New HIV TESTING SERVICES 2019 - WHO · 2020. 3. 25. · 1 Web Annex A CONSOLIDATED GUIDELINES ON HIV TESTING SERVICES 2019 Web Annex A. GRADE Table: Which demand creation approaches

1 Web Annex A

CONSOLIDATED GUIDELINES ON

HIV TESTING SERVICES

2019 Web Annex A. GRADE Table: which demand creation approaches are effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care? ISBN 978-92-4-001173-1 (electronic version)

2 Web Annex A

Consolidated guidelines on HIV testing services, 2019. Web Annex A. GRADE table: which demand creation approaches are effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care? ISBN 978-92-4-001173-1 (electronic version) This publication was originally published under WHO reference number WHO/UCN/HHS/19.40.

© World Health Organization 2020

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3 Web Annex A

Contents

Table A1: GRADE table for incentives ......................................................................................................................................................................................................... 4

Table A2: GRADE table for mobilization ..................................................................................................................................................................................................... 9

Table A3: GRADE table on advertisement of special attribute ............................................................................................................................................................ 12

Table A4: GRADE table on peer-led interventions ................................................................................................................................................................................. 15

Table A5: GRADE table on personalized content and messages ........................................................................................................................................................ 17

Table A6: GRADE table on personal invitation letters ........................................................................................................................................................................... 19

Table A7: GRADE table on general counselling ...................................................................................................................................................................................... 21

Table A8: GRADE table for couple-oriented counselling ...................................................................................................................................................................... 25

Table A9: GRADE table for message or content framing...................................................................................................................................................................... 27

Table A10: GRADE table for motivation-oriented counselling ............................................................................................................................................................ 30

Table A11: GRADE table for reduced duration or intensity of counselling ....................................................................................................................................... 32

Table A12: GRADE table for video and audio.......................................................................................................................................................................................... 34

Table A13: GRADE table for social media-based interventions ........................................................................................................................................................... 37

Table A14: GRADE table for website (non-social media) based interventions ................................................................................................................................ 39

Table A15: GRADE table for SMS ............................................................................................................................................................................................................... 41

4 Web Annex A

Table A1: GRADE table for incentives Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are incentives effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?

Certainty assessment № of patients Effect

Certainty Importance № of studies

Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

Incentives Standard of Care Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (fixed value, conditional, cash incentives to clients)

5 a randomized trials

serious b not serious c not serious not serious d none e,f 3498/6381 (54.8%) g,h

2689/5802 (46.3%) g

RR 1.52 (1.28 to 1.80) i,j

241 more per 1,000 (from 130 more to 371 more)

⨁⨁⨁◯ MODERATE

CRITICAL

Uptake of HIV testing -- lottery-based incentives vs SOC

2 k randomized trials

very serious l

not serious not serious not serious none 253/717 (35.3%) 178/914 (19.5%) RR 1.45 (0.74 to 2.86)

88 more per 1,000 (from 51 fewer to 362 more)

⨁⨁◯◯ LOW

CRITICAL

Uptake of HTS (incentives to providers)

1 m randomized trials

very serious n

serious o not serious serious p none Performance-based financing associated with significant improvement in uptake of HIV testing compared to no performance-based financing (61 more patients tested per month). However, improvement in uptake of testing was comparable between performance-based financing and financing that was not tied to performance.

⨁◯◯◯ VERY LOW

CRITICAL

Uptake of HIV testing (fixed value versus lottery incentives to clients, with gain and loss framing)

1 q randomized trials

serious r serious o not serious not serious none 1274/1694 (75.2%) s

649/833 (77.9%) RR 0.97 (0.92 to 1.01)

23 fewer per 1000 (from 62 fewer to 8 more)

⨁⨁◯◯ LOW

CRITICAL

5 Web Annex A





Absolute (95% CI)

Uptake of HIV testing (non-financial conditional incentives to clients)

1 t randomized trials

very serious u

serious o not serious not serious none 7852/14 099 (55.7%)

1062/10 580 (10.0%)

RR 5.55 (3.63 to 8.47) j

457 more per 1000 (from 264 more to 750 more)


CRITICAL

Uptake of HIV testing (fixed value unconditional incentive to client)

1 v randomized trials

very serious w

serious o not serious not serious none 45/61 (73.8%) 21/88 (23.9%) RR 3.09 (1.86 to 5.12) j



CRITICAL

Uptake of HIV testing (variable value conditional incentives)

1 x randomized trials

very serious y

serious o not serious not serious none Reported that variable value conditional incentives increased uptake by 57%.


CRITICAL

Uptake of HIV testing (fixed value, cash incentives conditional or immediate unconditional)

1 z randomized trials

serious aa serious o not serious not serious none 4 arm RCT comparing 1) $10 fixed value incentive for testing immediately, but not conditional on returning for test results, 2) a “soft commitment” of clients agreeing that they would return for testing, 3) $10 fixed value incentive conditional on testing and returning for results, vs standard of care control. Count data were not able to be extracted as proportions were adjusted and not ITT, and the authors separated getting an HIV test done from returning for HIV test results. Generally, 12% tested in control arm, there was no significant impact of soft commitment or delayed incentives, but 64% got tested in immediate incentive. For receiving results, the authors report that control arm had 6% uptake, which increased to 14% for immediate incentives, but that among those that got tested, return for results was 50% lower among those with immediate incentive.

⨁⨁◯◯ LOW

CRITICAL

Linkage to care among positives (incentives to clients)

6 Web Annex A





Absolute (95% CI)

1 ab randomized trials

serious ac serious o not serious very serious ad

none 43/47 (91.5%) ae,af

2/3 (66.7%) ae RR 1.36 (0.61 to 3.05)

240 more per 1000 (from 260 fewer to 1,000 more)


CRITICAL

Linkage to care among positives (incentives to providers)

1 m randomized trials

very serious n

serious o not serious very serious ag

none Performance-based financing was not associated with changes in linkage to prevention of mother-to-child transmission of HIV or HIV care clinic.


New HIV-positive diagnoses - not reported

- - - - - - - - - - - - CRITICAL

Yield of HIV testing

2 ah randomized trials

very serious ai

not serious aj not serious serious ak none 43/551 (7.8%) al,am,an

3/77 (3.9%) al RR 1.47 (0.48 to 4.54)

18 more per 1000 (from 20 fewer to 138 more)


IMPORTANT

Viral suppression - not reported

- - - - - - - - - - - - IMPORTANT

Linkage to prevention

1 ap randomized trials

very serious aq

serious o not serious serious ar none 207/577 (35.9%) as

15/53 (28.3%) as RR 1.27 (0.81 to 1.97)



