International Scholarly Research Notices

International Scholarly Research Notices / 2016 / Article

Review Article | Open Access

Volume 2016 |Article ID 6304820 | 24 pages | https://doi.org/10.1155/2016/6304820

Returning for HIV Test Results: A Systematic Review of Barriers and Facilitators

Academic Editor: Li-Yin Chien
Received11 Jul 2016
Revised11 Oct 2016
Accepted19 Oct 2016
Published15 Dec 2016

Abstract

This systematic review aims to identify factors that facilitate or hinder the return for HIV test results. Four electronic databases were searched. Two independent reviewers selected eligible publications based on inclusion/exclusion criteria. Quantitative studies published since 1985 were included. Thirty-six studies were included in the final review. Individual level barriers included sociodemographic characteristics, such as being a male, of young age and low education level, risk behaviours such as injecting drugs, having multiple sexual partners, and psychosocial factors. Older age, higher education level, being a woman, having high self-esteem, having coping skills, and holding insurance coverage were identified as facilitators. Interpersonal barriers and facilitators were linked to risk behaviours of sexual partners. Contextual barriers included essentially the HIV testing center and its characteristics. This review identified the most important factors that need to be addressed to ensure that people return for their HIV test results.

1. Introduction

HIV testing and counselling (HTC) is the cornerstone of treatment, care, and prevention [1, 2]. It is particularly through HTC that the ambitious goal of 90, 90, 90 (90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; 90% of all people receiving antiretroviral therapy will have viral suppression), by 2020 [3] can be reached. Previously, most efforts were focused on voluntary counselling and testing (VCT) as the primary means of providing testing and encouraging people to become aware of their HIV status [2]. However, coverage remains low and many infected persons in both developed and developing countries remain undiagnosed. Despite the availability of rapid test with the possibility to have the results approximately in 20 to 30 minutes, in some contexts particularly, there are many who get tested but fail to return for their results [46]. For example, in the USA, data from HIV testing performed at publicly funded counselling and testing sites using conventional HIV enzyme immunoassay (EIA) testing from 1999 through 2002 found that 19% to 22% of people with positive preliminary HIV tests did not return for their test results [6]. In 2009, a survey conducted in 12 Sub-Saharan Africa countries with high HIV prevalence showed that only 10% of women and 12% of men were tested and received their test results [7]. In an evaluation of five years of routine program data in Vietnam, Hong et al. found a failure to return (FTR) rate of 3.5% [8]. In a study of female sex workers in China, Xu et al. found a FTR rate of 47.1% [9]. More recently, in France, Laanani et al. (2015) and Pahlavan et al. (2015), respectively, found a FTR rate of 6.5% in a study conducted in a free and anonymous screening center [10] and 14.5% in an HIV-positive population [11].

Identifying and targeting these people may improve the return rate for VCT and the proportion of individuals who are aware of their status. Therefore, the objective of this systematic review is to identify the factors that prevent people who are tested for HIV from returning for their results or facilitate their doing so.

2. Methods

This systematic review examines barriers and facilitators associated with returning for HIV test results in various types of populations and settings. The outcome variable, returning for HIV testing results, is dichotomous. From this point of view, some studies concerned factors associated with returning for HIV test results, while others focused on failure to return (FTR). This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [44].

2.1. Search Strategy

A comprehensive search strategy was developed to identify studies published between January 1985 (introduction of HIV tests) and June 2015. Four electronic databases were searched (PubMed/Biomed Central/Medline, Embase, PsycINFO, and Web of Science), combining terms related to HIV, counselling/testing, and return/failure to return. Retrieved references were imported into Endnote X7, and then duplicates were removed. The detailed search strategy is available upon request.

2.2. Study Selection

All identified records (,019) were initially screened by two independent investigators and verified by a third researcher. Eligible studies had to meet the following criteria: (1) be an original research study; (2) be written in English or in French; (3) report adolescents, adults, pregnant women, men who have sex with men (MSM), injecting drug users (IDUs), or female sex workers (FSWs); (4) include participants undergoing HIV tests; (5) use a quantitative method to assess return or failure to return for HIV test results; and (6) report a statistical association between a potential predictor/correlate and return or FTR. Study designs of interest were cross-sectional and longitudinal. No geographical restrictions were applied. The reference lists of the relevant articles were also reviewed for additional publications.

A short list of records was prepared and the full text reviewed independently by two authors. Citations that were clearly irrelevant were excluded. Uncertainties and disagreements about inclusion were resolved through discussion involving both investigators (see Figure 1 for flowchart of systematic review).

2.3. Data Extraction

Two authors independently extracted data from each study that fulfilled the inclusion criteria using a standard form. Study characteristics (name of the first author, year of publication, country in which the study was conducted, study design, sampling approach, participating characteristics, and HIV testing procedure) as well as key findings related to factors associated with return or failure to return for HIV test results were extracted. Any factors analyzed associated with FTR or return for HIV test results were listed, and the results of multivariate statistical tests for association (odds ratio) were noted. For studies where a multivariate statistical test was not done, the results of bivariate analyses were noted. When the result of the measure of association in multivariate analysis was not significant and not reported by authors, the factor was not considered in the synthesis.

2.4. Quality Assessment

The Newcastle-Ottawa Scale (NOS) for cohort studies and an adapted form of the Newcastle-Ottawa cohort scale for cross-sectional studies were used to assess methodological quality. NOS is a tool for assessing the quality of nonrandomized studies to be used in a systematic review [45]. Each study is judged with a “star system” on three points: the selection of study groups, the comparability of the groups, and the ascertaining of exposure or outcome. Studies for which at least five out of nine items on the NOS were deemed satisfactory and in which appropriate statistical analysis (e.g., multivariate controlling for confounders) was conducted were considered to be of sufficient methodological quality and included in the review (maximum score of 10 for cross-sectional studies and 9 for cohort studies). At each stage of the quality assessment, the reviewers discussed among themselves until a consensus was reached on which studies to include.

