Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
PLoS Med. 2013 Aug;10(8):e1001496. doi: 10.1371/journal.pmed.1001496. Epub 2013 Aug 13.
Effective national and global HIV responses require a significant expansion of HIV testing and counselling (HTC) to expand access to prevention and care. Facility-based HTC, while essential, is unlikely to meet national and global targets on its own. This article systematically reviews the evidence for community-based HTC.
PubMed was searched on 4 March 2013, clinical trial registries were searched on 3 September 2012, and Embase and the World Health Organization Global Index Medicus were searched on 10 April 2012 for studies including community-based HTC (i.e., HTC outside of health facilities). Randomised controlled trials, and observational studies were eligible if they included a community-based testing approach and reported one or more of the following outcomes: uptake, proportion receiving their first HIV test, CD4 value at diagnosis, linkage to care, HIV positivity rate, HTC coverage, HIV incidence, or cost per person tested (outcomes are defined fully in the text). The following community-based HTC approaches were reviewed: (1) door-to-door testing (systematically offering HTC to homes in a catchment area), (2) mobile testing for the general population (offering HTC via a mobile HTC service), (3) index testing (offering HTC to household members of people with HIV and persons who may have been exposed to HIV), (4) mobile testing for men who have sex with men, (5) mobile testing for people who inject drugs, (6) mobile testing for female sex workers, (7) mobile testing for adolescents, (8) self-testing, (9) workplace HTC, (10) church-based HTC, and (11) school-based HTC. The Newcastle-Ottawa Quality Assessment Scale and the Cochrane Collaboration's "risk of bias" tool were used to assess the risk of bias in studies with a comparator arm included in pooled estimates. 117 studies, including 864,651 participants completing HTC, met the inclusion criteria. The percentage of people offered community-based HTC who accepted HTC was as follows: index testing, 88% of 12,052 participants; self-testing, 87% of 1,839 participants; mobile testing, 87% of 79,475 participants; door-to-door testing, 80% of 555,267 participants; workplace testing, 67% of 62,406 participants; and school-based testing, 62% of 2,593 participants. Mobile HTC uptake among key populations (men who have sex with men, people who inject drugs, female sex workers, and adolescents) ranged from 9% to 100% (among 41,110 participants across studies), with heterogeneity related to how testing was offered. Community-based approaches increased HTC uptake (relative risk [RR] 10.65, 95% confidence interval [CI] 6.27-18.08), the proportion of first-time testers (RR 1.23, 95% CI 1.06-1.42), and the proportion of participants with CD4 counts above 350 cells/µl (RR 1.42, 95% CI 1.16-1.74), and obtained a lower positivity rate (RR 0.59, 95% CI 0.37-0.96), relative to facility-based approaches. 80% (95% CI 75%-85%) of 5,832 community-based HTC participants obtained a CD4 measurement following HIV diagnosis, and 73% (95% CI 61%-85%) of 527 community-based HTC participants initiated antiretroviral therapy following a CD4 measurement indicating eligibility. The data on linking participants without HIV to prevention services were limited. In low- and middle-income countries, the cost per person tested ranged from US$2-US$126. At the population level, community-based HTC increased HTC coverage (RR 7.07, 95% CI 3.52-14.22) and reduced HIV incidence (RR 0.86, 95% CI 0.73-1.02), although the incidence reduction lacked statistical significance. No studies reported any harm arising as a result of having been tested.
Community-based HTC achieved high rates of HTC uptake, reached people with high CD4 counts, and linked people to care. It also obtained a lower HIV positivity rate relative to facility-based approaches. Further research is needed to further improve acceptability of community-based HTC for key populations. HIV programmes should offer community-based HTC linked to prevention and care, in addition to facility-based HTC, to support increased access to HIV prevention, care, and treatment.
International Prospective Register of Systematic Reviews CRD42012002554 Please see later in the article for the Editors' Summary.
