Screening for HIV and linkage to care in adolescents: insights from a systematic review of recent interventions in high- versus low- and middle-income settings

Figures & data

Table 1 Barriers to HIV testing for adolescents

Concerns about correct self-test operation^Citation82

Confidentiality using parental insurance/parental consent^Citation16,Citation19

Conflicts with school hours^Citation20

Cost^Citation21,Citation82

Drug use^Citation24

Fear of disclosure^Citation15

Fear of heterosexist bias^Citation13,Citation83

Fear of job consequences^Citation84

Fear of rejection from partners/parents/peers^Citation9,Citation14^–^Citation17,Citation84

Fear of results^Citation9,Citation15^–^Citation17

Inaccurate information from testing locations^Citation20

Inconvenience^Citation18

Lack of knowledge/low health literacy^Citation12,Citation15,Citation17

Lack of youth-friendly/Lesbian, Gay Bi, Trans (LGBT)-friendly spaces^Citation15

Lack of social support^Citation82

Never offered HIV test^Citation10

Patient-provider trust/communication^Citation11,Citation19,Citation83

Perceived healthy status/susceptibility/risk^Citation9^–^Citation12,Citation14

Privacy concerns^Citation18,Citation19,Citation83

Racial/ethnic differences^Citation23,Citation24

Sex differences (male/female)^Citation24

Socioeconomic status^Citation25

Stigma, HIV-related^Citation9,Citation12^–^Citation14,Citation16,Citation1

Stigma, LGBT-related^Citation13,Citation23

Figure 1 PRISMA figure of inclusion/exclusion criteria.

Table 2 Interventions to increase HIV testing among adolescents, published between January 1, 2015, and April 28, 2018