2.5. Data Synthesis and Combined Effect Sizes Associated with Return

Factors associated with either return or failure to return may be arranged into barriers and facilitators inspired by the Socioecological Model (SEM), which is a framework to examine the multiple effects and interrelatedness of environmental, contextual, and social factors on individual behaviour [46, 47]. Recognizing that most public health challenges are too complex to be adequately understood and addressed from single level analyses, the SEM includes a more comprehensive approach that integrates multiple levels of influence to impact health behaviour and ultimately health outcomes. These levels of influence include intrapersonal and interpersonal factors, organizational factors, and structural factors. In this review, due to their small number, organizational and structural factors were grouped as contextual factors.

Since we anticipate a potential variability of the methodology (e.g., measures of studied factors) across the included studies, we used a random-effects model based on the inverse variance method to estimate the pooled odds ratio (OR) for each factor potentially associated with returning for HIV test results and its 95% confidence interval (CI) [48, 49]. The Higgins’s statistic was used to quantify the percentage of the variability in individual effect size estimates which is attributable to the heterogeneity [50, 51]. This heterogeneity was tested using a chi-squared test [50, 51]. Moreover, we performed sensitivity analysis by removing the included studies from the pooled size estimation one at a time. These analyses allowed us to explore the individual contribution of each study to the heterogeneity in the meta-analysis. When we could not explain the heterogeneity, we have interpreted the pooled effect size estimates with caution because these effect sizes would be explained by other factors, which were not taken into account in our analyses. A value of less than 0.05 was considered statistically significant. Analyses were performed in Review Manager (version 5.3).

3. Results

3.1. Study Selection

The primary search strategy identified 3,019 potentially relevant citations. After the removal of duplicates and the initial title and abstracts screening, 60 citations were kept for the full-text review. Studies were excluded if they did not report quantitative results () or just reported the rate of return or failure to return (FTR) without assessment of associated factors (). The remaining 36 studies were appraised for their methodological quality and included in the analysis. No study was excluded on the basis of quality assessment. A flow chart illustrating the selection process is shown in Figure 1.

3.2. Study Characteristics

Table 1 provides a brief overview of the key characteristics of the included studies. Of the 36 included studies, 10 were longitudinal cohort studies and 26 were cross-sectional studies. Seven of the studies were carried out in Sub-Saharan Africa; seventeen in the USA; three in Australia; six in Asia; and one in Brazil. Populations under study were diverse, including general population (), pregnant women (), injecting drug users (), men who have sex with men (), high-risk heterosexual individuals (), HIV-positive individuals (), factory workers (), individuals with psychiatric problems (), adolescents (), HIV-negative individuals (), and female sex workers (). The outcome of interest was dichotomous, with 20 studies focused on failure to return and 16 on return for HIV test results.


Reference (short)CountryAimPopulationOutcomes delaySample ()Study designFTR/return rateFactors significantly associated with FTR/return

Slutsker et al. (1992) [12]USAAssess the extent of and characteristics associated with FTR for posttest counseling in individuals seeking HIVGeneral population30 days9,644Cross-sectional24% failed to return for their test resultsBeing tested at non-HIV clinic
Being aged 10–29 years
Blacks
Recent IVDU
Individuals choosing confidential testing

Wimonsate et al. (2011) [13]ThailandEvaluate factors associated with HIV testing history and returning for HIV test resultsMen who have sex with men (MSM)7 days for a maximum of 3 months2,409Cross-sectional24.9% returned to receive the test resultsBeing classified as MSW
Older age (≥29)
Lacking a family confidant
Self-reported history of STI
Testing HIV-negative

Bergenstrom et al. (2007) [14]VietnamAssess factors associated with return to posttest counselingInjecting drug users (IDUs)Not mentioned309Cross-sectional54% returned to receive the test resultsResidence in Bac Ninh town centre (urban district)

Catania et al. (1990) [15]USATo examine social, demographic, and psychological predictors of people who fail to return for their test resultsGeneral populationNot mentioned1,007Cross-sectional28% failed to return for their resultsHIV test knowledge
AIDS anxiety
Education
Age at the moment of blood transfusion

Desai and Rosenheck (2004) [16]USATo determine the rates and predictors of HIV testing and receipt of results among homeless adults with serious mental illness in the initial 3-month period after contact with a community-based case management programHomeless persons with serious mental illness3 months2,135Longitudinal/cohortAmong those tested, 88.8% reported receiving their test resultsPositive association with:
Level of education
Negative association with:
Being disabled
Outpatient medical service utilization
Having a sexually transmitted disease other than HIV
Drug problems at baseline
Worsening drug problems over the course of follow-up
Frequency of HIV testing during follow-up
Prior testing history

Dinh et al. (2005) [17]VietnamTo identify the factors associated with declining HIV testing and the failure to return for resultsPregnant womenNot mentioned266Cross-sectional55.3% returned for their resultsEducational level below the 12th grade

Ellen et al. (2004) [18]USATo determine the posttest counselling (PTC) rates for HIV-infected and uninfected individuals receiving HIV counselling and testing on a mobile STD/HIV screening clinic and to determine whether individuals at highest risk for transmitting their infection were less likely to receive PTC than those at lower risk for transmittingHIV-positive individuals
HIV-negative individuals
14 days2,022Cross-sectional66% (infected), 46% (not infected) returned for their resultsAmong not infected:
(i) Being female
(ii) Drug treatment in last 3 months
(iii) Engaged in sex work over 3 months ago
(iv) Having engaged in sex work in last 3 months
Among infected:
(i) Drug treatment in last 3 months