有效的国家和全球艾滋病毒应对措施需要大幅扩大艾滋病毒检测和咨询（HTC），以扩大预防和护理的获取机会。基于机构的 HTC 虽然必不可少，但仅凭它本身不太可能实现国家和全球目标。本文系统地审查了以社区为基础的 HTC 的证据。
2013 年 3 月 4 日在 PubMed 上进行了搜索，2012 年 9 月 3 日在临床试验注册处进行了搜索，2012 年 4 月 10 日在 Embase 和世界卫生组织全球索引医学进行了搜索，检索包括社区 HTC（即在卫生机构外进行的 HTC）的研究。如果研究包括基于社区的检测方法，并报告了以下一个或多个结果，则合格：接受检测的比例、首次接受 HIV 检测的比例、诊断时的 CD4 值、与护理的联系、HIV 阳性率、HTC 覆盖率、HIV 发病率或每人检测费用（结果在文本中进行了全面定义）。本文综述了以下社区 HTC 方法：（1）挨家挨户检测（系统地向一个集水区的家庭提供 HTC），（2）面向普通人群的流动检测（通过流动 HTC 服务提供 HTC），（3）索引检测（为 HIV 感染者和可能接触过 HIV 的人的家庭成员提供 HTC），（4）男男性行为者的流动检测，（5）注射毒品使用者的流动检测，（6）女性性工作者的流动检测，（7）青少年的流动检测，（8）自我检测，（9）工作场所 HTC，（10）教会 HTC，和（11）学校 HTC。使用纽卡斯尔-渥太华质量评估量表和 Cochrane 协作的“偏倚风险”工具评估了纳入汇总估计值的有对照臂的研究的偏倚风险。117 项研究，包括 864651 名完成 HTC 的参与者，符合纳入标准。接受社区 HTC 的人接受 HTC 的比例如下：索引检测，12052 名参与者中的 88%；自我检测，1839 名参与者中的 87%；流动检测，79475 名参与者中的 87%；挨家挨户检测，555267 名参与者中的 80%；工作场所检测，62406 名参与者中的 67%；和学校 HTC，2593 名参与者中的 62%。关键人群（男男性行为者、注射毒品使用者、女性性工作者和青少年）的流动 HTC 参与率从 9%到 100%不等（在 41110 名参与者的研究中），异质性与检测提供方式有关。社区方法增加了 HTC 接受率（相对风险 [RR] 10.65，95%置信区间 [CI] 6.27-18.08）、首次接受检测者的比例（RR 1.23，95% CI 1.06-1.42）和 CD4 计数超过 350 个细胞/µl 的参与者比例（RR 1.42，95% CI 1.16-1.74），并获得较低的阳性率（RR 0.59，95% CI 0.37-0.96），与基于机构的方法相比。在接受社区 HTC 的 5832 名参与者中，80%（95% CI 75%-85%）获得了 HIV 诊断后的 CD4 测量值，在接受 CD4 测量值表明符合条件的 527 名社区 HTC 参与者中，有 73%（95% CI 61%-85%）开始接受抗逆转录病毒治疗。关于将未感染 HIV 的参与者与预防服务联系起来的数据有限。在中低收入国家，每人检测费用范围为 2 美元至 126 美元。在人群层面，社区 HTC 增加了 HTC 覆盖率（RR 7.07，95% CI 3.52-14.22）和降低了 HIV 发病率（RR 0.86，95% CI 0.73-1.02），尽管发病率降低缺乏统计学意义。没有研究报告因接受检测而产生任何危害。
社区 HTC 实现了较高的 HTC 接受率，覆盖了 CD4 计数较高的人群，并将他们与护理联系起来。与基于机构的方法相比，它还获得了较低的 HIV 阳性率。需要进一步研究进一步提高关键人群对社区 HTC 的接受程度。艾滋病毒规划应提供与预防和护理相结合的社区 HTC，除了基于机构的 HTC 外，以支持更多地获得艾滋病毒预防、护理和治疗。
国际前瞻性系统评价注册处 CRD42012002554 请在文章后面查看编辑摘要。
