HIV Testing Strategies Employed in Health Care Settings in the European Union/European Economic Area (EU/EEA)

Evidence From a Systematic Review

S Desai; L Tavoschi; AK Sullivan; L Combs; D Raben; V Delpech; SF Jakobsen; AJ Amato-Gauci; S Croxford


HIV Medicine. 2020;21(3):163-179. 

In This Article

Abstract and Introduction


Objectives: Despite the availability of HIV testing guidelines to facilitate prompt diagnosis, late HIV diagnosis remains high across Europe. The study synthesizes recent evidence on HIV testing strategies adopted in health care settings in the European Union/European Economic Area (EU/EEA).

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and systematic searches were run in five databases (2010–2017) to identify studies describing HIV testing interventions in health care settings in the EU/EEA. The grey literature was searched for unpublished studies (2014–2017). Two reviewers independently performed study selection, data extraction and critical appraisal.

Results: One hundred and thirty intervention and/or feasibility studies on HIV testing in health care settings were identified. Interventions included testing provision (n = 94), campaigns (n = 14) and education and training for staff and patients (n = 20). HIV test coverage achieved through testing provision varied: 2.9–94% in primary care compared to 3.9–66% in emergency departments. HIV test positivity was lower in emergency departments (0–1.3%) and antenatal services (0–0.05%) than in other hospital departments (e.g. inpatients: 0–5.3%). Indicator condition testing programmes increased HIV test coverage from 3.9–72% before to 12–85% after their implementation, with most studies reporting a 10–20% increase. There were 51 feasibility and/or acceptability studies that demonstrated that HIV testing interventions were generally acceptable to patients and providers in health care settings (e.g. general practitioner testing acceptable: 77–93%).

Conclusions: This review has identified several strategies that could be adopted to achieve high HIV testing coverage across a variety of health care settings and populations in the EU/EEA. Very few studies compared the intervention under investigation to a baseline, but, where this was assessed, data suggested increases in testing.


In 2017, 49% of people diagnosed with HIV infection were first identified at a late stage of infection (CD4 count < 350 cells/μL) in Europe.[1] Late diagnosis is associated with increased risk of morbidity and mortality[2,3] as well as increased risk of onward transmission of HIV as a consequence of delayed initiation of treatment.[4] The Joint United Nations Programme on HIV/AIDS (UNAIDS) set the global 90–90-90 target where 90% of all people with HIV infection should be diagnosed, 90% of those diagnosed should receive HIV treatment and 90% of those on treatment should have a suppressed viral load by 2020.[5] HIV testing is therefore a vital first step in the HIV care continuum and in Europe it has historically been offered in traditional health care settings, such as sexual health clinics, antenatal services and voluntary counselling and testing sites. Testing guidance for sexually transmitted infection (STI)/genitourinary/dermato-venereology clinics exists at national, European and international levels promoting universal testing offer.[6–10] However, other health care settings that are nonspecialist for HIV and where patients are presenting for the management of other conditions present opportunities to increase HIV testing, thereby reducing undiagnosed infections. In 2016, an estimated 101 400 people were living with undiagnosed HIV infection in the European Union/European Economic Area (EU/EEA), and, although this represents a decline in the number since 2012, it highlights the continued need for effective HIV testing programmes to improve HIV test coverage.[11]

The World Health Organization (WHO) consolidated guidelines on HIV testing services, recommending that HIV testing services should be integrated with other relevant clinical services such as those for tuberculosis (TB), maternal health, sexual and reproductive health and harm reduction programmes, especially as these services attract populations considered to be at higher risk for HIV infection.[9] The guidelines endorse the use of provider-initiated testing and counselling when the epidemic is generalized and the routine offer of testing for all clients in all health facilities (including primary care, inpatient and outpatient services and all services for key populations) is recommended as an effective way to identify people with HIV infection.

Although guidance is available from international organizations and national public health bodies to inform service provision for HIV testing,[12] health care providers within European countries need to be able to operationalize these into clinical practice so as to diagnose HIV infection at an earlier stage of infection. An evidence synthesis published in 2010 by the European Centre for Disease Prevention and Control (ECDC) showed that a number of strategies could reduce missed opportunities for HIV testing, including indicator condition (IC)-guided testing, which involves offering testing to all patients presenting to care with an AIDS-defining illness or with an HIV 'indicator' condition (IC).[8] An HIV IC is a condition associated with an undiagnosed HIV prevalence of at least 1 per 1000.[13] Other strategies were routine HIV testing implemented as part of routine care in health care settings and the use of rapid tests that offer immediate results.

A recent evaluation of the 2010 ECDC guidance found that, although the document was considered important for policy and guideline development, an update to the guidance was necessary to incorporate new approaches and technologies that have been adopted to increase testing offer and coverage in recent years.[14] The purpose of this paper is to present the recent body of evidence on HIV testing strategies employed in health care settings in Europe. Additionally, the paper reviews the evidence on testing provision strategies that increase HIV testing coverage and on the feasibility and acceptability of HIV testing strategies. The systematic review described here was conducted as part of a wider review of the evidence on HIV testing in the EU/EEA and barriers to testing to update the 2010 ECDC HIV testing guidance.