Erbelding et al. (2004) [19]USATo analyse data on STD clinic patients undergoing HIV testing between who tested HIV-negative to describe characteristics associated with “nonreturn” for resultsHIV-negative individuals1 week31,777Retrospective cross-sectional48% returned for their resultsAge < 30
Reason for initial test visit (HIV testing, STD symptoms, contact to STD, STD test positive, check-up)
Risk behaviours (ever had same sex contact, ever used injection drugs, ever used inhaled cocaine, ever exchanged sex for money/drugs, ever had sex partner who used injection drugs, ever had sex partner with HIV/AIDS, ever had partner who exchanged sex for money/drugs, ≥ two partners, past month)
STD at test visit (gonorrhea, syphilis, other STD)

Healey et al. (2010) [20]AustraliaTo assess the proportion of patients who returned for HIV results and factors predicting returnGeneral populationWithin 4 weeks159Retrospective cross-sectional45% returned for their resultsMale gender
Attending the men-only outreach clinic
Having a first HIV test at the clinic
Having sex overseas in the past year

Hightow et al. (2003) [21]USATo assess the prevalence and predictors of receiving HIV test resultsGeneral population2 weeks later508Retrospective cohort55% (overall) failed to return for test resultHIV testing history
STD diagnosis (HPV)
Demographic characteristics (black race)

Hong et al. (2011) [8]VietnamTo assess whether this program was reaching its targeted populations and examined factors that influenced their service utilizationGeneral population1 week158,888Retrospective cross-sectional3.5% indicated failure to return for test resultsClients from the Central Highlands provinces
Those who were referred by peer educators
Those reporting no receipt of prior test results

Kinsler et al. (2007) [22]USATo examine time trends of FTR for HIV test results among a mobile van population in Los AngelesGeneral population7 days7,724Retrospective cross-sectionalFTR by years were as follows: 18% (1997); 24% (1998); 28% (1999); 37% (2000); 43% (2001); 37% (2002); 41% (2003); 35% (2004)Those testing positive
Women
Black
Latino
Those older than 20 years of age

Laanani et al. (2015) [10]FranceTo assess factors associated with FTR for HIV test results in a free and anonymous screening centre (CDAG) in ParisGeneral population3 days after the blood sampling710Cross-sectional6.5% (overall) failed to returnPeople who did not specify their birthplace
People who were living outside of the Paris region
Having sex with 6 partners or more during the last year
Reporting visiting for clinical symptoms
Having absolutely no self-perceived risk
Having a higher self-perceived risk

Ladner et al. (1996) [23]RwandaTo identify factors associated with failure to return for HIV posttest
To assess the prevalence and predictors of counseling in pregnant women in Kigali
Pregnant womenApproximately 2 weeks later765Longitudinal/cohortAmong 68.8% returned for their resultsPositive HIV test result

Lazebnik et al. (2001) [24]USATo quantify the proportion of adolescents who return for their test results and posttest counseling in a free clinic setting and to identify the characteristics predicting their returnAdolescentsWithin 10 days285Retrospective cohort42% (overall) returned for their resultsHaving unprotected sex while using drugs or alcohol
Coming to clinic only for HIV testing
Having private health insurance

Machekano et al. (2000) [25]ZimbabweTo describe the correlates of HIV test results-seeking behavior and the use of partner counseling testing services among study participantsMale factory workersAfter 2 weeks3,383Longitudinal/cohort56% returned for resultsReporting an STD
Lower monthly salary

Mmbaga et al. (2009) [26]TanzaniaTo assess the prevalence and predictors of failure to return for HIV posttest counseling among adultsGeneral population2 weeks after blood sample collection890 (women) 601 (men) Total = 1,491Cross-sectional50.9% failed to return for resultsLack of formal education or no education
Lack of HIV/AIDS transmission knowledge
Lack of knowledge of antiretroviral therapy availability
Perceived low risk of HIV infection
Men who were not ready to share their HIV results with their partners
Individuals who reported recent (past month) involvement in multiple sexual partners
Failure to use condom during last casual sex among men
HIV seropositive individuals

Molitor et al. (1999) [27]USATo determine the primary predictors of FTR for each of eight types of publicly funded sites in California Predictors of FTR were examined from among those variables assessed during the pretest, risk assessment session.General population2 weeks later370,220Retrospective cross-sectionalThe FTR rate for the entire sample was 16.4%The type of site at which testing took place (mobile testing,)
Race/ethnicity (african american)
Risk behavior (IUD)
Having sex for money or drugs
Blood transfusion
Sex partner at risk
Multiple sex partners
History of FTR
Age (<20)

Msuya et al. (2006) [28]TanzaniaTo determine the predictors of failure to return (FTR) for HIV posttest results among pregnant womenPregnant womenAfter 1 week2,413Longitudinal/cohort7% failed to returnFailure to bring the partner
Site of recruitment
Occasional alcohol consumption
Age of 25 to 29 years
Gestation age of 29 weeks or longer
Alcohol intake by male partner
Male who frequently travel
Never having discussed reproductive health issues with their partners

Sahlu et al. (1999) [29]EthiopiaTo describe sexual behaviours, perception of risk of HIV infection, and factors associated with attending HIV posttest counseling (PTC) among Ethiopian adultsFactory workers30 days later at the project’s clinic407 (male) 344 (female)
Total = 751
Longitudinal/cohort43.5% returned for the test resultsPositive association with:
Being a manual worker
History of recent casual sexual relationships
Good knowledge of HIV infection
Belief that medical follow-up improves the course of HIV infection
History of genital symptoms
Positive syphilis serology
Recent weight loss
Negative association with:
Belief that HIV/AIDS can be cured
Never having been married
Having five or less children
Having been raped
Having used health facilities in the past year

Sesay and Chien (2012) [30]GambiaTo describe the proportion of clients failing to return for an HIV-test result and to examine the factors associated with failure to return (FTR)General populationFollowing day after testing1,755Retrospective cross-sectional30% (overall) failed to returnMale gender
Age under 18
Senegalese and persons of others nationality
Participants with primary and secondary school education
Having ever used condoms
Those who resided in a urban area

