HIV Testing Uptake According to Opt-In, Opt-Out or Risk-Based Testing Approaches: a Systematic Review and Meta-Analysis

Abstract

Purpose of Review Improving HIV testing uptake is essential to ending the HIV pandemic. HIV testing approaches can be opt-in, opt-out or risk-based. This systematic review examines and compares the uptake of HIV testing in opt-in, opt-out and risk-based testing approaches. Recent Findings There remain missed opportunities for HIV testing in a variety of settings using different approaches: opt-in (a person actively accepts to be tested for HIV), opt-out (a person is informed that HIV testing is routine/standard of care, and they actively decline if they do not wish to be tested for HIV) or risk-based (using risk-based screening tools to focus testing on certain individuals or sub-populations at greater risk of HIV). It is not clear how the approach could impact HIV test uptake when adjusted for other factors (e.g. rapid testing, country-income level, test setting and population tested). Summary We searched four databases for studies reporting on HIV test uptake. In total, 18,238 records were screened, and 150 studies were included in the review. Most studies described an opt-in approach (87 estimates), followed by opt-out (76) and risk-based (19). Opt-out testing was associated with 64.3% test uptake (I2 = 99.9%), opt-in testing with 59.8% (I2 = 99.9%) and risk-based testing with 54.4% (I2 = 99.9%). When adjusted for settings that offered rapid testing, country income level, setting and population tested, opt-out testing had a significantly higher uptake (+ 12% (95% confidence intervals: 3–21), p = 0.007) than opt-in testing. We also found that emergency department patients and hospital outpatients had significantly lower HIV test uptake than other populations.

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis.

“…This lower rate of testing in emergency departments is consistent with a systematic review of HIV testing in low-resource settings, suggesting missed opportunities for better integration of HIV testing into emergency departments [36]. This could include routinely offering HIV testing to all clients being tested for other STIs (opt-out) [37,38], improving access to HIV/syphilis dual testing or multiplex HIV/STI testing platforms, ensuring robust systems for follow-up, and providing education and training to the health workforce in line with the WHO and national testing guidelines.…”

Organisation of testing services, structural barriers and facilitators of routine HIV self-testing during sexually transmitted infection consultations: a qualitative study of patients and providers in Abidjan, Côte d’Ivoire

“…Our observations suggest that when HIV testing was routinely implemented for all patients (in Services 1–2), health professionals were more likely to propose HIV testing to all patients. A systematic review comparing HIV testing approaches found that, in other contexts, opt-out “ testing had higher uptake than opt-in and risk-based testing ” [ 19 ]. This approach would not be recommended for low-burden settings in which the focus is on key populations.…”

Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease

“…1 Although HIV testing rates have improved over time, barriers continue to exist, and testing rates remain suboptimal among disproportionately affected groups, 12 regardless of whether opt-in, opt-out, or risk-based testing approaches are used. 13 Both groups share some barriers to HIV testing, but certain barriers are unique to each. Recognizing these barriers-structural, intrapersonal, and interpersonal-is crucial to timely HIV testing and appropriate therapy initiation.…”

“…Although only 38% of the US population resided in the South in 2019, the region accounts for approximately 51% of new HIV cases; African Americans, especially Black women and Black men who have sex with men (MSM), are disproportionately affected 1 . Although HIV testing rates have improved over time, barriers continue to exist, and testing rates remain suboptimal among disproportionately affected groups, 12 regardless of whether opt-in, opt-out, or risk-based testing approaches are used 13 . Both groups share some barriers to HIV testing, but certain barriers are unique to each.…”