Interventions to increase adolescent HIV testing in high-income countries
Authors	Publication and date	Location	Number of subjects	Ages (target population)	Study type	Intervention description	Results of intervention on testing	Linkage to care
Behavioral/educational interventions
Letourneau, et al^Citation29	Journal of Substance Abuse Treatment, 2017	South Carolina, USA	105	11–17 (juvenile drug court attendees)	Randomized, controlled	Risk Reduction Therapy for Adolescents (RRTA, n=45) versus UC (n=60); RRTA: Family focused contingency management with adolescent-parent dyads (24 weekly sessions, 60–90 minutes each)	HIV testing prevalence increased from 16% to 25% for RRTA and decreased from 17% to 14% for UC baseline versus 12-month follow-up (not significant); non-significant between-group difference RRTA versus UC (OR 2.15, 95% CI 0.49–9.36)	None
Donenberg, et al^Citation30	Journal of Child and Family Studies, 2015	USA	54	13–17 (youth on probation)	Pre–post evaluation	Preventing HIV/AIDS among Teens (PHAT Life), an HIV-prevention program for teens on probation using group role-plays, videos, games, and skill development activities	HIV testing changes varied by sex (OR 2.99, P=0.11); 19% (n=6) of males reported being tested for HIV in the previous 6 months at baseline, compared to 41% (n=13) who reported an HIV test in the previous 3 months at follow-up; 36% (n=8) of females reported being tested for HIV at both time points; HIV testing increased for males (OR 2.99, 95% CI 1.42–6.31, P=0.004) but not for females (OR 1.00, 95% CI 0.33–3.06, P=1.00)	None
Alternative venue/self-testing
Merchant, et al^Citation31	AIDS and Behavior, 2018	USA	425	18–24 (MSM)	Randomized	Randomized 1:1:1 for oral rapid test, mail-in blood test, or medical facility of choice	54% completed assigned test overall (62% oral test, 40% mail-in blood, 56% facility testing); oral and facility tests had greater completion rates than mail-in (P<0.01 each)	None
Holliday et al^Citation32	Journal of Health Care for the Poor and Underserved, 2017	USA	2,385	18–24 (African Americans attending historically black colleges and universities)	Observational, prospective	Campus and Community HIV and Addiction Prevention (CCHAP): HIV testing plus 1-hour interactive peer-led HIV and substance-use workshop, and environmental strategies	2,383 tested (99.9%); 15 HIV infections (0.6%)	15/15 (100%)
Miller et al^Citation34	JAMA Pediatrics, 2017	USA	3,301	13–24 (sexual minority males of color)	Observational, prospective	Multisite HIV testing program designed to encourage localized HIV testing programs focused on self-identified sexual minority males evaluating universal testing, targeted testing, and combination testing	Universal testing: 35 sexual minority males, 1 (0.1%) new HIV infection; targeted testing: 236 sexual minority males, 16 (3.2%) new HIV infections; combination testing: 693 sexual minority males, 39 (2.1%) new HIV infections	None
Buzi et al^Citation33	Public Health Reports, 2016	Texas, USA	34,299	13–23 (family planning clinic attendees)	Observational, retrospective	Implementation of routine opt-out testing versus opt-in testing	50% increase in HIV testing in opt-out testing; during opt-out, 0.3% were HIV infected	None
Technology/mobile health
Bauermeister et al^Citation36	AIDS and Behavior, 2015	USA	130	15–24 (MSM)	Randomized, controlled	Full Get Connected! program versus testing site locator control; Get Connected! a tailored online HIV/STI testing intervention designed with input from a youth advisory board	32 (25%) received HIV testing, 32% in full intervention, and 29% in locator only (no significant difference)	None
Ybarra et al^Citation38	Pediatrics, 2017	USA	302	14–18 (MSM)	Randomized, controlled	Randomized 1:1 Guy2Guy intervention versus self-esteem control; Guy2Guy: 5–10 daily text messages for 5 weeks, content included HIV information, motivation, behavioral skills, HIV testing, healthy relationships	Intervention more likely to receive HIV testing compared to control: 55% versus 28% (OR 3.42, 95% CI 1.65–7.09, P=0.001)	None
Washington et al^Citation39	IAS, 2016	California, USA	142	18–30 (black MSM)	Randomized, controlled	Intervention versus control; intervention group watched five 60-second videos per week featuring vignettes from BMSM characters, and posted reflections using chat feature; control group viewed standard HIV text information	Retention rates of 71% for intervention group and 78% for control group; BMSM in intervention group was 7 times more likely to have tested for HIV (OR =7.00, 95% CI 1.72–28.33, P=0.006)	None
Dowshen et al^Citation37	AIDS and Behavior, 2015	Pennsylvania, USA	At least 1,500 interacted with campaign	13–17 (primary target); 18–24 (secondary target)	Pre–post evaluation	IknowUshould2 campaign to improve STIs/HIV knowledge and testing; included traditional media (print ads, t-shirts, radio, hotline) and new media (website, Facebook, Twitter, Instagram, YouTube)	Significant increase in proportion of CHOP Family Planning clinic visits at which HIV test was conducted (5.4% versus 19.0%, P<0.01)	None
Aronson et al^Citation35	Journal of Mobile Technology in Medicine, 2016	New York, USA	100	18–24 (youth in ED who declined HIV testing)	Observational, prospective	Tablet-based sexual risk and substance abuse questionnaire and video on HIV testing; high-risk participants enrolled in weekly text messages for 12 weeks	30 (30%) individuals agreed to HIV testing after using tablet; 21 (70%) agreed to receive text messaging	None