Sorin et al. (1996) [31]USAAnalyses predictors of women’s decisions to accept testing voluntarily and return for their test resultsPregnant womenNot mentioned6,104Retrospective cross-sectional50% of those tested returned for posttest counselingMinorities (Blacks, Hispanics)
Self-paying clients/uninsured
Women receiving less than five prenatal care visits during their pregnancies
Receiving a positive test result

Melo et al. (2012) [32]BrazilTo examine characteristics associated with rates of psychiatric patients receiving their serologic test results for HIV and other sexually transmitted infectionsPsychiatric patientsAfter a maximum of 4 attempts2,080Cross-sectional79.6% (overall) returned for the resultsLiving in the same city where the treatment centers were located
Being single
Not having heard of AIDS
Not having been previously HIV tested
Regular free distribution of condoms to patients

Stein and Nyamathi (2000) [33]USATo assess gender differences in psychosocial and behavioural predictors of HIV testing and returning for results in a high-risk sampleHeterosexual persons at high risk for HIVNot mentioned428 (male) 621 (female) Total = 1,049Cross-sectionalMen: 17% and women: 15% failed to returnInjection drug use
Self-esteem
Social support
AIDS knowledge
Poor access
Perceived risk
Sexual risk
Negative coping
Positive coping
History of HIV test and return for test results

Sullivan et al. (2004) [34]USATo document the frequency of self-reported failure to return for HIV test results (FTR) and associated reasons among persons at high risk for HIV infectionMSM, IDUs, high risk heterosexuals (HRHs)Not mentioned782 (MSM) 697 (HRHs) 762 (IDUs) Total = 2,241Cross-sectionalOverall: 18.4% failed to returnAmong HRHs:
Higher educational attainment (<high school)
Full time employment (<35 hours)

Tao et al. (1999) [35]USATo determine the frequency and predictors of receipt of HIV test results for all tested persons in 1994 and 1995 in US publicly funded counseling and testing programsGeneral populationNot mentioned19,127 (1994) 16,848 (1995) Total = 35,975Cross-sectionalIn 1994, 12.5%(±1.0%) and 13.3% (±0.9%) in 1995 had not received their test resultPeople whose test was compulsory
People for whom test was required for hospitalization or surgery
Black people recommended by doctor
Health department
Sex partner
Other reasons

Valdiserri et al. (1993) [36]USATo identify factors independently associated with returning for HIV result disclosure and posttest counseling servicesGeneral populationNot mentioned557,967Retrospective cross-sectionalOn average, 63% of persons who received HIV pretest counseling and testing returned to learn their test results and obtain posttest counselingSTD clinic
Family planning clinic
Tuberculosis clinic
Private Physician
College education
Race or ethnicity (Black)
Age 13–19
Age 50 or older
Age 40–49
MSM
MSM and IDU
HIV positive
Sex partner at risk
Blood recipient

Van De Ven et al. (2000) [37]AustraliaTo know the extent of HIV testing overall and the factors associated with not having HIV test resultsMSMNot mentioned5,299Cross-sectionalOverall, 13.3% of the men did not have HIV test resultsYounger age
City of residence (Melbourne and Perth)
Occupation (clerical/sales and plant operator/labourer)
Bisexual/heterosexual
Fewer gay friends
Fewer male sexual partners
Sex with regular and casual partners (having anal intercourse per se with such partners)

Wiley et al. (1998) [38]USATo determine the characteristics associated with not receiving an HIV test result in an STD clinic settingGeneral population7 to 10 days later6,988Cross-sectional49% did not receive their resultsRequesting an HIV test
No tested previously for HIV infection
Blacks Hispanic/Latino
Others

Xu et al. (2011) [9]ChinaTo analyse the risk factors associated with previous HIV-testing and current posttest follow-up among FSWs in Kaiyuan and Gejii, Yunnan, ChinaFemale sex workers4 weeks1,621Longitudinal/cohortOverall: 53.3% failed to return≥9 years of school
<5 clients in the recent week
Were from another province
Were from another city

Ziek et al. (2000) [39]USATo examine demographic and behavioral factors related to taking an HIV test and returning for results in a sample of out-of-treatment IDUs and crack smokersIDUs and crack smokers3 weeks927Longitudinal/cohort81% return to receive test resultsAge per decade
High school graduated
Ever exchanged sex for money
Ever in prison

Cartoux et al. (1998) [40]Ivory Coast and Burkina FasoTo evaluate the attitude of pregnant women towards HIV testing in two cities of West Africa: Abidjan, Côte d’Ivoire, and Bobo-Dioulasso, Burkina FasoPregnant women2 or 3 weeks9,724Longitudinal/cohort41.6 % in Abidjan and 18.25% in Bobo-Dioulasso, failed to returnCounselor’s attitude
Weeks of gestation
Muslim
Positive HIV infection status
Being merchant profession
Being employee (other)
Being 3–6 years in couple
Living in Bobo-Dioulasso
Having knowledge of AIDS
Not using condom for prevention

Pahlavan et al. (2015) [11]FranceTo assess the proportion of FTR for an HIV-positive test result among those who tested positive and to identify risk factors associated with FTRHIV-positive patientsPatient who did follow up for 1 year509Retrospective cross-sectionalFTR rate was 14.5%Heterosexual orientation

Chan et al. (2007) [41]AustraliaTo examine the proportion and characteristics of patients who returned to a large sexual health service to obtain their HIV test resultsPopulations at high risk of STIs and HIVWithin one month8,715Cross-sectional studyOverall 79.7% returned within one month of HIV testing,For male gender
Being an HIV contact MSM
Having more than five sex partners or overseas sex partners in the past 12 months being overseas born

Healey et al. (2010) [20]AustraliaTo assess the proportion of patients who returned for HIV results and factors predicting returnGeneral populationWithin four weeksFiles of 218 patientsCross-sectional study (a retrospective review of patients’ files)45% returned for their resultsMale gender
Attending the men-only outreach clinic
Having the first HIV test at the clinic
Having sex with overseas-born individual in the past year

3.3. Quality Appraisal Results

Studies were generally of high quality (see Table 2). A total of 3 cohort studies scored 9/9, one study scored 8/9, and 6 studies scored 7/10. For the cross-sectional studies, one study scored 9/10, 11 studies scored 8/10, 4 studies scored 7/10, 4 studies scored 6/10, one study scored 5/10, and one study scored 4/10.