IMPORTANT

Time to retesting - not reported

- - - - - - - - - - - - NOT IMPORTANT

7 Web Annex A

CI: Confidence interval; RR: Risk ratio; MD: Mean difference

Explanations

a. A total of 12 trials exist for incentives; 5 were pooled for analysis representing those with fixed value conditional financial incentives to patients versus an unincentivized control (Choko, Kranzer, Saxena, Montoy, and Chamie 2018b). Among the 12 RCTs; 5 cluster RCT (Sibanda, Choko, Hawk, Kranzer, DeWalque); 7 individual RCT (Saxena, Chamie 2018a, Montoy, Njuguna, Kim, Chamie 2018b, and Macis). b. Cochrane risk of bias used; Chamie 2018b (limited content): high risk of bias due to absence of blinding of participants and personnel, and unclear risk of bias for other domains. Saxena: absence of blinding of participants and personnel, risk of bias unclear for allocation concealment, selective reporting, blinding of outcome assessors, and incomplete outcome data. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Kranzer: high risk of bias for blinding (participants, personnel, and outcome assessor), incomplete outcome data, recruitment bias, loss of clusters, and other source of bias. Montoy: high risk of bias for allocation concealment, blinding (participants, personnel, and outcome assessor) incomplete outcome data, and other source of bias related to generalizability of the findings. Downgrade 1. c. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention (incentive type, incentive amount, incentive conditionality), heterogeneity in the population, and heterogeneity in the follow-up time. d. Pooled estimate has reasonable precision. Not downgraded. e. Publication bias detected using Eggers methods at p<0.05 level, but given the limitations of this test's performance with <10 trials, no downgrading. f. One of three trials that examined different levels of the same type of incentive saw dose response relationship (Choko). Two showed minor dose response relationships consistently (Chamie 2018a, Chamie 2018b). One showed no dose response relationship (Njuguna). Not upgraded for dose response relationship. g. Data from 5 studies including cluster and individual RCTs. h. Njuguna trial did not have a control arm, so could not be pooled; Njuguna et al conducted a 3-arm individual randomized trial testing the effect of $5, $10, and $15 fixed value conditional incentives without a standard of care arm among children in Kenya. Uptake of HIV testing did not differ between the arms (75% vs 70% vs 75%). One child of 53 tested children were HIV positive (1.8% yield). Risk of bias was high for blinding for participants and personnel and unclear for blinding for outcome assessors and complete outcome assessment. i. Significant publication bias detected. Adjusted estimate using trim and fill is 1.19 (1.00, 1.43) j. Adjustment was made to log standard error of cluster RCTs using an ICC of 0.095. Across the review, just 2 studies reported ICC (Ezeanolue: 0.14 (reported in results), Figueroa: 0.05 (reported in methods power calculations)). As this trial did not report ICC, the average of the two other studies' ICCs was used. k. Choko ($30 lottery arm) and Kranzer ($5 or $10 lottery arm) included l. Cochrane risk of bias used; absence of blinding was not used to downgrade evidence as the mechanism of action for demand creation interventions requires awareness of the intervention. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Kranzer: high risk of bias for blinding (participants, personnel, and outcome assessor), incomplete outcome data, recruitment bias, loss of clusters, and other source of bias. This all resulted in downgrading two steps. m. DeWalque was only study that reported on incentives to providers. Data were not extractable in counts, there were numerous methodologic challenges with the study, and it was not possible to determine whether the analysis output was an intent to treat analysis. The narrative interpretation is included. n. Risk of bias was unclear on all elements in this abstract without a linked published manuscript. Outcome was determined on the subset of individuals who completed the prior step, not the fully randomized groups, therefore downgraded two steps. o. Not possible to assess consistency from a single study. Downgraded one step. p. In this cluster RCT, unable to assess whether clustering was accounted for appropriately. Could impact precision. Downgraded one step. q. Chamie 2018a r. Chamie 2018a: Risk of bias assessment revealed high risk of bias due to absence of blinding of participants and personnel, and unclear risk of bias related to blinding of outcome assessors and study power. Downgraded one step. s. Within the same trial, Emperador et al investigated the impact of the aforementioned intervention ($1 low value loss, gain, or lottery) on female partner HIV testing uptake. They found that there was no difference in female partner HIV testing uptake based on male partner incentive framing (58% vs 60% vs 63%, respectively). There was potential bias due to absence of blinding of participants and personnel. Since link to a published manuscript was not available, risk of bias assessment was unclear for all other domains, but bias due to incomplete outcome data t. Sibanda

8 Web Annex A

u. Sibanda: There were several major concerns with risk of bias, including allocation concealment, blinding (participants, personnel, and outcome assessors), selective outcome reporting, recruitment bias, and baseline imbalances. Risk of bias related to blinding of outcome assessors and other source of bias was not clear. Downgraded 2 steps v. Hawk w. Hawk: There were several serious concerns with risk of bias in this study including sequence generation, blinding of participants and personnel, blinding of outcome assessors, allocation concealment, incomplete outcome data, other bias in terms of pre-enrollment differences in recruitment, recruitment bias, and loss of clusters. Risk of bias assessment revealed unclear risk of bias related to selective reporting, incorrect analyses, and comparability of the study with individually randomized trials. Downgraded 2 steps. x. Kim y. Kim: Risk of bias assessment raised concerns about blinding (participants, personnel, outcome assessor), incomplete outcome assessment and inappropriate analysis that did not allow for extraction. Unclear sequence generation method, allocation concealment method, reporting bias, recruitment bias, and other source of bias. Downgraded 2 steps z. Macis aa. Macis: Risk of bias revealed unclear risk of bias for all elements. Risk of bias assessment was limited by the poster abstract. Downgraded 1 step. ab. 2 RCTs included: Choko and Njuguna, both individual RCTs, reported on linkage to care, but Njuguna did not include an SOC arm. Choko data presented. ac. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Njuguna: Risk of bias was high for blinding for participants and personnel and unclear for blinding for outcome assessors and complete outcome assessment. Outcome was determined on the subset of individuals who completed the prior step, not the fully randomized groups, therefore downgraded one step. ad. Meta-analysis strongly lacks precision due to small sample size ae. Choko: 10/11, 10/11, 13/14, 4/4, 2/3 in intervention arms linked to care, 2/3 linked to care in control arm; Njuguna: 1/1 linked to care (this trial has no standard of care comparator arm). af. Njuguna trial did not present linkage by trial arm: 1/1 (100%) linked to care ag. Data not reported to support abstract statement that interventions had no effect on linkage to PMTCT and ART care. Downgraded two steps ah. Estimates of yield available as counts from Hawk (cluster RCT), Choko (individual RCT). Information on yield reported for Sibanda (cluster RCT), but extraction of counts or relative effect not possible from presented analysis. Information on yield reported for Njuguna (individual RCT), but no control arm. ai. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Outcome was determined on the subset of individuals who completed the prior step, not the fully randomized groups, therefore downgraded two steps. aj. Heterogeneity in yield can reasonably be attributed to heterogeneity in populations. ak. Meta-analysis estimate lacks precision. al. Hawk: 0/45 tested positive in intervention arm and 0/21 tested positive in the control arm; Njuguna 1/53 children tested positive (this trial has no standard of care comparator arm); Choko: 11/85, 11/155, 14/266, 4/30, 3/84 tested positive in the intervention arms and 3/56 tested positive in the control arm. Data from Sibanda and Chamie could not be extracted in count format. Yield in Chamie was 7.6% overall and ranged from 5.8% in loss-framed incentive through 9.4% in gain-framed incentive. am. Choko trial yield data was not available by randomization arm and therefore could not be pooled: 7.6% overall and ranged from 5.8% in loss-framed incentive through 9.4% in gain-framed incentive an. Njuguna trial did not have yield stratified by arm: 1/53 children tested positive (1.9%) ao. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Njuguna: Risk of bias was high for blinding for participants and personnel and unclear for blinding for outcome assessors and complete outcome assessment. Downgraded one step. ap. Choko is only trial to report linkage to prevention, defined as counseling and VMMC (if uncircumcised) or counseling alone (if circumcised). aq. Choko: high risk of bias for blinding of participants and personnel, blinding of outcome assessors, allocation concealment and recruitment bias; other source of bias in terms of study power and social desirability bias were not clear. Outcome was determined on the subset of individuals who completed the prior step, not the fully randomized groups, therefore downgraded two steps. ar. Meta-analysis is moderately imprecise, suggests a meaningful benefit, but crosses 1. as. Choko: 31/74, 47/144, 84/252, 6/26, 39/81 in intervention arms and 15/53 in control arm who tested negative linked to prevention services.

9 Web Annex A

Table A2: GRADE table for mobilization Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is mobilization effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?


Certainty Importance № of

studies

Study

design Risk of bias Inconsistency Indirectness Imprecision Other considerations Mobilization Standard of care

Relative

(95% CI)

Absolute

(95% CI)

Uptake of HIV testing

5 a randomised

trials

very serious b,c

not serious d not serious not serious none 18651/33004

(56.5%)

5115/33189

(15.4%)

RR 2.11

(1.41 to 3.15) e,f

171 more

per 1,000

(from 63

more to

331 more)

⨁⨁◯◯

LOW

CRITICAL

Uptake of HIV testing (sports- and theatre-based mobilization)

1 h randomised

trials

very serious i serious g not serious serious j none The intervention was not associated with a greater improvement

in HIV testing uptake (baseline to endline, 60% to 67% vs 63% to

69%).

⨁◯◯◯

VERY LOW

CRITICAL

Uptake of HIV testing (mobilization through messages of community benefit of HIV treatment)

1 k randomised

trials

serious l serious g not serious serious m none Reported an overall increase of HIV testing uptake of 60%, 72%

among men and 50% among women; baseline levels were low.

Count data unavailable.

