Mapping evidence of intervention strategies to improving men’s uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

We conducted a scoping review of published peer-reviewed and grey literature (literature non-formally published scholarly or substantive information) studies on the intervention strategies to improving men’s uptake to HIV testing services in SSA. Methods for this study were guided by Arksey and O’Malley’s (2005) scoping review framework [30], and Levac et al. (2010) methodological enhancement for scoping review projects [31]. According to Arksey and O’Malley’s framework, there are five different stages in undertaking a scoping review: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data and (5) collating, summarising and reporting the results. We also followed the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation [32]. The Population, Concept and Context (PCC) framework was also employed in this study to determine the eligibility of research question (Table 1).

The Population, Concept and Context (PCC) framework was employed in this study to determine the eligibility of research question (Table 1). The framework indicate that our study’s population was men of all age groups in SSA, while our concept was HIV testing. The interventions employed in the included studies involved education about HIV; testing men for HIV at community level and at homes, encouraging men to test for HIV during ANC visits, offering incentives to attract men to test for HIV and encouraging men to test for HIV when after their sexual partners have been diagnosed with HIV.

The article searches were inclusive of databases, such as, PubMed/MEDLINE, American Doctoral Dissertations via EBSCO host, Union Catalogue of Theses and Dissertations (UCTD) and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. Publications by Medical Research Council and Human Sciences Research Council were also reviewed. Websites, such as, the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and governmental websites and statistics institutions were also searched for policies and guidelines on HIV testing among men. We searched for published and grey literature studies from January 1990 to August 2018. We used the following search key words: HIV testing; linkage to care, Africa. Boolean terms such as ‘AND’ and ‘OR’ were also used. We included the Medical Subject Headings (MeSH) terms in the keyword search. Following keyword search, eligible studies were exported to the Endnote version 7 library for abstract screening and full article screening.

Abstracts and full articles screening were conducted by the two independent reviewers, MH and SM, with guidance from the eligibility criteria for this study. The eligibility criteria was designed to limit the study to focus only on the articles that address issues described in the research question: what are intervention strategies aimed at improving men’s uptake to HIV testing services in SSA? We worked closely with the University of KwaZulu-Natal library services during database searching and retrieval of articles. Studies that could not be retrieved from databases were be obtained by contacting authors. The PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation was employed to report the screening of results.

To determine the quality of the selected studies, a Mixed Method Appraisal Tool (MMAT) version 2018 [33], was adopted and piloted by the two independent reviewers (MH and SM). The MMAT is a critical appraisal tool that is designed for the appraisal stage of systematic mixed studies reviews, like reviews that include qualitative, quantitative and mixed methods studies [33]. The tool permits to appraise the methodological quality of five categories to studies: (1) qualitative research, (2) randomized controlled trials, (3) non-randomized studies, (4) quantitative descriptive studies, and (5) mixed methods studies [33]. This tool was adopted and used in this study to appraise the above-mentioned categories, in which all included studies proved to have followed proper methodological approaches.

Seven studies used qualitative research method [35‐41], eight studies were quantitative [6, 7, 42‐47], four were mixed methods (both quantitative and qualitative) [5, 48‐50], two were randomized controlled trials [23, 51], two did not specify [22, 52], and one was a systematic review [53] (Fig. 2). More than 10 African countries were represented in the included studies (Fig. 3). The majority of included studies (83%) were published from 2010 onwards. The characteristics of included studies are also shown in Table 2.

All of the included studies which underwent methodological quality assessment scored the high quality score between 80 and 100%. The overall evidence was considered to have minimal risk of bias.

The following main themes emerged from the included studies: education about HIV; Community-Based HIV testing; Home-Based HIV testing; ANC HIV testing; HIV testing incentives; HIVST; Partner HIV testing or Index testing.

Evidence on education was reported in thirteen studies, which covered more than ten countries in SSA [6, 22, 23, 36, 39, 41, 43‐47, 51, 52]. Different studies indicated that such educational interventions should involve local leaders, including chiefs [36] and/or be part of the community-based outreach campaigns [22, 36, 39, 46, 52].Other studies found that having a higher HIV/AIDS-related knowledge was associated with improved engagement with HIV testing services [43] and reduced sexual risk behaviour [45]. Educational strategies for men may also work best if they are driven by other men [23, 36], in order to fight the stigma and masculinity challenges preventing men from testing for HIV [23, 43]. Educational programmes may include the basic HIV information [47], HIV transmission [6, 43], risk reduction strategies [43, 44], confidentiality [43]. For example, these may be in the form of presentations at local clinics, community gatherings or during outreach campaigns. There remain an educational gap on HIV programmes that are specifically tailored for men.