(a)

StudySelection ComparabilityOutcomeTotal (/10)
Representativeness Sample sizeNonrespondentsAscertaining of exposureAssessment of outcome Statistical test

Bell et al. (1997) [42]3
Bergenstrom et al. (2007) [14]6
Catania et al. (1990) [15]6
Chan et al. (2007) [41]7
Dinh et al. (2005) [17]6
Ellen et al. (2004) [18]7
Erbelding et al. (2004) [19]8
Healey et al. (2010) [20]5
Hong et al. (2011) [8]8
Kawichai et al. (2006) [43]8
Kinsler et al. (2007) [22]8
Laanani et al. (2015) [10]8
Mmbaga et al. (2009) [26]8
Molitor et al. (1999) [27]8
Pahlavan et al. (2015) [11]7
Sesay and Chien (2012) [30]7
Slutsker et al. (1992) [12]8
Sorin et al. (1996) [31]8
Melo et al. (2012) [32]9
Stein and Nyamathi (2000) [33]6
Sullivan et al. (2004) [34]8
Tao et al. (1999) [35]7
Valdiserri et al. (1993) [36]8
Van De Ven et al. (2000) [37]4
Wiley et al. (1998) [38]7
Wimonsate et al. (2011) [13]8

(b)

StudySelectionComparabilityOutcomeTotal (/9)
RepresentativenessSelection of nonexposed cohortAscertaining of exposurePresence of outcomeAssessment of outcome Follow-upAdequacy of follow-up

Cartoux et al. (1998) [40]9
Desai and Rosenheck (2004) [16]7
Hightow et al. (2003) [21]9
Ladner et al. (1996) [23]9
Lazebnik et al. (2001) [24]7
Machekano et al. (2000) [25]8
Msuya et al. (2006) [28]7
Sahlu et al. (1999) [29]7
Xu et al. (2011) [9]7
Ziek et al. (2000) [39]7

3.4. Barriers and Facilitators of Returning for HIV Test Results

In total, 236 factors associated with returning for HIV test results were identified. Among these, 123 factors were reported as barriers and 70 as facilitators. The association was not statistically significant for 72 factors. At the individual level, factors were classified into sociodemographic characteristics (), risk behaviours (), perceived risk (), HIV knowledge (), reasons for visit/testing (), HIV test results (), history of testing (), psychosocial factors (), and other individual factors (). Factors grouped at the interpersonal level were risk partner behaviours (), social support (), knowledge of person with HIV (), domestic violence (), and other interpersonal factors such as partner age (), years in couple (), and communication within the couple (). Contextual factors comprised the type of clinic attended (), year of testing (), and characteristics of the testing center, such as availability of counselling (), condom distribution (), clinic visit (), confidential testing (), and location of the testing center in the same city as treatment center () (see Table 3).


FactorsBarrierFacilitatorInsignificantTotal

Individual factors13681111328

(A) Sociodemographic characteristics573561153
(1) Age14111944
 (1.1) Younger age11
  (1.2) Older age11
  (1.3) Childhood 12 years and under22
  (1.4) Under 30 years including 34 years and under101718
  (1.5) 30 years old and over371222
(2) Gender639
  (2.1) Female314
  (2.2) Male325
(3) Sexual orientation4127
  (3.1) Heterosexual2114
  (3.2) Bisexual or heterosexual11
  (3.3) Transgender11
  (3.4) Other orientation11
(4) Education54312
  (4.1) None or low education426
  (4.2) High school education and more1416
(5) Marital status13610
  (5.1) Single/unmarried1113
  (5.2) Married/living with partner112
  (5.3) Divorced/separated33
  (5.4) Widowed112
(6) Occupation13812
  (6.1) Working3811
  (6.2) Other occupation11
(7) Living condition112
  (7.1) Incarcerated11
  (7.2) Homeless11
(8) Residence24511
  (8.1) Urban14510
  (8.2) Rural11
(9) Place of birth37212
  (9.1) From other city11
  (9.2) From other province11
  (9.3) Abroad/overseas112
  (9.4) Different parts of Vietnam3317
  (9.5) Other place of birth11
(10) Nationality213
  (10.1) From another country22
  (10.2) From a tribe11
(11) Ethnicity132823
  (11.1) Black5139
  (11.2) Hispanic/Latino527
  (11.3) Asian/Pacific islander123
  (11.4) Native American/Alaskan213
  (11.5) White11
(12) Religion134
  (12.1) Christian33
  (12.2) Muslim11
(13) Weeks of gestation33
  (13.1) Fewer than 3511
  (13.2) More than 3522
(14) Having 5 or fewer children11

(B) Risky behaviors39212484
(I) Self-reported risks35202479
(1) Number of sex partners72817
  (1.1) One22
  (1.2) 2 to 51124
  (1.3) More than 53148
  (1.4) Multiple33
(2) MSM1236
(3) Sex work5319
(4) Condom use2349
  (4.1) Protected sex1236
  (4.2) Unprotected sex1113
(5) Particular sex behavior123
  (5.1) Oral sex11
  (5.2) Overseas partners11
  (5.3) Sex with casual partner11
(6) Ever had sex112
  (6.1) Had sex11
  (6.2) No sex11
(7) History of STD other than HIV54110
(8) IDU81312
  (8.1) User81211
  (8.2) Nonuser11
(9) Other drug use314
(10) Blood-related risks2114
  (10.1) Blood transfusion112
  (10.2) Blood contact through behavior11
  (10.3) Hemophilia11
(11) Alcohol consumption112
  (11.1) Occasional drinker11
  (11.2) Daily drinker11
(12) Other self-reported risks11
(II) Symptoms415
(1) Genital/anal symptoms11
(2) Loss of weight11
(3) Prenatal care112
  (3.1) Low prenatal care11
  (3.2) Had prenatal care11
(4) Other symptoms11