⨁◯◯◯

VERY LOW

CRITICAL

Linkage to care among positives

1 n randomised

trials

serious o serious g not serious very serious p

none 34/41 (82.9%) 14/32 (43.8%) RR 1.90

(0.03 to 133.00)

394 more

per 1,000

(from 424

fewer to

1,000

more)

⨁◯◯◯

VERY LOW

CRITICAL

10 Web Annex A



studies

Study

design Risk of bias Inconsistency Indirectness Imprecision Other considerations Mobilization Standard of care

Relative

(95% CI)

Absolute

(95% CI)

New HIV positive diagnoses - not reported

- - - - - - - - - - - - CRITICAL

Yield of HTS

2 q randomised

trials

very serious r not serious not serious not serious s none 993/17094

(5.8%)

296/4240

(7.0%)

RR 0.60

(0.19 to 1.93) t

28 fewer

per 1,000

(from 57

fewer to

65 more)

⨁⨁◯◯

LOW

IMPORTANT

Yield of HTS -- randomized denominator

2 q randomised

trials

serious u not serious not serious not serious s none 993/29865

(3.3%)

296/30286

(1.0%)

RR 1.59

(0.48 to 5.28)

6 more

per 1,000

(from 5

fewer to

42 more)

⨁⨁⨁◯

MODERATE

IMPORTANT


- - - - - - - - - - - - IMPORTANT

Linkage to prevention - not reported

- - - - - - - - - - - - IMPORTANT

Retesting

1 v randomised

trials

very serious w

serious g,x not serious not serious s none 1633/7778

(21.0%)

114/1181

(9.7%)

RR 1.25

(0.16 to 9.90)

24 more

per 1,000

(from 81

fewer to

859 more)

⨁◯◯◯

VERY LOW

NOT IMPORTANT

CI: Confidence interval; RR: Risk ratio

11 Web Annex A

Explanations a. Figueroa, Ezeanolue, Berkley-Patton (12 month timepoint), Sweat (Tanzania, Zimbabwe, Thailand) and Rhodes. b. Figueroa: selective outcome reporting, poor fidelity, evidence of contamination, concurrent competing programs, differences in baseline characteristics, differential loss of clusters; Ezeanolue: high risk of bias related to blinding (participants, personnel, and outcome assessor) and baseline imbalance; risk of bias was not clear for incomplete outcome data, recruitment bias, and comparability of the study with individually randomized trials. Berkley-Patton: incomplete data and differential missingness by arm, differences in baseline characteristics, potential for recruitment bias and bias due to absence of blinding of participants and personnel; risk of bias assessment was unclear for allocation concealment, blinding of outcome assessors, comparability with individually randomized trials, selective reporting and other sources of bias such as social desirability bias. c. (continued) Sweat: High risk of bias related to blinding (participants, personnel, and outcome assessors), incorrect analysis and the comparability of the study with individually randomized trials. Missing data from Thailand was evident but not concerning. Unclear risk of bias related to random sequence generation method, allocation concealment, and baseline imbalance; Rhodes: evidence of contamination. Downgraded two steps. d. While there was large statistical heterogeneity, which may have been explained by population and setting, the decision was made to not downgrade because the intervention was associated with benefits in all other outcomes. Not downgraded. e. Adjustment was made to log standard error of cluster RCTs using an ICC of 0.095. Across the review, just 2 studies reported ICC (Ezeanolue: 0.14 (reported in results), Figueroa: 0.05 (reported in methods power calculations)). As only one of these trials reported the ICC, the average of the two other studies' ICCs was used. f. No significant publication bias detected with Egger's test, but adjusted estimate is 1.76 (1.26, 2.46). g. Not possible to assess consistency from a single study. Downgraded one step. h. Lippman i. Lippman: Risk of bias assessment suggested some mild concerns with contamination and mild level of missing data and refusals. Serious concern due to absence of blinding of participants and personnel. Risk of bias was not clear for random sequence generation, allocation concealment, blinding of outcome assessors, and incomplete outcome data. Downgraded two steps. j. No denominator data available, which limited assessment of precision. Downgraded one step. k. Derksen l. Derksen: Risk of bias assessment revealed unclear risk of bias for all domains due to the lack of information within the poster, but did include concerns about loss of clusters. Downgraded one step m. No count data available in poster to assess precision or sample size. Analysis not transparent. Downgraded one step. n. Ezeanolue contributed data (cluster RCT) o. Risk of bias: Ezeanolue: high risk of bias related to blinding (participants, personnel, and outcome assessor) and baseline imbalance. Risk of bias was not clear for incomplete outcome data, recruitment bias, and comparability of the study with individually randomized trials. Downgraded 1 step. p. Small data counts from a single study limit the precision in the estimate. Downgraded one step q. Ezeanolue and Sweat (Tanzania, Zimbabwe, and Thailand), both CRCTs r. Risk of bias: Ezeanolue: high risk of bias related to blinding (participants, personnel, and outcome assessor) and baseline imbalance. Risk of bias was not clear for incomplete outcome data, recruitment bias, and comparability of the study with individually randomized trials. Sweat: High risk of bias related to blinding (participants, personnel, and outcome assessors), incorrect analysis and the comparability of the study with individually randomized trials. Missing data from Thailand was evident but not concerning. Unclear risk of bias related to random sequence generation method, allocation concealment, and baseline imbalance. Outcome collected on subset of those who completed testing, not full group randomized. Downgraded two steps. s. While statistically imprecise, there are large numbers informing this estimate. Not downgraded. t. No significant publication bias detected with Egger's test. No difference in adjusted analysis u. Risk of bias: Ezeanolue: high risk of bias related to blinding (participants, personnel, and outcome assessor) and baseline imbalance. Risk of bias was not clear for incomplete outcome data, recruitment bias, and comparability of the study with individually randomized trials. Sweat: High risk of bias related to blinding (participants, personnel, and outcome assessors), incorrect analysis and the comparability of the study with individually randomized trials. Missing data from Thailand was evident but not concerning. Unclear risk of bias related to random sequence generation method, allocation concealment, and baseline imbalance. Downgraded one step. v. Sweat contributed data from 3 countries with a cluster RCT design. Each site considered a separate estimate, as this was how results were presented in manuscript and how trial was designed. w. Sweat: High risk of bias related to blinding (participants, personnel, and outcome assessors), incorrect analysis and the comparability of the study with individually randomized trials. Missing data from Thailand was evident but not concerning. Unclear risk of bias related to random sequence generation method, allocation concealment, and baseline imbalance. Outcome collected on subset, not full population randomized. Downgraded two steps x. Two settings have large differences in effect size, but otherwise comparable procedures within same trial.

12 Web Annex A

Table A3: GRADE table on advertisement of special attribute Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is advertisement of special attribute effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?




Advertisement of a special attribute of a clinic

Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS


very serious b,c

not serious d

not serious not serious e none 2382/5747 (41.4%) f,g

918/5350 (17.2%) f

RR 1.62 (1.06 to 2.48) h,i


⨁⨁◯◯ LOW

CRITICAL

Uptake of HIV testing (youth friendly services)

1 j,k randomized trials

serious l serious m not serious serious n none 728/750 (97.1%)

180/250 (72.0%)

RR 1.35 (0.84 to 2.15) k



CRITICAL

Linkage to care among positives - not reported

- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS

1 o randomized trials

very serious p

serious m not serious not serious none 5/425 (1.2%) q 8/166 (4.8%) RR 0.24 (0.08 to 0.74)

37 fewer per 1000 (from 44 fewer to 13 fewer)


IMPORTANT

13 Web Annex A




Advertisement of a special attribute of a clinic

Standard of Care

Relative (95% CI)

Absolute (95% CI)



serious r serious m not serious not serious none 5/1797 (0.3%) 8/909 (0.9%) RR 0.32 (0.10 to 0.97)