Solorio et al^Citation16	AIDS and Behavior, 2016	Washington, USA	50	18–30 (Latino MSM)	Observational, prospective	Tu Amigo Pepe pilot intervention: 16-week campaign included Spanish- language radio public service announcements, a website, social media outreach, a reminder system using mobile technology, print materials and a toll-free hotline	56% tested by the end of the campaign; 82% at baseline; 90% after campaign (OR 2.0; 95% CI 0.8–5.4; P=0.16)	None
Community/peer engagement
Shelley et al^Citation40	AIDS Education and Prevention, 2017	USA	298	18–29 (MSM)	Pre–post evaluation	Mpowerment (MP): community- level, community mobilization intervention to reduce sexual risk behavior by addressing psychosocial factors at individual, interpersonal, social, and structural levels (1) core group, (2) formal outreach, (3) M-groups, (4) informal outreach, (5) publicity, and (6) the project space	Increase in HIV testing from baseline (53.6%) to 3-month follow-up (65.0%, PR =1.20, P<0.01) and 6-month follow-up: (70.2%, PR =1.28, P<.001)	None
Camacho- Gonzalez et al^Citation41	AIDS, 2017	Georgia, USA	435	18–24	Observational, prospective	Metropolitan Atlanta Community Adolescent Rapid Testing Initiative (MACARTI) intervention: combined nontraditional venue HIV testing, motivational interviewing, and case management	Identified 49 (11.3%) HIV infections	Higher for MACARTI compared to SOC (96% versus 57%, P<0.001)
Interventions to increase adolescent HIV testing in low- and middle-income countries
Authors	Publication and date	Location	Number of subjects	Ages (Target Population)	Study type	Intervention description	Results of intervention on testing	Linkage to care
Behavioral/educational interventions
Firestone et al^Citation55	Global Health: Science and Practice, 2016	Liberia	1,052	15–35 (out-of- school youth)	Randomized, controlled	HealthyActions intervention versus control; HealthyActions: 6-day intensive group learning on sexual and reproductive health	Control less likely to receive HIV test (OR 0.45, 95% CI 0.38–0.53, P<0.001)	None
Jani et al^Citation56	Journal of the International AIDS Society, 2016	Ethiopia	730	15–18	Pre–post evaluation	Three-month client-centered, counselor-delivered psychosocial intervention involving individual, group, and creative arts therapy counseling sessions	HIV testing increased by 80% for females (AOR 1.8, 95% CI 1.13–2.97) and by 630% for males (AOR 7.3, 95% CI 2.6–20.7)	None
Alternate venue/self-testing
Shanaube et al^Citation45	AIDS, 2017	Zambia and South Africa	15,456	15–19	Community- randomized, controlled	PopART for Youth (P-ART-Y): door-to-door combination prevention delivered by trained community health workers	72.3% accepted intervention; HCT uptake was 80.6%; 135 (1.6%) new HIV infections diagnosed; control arm data was not yet available	None
Pettifor et al^Citation42	CROI, 2018	South Africa	284	18–24 (females only)	Randomized, controlled	Randomized into standard of care arm with invitation to local clinic for free HCT (n=144) or choice arm offering free HCT or self-testing (n=140); five self- testing kits or five testing invitations given to each woman, one for herself and four for peer referrals	96% randomized to choice arm chose self-testing; 97% who returned for 3-month follow- up from choice arm reported testing compared to 48% from HCT arm (RR 2.00, 95% CI 1.66–2.40); more peer referrals from choice arm (66% of total peer referrals)	None
Hector et al^Citation58	PloS One, 2018	Mozambique	496	16–20	Observational, prospective	Assisted oral self- testing	299 (60%) oral self-tests; 1.7% HIV-infected	None
Ahmed et al^Citation57	Tropical Medicine and International Health, 2017	Malawi	165	1–24 (only >15–24 data reported in this row)	Observational, prospective	Home- or facility- based HIV testing and counseling offered for untested children of known adults living with HIV	Home-based: 2/156 new HIV diagnoses (1.3%); facility-based: 5/9 new HIV diagnoses (55.6%)	Home- based: 1/2 (50%); Facility- based: 3/5 (60%)
Mugo et al^Citation50	Sexually Transmitted Infections, 2015	Kenya	1,490	18–29	Observational, prospective	Pharmacy workers referred clients purchasing medicine for fever, sexually transmitted infection symptoms, diarrhea, or body pains	353 (24%) were tested for HIV; 14 (4.0%) were newly diagnosed with HIV	None
Fatti et al^Citation43	IAS, 2016	South Africa	4,800	10–19	Observational, prospective	Three testing strategies employed as part of combination program in two districts: index client trailing, door- to-door testing, and campaign testing at events; routine HIV testing program data used	4,756 (99.1%) consented to HIV testing; first HIV test for 90% of males and 85.7% of females (P<0.0001); 7.5% of females tested HIV+ compared to 3.9% of males (P<0.0001); HIV positivity was higher at campaigns (9.4%) than through index client trailing (6.0%) or door-to-door testing (5.9%) (P=0.019)	None
Rousseau- Jemwa et al^Citation44	IAS, 2016	South Africa	1,285	12–24	Observational, prospective	Nurse-led, counselor- supported Tutu Teen Truck (TTT) mobile clinic offering HTC services at targeted locations (taxi ranks, shopping/community centers, sports fields, opposite schools)	45.6% had no prior HIV test before TTT; 2.7% were newly diagnosed	None
Technology/mobile health