(C) Perception of risk51814
(1) Level of perception51814
  (1.1) No risk22
  (1.2) Low risk123
  (1.3) Medium risk/some risk1113
  (1.4) High risk145
  (1.5) Unknown risk11

(D) HIV knowledge628
(1) Level of knowledge628
  (1.1) No/low knowledge314
  (1.2) Have knowledge213
  (1.3) No knowledge about ART availability11

(E) Visiting reason810624
(1) Compulsory11
(2) HIV testing235
(3) STI screening11
(4) Have symptoms11
(5) Risk behavior taking1113
(6) Partner-related reasons1113
  (6.1) Partner is infected11
  (6.2) Partner is at high risk11
  (6.3) Current relationship11
(7) Casual contact with HIV-infected person11
(8) Recommended by professional1113
(9) Clinical procedure11
(10) Blood transfusion11
(11) Unknown/other1124

(F) HIV test result45413
(1) Positive HIV test44210
(2) Negative HIV test123

(G) Testing history82616
(1) Prior HIV testing4239
  (1.1) Tested previously2136
  (1.2) Not tested previously213
(2) Prior HIV testing status112
  (2.1) Prior negative HIV test11
  (2.2) Prior negative HIV test11
(3) Previously FTR/return325
  (3.1) Previously FTR314
  (3.2) Previously return11

(H) Psychosocial factors729
(1) Beliefs33
  (1.1) Did not believe in self-prevention from HIV11
  (1.2) Belief that HIV can be cured11
  (1.3) Belief that medical follow-up can improve course of HIV11
(2) Psychological characteristics426
  (2.1) Self-esteem11
  (2.2) Positive coping skills11
  (2.3) Anxiety about HIV44

(I) Others individual factors2327
(1) Other age-related factors22
  (1.1) Over 17 at outset of sexual activity11
  (1.2) Over 17 at marriage/cohabitation11
(2) Being disabled11
(3) Treated for drugs22
(4) Health coverage112
  (4.1) Private coverage11
  (4.2) No coverage11

Interpersonal factors19121546

(A) Risky partner behaviors96722
(1) Partner STD infections1315
  (1.1) HIV-infected314
  (1.2) STD-infected11
(2) Partner alcohol/drug use224
  (2.1) IDU123
  (2.2) Alcohol consumer11
(3) Partner sexuality22
  (3.1) MSM11
  (3.2) Bisexuality11
(4) Partner and sex work2114
  (4.1) Sex worker213
  (4.2) Client of sex work11
(5) Partner has multiple sex partners11
(6) Partner is traveling11
(7) Partner did not test11
(8) Partner has other risks/unknown risks224

(B) Social support45211
(1) Family relationship213
  (1.1) Living with nonrelatives11
  (1.2) Living with spouse11
  (1.3) Living with relatives11
(2) Number of gay friends33
  (2.1) Few gay friends11
  (2.2) Some gay friends11
  (2.3) Mostly gay friends11
(3) Having social support213
(4) Having a counselor11
(5) Lacking a family confidant11

(C) Knowledge of person with HIV112
(1) Have knowledge of someone with HIV112

(D) Other interpersonal factors51511
(1) Partner age33
  (1.1) 25 to 34 years old11
  (1.2) 34 to 71 years old11
  (1.3) Unknown11
(2) Years in couple112
  (2.1) 3 to 6 years11
  (2.2) 7 years and more11
(3) Communication112
  (3.1) No discussion about reproductive health issues with partner11
  (3.2) Desire to share results11
(4) Domestic violence314
  (4.1) Abuse by partner11
  (4.2) Rape213

Contextual factors266133

(1) Type of clinic attended173121
  (1.1) Family planning clinic22
  (1.2) STD clinic213
  (1.3) Detention facility112
  (1.4) Primary care clinic11
  (1.5) HIV test clinic11
  (1.6) Mobile clinic11
  (1.7) Prenatal/obstetric clinic11
  (1.8) Drug treatment center11
  (1.9) Health department22
  (1.10) Outpatient medical service11
  (1.11) Private physician11
  (1.12) College11
  (1.13) Base clinic11
  (1.14) Other type of clinic33
(2) Clinic visit (to a facility)11
(3) Counselling (no pretest counselling)11
(4) Year tested77
  (4.1) 199811
  (4.2) 199911
  (4.3) 200011
  (4.4) 200111
  (4.5) 200211
  (4.6) 200311
  (4.7) 200411
(5) Other contextual factors123
  (5.1) Condom distribution11
  (5.2) Same city as treatment center11
  (5.3) Confidential testing11

Grand total18199127407

3.5. Individual Level
3.5.1. Sociodemographic Characteristics

Age was the most reported factor (). This factor has been reported as a barrier to returning for results in 7 studies [12, 19, 27, 28, 30, 36, 37] and as a facilitator in 5 studies [13, 22, 35, 36, 39]. The association between age and returning for HIV test results was insignificant in 10 studies [10, 1214, 26, 2830, 35, 41]. In these studies, being 30 years of age or over was reported as a facilitator in 4 studies [13, 22, 35, 36] and as a barrier in just a single study [27]. On the other hand, having less than 30 years of age was reported as barrier in 6 studies [12, 19, 27, 28, 30, 36] and as facilitator in 2 studies [22, 36].

