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


This systematic review has identified a significant body of evidence on HIV testing in health care settings in Europe. Testing has been provided in a range of clinical settings with results suggesting that it is feasible to achieve high testing coverage, and that it is acceptable for providers and service users. HIV testing positivity ranged widely, from 0 to 25%, with higher positivity rates observed with certain strategies such as partner notification, IC testing and testing among risk groups compared to strategies that offered testing to the general population, including lower risk groups. However, the data also highlight that there is considerable room to increase the offer of testing in health care settings, particularly in primary care and emergency departments.

Evidence from systematic reviews shows that, in primary care, barriers to testing are related to the clinician's knowledge,[17,148] as well as the clinician's anxiety associated with raising the topic of HIV testing with patients.[149] Improving testing in primary care is important because in many countries more testing takes place in primary care than in specialized services, as those countries have a testing strategy that primarily uses GPs (e.g. the Netherlands and Germany).[12] Furthermore, an evaluation of the impact of the guidance highlighted that, while over half the respondent countries reported that their national testing guidelines were closely aligned with the 2010 European guidance, only 35% included the relevant recommendations on routine offering in primary care.[150] Testing in primary care is highly acceptable to all patients, with one study among MSM also reporting primary care as an acceptable setting, and therefore interventions that increase knowledge and provide training for primary care staff could be successful at increasing test coverage. The knowledge and capability of health care staff could be enhanced through education interventions. One study in this review gave GPs training in sexual health clinical skills and achieved large increases in testing rates from 1056 tests before to 2333 after the intervention,[105] which emphasizes the impact on testing once GPs are enabled to offer testing.

In addition to testing in primary care, there are other strategies identified in this review that could improve testing coverage in health care settings in Europe, including: scaling up IC testing across all settings; introducing testing in high-prevalence areas, although the majority of studies implementing this strategy are from the UK; and implementing integrated testing for BBVs in settings such as drug services and prisons and HIV and STI testing in STI clinics. Although IC testing is an effective strategy to diagnose HIV infection and results in high positivity rates, it is not always included in national or speciality testing guidelines for specific ICs and, where it is included, the scale of implementation is quite variable.[151,152] The concept of testing based on high diagnosed sero-prevalence areas assumes that areas of high diagnosed prevalence are likely to also have high rates of undiagnosed infections. This strategy removes the need to target specific populations, which was found to be unacceptable to primary care providers in one study in this review. The adopted strategy will, however, depend on the health care setting. Finally, integrated testing for BBVs was recently recommended in prisons by the ECDC/European Monitoring Centre for Drugs and Drug Addiction guidance.[153]

There were only three studies set in community-based drug services and pharmacies. These venues potentially have an important role in HIV testing by reaching populations that do not necessarily attend traditional health care venues and by acting as a bridge between health care and the community. Community-based pharmacies are acceptable venues for HIV testing where testing can be implemented with basic teaching and skills provision to the pharmacist.[48,49] Pharmacies are already an established model of delivery for chlamydia testing,[154] which only highlights the growing role of pharmacies in public health provision. Rapid testing or self-sampling kits were the adopted testing strategies in this setting. The added benefit of self-sampling kits is the possibility of providing integrated testing for BBVs and STIs.[102]

The distribution of self-sampling and self-testing kits for HIV from other health care settings (e.g. STI clinics) has been found to be acceptable among MSM[44,52] and people attending free and anonymous testing services.[108] However, further evidence is needed to understand whether this strategy can increase testing frequency in high-risk groups including MSM.

There were some limitations to this systematic review. There was only one study from Eastern Europe, which could have implications for the applicability and reproducibility of the review findings to this region. There were methodological concerns relating to measuring increases in test coverage. Although this review aimed to document the impact of intervention on increasing test coverage, a very small proportion of studies included a baseline measure or a comparator group to allow assessment of improvements in testing. Where comparisons could be made, the timeframe over which the impact of the intervention was assessed varied between studies, with most being assessed immediately after the intervention. Future studies should consider implementing interventions over longer timeframes. We restricted the review to the EU/EEA, so we may have missed studies that were applicable to and reproducible in the European setting. Finally, studies with positive findings or using novel approaches are more likely to be published. The inclusion of conference abstracts and reports (35%; 46 of 130) is therefore important to reduce publication bias; however, the quality of these studies has not been assessed. Without this assessment, we cannot know the reliability and reproducibility of the presented results. It is important that all findings including those from conference abstracts are published in peer-reviewed journals. There are three important strengths to this review. The review employed the robust PRISMA methodology which is standardized and reproducible. Secondly, the scope of the questions facilitated a broad and all-encompassing review of the literature on HIV testing in health care settings. Thirdly, the review included papers not in English, which were translated.