Njuguna et al^Citation49	Sexually Transmitted Diseases, 2016	Kenya	600	18–24 (females only)	Community- randomized, controlled	Randomized by college to SMS intervention or control; intervention: weekly SMS on HIV and reproductive health topics	HIV testing within 6 months: 67% from the intervention arm and 51% from the control arm (HR 1.57, 95% CI 1.28–1.92)	None
Mugo et al^Citation51	PloS One, 2016	Kenya	410	18–29 evaluated for acute HIV infection	Randomized, controlled	Randomized 1:1 to enhanced versus standard appointment reminders to return for repeat HIV testing; standard reminders: a dated appointment card; enhanced reminders: a dated appointment card plus SMS and phone call reminders, or in-person reminders for participants without a phone	Repeat test attendance was 41% (85/207) for standard group and 59% (117/199) for the enhanced group (RR 1.4, 95% CI 1.2–1.7)	None
Nevendorff, et al^Citation61	IAS, 2016	Indonesia	Not specified	Unspecified (young key population)	Retrospective, observational	YKP-friendly training for service providers; YKP sensitization workshop for outreach workers; online communication platform developed	66% increase in HIV testing of YKPs compared to baseline data	67% increase in YKP receiving ART compared to baseline data
Incentives
Dakshina et al^Citation62	IAS, 2016	Zimbabwe	2,796	8–17	Randomized, controlled	Households with eligible children were randomized to one of three arms: 26% standard of care (no monetary incentive; n=735), 41% monetary prize draw (10, 5, or 0 USD with probability of picking as 0.06, 0.07, and 0.90, respectively; n=1,155), and 32% monetary incentive (2 USD; n=906)	Overall 35.7% of those eligible were tested; 15% in SOC arm, 37% in prize draw arm, and 48% in monetary incentive arm attended HIV testing; significantly more adolescents attended HIV testing with monetary incentive	None
Chapman et al^Citation54	IAS, 2015	Zambia	1,813	11–17 (orphans and vulnerable children)	Pre–post evaluation	Survey before and after participation in the STEPS program (Sustainability through Economic Strengthening, Prevention, and Support); 86% response rate at endline (1,813/2,099)	More likely to report having had an HIV test after STEPS (21% pre versus 28% post)	None
Oyewale et al^Citation53	Current Opinions in HIV and AIDS, 2016	Bangladesh	239	15–24 (MSM and transgender individuals)	Observational, prospective	Effectiveness of voucher scheme to access HIV testing	160 (76%) tested; 1 HIV infection	1/1 (100%)
Youth-friendly services
Aninanya et al^Citation60	PloS One, 2015	Ghana	2,664	15–17	Community- randomized, controlled	26 communities randomized to intervention or comparison; Intervention: school- based curriculum, out-of-school outreach, community mobilization, and health-worker training in youth-friendly health services; comparison: only community mobilization and health-worker training	9.7% increase in testing with intervention (OR 1.16, 95% CI 0.85–1.58, P>0.05)	None
Aung et al^Citation59	Journal of Adolescent Health, 2017	Myanmar	613	15–24 (MSM)	Non- randomized, community controlled	Link Up intervention townships versus control townships; Link Up intervention: community- and clinic-based services that were youth friendly and tailored to meet the specific needs of YMSM including peer education and outreach and youth MSM-friendly clinic	HIV testing increased from 45% to 57% for Link Up and stayed the same for control at 29%; no significant difference between Link Up and control (AOR 1.45, 95% CI 0.66–3.17, P=0.35)	None
Peer/community interventions
Rotheram- Borus et al^Citation47	AIDS and Behavior, 2016	South Africa	142	18–25 (unemployed males)	Community- randomized, controlled	Randomized neighborhoods to immediate intervention or delayed control; Intervention: Grassroot Soccer program with trained coaches, random rapid diagnostic tests for alcohol/drugs, and vocational training	29% testing in immediate versus 24% in delayed (no significant difference)	None
Hershow et al^Citation46	Sport in Society, 2015	South Africa	1,953	12–16 (females only)	Pre–post evaluation	Survey before and after participation in SKILLZ Street intervention developed by Grassroot Soccer (GRS); SKILLZ Street: Female coaches deliver an afterschool education program consisting of 10, 2 hour biweekly sessions	69% tested for HIV	None
Hossain et al^Citation52	IAS, 2016	Bangladesh	1,005	18–24 (female sex workers)	Pre–post evaluation	Link Up peer outreach intervention at select brothels compared to comparison brothels without intervention	68% in intervention brothels reported contact with peer educator; significantly higher odds of HIV testing uptake (AOR 1.76, 95% CI 1.04–2.96) and receipt of HIV test results (AOR 6.56, 95% CI 1.79–24.12) with peer educator contact; multivariate analyses showed no significant difference between improvement at intervention sites versus comparison sites	None
Reif et al^Citation63	AIDS Patient Care and STDs, 2016	Haiti	3,425	10–24	Observational, prospective	Community-based adolescent HIV testing campaign with community sensitization and active recruitment by CHWs	3,348 (98%) accepted an HIV test; HIV prevalence was 2.65% (n=89)	89/89 (100%)
Kadede et al^Citation48	AIDS, 2016	Uganda and Kenya	116,326	10–24	Observational, prospective	SEARCH hybrid strategy: 2-week community health campaign that included HIV testing, followed by home-based testing of community health campaign nonparticipants	86,421 (88%) adolescents tested for HIV; 1,843 (2.1%) diagnosed positive	None