Level of education was reported in nine studies. In 4 studies [15, 17, 26, 30], it was reported as a barrier to returning for HIV test results, especially for people with no education or a low level of education. In 3 studies [9, 34, 39], it was reported as a facilitator for those with a medium or high level of education.

In studies with a mixed population (women and men) when sexual orientation was reported (), being heterosexual or bisexual appeared as a barrier to returning for HIV test results [11, 36, 37].

Marital status was reported in six studies. In these studies, being married or living in a couple [8] and being a widower [8] emerged as facilitators of a return for results.

3.5.2. Risk Behaviours

Several risk behaviours were positively or negatively associated with a return for results. The number of sexual partners during the last 6 to 12 months was reported in 8 studies. In 5 of these studies [8, 10, 26, 27, 37], having more than 5 sexual partners was reported as a barrier to returning for HIV test results. Otherwise, having a single sexual partner during the last 6 to 12 months [22, 37] was not significantly associated with a return for results. Using a condom has been reported as both a barrier [30] and as a facilitator [26, 41], but in most cases, the association was not significant [14, 37, 39]. Having a history of STIs was reported in nine studies. However, it was reported equally as a barrier [16, 19, 29, 41] or a facilitator [13, 22, 25, 31] as regards a return for HIV test results.

3.5.3. Perceived Risk

Perceived risk has been reported in nine studies. In those studies, having low perceived risk [26] () and not seeing oneself at risk [10, 27] () was reported as a barrier to a returning for test results. However, this result is somewhat controversial because one of these two studies showed that having high-perceived risk [10] was a barrier to a return for results, and having a medium perceived risk was reported at the same time as a barrier in one study [14] and as a facilitator in another [33]. In addition, the association was insignificant for 4 studies [10, 35, 38, 39].

3.5.4. Psychosocial Factors

The association between the return for HIV test results and psychosocial factors showed divergent results (). For instance, not believing in self-prevention from HIV [26], believing that HIV can be cured [29], and thinking that a medical follow-up can improve the course of HIV [29] were reported as barriers to a return for test results. However, having high self-esteem [33] and positive coping skills [33] appeared as a facilitator for a return for results. Feeling anxious about HIV was reported as a barrier [15, 42] to a return for HIV test results.

3.5.5. Health Coverage

The association between the existence of health coverage and a return for results was studied in two articles. Having health coverage [24] appeared as a facilitator and not having health coverage as a barrier [31].

3.6. Interpersonal Level

Interpersonal factors were reported in 18 studies. The most common factors were risk behaviours of the sexual partner. The association of these factors with a return for results was investigated in seven publications. The HIV status of the sexual partner [8, 19, 41] () or being a client of a sex worker [8] () was identified as a facilitator for a return for HIV test results in three studies. Having a sexual partner who is a sex worker [8, 41] (), having a partner who drinks alcohol [28] () or consumes drugs [41] (), having a partner who is always travelling [28] (), and having a partner who did not test [28] () were all reported as a barrier to returning for results. Domestic violence (abused by a partner) [28] and rape [16, 29] were reported as barriers to a return for test results in three studies.

The association between a return for results and the availability of a social network has been studied in six studies. On the one hand, it appears that having one or more gay friends [37], having a counsellor [40], or knowing someone infected with HIV [35] are barriers to a return for results. On the other hand, having social support [40] (friends) and lacking a family confidant [38] were reported as facilitators of a return for test results.

3.7. Contextual Level

A negative association was found between the return for HIV test results and having a confidential test in one study [12]. The same negative association was found when the testing was done in facilities such as family planning clinics [27, 36] (), a detention facility [27] (), a primary care clinic [27] (), an HIV testing clinic [27] (), a mobile clinic [27] (), a prenatal/obstetric clinic [36] (), a drug treatment center [36] (), a health department [27, 36] (), an outpatient medical service [16] (), and a sexual health clinic [20] (). However, the association was positive in the case of a physician clinic [36] () and a college [36] (). Other organizational factors, such as the year of testing [22] (), condom distribution during the visit [46] (), or having tested in a center located in the same city as the treatment center [46] () and not having pretest counselling, emerged as facilitators of a return for results.

3.8. Combined Effect Sizes of Factors Associated with a Return for HIV Test Results

The pool estimates and sensitivity analysis of the association of the return for HIV test results with certain factors, including gender (men versus women) and race (black versus white) for studies conducted in the USA, injection drug use (no versus yes), HIV test results (positive versus negative), and HIV testing history (no versus yes), are shown in Table 3. The combined analysis showed that being female [8, 1820, 22, 30, 34, 35] is significantly associated with a return for results (OR = 0.86, 95% CI = 0.77–0.96) when studies with specific population (MSM, HIV negative, pregnant women) are excluded. In the studies from the USA, black people tend to return less frequently for their results than white people (OR = 0.76, 95% CI = 0.64–0.90) [12, 18, 22, 27, 3436, 38, 39]. There is no significant association between returning for test results and HIV test results or HIV testing history. Finally, the association between injection drug use and returning for test results was significant (OR = 0.85, 95% CI = 0.75–0.96) [8, 12, 14, 22, 41] when only the general population was considered. Thus, being an IUD appears as a barrier for returning for HIV test results.

4. Discussion

The objective of this review was to report the factors that were statistically associated with the return for HIV test results in different studies, regardless of the target population, the HIV test method used (standard or rapid tests), the waiting time for results, or the country. Despite these different contexts, periods, and populations, the majority of studies considered the same factors. The vast majority of reported factors are found at the individual level (sociodemographic characteristics, risk behaviours, individual risk perception, and test results). Very few studies have reported contextual factors, such as organizational factors, policies, economic factors, or social factors.

The differences in statistical analysis (classification, categorization, and reference group) introduced a great deal of heterogeneity with respect to the studies. Thus, it was not possible to combine effect sizes for all factors. The factors not included in the meta-analysis were grouped into barriers and facilitators based on their statistical association with the dependent variable (return for HIV test results).