⨁⨁◯◯ LOW

Viral load among positives - not reported

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT

Retesters - not reported

- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. A total of 3 cluster RCTs (Corbett, Rosenberg, Aninanya) and one individual RCT (Ditekemena) were included in review. Pooling conducted for Corbett and Ditekemena. b. Risk of bias assessments revealed several concerns that resulted in downgrading 2 steps: Corbett, high concerns in blinding of participants and personnel, incomplete outcome data due to loss of 2 clusters and selective outcome reporting; blinding of outcome assessors and recruitment bias is not clear. Ditekemena: absence of blinding of participants and personnel, and outcome assessors; unclear random sequence generation approach; reporting bias and other bias in terms of the nature of the intervention are not clear. Rosenberg, estimates were adjusted and crude count data were not available, and analysis was potentially incorrect (no mention was made of accounting for clustering); risk of bias for all other domains was not clear, but there were no concerns about differential loss of clusters. c. (cont) Aninanya, incomplete outcome data, absence of blinding of participants, personnel and outcome assessors, inappropriate randomization approach (there were two pilot sites where the intervention was introduced prior to the RCT; these sites were lumped into the intervention arm, without sensitivity analyses to show how the results may have differed when excluding the pilot sites), potential for recruitment bias, and moderate baseline imbalances; there is an unclear risk of bias related to selective reporting and comparability with individually randomized trials. Downgraded 2 steps. d. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention, heterogeneity in the population, and heterogeneity in the follow-up time. e. Precision is reasonable in meta-analysis. Not downgraded f. Excludes data from Rosenberg due to unavailable count data. Adjusted estimates show 97% uptake in intervention and 52% uptake in control for this trial. g. One study (Corbett) presented two estimates of the relative impact of uptake. When they defined the outcome as "collected voucher", the outcome was 586/3,532 (19.2%) uptake, but when they defined the outcome as "reported completed HTS" the outcome was 125/3,532 (3.5%). The latter suggests a large effect size, but the former may be more conservative; no outcome was declared primary in the manuscript. h. Publication bias not significant with Eggers test, but adjusted estimate crossed null value: 1.29 (0.85, 1.96)

14 Web Annex A

i. Adjustment was made to log standard error of cluster RCTs using an ICC of 0.095. Across the review, just 2 studies reported ICC (Ezeanolue: 0.14 (reported in results), Figueroa: 0.05 (reported in methods power calculations)). j. Rosenberg k. Aninanya not included; trial included youth friendly services in both intervention and control and found that school-based youth education and outreach mobilization did not increase uptake of HIV testing. Data: baseline: 55/1,692 (3.2%) vs endline: 167/1,288 (13.0%); baseline: 73/1,912 (3.8%) vs endline: 157/1,376 (11.4%). Risk of bias assessment raised several concerns, including incomplete outcome data, inappropriate randomization approach (there were two pilot sites where the intervention was introduced prior to the RCT; these sites were lumped into the intervention arm, without sensitivity analyses to show how the results may have differed when excluding the pilot sites), potential for recruitment bias, and moderate baseline imbalances. l. Risk of bias assessment revealed concerns about potentially incorrect analysis (no mention was made of accounting for clustering), unclear risk of bias for all elements besides loss of clusters. Downgraded 1 step. m. Not possible to assess consistency from a single study. Downgraded one step. n. Meta-analysis is not precise; downgraded one step o. Ditekemena (individual RCT) p. Risk of bias assessment revealed some concerns for the Ditekemena study: absence of blinding of participants and personnel, and outcome assessors. Unclear random sequence generation approach. Reporting bias and other bias in terms of the nature of the intervention are not clear. Denominator is number tested, not number randomized. Downgraded two steps. q. Two intervention arms of Ditekemena had similar yield. Bar-based (3/236) and church-based (2/189). r. Risk of bias assessment revealed some concerns for the Ditekemena study: absence of blinding of participants and personnel, and outcome assessors. Unclear random sequence generation approach. Reporting bias and other bias in terms of the nature of the intervention are not clear. Downgraded one step.

15 Web Annex A

Table A4: GRADE table on peer-led interventions Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are peer-led interventions effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias

Inconsistency Indirectness Imprecision Other considerations

Peer-led interventions

Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (peer-led vs not peer-led)


serious b not serious not serious not serious none 112/442 (25.3%)

74/454 (16.3%)

RR 1.31 (1.00 to 1.72) c,d



CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS

1 e randomized trials

very serious f

serious g not serious serious h none 4/69 (5.8%) 4/58 (6.9%) RR 0.84 (0.22 to 3.21)



IMPORTANT



serious i serious g not serious serious h none 4/164 (2.4%) 4/176 (2.3%) RR 1.07 (0.27 to 4.22)



IMPORTANT


- - - - - - - - - - - - IMPORTANT

16 Web Annex A





Peer-led interventions

Standard of Care

Relative (95% CI)

Absolute (95% CI)


- - - - - - - - - - - - IMPORTANT

Retesters - not reported

- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. Data available from 3 cluster RCTs (Young 2013, Young 2015, Wagner) and 3 individual RCTs (Outlaw, Wilton, Adam). Data from Adam were not able to be extracted as counts. Only Wilton and Young 2015 compared a peer-led intervention to a control arm. b. Risk of bias assessment for Wilton saw high risk of bias due to incomplete data and absence of blinding of participants and personnel. The risk of bias was unclear for random sequence generation, allocation concealment, and blinding of the outcome assessors. Downgraded one step c. No significant publication bias detected. Adjusted estimate is slightly different: 1.63 (1.08, 2.46). Two additional studies were identified that tested the same question, but did not have poolable results: Adam: peer mentors increase uptake of HIV testing through Facebook and in-person groups (based on multi-level models, the slope coefficient for HIV testing showed reliable positive change as a result of this intervention). Wagner: peer-led mobilization does not increase uptake of HIV testing (both intervention and control increased testing compared to pre-intervention data, control OR: 1.66; intervention OR: 1.99 compared to pre-intervention baseline. d. (cont) Risk of bias: Wagner: The group allocation methods are unclear including the intended unit of randomization, however some adjustment for clustering by district was made in their statistical models. Risk of bias related to baseline imbalance and blinding (participants, personnel, and outcome assessor) is unclear. Adam: Risk of bias assessment raised concerns about external validity due to sampling strategy and blinding of participants and personnel for all outcomes. Downgraded one step. Methods of sequence generation, allocation concealment, and blinding of outcome assessors are unclear. e. Wilton f. Wilton had high risk of bias due to incomplete outcome data and blinding of participants and personnel; risk of bias for randomization sequence, allocation sequence, and blinding of outcome assessors was unclear. Outcome collected on subset of those who tested rather than all randomized. Downgraded two steps. g. Not possible to assess consistency from a single study. Downgraded one step. h. Meta-analysis was somewhat imprecise i. Wilton had high risk of bias due to incomplete outcome data and blinding of participants and personnel; risk of bias for randomization sequence, allocation sequence, and blinding of outcome assessors was unclear. Downgraded one step.

17 Web Annex A

Table A5: GRADE table on personalized content and messages Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are personalized content and messages effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Tailored content

Standard of care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (tailored vs not tailored)


serious b not serious c not serious not serious d none 2493/3275 (76.1%)

2486/3314 (75.0%)

RR 1.13 (0.86 to 1.48) e



CRITICAL

Uptake of HIV testing -- tailored ethnic and gender messaging

1 f randomized trials

serious g serious h not serious not serious none 2452/2950 (83.1%)

2468/3050 (80.9%)

RR 1.03 (1.00 to 1.05)


⨁⨁◯◯ LOW

Linkage to care among positives (number) - not reported

- - - - - - - - - - - - CRITICAL

New HIV positive diagnoses (number) - not reported

- - - - - - - - - - - - CRITICAL

Yield of HTS (number) - not reported

- - - - - - - - - - - - IMPORTANT

Viral suppression (number) - not reported

- - - - - - - - - - - - IMPORTANT

Linkage to prevention (number) - not reported

- - - - - - - - - - - - IMPORTANT

Retesters (number) - not reported

18 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Tailored content

Standard of care

Relative (95% CI)

Absolute (95% CI)

