidence among MSM.

Conclusions

HIV diagnoses and CD4 and Bayesian hierarchical model estimates indicated decreases in HIV incidence overall, among both sexes and all race or ethnicity groups. Further progress depends on effectively reducing HIV incidence among MSM, among whom the majority of new infections occur.

Modeling and Cost-Effectiveness in HIV Prevention

With HIV funding plateauing and the number of people living with HIV increasing due to the rollout of life-saving antiretroviral therapy, policy makers are faced with increasingly tighter budgets to manage the ongoing HIV epidemic. Cost-effectiveness and modeling analyses can help determine which HIV interventions may be of best value. Incidence remains remarkably high in certain populations and countries, making prevention key to controlling the spread of HIV. This paper briefly reviews concepts in modeling and cost-effectiveness methodology and then examines results of recently published cost-effectiveness analyses on the following HIV prevention strategies: condoms and circumcision, behavioral- or community-based interventions, prevention of mother-to-child transmission, HIV testing, pre-exposure prophylaxis, and treatment as prevention. We find that the majority of published studies demonstrate cost-effectiveness; however, not all interventions are affordable. We urge continued research on combination strategies and methodologies that take into account willingness to pay and budgetary impact.

Factors associated with previously undiagnosed human immunodeficiency virus infection in a population of men who have sex with men and male-to-female transgender women in Lima, Peru

The aim of the study was to identify factors associated with undiagnosed human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) and male-to-female transgender women in Lima, Peru.We analyzed characteristics of 378 MSM and transgender women recruited from 2 sexually transmitted infection (STI) clinics in Lima, Peru. Descriptive analyses compared: (A) HIV-uninfected, (B) previously undiagnosed HIV-infected, and (C) previously diagnosed HIV-infected participants. Multivariable logistic regression models identified: (1) correlates of previously undiagnosed HIV-infection among participants thought to be HIV-uninfected (B vs A); and (2) correlates of previously undiagnosed HIV-infection among HIV-infected participants (B vs C). Subanalysis identified correlates of frequent HIV testing among participants thought to be HIV-uninfected.Among participants, 31.0% were HIV-infected; of those, 35.0% were previously undiagnosed. Among participants thought to be HIV-uninfected (model 1), recent condomless receptive anal intercourse and last HIV test being over 1-year ago (compared to within the last 6-months) were associated with increased odds of being previously undiagnosed HIV-infected (adjusted odds ratio [aOR] = 2.43, 95% confidence interval [95%CI] = 1.10-5.36; aOR = 2.87, 95%CI = 1.10-7.53, respectively). Among HIV-infected participants (model 2), recent condomless receptive anal intercourse was again associated with previously undiagnosed HIV-infection (aOR = 2.54, 95%CI = 1.04-6.23). Achieving post-secondary education and prior syphilis infection were associated with lower odds of having previously undiagnosed HIV-infection (aOR = 0.35, 95%CI = 0.15-0.81; aOR = 0.32, 95%CI = 0.14-0.75, respectively).Reporting semiannual testing was associated with higher educational attainment, identifying as a transgender woman, or reporting a history of syphilis (aOR = 1.94, 95%CI = 1.11-3.37; aOR = 2.40, 95%CI = 1.23-4.70; aOR = 2.76, 95%CI = 1.62-4.71, respectively). Lower odds of semiannual testing were associated with recent condomless insertive anal intercourse or reporting a moderate or high self-perceived risk of acquiring HIV (aOR = 0.56, 95%CI = 0.33-0.96; aOR = 0.32, 95%CI = 0.18-0.59 and aOR = 0.43, 95%CI = 0.21-0.86, respectively).In our study, undiagnosed HIV-infection was associated with recent condomless receptive anal intercourse, infrequent HIV testing, lower education, and absence of prior syphilis diagnosis. Infrequent HIV testing was associated with lower education, not identifying as transgender, recent condomless insertive anal intercourse, absence of prior syphilis diagnosis, and higher self-perceived risk of HIV. Further efforts to decrease HIV transmission and increase HIV-serostatus awareness should be directed towards effectively promoting condom use and frequent HIV testing, integrated with STI management.

Systematic review of mobile health behavioural interventions to improve uptake of HIV testing for vulnerable and key populations

Introduction This systematic narrative review examined the empirical evidence on the effectiveness of mobile health (mHealth) behavioural interventions designed to increase the uptake of HIV testing among vulnerable and key populations. Methods MEDLINE/PubMed, Embase, Web of Science, and Global Health electronic databases were searched. Studies were eligible for inclusion if they were published between 2005 and 2015, evaluated an mHealth intervention, and reported an outcome relating to HIV testing. We also reviewed the bibliographies of retrieved studies for other relevant citations. The methodological rigor of selected articles was assessed, and narrative analyses were used to synthesize findings from mixed methodologies. Results A total of seven articles met the inclusion criteria. Most mHealth interventions employed a text-messaging feature and were conducted in middle- and high-income countries. The methodological rigor was moderate among studies. The current literature suggests that mHealth interventions can have significant positive effects on HIV testing initiation among vulnerable and key populations, as well as the general public. In some cases, null results were observed. Qualitative themes relating to the use of mobile technologies to increase HIV testing included the benefits of having low-cost, confidential, and motivational communication. Reported barriers included cellular network restrictions, poor linkages with physical testing services, and limited knowledge of appropriate text-messaging dose. Discussion MHealth interventions may prove beneficial in reducing the proportion of undiagnosed persons living with HIV, particularly among vulnerable and key populations. However, more rigorous and tailored interventions are needed to assess the effectiveness of widespread use.