Fifteen studies presented evidence on community-based HIV testing [6, 22, 23, 35, 36, 41, 42, 44, 46‐51, 53]. Five studies indicated that most men preferred using community-based HIV testing services [22, 23, 36, 49, 53], as compared to facility-based testing [36, 50] due to stigma emanating from being seen at an HIV testing site [36]. Hensen et al. (2014) has demonstrated that, in SSA community-bases HIV testing had a significant effect on reaching a high number of clients who tested for HIV and the positivity rate, when compared to facility-based testing [53]. In addition to the reduced stigma associated with community-based HIV testing services, this strategy also reduces the financial costs associated with travelling to facilities and improves access to HIV testing services among men of lower socio-economic status [51]. It also helps reach younger men as well [47, 48]. Although community-based HIV testing reduces the stigma associated with HIV testing, it does not eliminate barriers to men’s uptake to HIV testing services completely [35]. Clients still have to travel to clinics and wait in long queues to obtain ART after testing HIV positive [22]. Sharma et al. (2017) has demonstrated that the incorporation of the ‘test and treat’ strategy as part of the community-based HIV testing services may help reduce loss to follow-up associated with facility-based ART initiations [22]. A study conducted in Uganda, concluded that expanding community mobile clinics throughout the country and rural communities, is essential to attract men to HIV testing services [6] as well as earlier linkage to ART services [22]. Sharma et al. (2017) and Stephenson et al. (2013) recommend the need for tailored community-based HIV services to support the needs of men, including flexible hours, convenient and private access to care and multiple follow-up visits [22, 46]. Despite the robust evidence on the benefits to community HIV testing among men in SSA, there remains a gap as far as ART initiations of HIV positive clients found through this community-based testing.

Evidence on home-based testing as a strategy for improving men’s HIV uptake was reported in seven articles, representing more than ten SSA countries [22, 23, 36, 38, 40, 51, 53]. Studies conducted in Lesotho, Nigeria, Zambia and South Africa revealed that men are more open to HIV testing when it is conducted at home [23, 36, 38, 51], due to fear of being stigmatised in clinic settings [36], as well as judgements by healthcare workers [38]. The supervised home-based counselling and testing services has been shown to be especially effective [36, 51]. Two studies further indicated that home-based testing will not only improve men’s uptake to HIV testing, but the strategy will further help promote couple’s testing [40, 53], as well as HIV testing outcomes discloser among couples [36]. As high as 53% (n = 1499) of men accepted home-based HIV testing services in a study conducted in rural Zambia [51]. Although home-based testing has been found to attract more men for HIV testing services, another study revealed that home-based HIV testing reaches lesser numbers of men when compared to mobile testing [53]. This study further indicated that despite the improved number of men’s HIV uptake during home-based testing, the impact at which this strategy is making, become limited when it is conducted among highly mobile communities, because men are less likely to be at home due to employment [53]. While home-based HIV testing strategy is effective, there remain challenges for HIV uptake especially posed by mobile populations.

Evidence on ANC HIV testing as a strategy for improving men’s HIV uptake was reported in nine articles, covering more than eight SSA countries [5, 22, 23, 38, 40, 48, 49, 51, 53]. This strategy is sometimes referred to as ‘Partner testing’ [38, 51]. At least four studies revealed that ANC acts as an important tool for improving men’s HIV uptake [22, 38, 49, 53], although only a few of them benefit from this strategy [5, 23, 48]. As high as 72% of study participants of a study conducted in Malawi were open to receiving HIV testing information and advices in the company of their wives, while only 14 and 13% preferred receiving the same information in the presence of peers or alone, respectively [48]. In support of this, another Ugandan study indicated that as high as 91% of interviewed study participants supported HIV testing with their wives or partners [49]. While this strategy has the ability to improve men’s HIV uptake, a study by Aarnio, further indicated that this strategy’s shortcoming is that very few men accompany their wives or partners to clinics for antenatal visits [48], with the rates ranging between 1.8 to 32% in the SSA region [23]. Only 25% of men in a study conducted in Burkina Faso tested for HIV during ANC visits as a result of their wives’ request [5]. Challenges of mistrust between couples, lack of HIV awareness and fear were cited as the main factors affecting men’s participation in their wives’ or partners’ HIV testing during ANC visits [23]. Despite the ANC HIV testing potential to increasing men’s HIV uptake, there remain a coverage gap given the lower numbers of men this strategy can attract.