- - - - - - - - - - - - NOT IMPORTANT

CI: Confidence interval; RR: Risk ratio

Explanations

a. A total of 7 RCTs were included in the review: Bauermeister, Bull, Blas, O'Connor, Cordova, Kalichman 1993, and Kalichman 1995. Bauermeister, Blas, and O'Connor were pooled as they compared a tailored counseling intervention to a standard of care control. b. Risk of bias assessment: Bauermeister: serious concerns related to incomplete outcome data and unclear risk of bias for all other domains; Blas: no serious concerns except potential for bias due to absence of blinding of participants and personnel; risk of bias related to blinding of outcome assessors, incomplete outcome data, and other source of bias is not clear. O'Connor: unclear risk of bias on all elements, except high risk of bias on blinding of participants and personnel and outcome assessors. Downgraded one step c. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention, heterogeneity in the population, and heterogeneity in the follow-up time. d. Precision in the meta-analysis is reasonable, but crosses 1. Not downgraded e. Publication bias not significant using Egger's test; adjusted estimate was not meaningfully different 1.03 (0.81, 1.31). Two additional RCTs testing the same question were identified but were not poolable: Bull: uptake of HIV testing was higher in intervention than control (85% and 80%). Cordova: uptake was higher in intervention than control (52% vs 45.8%). g. Bull: Risk of bias assessment indicated high risk of bias due to incomplete outcome data for all outcomes and selective outcome reporting. Cordova: Risk of bias assessment was limited by the poster abstract. Unclear risk of bias for all domains except random sequence generation methods. Not downgraded f. O'Connor provided count data to inform estimate. Kalichman 1993 tested the same concept, but not count data; tailored content was associated with improved uptake of HIV testing. Kalichman 1995 included gender and ethnicity matching in both intention and control arms. g. O'Connor: Risk of bias assessment indicated high risk of bias due to absence of blinding (participants, personnel, outcome assessor); risk of bias assessment revealed unclear risk for the remaining domains Downgraded one step. h. Not possible to assess consistency from a single study. Downgraded one step.

19 Web Annex A

Table A6: GRADE table on personal invitation letters Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are personal invitation letters effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Personalized letter

Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS

1 a,b randomized trials

serious c serious d not serious serious e none 82/530 (15.5%)

68/530 (12.8%)

RR 1.21 (0.90 to 1.62)



CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS


very serious c

serious d not serious very serious g

none 3/82 (3.7%) 0/68 (0.0%) RR 1 (-- to --) i



IMPORTANT



serious h serious d not serious not serious none 3/530 (0.6%) 0/530 (0.0%) RR 1 (-- to --) i

0 fewer per 1000 (from -- to --)

⨁⨁◯◯ LOW

IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT

20 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Personalized letter

Standard of Care

Relative (95% CI)

Absolute (95% CI)


- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. 3 studies: Byamugisha, Mohlala, and Turan included in report. No studies had count data and compared personalized letter to standard of care with no letter. Byamugisha assessed the impact of a personalized invitation letter and contributed data to point estimate. b. 1 RCT (Mohlala) suggests that an HIV-specific invitation letter increases uptake of testing relative to a general clinic letter; 1 RCT (Turan) used a personalized letter in both intervention and control c. Byamugisha: Risk of bias assessment that the control group in this study also received an intervention, resulting in higher HTS uptake than previous studies in this population have found. High risk of bias due to absence of blinding of participants and personnel. Denominator is conditional on those tested, not full denominators randomized. Downgraded two steps. d. Not possible to assess consistency with one study. Downgraded one step. e. Shows appreciable benefit, but crosses 1. Downgraded one step. f. Byamugisha g. Estimate is highly imprecise. Downgraded 2 steps h. Byamugisha: Risk of bias assessment that the control group in this study also received an intervention, resulting in higher HTS uptake than previous studies in this population have found. High risk of bias due to absence of blinding of participants and personnel. Downgraded one step. i. RR not estimable due to 0 count in numerator.

21 Web Annex A

Table A7: GRADE table on general counselling Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is general counselling effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations

General counselling

Standard of care

Relative (95% CI)

Absolute (95% CI)

Uptake of HIV testing (HIV specific information pooled)


serious b,c not serious d not serious serious e none 507/1606 (31.6%)

486/1613 (30.1%)

RR 1.38 (0.93 to 2.06)


⨁⨁◯◯ LOW

Uptake of HIV testing (HIV information -- teenagers in US)


serious g serious h not serious serious i none No change in uptake of testing: overall: (11.8 to 12.6%), in males (5 to 6.7%), in females (16.4 to 16.6%)


Uptake of HIV testing (HIV information and economic empowerment)

2 j randomized trials

very serious k

not serious not serious not serious none 29/323 (9.0%) 18/746 (2.4%) RR 1.80 (1.05 to 3.08)


⨁⨁◯◯ LOW

Uptake of HIV testing (group-based)

1 l randomized trials

serious m serious h not serious serious n none 20/198 (10.1%) o

10/200 (5.0%) RR 2.02 (0.67 to 6.08) o



22 Web Annex A




General counselling

Standard of care

Relative (95% CI)

Absolute (95% CI)

Uptake of HIV testing (therapeutic alliance – people who inject drugs)

1 p randomized trials

serious serious h not serious not serious none 12/209 (5.7%) 17/211 (8.1%) RR 0.71 (0.31 to 1.66)


⨁⨁◯◯ LOW

CRITICAL

Uptake of HIV testing (risk reduction and HIV test information vs offsite testing – people who inject drugs)


serious r serious h not serious not serious none 338/433 (78.1%)

78/429 (18.2%)

RR 4.29 (3.22 to 5.73) s


⨁⨁◯◯ LOW

CRITICAL

Uptake of HIV testing (billboard and radio ads delivered via email)

1 t randomized trials

serious u serious h not serious serious i none Two weeks after intervention group participants were more likely than control group participants to report having an HIV test (OR: 1.4), but by 6 weeks were less likely (OR: 0.57), neither of these odds ratios were statistically significant



- - - - - - - - - - - - CRITICAL

New HIV positive diagnoses (people who inject drugs)

1 v randomized trials

serious w serious h not serious serious x none 2/685 (0.3%) 1/429 (0.2%) RR 1.39 (0.11 to 17.24)



CRITICAL

Yield of HTS - not reported

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT

23 Web Annex A




General counselling

Standard of care

Relative (95% CI)

Absolute (95% CI)

Linkage to prevention

1 y randomized trials

very serious z

serious h not serious not serious none 28/51 (54.9%) 35/45 (77.8%) RR 0.71 (0.53 to 0.95)



IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT

Baseline CD4 among positives - not reported

- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. Booth (2 session), Simpson, Dolcini, Ybarra (6 month uptake), Festinger b. Booth: Risk of bias is high due to incomplete outcome and absence of blinding of participants and personnel; allocation concealment method is unclear. Simpson: Risk of bias is low for this study but concerns about blinding of the participants and personnel remain. Dolcini: There is a high risk of bias related to blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, comparability with individually randomized trials, baseline imbalances, and the fact that study outcomes were based on self-report; risk of bias assessment revealed unclear risk of bias for random sequence generation, allocation concealment, selective reporting, study analysis and recruitment. Ybarra: Risk of bias assessment identified differential loss to follow-up and absence of blinding of the participants and personnel; risk of bias due to absence of blinding of the outcome assessor was not clear. c. (cont) Festinger: Risk of bias assessment revealed concern with the randomization allocation sequence generation. Downgraded one step d. While there is high statistical heterogeneity, overall in favor of benefit. e. Possibly important benefit but meta-analysis estimate and CI are imprecise f. McKee g. McKee: There is a high risk of bias related to selective reporting, blinding of participants and personnel, and blinding of outcome assessors. Risk of bias unclear without a linked published manuscript for random sequence generation, allocation concealment, incomplete outcome data, and other sources of bias. Downgraded one step h. Not possible to assess consistency with one study. Downgraded one step i. No denominator data to assess precision. Downgraded one step j. Spielberg and Pronyk k. Spielberg: There is a high risk of selection bias and reporting bias; risk of bias unclear for all other domains but did not include concerns about baseline imbalance and differential loss of clusters. Pronyk: Risk of bias revealed concerns with absence of blinding (participants, personnel, and outcome assessors), incomplete outcomes, selective outcome reporting, and loss of clusters; risk of bias not clear for allocation concealment and comparability of the study with individually randomized trials. Downgraded two steps l. Jiraphongsa and Firestone both tested this. Firestone design made unpoolable with Jiraphongsa; included in footnote only.