Although the factors have been grouped into categories according to the ecological model, it is important to specify, in accordance with the socioecological approach, that the categories are not exclusive but rather influence each other.

4.1. Sociodemographic Factors

Age and level of education acted both as barriers and facilitators. However, the trend indicates firstly that young people and individuals with a low level of education were less likely to return for their results. Indeed, there is evidence that young people are often less informed about HIV and also exhibited a lower rate of HIV testing than adults [45, 46, 52]. They are unaware of their risk behaviours and are less likely to return for their test results. Conversely, individuals with higher levels of education can better understand the importance of screening [44, 53] and are more likely to return for their results.

4.2. Risk Behaviours

The literature has shown an association between the return for test results and risk behaviours [52, 54]. In fact, people who display risk behaviours can also develop fear and anxiety with respect to knowing their test results. In these circumstances, they are less likely to return for their results even if they had the courage to get tested. Thus, in this review, the positive test result, injection drug use, a high number of sexual partners, getting paid to have sex, and having symptoms of sexually transmitted infections (STIs) at a testing visit were reported as barriers to returning for test results.

4.3. Perceived Risk

Studies that have examined the association between perceived risk and a return for test results are sometimes contradictory. Indeed, some studies have shown that people who have a high-perceived risk of contracting HIV were more likely to return for their results [33, 55]. Other studies have shown that people with a low perceived risk do not return for their results [10, 14, 26, 27]. This second situation might be explained by the fact that many people at high risk of contracting HIV do not perceive themselves as at risk [5658]. Therefore, they do not see the importance of returning for their results and knowing their status. This is why it is recommended that the education of individuals be intensified in order to foster a high and precise perception of risk.

4.4. Interpersonal Factors

The sexual partner’s risk behaviours were the most frequent group of factors influencing a return for test results. Furthermore, having social support, having an HIV infected partner, or being a client of a sex worker have been reported as factors that encourage people to return for their results. In fact, having sex with a high-risk person might increase the perceived risk, which leads the exposed person to learn his or her HIV status [59]. On the other hand, the family and social network provide social support and reinforce social norms [60] that might encourage a return for results. In contrast, being a member of a social network of people at risk, such as a partner of a sex worker, of an alcoholic, or of a drug user, having gay friends, or knowing someone infected by HIV tend to hinder a return for results. These risk groups often experience discrimination and stigmatization [1, 61]. Therefore, they are less likely to get tested, to return for their results, to disclose their HIV status to others, to adopt preventive behaviours, or to access treatment services, care, and support. Finally, domestic violence (intimate partner violence) and sexual assault also hinder a return for results. Despite the implementation of strategies that enable women to get tested at opportune moments such as during pregnancy or childbirth, domestic violence remains a barrier for the entire testing process [6264]. First, the female victim of sexual violence is afraid to return for her results and know her HIV status because she is afraid of being rejected by her partner who can blame her for having tested without his consent and for being responsible for his contamination in the case of a positive result [62, 64, 65]. Second, the feeling of guilt and fear of victimization and stigmatization experienced by a raped woman can hinder her return for results even if she could be tested [62, 66, 67].

4.5. Contextual Factors

The HIV testing center and its characteristics were the most frequent contextual factors reported in different studies. Getting tested in most of the sites appeared as a barrier to returning for test results. One reason may be the type of screening test offered at these sites. Many of the studies in this review were conducted before the use of rapid tests. Recently, several HIV testing centers in developed countries and in developing countries have reported an increase in the demand for testing, the proportion of people who received posttest counselling, and the knowledge of status following the introduction of rapid tests [6872]. Other studies also showed that clients prefer the centers where they can receive their results without delay on the same day [7375]. However, it is also reported that when the testing center is linked with the treatment, the pretest counselling is done well, and there is distribution of condoms, this set of factors encourages people to return for their results [1, 7, 32, 53].

This literature review has some limitations. Firstly, the differences in the measurement of factors and the specificity of certain populations (injection drug users, pregnant women, female sex workers, and men who have sex with men) introduce heterogeneity and do not allow meta-analyses for all factors. Secondly, most of the studies were conducted before the advent of rapid testing, but nowadays HIV testing is performed by rapid tests. Therefore, the issue of failure to return for HIV test results is only important in very specific contexts. The use of rapid tests might change the distribution and frequency of certain factors.

A majority of the studies were conducted in the USA The countries of Sub-Saharan Africa, which represent 2/3 of infected people worldwide, do not often publish their results, or only publish their results in local journal articles, which are not indexed in most databases.

Our search strategy was limited to publications in English and French. Only articles published in peer-reviewed journals were considered; grey literature and conference proceedings were not. This may have some implications for the external validity of our results. However, the review included a large number of studies, covering different regions, a broad range of populations, and barriers and facilitators with respect to returning for HIV test results. Furthermore, to the best of our knowledge, this is the first review to focus on factors associated with returning for HIV test results.

5. Conclusion

Helping more people learn their HIV status requires the strengthening of counselling and testing services. Returning for HIV test results is the gateway for knowledge and acceptance of HIV status. Various recently implemented strategies, such as provider-initiated testing and counselling, community-based testing and counselling, home-based testing and counselling, and the use of rapid tests, might not be effective if the people tested are not well advised and do not accept their results.

This review identified important factors that need to be addressed to ensure that people return for their HIV test results. Most barriers and facilitators identified were found at the individual level. These results highlight the fundamental role of counselling. Individuals most likely to fail to return for their results must be identified and targeted by the counsellor and delivered a specific message.

Competing Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Supplementary Materials

The supplementary file presents the number factors associated with failure to return (FTR) and the return for HIV test results per studies. The factors are classified in barriers and facilitators.

  1. Supplementary Material

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Copyright © 2016 Patrice Ngangue et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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