Five studies reported evidence on providing incentives to improve HIV uptake among men [7, 35, 36, 41, 51]. These studies were conducted in six different SSA countries. These incentives may be in a form of money, food, calling cards or t-shirts [36]. This HIV testing strategy is supported by Hensen et al. (2015) study, which indicated that these incentives may either be in the form of finance or material, given the impact these may have, especially if used as in the ANC to link men into HIV testing after their female partners have been tested in clinics [51]. While Hensen et al. (2015) study recommends incentives as an effective strategy during ANC visits, another study conducted in South Africa found that an incentive HIV testing strategy does not only improve men’s HIV uptake but also HIV testing positivity yield in mobile settings, especially when these are compared with clinic-based HIV testing services [7]. As high as 15% positivity rates were found through incentives in mobile clinic as compared to the usual 8% when incentives were not involved [7]. Again, 60% of first-time men testers were reached using incentives versus the usual 42% [7]. Incentives do increase men’s HIV uptake even at clinics settings specifically the Community Health Centres (CHCs) [35]. Although incentives have been noted to improve men’s HIV uptake and positivity rates, there remains ethical concerns towards this strategy, as it exposes people to bribery, autonomy and client coercion [7, 41]. Incentivised HIV testing strategies remain controversial in SSA.

Evidence on self-testing as a strategy to improve HIV testing among men was reported in four articles [22, 37, 51, 53]. Some of these studies revealed that HIVST is capable of improving HIV uptake among men [22, 37, 53], because it is cost-effective [22, 37], confidential and convenient [37]. This HIV testing strategy was noted as effective and an alternative strategy to facility based testing due to long queues and waiting times experienced in these settings [37]. This study further revealed that HIV-self testing helps address men’s discomforts, which occur as a result of engaging with healthcare workers [37]. While this strategy removes many HIV testing barriers among men, it also improves men’s autonomy [51], which addresses masculinity issues. HIV self-testing strategy has as high as 70 to 94% of acceptability rates [37]. Although HIV-self testing is suggested as a viable alternative for improving HIV uptake among men in Africa, however, this HIV testing strategy, has its own limitations. These limitations include the fact that confirmatory tests are still required after using the HIV-self testing kits [22]. Although this is the case, HIV-self testing strategy remain one of the prominent strategies to improve HIV testing uptake in Africa, even among high risk men [22, 37]. More research is needed to establish and improve the accuracy of self-test kits (given the confirmatory test required after using HIVST); monitoring of test kits and LTC of clients after testing HIV positive.

Partner HIV testing as a strategy to encourage men on HIV uptake was discussed in four articles, covering more than five SSA countries [22, 23, 39, 40]. Partner testing, otherwise known as index testing is the process of notifying partners of newly diagnosed HIV-positive clients [22, 23]. According to a study conducted in Uganda, partner testing is likely to reduce mistrust and increasing faithfulness among partners [40]. In SSA, the partner testing strategy reached more men for HIV testing services when using active notification (contract referral or provider tracing) (50%) versus the passive notification in which index cases are asked to refer their sexual partners to the clinics for HIV testing services (15%) [22].

All included studies underwent quality appraisal using an approved tool, the MMAT. Our full article screening tool was piloted to ensure the reliability of included studies as demonstrated by the degree of agreement results. Analysis of the results of full article screening show that there was 95.24% agreement versus 95.24% expected by chance which constitutes a considerably high agreement between screeners (Kappa statistic = 0. 00 and p-value < 0.05) (Additional file 1). In addition, the McNemar’s chi-square statistic suggests that there is not a statistically significant difference in the proportions of yes/no answers by reviewer with p-value > 0.05. Although our title screening included a wide range of databases, the overall search strategy may have been biased toward public health and social sciences. Searching other bibliographic databases may have yielded additional published studies. Despite the generally relevant key words/terms used while searching for relevant articles in different databases, other terms may also exist as reference to HIV testing. While our review included any article published in any language, our search was conducted using only English terms. Despite these limitations, we believe that our search strategy was comprehensive in reviewing the public health and social sciences literature on the strategies and interventions to improving HIV testing among men in SSA.

Our study findings show that the HIVST strategy is one of the preferred interventions by many men [75] and it has been shown to get more men testing for HIV in similar settings [76‐79]. However, more research is needed to establish the accuracy of test kits (given the confirmatory test required after using HIVST); monitoring of test kits and LTC of clients after testing HIV positive. Our study findings further show that there is limited published systematic scoping reviews specific to streamlining the effective HIV testing strategies, in order to address the first 90 of the 90–90-90 HIV cascade, particularly among men in SSA.

We concur that strategies aimed at improving men’s HIV testing at the comfort of their homes and through community or mobile clinics should be strengthened and expanded to attract more men [7, 46]. However, we further recommend that community mobile clinics should also initiate clients tested HIV positive on ART services, otherwise direct LTC challenges will remain. We further believe that attracting men at taxi ranks and close to their work places may also be beneficial towards addressing the first 90 of the HIV cascade, especially because men in general prefer testing outside of the clinic setting [44].