24 Web Annex A

m. Jiraphongsa: There is high risk of incomplete outcome data and some baseline imbalance along with potential for bias due to absence of blinding of participants and personnel and blinding of the outcome assessors. Unclear risk of bias for allocation concealment, recruitment bias, reporting bias, and other source of bias. Downgraded one step n. Meta-analysis CI imprecise. o. Firestone used a difference in differences approach. Count data are as follows, and not summed in the above reported number of patients: INTERVENTION: Baseline: 241/639 (38%) vs Endline: 482/549 (88%); Baseline: 237/518 (46%) vs Endline: 211/503 (42%). p. Booth q. Metsch r. Metsch: Risk of bias indicated absence of blinding of participants and personnel and other source of bias related to the study analysis. Unclear allocation concealment methods. Downgraded one step s. RR shown compares risk reduction counseling with onsite HIV test to offsite HIV test; RR comparing HIV information with onsite HIV test to offsite is: RR: 4.55 (3.42, 6.07) t. Uhrig u. Uhrig: Risk of bias assessment revealed concerns about incomplete outcome ascertainment and blinding of participants and personnel. Random sequence generation methods and other source of bias are not clear. Downgraded one step. v. Metsch contributed data w. Metsch: high risk of incomplete outcome data and blinding of participants and personnel, unclear risk of allocation concealment. Outcome assessed on subset of those who tested rather than those randomized. Downgraded one step. x. Meta-analysis estimate is imprecise y. Pronyk z. Pronyk: high risk of bias for blinding (participants, personnel, and outcome assessors), incomplete outcome assessment, selective outcome reporting, loss of clusters. Unclear risk of bias for allocation concealment and comparability with individually randomized trial. Outcome assessed on subset of those who tested rather than those randomized. Downgraded two steps.

25 Web Annex A

Table A8: GRADE table for couple-oriented counselling Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is couple-oriented counselling effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Couple oriented counselling

Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS


serious b not serious c not serious not serious none 716/1893 (37.8%)

441/1568 (28.1%)

RR 1.50 (1.06 to 2.10) d



CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS


very serious f

serious g not serious serious h none 31/78 (39.7%) 9/33 (27.3%) RR 1.46 (0.78 to 2.71)



IMPORTANT



serious i serious g not serious serious h none 31/226 (13.7%)

9/118 (7.6%) RR 1.80 (0.89 to 3.65)



IMPORTANT


26 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Couple oriented counselling

Standard of Care

Relative (95% CI)

Absolute (95% CI)

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT

New outcome

not estimable

-

New outcome

not estimable

-


Explanations

a. Orne-Gliemann (3 countries), Chiou, Matovu b. Risk of bias: Orne-Gliemann: Serious concerns about blinding of the participants and personnel and other source of bias related to misclassification; missing value of the main outcome in the study was considered as no outcome. Chiou: High risk of bias due to absence of blinding of participants and personnel; unclear risk of bias for allocation concealment, sequence generation, blinding of outcome assessors, selective reporting, and external generalizability. Matovu: absence of blinding of participants and personnel, incomplete outcome ascertainment and low external validity, unclear risk of bias for the remaining domains except random sequence generation. Downgraded one step. c. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention, heterogeneity in the population, and heterogeneity in the follow-up time. d. Significant publication bias detected using Eggers test and p<0.05; adjusted estimate is 1.05 (0.75, 1.47) e. Chiou f. Chiou: High risk of bias due to absence of blinding of participants and personnel; unclear risk of bias for allocation concealment, sequence generation, blinding of outcome assessors, selective reporting, and external generalizability. Outcome assessed among subset who tested rather than all randomized. Downgraded two steps. g. Not possible to assess consistency with one study. Downgraded one step. h. Point estimate and confidence interval are relatively imprecise and include possibility of harm. Downgraded one step. i. Chiou: High risk of bias due to absence of blinding of participants and personnel; unclear risk of bias for allocation concealment, sequence generation, blinding of outcome assessors, selective reporting, and external generalizability. Downgraded one step.

27 Web Annex A

Table A9: GRADE table for message or content framing Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is message or content framing effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Message framing/content

Standard of care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (community benefit of HIV treatment vs individual benefit)


serious b serious c not serious serious d none Mobilization using messages about reduced transmission potential of HIV with treatment increased uptake of HIV testing 60%. No denominator data.


CRITICAL

Uptake of HIV testing (gain vs loss frame)


serious f serious c not serious serious d none

OR 1.87 (1.07 to 3.28) g

2 fewer per 1,000 (from 3 fewer to 1 fewer)


CRITICAL

Uptake of HIV testing (motivation vs information message, plus message frequency)

1 h randomized trials

serious i serious c not serious not serious j none 547/1752 (31.2%) 224/801 (28.0%)

RR 1.26 (0.97 to 1.62) k


⨁⨁◯◯ LOW

CRITICAL

Uptake of HIV testing (risk-related vs risk-agnostic)

1 l randomized trials

serious m serious c not serious serious n none 98/870 (11.3%) 112/834 (13.4%)

RR 0.84 (0.65 to 1.08)

21 fewer per 1,000 (from 47 fewer to 11 more)


CRITICAL

28 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Message framing/content

Standard of care

Relative (95% CI)

Absolute (95% CI)

Uptake of HIV testing (behavioural insights and primers)


very serious p

serious c not serious not serious none Factorial design; authors concluded that behavioural insights messages, but not primers, increased uptake of testing. Point estimates for each of the arms were small and did not reach significance individually: primer: 1.01; behavioural insight: 1.05; primer + behavioural insight: 1.07.


CRITICAL

Linkage to care among positives (number) - not reported

- - - - - - - - - - - - CRITICAL

New HIV positive diagnoses (number) - not reported

- - - - - - - - - - - - CRITICAL

Yield of HTS (number) - not reported

- - - - - - - - - - - - IMPORTANT

Viral suppression (number) - not reported

- - - - - - - - - - - - IMPORTANT

Linkage to prevention (proportion) - not reported

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT

CI: Confidence interval; RR: Risk ratio; OR: Odds ratio; MD: Mean difference

Explanations

a. Derksen (cluster) b. Derksen: Risk of bias assessment revealed unclear risk of bias for all domains due to the lack of information within the poster, but did include concerns about loss of clusters. Downgraded one step c. Not possible to assess consistency from one study. Downgraded one step d. No denominator data available to assess precision. Downgraded one step. e. Apanovitch

29 Web Annex A

f. Apanovitch: There was a high risk of bias due to incomplete outcome data and other sources of bias (messaging framing groups were combined in the analysis; HIV testing was self-reported). Risk of bias assessment revealed unclear risk of bias for sequence generation, allocation concealment, blinding of the participants and personnel, blinding of the outcome assessors, and selective reporting Downgraded one step. g. OR and 95%CI reported by study. Count data not available for extraction. h. De Tolly i. De tolly: There was a high risk of bias for incomplete outcome data and there was low external validity. Risk of bias assessment showed unclear risk of bias for other domains. Downgraded one step. j. Individual point estimates are relatively precise. Not downgraded k. None of the arms had a significant difference on uptake of testing, but they were varied: 3 SMS motivation: 0.98 (0.75, 1.28); 10 SMS motivation: 1.17 (0.90, 1.51); 3 SMS information: 1.06 (0.81, 1.38); 10 SMS information: 1.26 (0.97, 1.62) l. Mikolajczak m. Mikolajczak: Risk of bias assessment indicated a high risk of bias due to incomplete outcome data and unclear risk of bias for the remaining domains. Downgraded one step. n. Important difference but crosses 1. Downgraded one step o. Brown p. Brown: There was high risk of bias related to sequence generation, allocation concealment, blinding of outcome assessors, and the fact that >6000 individuals were not randomized due to data collection error. Downgraded 2 steps

30 Web Annex A

Table A10: GRADE table for motivation-oriented counselling Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is motivation-oriented counselling effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Motivation-oriented counselling

Standard of Care -- CONTROL

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS


serious b not serious c not serious not serious none 48/143 (33.6%)

35/145 (24.1%)

RR 1.52 (1.07 to 2.17) d



CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS


very serious f

serious g not serious very serious h

none 0/13 (0.0%) 0/6 (0.0%) RR 1 (-- to --) i

0 fewer per 1,000 (from -- to --)


IMPORTANT



serious j serious g not serious very serious h

none 0/29 (0.0%) 0/31 (0.0%) RR 1 (-- to --) i

0 fewer per 1,000 (from -- to --)