Abbreviations: UC, Usual Care; PR, prevalence ratio; ART, antiretroviral therapy; RRTA, risk reduction therapy for adolescents ; PHAT, preventing HIV/AIDS among teens, MSM, men who have sex with men; JAMA, Journal of the American Medical Association; STI, sexually transmitted infection, ED, emergency department; BMSM, black men who have sex with men; SMS, short messaging service; YKP, young key population; ART, antiretroviral therapy; SOC, standard of care.

Table 3 Categories of HIV testing interventions

Category	Definition	Examples
Behavioral/educational	Interventions that provided information on HIV and/or focused on behavioral change	• Cognitive behavior therapy • Behavior management training
Alternative venue/self-testing	Interventions that provided HIV counseling and testing outside of traditional health care facilities	• Mobile testing vans • In-home testing • Oral, home self-testing
Technology/mobile health	Interventions using social media, internet, or mobile phones	• Text messaging • Online chat groups
Incentives	Interventions that provided monetary or coupon reimbursement for HIV testing	• Cash • Prize draw
Youth-friendly services	Interventions that focused explicitly on targeting services for an adolescent population	• Health-worker training • Youth-friendly facilities
Peer/community	Interventions that used interactions with trained community members, peers, or groups	• Youth soccer programs • Community testing campaigns or events

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