Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines

ABSTRACT

New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users’ values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients’ uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (≥98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.

KEYWORDS:

• HIV testing
• HTS
• lay providers
• task shifting
• task sharing

Acknowledgments

We wish to thank Rachel Rieder, Kathleen Ridgeway, Shristi Pandey, and Kate Perepezko for their help with abstract screening. We also thank the members of the WHO consolidated HIV testing guideline development group for their feedback and suggestions. This research was supported by the World Health Organization, Department of HIV/AIDS.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

ORCID

P. T. Yeh http://orcid.org/0000-0002-7425-0382

Additional information

Funding

This work was supported by the World Health Organization, Department of HIV/AIDS.