IMPORTANT


- - - - - - - - - - - - IMPORTANT


31 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Motivation-oriented counselling

Standard of Care -- CONTROL

Relative (95% CI)

Absolute (95% CI)

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. Total of 3 trials included in report: Simbayi, Carey, Bentz (individual RCTs); all pooled b. Risk of bias: Simbayi: Absence of blinding of the participants and personnel, incomplete outcome ascertainment and poor external generalizability due to high refusal rates; risk of bias unclear for allocation concealment and blinding of outcome assessors. Carey: Potential for high risk of bias due to absence of blinding of participants and personnel and outcome assessors; sequence generation and allocation concealment methods not clear. Bentz: Risk of bias is low for this study except for blinding of the participants and personnel, for which risk of bias is high. Downgraded one step. c. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention, heterogeneity in the population, and heterogeneity in the follow-up time. d. Publication bias was not significant; adjusted estimate using trim and fill: 1.21 (0.82, 1.79) e. Carey f. Risk of bias: Carey: Potential for high risk of bias due to absence of blinding of participants and personnel and outcome assessors. Sequence generation and allocation concealment methods not clear. Outcome assessed on subset of those who completed testing rather than those randomized. Downgraded two steps. g. Not possible to assess inconsistency with one trial. Downgraded one step h. Meta-analysis is very imprecise i. RR cannot be calculated when there are zero counts. j. Risk of bias: Carey: Potential for high risk of bias due to absence of blinding of participants and personnel and outcome assessors. Sequence generation and allocation concealment methods not clear. Downgraded one step.

32 Web Annex A

Table A11: GRADE table for reduced duration or intensity of counselling Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is reduced duration or intensity of counselling effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Reduced duration counselling

Regular duration counselling

Relative (95% CI)

Absolute (95% CI)

Uptake of HIV testing (reduced duration vs typical duration


serious b not serious not serious not serious none 353/614 (57.5%)

327/634 (51.6%)

RR 1.05 (0.99 to 1.11)



CRITICAL

Uptake of HIV testing (interactive vs didactic)

1 c randomized trials

very serious d

serious e not serious serious f none 31/161 (19.3%)

16/152 (10.5%)

RR 1.83 (0.78 to 4.30)



CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


33 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Reduced duration counselling

Regular duration counselling

Relative (95% CI)

Absolute (95% CI)

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. Cohan, Edelman, Merchant 2015 (individual RCTs) pooled b. Risk of bias: Cohan: Risk of bias assessment raised no concerns except high risk of bias due to absence of blinding of participants and personnel. Edelman: Risk of bias assessment indicated that there is potential for selection bias, reporting bias and bias due to absence of blinding of participant and personnel. Merchant 2015: Risk of bias assessment revealed potential baseline imbalances and selective reporting, as well as absence of blinding of participants and personnel. Downgraded one step. c. Diallo d. Diallo: Risk of bias revealed concerns with blinding of participants and personnel, blinding of outcome assessors, incomplete outcome assessment and baseline differences. Unclear risk of bias related to recruitment bias, reporting bias, and comparability of the study with individually randomized trials. Downgraded two steps. e. Not possible to assess consistency with one study. Downgraded one step. f. Point estimate and CI is imprecise and sample size is very small. Downgraded one step.

34 Web Annex A

Table A12: GRADE table for video and audio Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are video and audio effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?





Video and Audio platforms

Text or provider-based platforms

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (video vs text)


serious b not serious c not serious not serious d none 177/2141 (8.3%)

107/1466 (7.3%)

RR 1.38 (0.82 to 2.32) e



CRITICAL

Uptake of HTS (audio vs text)


serious f not serious c not serious not serious g none 1190/1958 (60.8%)

706/1177 (60.0%)

RR 1.05 (0.84 to 1.31) h



Uptake of HTS (video vs person)


serious i not serious c not serious not serious g none 359/560 (64.1%)

33/561 (5.9%)

RR 10.37 (1.80 to 59.88) j

551 more per 1000 (from 47 more to 1,000 more)


1 k randomized trials

serious l serious m not serious not serious none 193/215 (89.8%)

109/215 (50.7%)

RR 1.77 (1.54 to 2.04)


⨁⨁◯◯ LOW

35 Web Annex A





Video and Audio platforms

Text or provider-based platforms

Relative (95% CI)

Absolute (95% CI)


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS (video vs in-person)


very serious p

not serious c not serious very serious q

none 1/302 (0.3%) 0/25 (0.0%) RR 1 (-- to --) t



IMPORTANT

Yield of HTS (video vs in-person) -- randomized denominator


serious r not serious not serious serious s none 1/358 (0.3%) 0/359 (0.0%) RR 1 (-- to --) t

0 fewer per 1000 (from -- to --)

⨁⨁◯◯ LOW

IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

36 Web Annex A

a. This section of the report Includes 11 individual RCTs. Sets were pooled to combine video vs text (Blas, Hirshfield, and Washington), audio vs text (Alemagno, Merchant 2011, Richens), and video vs in-person (Calderon 2007, Calderon 2011, Kurth). The other studies were not poolable b. Risk of bias assessment revealed: Blas: no serious concerns except potential for bias due to absence of blinding of participants and personnel; risk of bias related to blinding of outcome assessors, incomplete outcome data, and other source of bias is not clear. Hirshfield: high risk of bias due to selective outcome reporting, incomplete outcome data, and absence of blinding of participants and personnel; risk of bias not clear for blinding of outcome assessors and other bias in terms of external validity of the study. Washington: high risk of bias due to incomplete outcome data and unclear risk of bias for the remaining domains except selective reporting. Downgraded one step c. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention, heterogeneity in the population, and heterogeneity in the follow-up time. d. All studies besides Washington have relatively large sample sizes; Washington has a small sample size of 28 in each of intervention and control. Not downgraded e. Publication bias was not significant, but adjusted estimate using trim and fill was reasonably different: 0.96 (0.58, 1.59) f. Risk of bias revealed: Alemagno: incomplete outcome assessment and high risk of bias due to absence of blinding of participants and personnel; methods for allocation concealment and blinding of outcome assessors were not clear. Merchant: uptake of testing may have been higher in control condition due to prompting by questionnaire, serious concern due to absence of blinding of outcome assessors. Richens: absence of blinding of participants and personnel, incomplete outcome data, as those who withdrew or did not participate were dropped from analyses even though non-participation appeared to differ across arms. Downgraded one step. g. Meta-analysis precision is relatively precise. Not downgraded h. Publication bias not significant, but adjusted estimate using trim and fill is somewhat different: 0.98 (0.39, 2.42) i. Risk of bias revealed: Calderon 2007: high risk of bias due to differential outcome assessment, low external generalizability, absence of blinding of participants and personnel, and absence of blinding of outcome assessors; unclear risk of reporting bias. Calderon 2011: no serious concerns except potential for bias due to absence of blinding of participants and personnel and outcome assessors; unclear risk of reporting bias. Kurth: incomplete and differential outcome ascertainment; absence of blinding (participants, personnel, and outcome assessor) Downgraded one step. j. Publication bias not significant, but adjusted estimate using trim and fill was substantially different: 2.32 (0.46, 11.71) k. Wang l. Wang: Risk of bias assessment indicated high risk of bias due to incomplete outcome data for all outcomes, absence of blinding of the participants and personnel, selective outcome reporting, and other sources of bias. Risk of bias not clear for blinding of outcome assessor. Downgraded one step m. Not possible to assess consistency from a single study. Downgraded one step. n. Wang had linkage to care data, but did not have a comparator arm and therefore was not presented as an RR. o. Calderon 2011 and Kurth contributed data p. Calderon 2011: no serious concerns except potential for bias due to absence of blinding of participants and personnel and outcome assessors; unclear risk of reporting bias. Kurth: incomplete and differential outcome ascertainment; absence of blinding (participants, personnel, and outcome assessor). Outcome assessed on subset who tested rather than all randomized. Downgraded two steps. q. Meta-analysis is very imprecise. Downgraded two levels r. Calderon 2011: no serious concerns except potential for bias due to absence of blinding of participants and personnel and outcome assessors; unclear risk of reporting bias. Kurth: incomplete and differential outcome ascertainment; absence of blinding (participants, personnel, and outcome assessor). Downgraded one step. s. Meta-analysis is relatively imprecise, including both meaningful benefit and harm. Downgraded one step. t. RR is not estimable given numerators of 0.

