Acute and early HIV infection screening among men who have sex with men, a systematic review and meta‐analysis

Abstract

Introduction: Screening for acute and early HIV infections (AEHI) among men who have sex with men (MSM) remains uncommon in sub-Saharan Africa (SSA). Yet, undiagnosed AEHI among MSM and subsequent failure to link to care are important drivers of the HIV epidemic. We conducted a systematic review and meta-analysis of AEHI yield among MSM mobilized for AEHI testing; and assessed which risk factors and/or symptoms could increase AEHI yield in MSM. Methods: We systematically searched four databases from their inception through May 2020 for studies reporting strategies of mobilizing MSM for testing and their AEHI yield, or risk and/or symptom scores targeting AEHI screening. AEHI yield was defined as the proportion of AEHI cases among the total number of visits. Study estimates for AEHI yield were pooled using random effects models. Predictive ability of risk and/or symptom scores was expressed as the area under the receiver operator curve (AUC). Results: Twenty-two studies were identified and included a variety of mobilization strategies (eight studies) and risk and/or symptom scores (fourteen studies). The overall pooled AEHI yield was 6.3% (95% CI, 2.1 to 12.4; I 2 = 94.9%; five studies); yield varied between studies using targeted strategies (11.1%; 95% CI, 5.9 to 17.6; I 2 = 83.8%; three studies) versus universal testing (1.6%; 95% CI, 0.8 to 2.4; two studies). The AUC of risk and/or symptom scores ranged from 0.69 to 0.89 in development study samples, and from 0.51 to 0.88 in validation study samples. AUC was the highest for scores including symptoms, such as diarrhoea, fever and fatigue. Key risk score variables were age, number of sexual partners, condomless receptive anal intercourse, sexual intercourse with a person living with HIV, a sexually transmitted infection, and illicit drug use. No studies were identified that assessed AEHI yield among MSM in SSA and risk and/or symptom scores developed among MSM in SSA lacked validation. Conclusions: Strategies mobilizing MSM for targeted AEHI testing resulted in substantially higher AEHI yields than universal AEHI testing. Targeted AEHI testing may be optimized using risk and/or symptom scores, especially if scores include symptoms. Studies assessing AEHI yield and validation of risk and/or symptom scores among MSM in SSA are urgently needed.

Peer Mobilization and Human Immunodeficiency Virus (HIV) Partner Notification Services Among Gay, Bisexual, and Other Men Who Have Sex With Men and Transgender Women in Coastal Kenya Identified a High Number of Undiagnosed HIV Infections

“…Our data suggest that if a more stringent cutoff of the behavioral or symptom score would be used to select people for HIV RNA testing, the AEHI yield could be up to 3.7% (behavioral score) or 20.0% (symptom score), while only offering HIV RNA testing to a small subset of participants. This is consistent with findings from our recently conducted meta-analysis, in which the pooled estimate for AEHI screening targeted to behaviorally vulnerable or symptomatic GBMSM was 11.1% (95% CI, 5.9%–17.6%) [ 18 ]. However, using a higher cutoff will inevitably miss a substantial proportion of AEHI cases and should only be used when resources are constrained.…”

“…We recently conducted a systematic review and meta-analysis of studies reporting strategies to mobilize GBMSM for AEHI testing [ 18 ]. We found that targeted AEHI testing (ie, testing of individuals with certain behavioral factors or symptoms) resulted in substantially higher AEHI yields than universal AEHI testing, and that AEHI yield may be increased by using published behavioral and/or symptom scores [ 19–21 ].…”

“…Considering the costs of HIV RNA testing, required for AEHI diagnosis [ 15 , 22 ], increasing AEHI yield through targeted testing may be an efficient strategy in less-resourced settings. However, no AEHI yield has been reported from screening GBMSM or TGW with published AEHI behavioral and/or symptom scores globally [ 18 ].…”

Age-dependent inequalities in HIV/STI burden and care receipt among men and transgender persons who have sex with men in Nairobi

“…Our findings concur with others in suggesting such approaches alone have unacceptably poor diagnostic performance 37,38 . The decreasing complexity and cost of point-of-care PCR technologies should encourage policy makers to re-evaluate the cost effectiveness of providing access to PCR-based HIV and STI diagnostics particularly in community settings 39 .…”

Involvement of African men and transgender women who have sex with men in HIV research: progress, but much more must be done

“…Palmer et al . [45] conducted a systematic review and meta‐analysis of studies reporting strategies of mobilising MSM for testing to identify acute and early HIV infection (AEHI) and their yield of AEHI cases. Overall, AEHI was identified in 6.3% (95% CI: 2.1 to 12.4) and acute HIV infection in 0.7% (95% CI: 0.4 to 1.2) of the visits at which it was assessed.…”