37 Web Annex A

Table A13: GRADE table for social media-based interventions Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are social media-based interventions effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Social media Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (number)

1 a,b randomized trials

serious c serious d not serious serious e none Social media improved uptake of HIV testing [64% (no denominator reported) vs 42% (no denominator reported)]


CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. Overall 5 trials were included in the report: 3 cluster RCTs (Rhodes, Young 2013, Young 2015), 1 individual RCT (Washington), and 1 stepped wedge trial (Tang 2018). Rhodes was the only study to compare social media to no social media. b. 4 RCTs (Young 2013, Young 2015, Tang 2018, Washington) used social media both in the intervention and control arms

38 Web Annex A

c. Rhodes: Risk of bias assessment indicated high risk of bias due to recruitment bias and absence of blinding of the participants and personnel. Unclear risk of bias for all other domains, but there were no concerns about allocation concealment, baseline imbalance and differential loss of clusters. Downgraded one step d. Not possible to assess consistency with one study. Downgraded one step. e. No denominator data, therefore unable to assess precision. Downgraded one step.

39 Web Annex A

Table A14: GRADE table for website (non-social media) based interventions Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Are website (non-social media) based interventions effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Website-based (not social media)

Standard of Care

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS


serious b not serious very serious c very serious d

none All 5 studies had heterogeneous website (non-social media) interventions; none of the studies compared a website-based intervention to a control arm without a website-based component


CRITICAL


- - - - - - - - - - - - CRITICAL


- - - - - - - - - - - - CRITICAL

Yield of HTS - not measured

- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

40 Web Annex A

a. There were 5 individual RCTs: Bauermeister, Bull, Blas, Mikolajczak, and Tang 2016. There were no studies that compared a website intervention to a control. No pooling was conducted b. Risk of bias assessment revealed: Bauermeister: high risk of bias due to incomplete outcome data, unclear risk of bias on all other elements. Blas: high risk of bias for blinding of participants and personnel, unclear risk of bias for blinding of outcome assessors, complete outcome data, and other biases. Mikolajczak: high risk of bias due to incomplete outcome data, unclear risk of bias for all other elements. Tang 2016: high risk of bias related to allocation concealment, random sequence generation, and blinding of outcome assessors unclear. Bull was not included in counts but had high risk of bias due to absence of blinding of participants and personnel, incomplete outcome data for all outcomes and selective outcome reporting; unclear risk of bias related to blinding of outcome assessors and other source of bias. Downgraded one step. c. These studies do not experimentally assess the impact of website-based interventions on uptake of HIV testing. d. Not applicable e. Tang 2016 reported yield, but it was not comparing a website-based intervention to a not website-based intervention: 36/114 (32%) vs 33/111 (30%).

41 Web Annex A

Table A15: GRADE table for SMS Author(s): Anjuli Wagner, Irene Njuguna, Jaclyn Escudero, Rachael Burke, Chris Obermeyer, Jill Neary, Bastien Mollo, Michelle Bulterys, Ruchi Tiwari, Hannah Han, Ngozi Kalu, Dorothy Mangale, Wenwen Jiang, Alison Drake, David Katz, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Nandi Siegfried, and Cheryl Johnson Question: Is SMS effective for increasing uptake of HIV testing and onward linkage to prevention, treatment and care?



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations SMS Standard of Care -- CONTROL

Relative (95% CI)

Absolute (95% CI)

Uptake of HTS (SMS vs no SMS)

3 a,b,c,d randomized trials

very serious e

not serious f not serious not serious g none 1622/8017 (20.2%)

754/2525 (29.9%)

RR 1.17 (1.03 to 1.32) h


⨁⨁◯◯ LOW

CRITICAL

Uptake of HTS (SMS vs voice call and instant message)

1 i randomized trials

serious j serious k not serious very serious l none 0/30 (0.0%) 4/60 (6.7%) RR 0.10 (0.00 to 4.12) m

60 fewer per 1,000 (from -- to 208 more)



- - - - - - - - - - - - CRITICAL

1 n randomized trials

serious o serious k not serious not serious none 2/172 (1.2%) 3/154 (1.9%) RR 0.60 (0.10 to 3.53) p


⨁⨁◯◯ LOW

CRITICAL

Yield of HTS


very serious r

not serious f not serious not serious none 2/654 (0.3%) 3/375 (0.8%) RR 0.79 (0.24 to 2.60)


⨁⨁◯◯ LOW

IMPORTANT


42 Web Annex A



Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations SMS Standard of Care -- CONTROL

Relative (95% CI)

Absolute (95% CI)


serious s not serious f not serious not serious none 2/1417 (0.1%) 3/1424 (0.2%) RR 0.93 (0.45 to 1.91)



IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - IMPORTANT


- - - - - - - - - - - - NOT IMPORTANT


Explanations

a. A total of 8 trials were included in the report: Mugo, de Tolly, Odeny, Wilson, Heerden, Kelvin 2018, Kelvin 2019, Njuguna (cluster RCT). Three studies that had count data and had SMS versus an unincentivized control were pooled (Mugo, de Tolly, Odeny). b. Wilson included SMS both in the intervention and control arms. c. Kelvin 2018 and Kelvin 2019 both investigated the impact of 3 different kinds of SMS on uptake of testing and yield, but did not include a control arm without SMS. d. Njuguna 2016 investigated SMS with different kinds of messages but did not include a control without SMS. e. Risk of bias assessment revealed: Mugo: no serious issues except the issues related to the absence of blinding (participants, personnel, and outcome assessor); de Tolly: incomplete outcome data and low external validity, unclear risk of bias on all other elements. Odeny: high risk of bias for incomplete outcome data and blinding of participants and personnel, unclear risk of bias for blinding of outcome assessors. Downgraded two steps f. Heterogeneity in effect size can reasonably be explained by heterogeneity in the intervention (de Tolly tested 2 types of mechanisms -- motivational messages and informational messages -- and two levels of intensity -- 3 messages and 10 messages -- all versus a standard of care control, while Odeny and Mugo both had enhanced standard of care control arms; heterogeneity in the population -- parents of infants (Odeny), high risk adults (Mugo), and adults (de Tolly). g. Meta-analysis estimate was relatively precise. Not downgraded h. Publication bias was not significant, and adjusted estimate not meaningfully different: 1.10 (0.98, 1.25) i. Heerden j. Heerden: Risk of bias assessment indicated high risk of bias for incomplete outcome data and unclear risk of bias for all other domains except allocation concealment. Downgraded one step. k. Not possible to assess consistency with one study. Downgraded one step l. Pooled estimates are imprecise due to small denominators. Downgraded one step

43 Web Annex A

m. Presented RR compares SMS vs voice call; the RR comparing SMS to instant message is RR=0.3 (95%CI: 0.01-17.19) n. Odeny o. Odeny: incomplete outcome data and absence of blinding of participants and personnel. Unclear risk of bias related to blinding of outcome assessor. Outcome assessed on subset who tested rather than denominator randomized. Downgraded one step. p. Currently checking code. RR given by code was 0.60 but expected RR of 1. Will fill once corrected. q. Mugo, Odeny, Wilson. r. Risk of bias assessment revealed: Mugo: no serious issues except the issues related to the absence of blinding (participants, personnel, and outcome assessor). Odeny: for incomplete outcome data and absence of blinding of participants and personnel; unclear risk of bias related to blinding of outcome assessor. Wilson: incomplete outcome data. Outcome assessed on subset who tested rather than denominator randomized. Downgraded two steps s. Risk of bias assessment revealed: Mugo: no serious issues except the issues related to the absence of blinding (participants, personnel, and outcome assessor). Odeny: for incomplete outcome data and absence of blinding of participants and personnel; unclear risk of bias related to blinding of outcome assessor. Wilson: incomplete outcome data. Downgraded one step.

44 Web Annex A

Documents

New HIV TESTING SERVICES 2019 - WHO · 2020. 3. 25. · 1 Web Annex A CONSOLIDATED GUIDELINES ON HIV TESTING SERVICES 2019 Web Annex A. GRADE Table: Which demand creation approaches