Background This systematic review summarises evidence on the HIV testing barriers and intervention strategies among Caribbean populations and provides pertinent implications for future research endeavours designed to increase rates of HIV testing in the region.
Methods We used a systematic approach to survey all literature published between January 2008 and November 2018 using four electronic databases (MEDLINE/PubMed, Embase, Web of Science and Global Health). Only peer-reviewed articles published in English that examined HIV testing uptake and interventions in the Caribbean with men, men who have sex with men, female sex workers, transgender women and incarcerated individuals were included.
Results Twenty-one studies met the inclusion criteria. Lack of confidentiality, access to testing sites, stigma, discrimination, poverty and low HIV risk perception were identified as key barriers to HIV testing. These barriers often contributed to late HIV testing and were associated with delayed treatment initiation and decreased survival rate. Intervention strategies to address these barriers included offering rapid HIV testing at clinics and HIV testing outreach by trained providers and peers.
Conclusion HIV testing rates remain unacceptably low across the Caribbean for several reasons, including stigma and discrimination. Future HIV testing interventions should target places where at-risk populations congregate, train laypersons to conduct rapid tests and consider using oral fluid HIV self-testing, which allows individuals to test at home.
- Key Populations
- Systematic Review
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The Caribbean is one of the most affected regions by the HIV epidemic.1 Efforts have been made to increase access to HIV testing; however, low rates of testing persist. Men who have sex with men (MSM) and transgender women (TGW) are two groups who often face barriers to engaging in HIV testing.2 3 These barriers include unemployment, underemployment and a lack of access to healthcare services.4 For these populations, same-sex practices could provoke violence and legal action. For example, in Jamaica, criminalisation of same-sex practices persists and acts as a barrier to MSM and TGW accessing HIV testing due to fear of legal action against them or their sexual partners, violence, and loss of employment due to the continued observation of the Offences Against the Person Act of 1864.5 Such criminalisation practices place an undue reporting burden on clinicians and further drives mistrust, fear and underutilisation of health services by members of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersexed, Asexual, Ally (LGBTQIA+) community. HIV-related stigma may also act as a psychological burden for both incarcerated and once-incarcerated men.6
Stigma has been defined as the disqualification of an individual from being fully accepted socially,7 while discrimination entails the unfair treatment of persons on the basis of their race, age, sex and so on.8 Both stigma and discrimination are barriers to testing for HIV as well as linkage to care.9 Intersecting identities such as being a black MSM and transgender female sex workers (FSWs) further stigmatise certain groups of people and have social and cultural ramifications.10 11 Indeed, MSM, intravenous drug users, transgender persons, incarcerated persons and FSWs often experience stigma and discrimination at disproportionate rates.12–14
Although several systematic reviews have been conducted to examine factors associated with HIV testing and intervention strategies in Sub-Saharan Africa,15–17 there is no published systematic review of HIV testing barriers and intervention strategies for the Caribbean region. In this paper, we address this gap by systematically reviewing the literature for studies that have assessed factors related to HIV testing rates, late HIV testing, HIV testing barriers, as well as HIV testing interventions in order to determine effective strategies to increase HIV testing in the Caribbean.
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.18 A literature search was conducted in February 2017 and was updated through April 2019 for papers that met the inclusion criteria. The electronic search included MEDLINE/PubMed, Embase, Web of Science, Global Health and a manual search. These databases were selected to cover a wide range of disciplines, from social sciences to interdisciplinary to biomedical research. A combination of controlled vocabulary and Boolean-paired keywords was used, relating to HIV; testing, screening or diagnosis; and countries in the Caribbean. In addition to searching electronic databases, the authors also reviewed the references of selected studies for other relevant citations. The search categories included the terms HIV, testing and Caribbean (see table 1).
Research studies that met the following criteria were included: (1) studies were based in the Caribbean; (2) HIV testing or screening was assessed; (3) the study was peer-reviewed; and (4) published in English. Exclusion criteria included unpublished studies (eg, conference abstracts or dissertations), papers published in languages other than English, and studies published before January 2008 or after December 2018. The time range chosen reflects intervention strategies which were deemed by the research team as ‘present’ studies and included articles that had been published no earlier than 10 years prior to the search. The included studies focused on men, MSM, FSWs, TGW and incarcerated individuals who were at least 18 years or older, were at risk for HIV infection and were living in the Caribbean.
Data were extracted using a set of four defined fields which specified that all articles be related to HIV testing in Caribbean countries, the full article was able to be retrieved, and the entire article was written in English. The research team worked together to review 1358 articles after duplicates were removed. Both team members independently reviewed the article search results as well as each article title and abstract to evaluate the relevance of each article; the articles were grouped into ‘Selected for Full-Text Review’ or ‘Does Not Meet Inclusion Criteria’. The research team then extracted the data from articles selected for full-text review; 27 articles were selected for full-text review and were summarised by their methods and findings to gauge their relevance and confirm that they met the inclusion criteria. Both team members independently read through each of the 27 articles in their entirety and summarised the methods, design and results to further assess the relevance of each article to the study. A third team settled any discrepancies and confusion between investigators regarding articles where no consensus had been reached pertaining to their inclusion for consistency purposes. A review protocol was developed for this study and can be accessed through contact with the study team.
The quality criteria proposed by the Critical Appraisal Skills Programme (CASP)19 were used to assess the methodological quality of the included articles to research design, sampling techniques, data collection, research strategy and data analysis. While CASP is regularly used to assess qualitative research enquiries, the research team deemed the criteria appropriate for evaluating quantitative papers because of its consideration of rigour, credibility, relevance and evaluation of research methods and data analysis. Ten criteria were used for the evaluation of both types of studies (table 2). Each criterion was marked by a check mark if it met the criteria or by an X on the checklist if the criteria were not met. Studies had to meet 7 out of 10 criteria items in order to be considered for full inclusion. Quality assessment was completed independently by two researchers. If disagreements arose, the article in question was discussed and the issue was resolved. Quality scores ranged from 70% to 100%.
This review uses a narrative synthesis approach, which enables the researchers to synthesise the findings of multiple studies through the use of words and text to elaborate on the findings of the synthesis.20 A narrative synthesis approach allows for the findings of the articles to be explained in depth. Each article was organised by themes, which included HIV testing rates, late testing and barriers to testing. The article findings were matched with their appropriate theme; some articles were included in all multiple themes.
The search strategy (figure 1) yielded 1941 results (PubMed n=774, Embase n=335, Web of Science n=564, Global Health n=268) prior to the removal of duplicate entries (n=583); 1358 unique results remained. Forty-eight articles were selected for full-text review. Twenty-one articles were excluded due to either their lack of focus on HIV testing or not being a peer-reviewed article. As shown in figure 1, 27 articles met the inclusion criteria and were included in this review. The studies were conducted in a variety of Caribbean countries (table 3).
HIV testing rates
HIV testing rates were examined in 10 studies.21–30 In Barbados, the number of people tested increased significantly from 14 403 tests completed in 2000 to 26 045 in 2010.22 Of 7354 men in Haiti, 65.24% (n=4838) had not been tested for HIV.22 In Puerto Rico, 59% of MSM had received a recent HIV test.23 In the Dominican Republic, of the 64 steady male partners of cis-gender FSWs living with HIV, only 76.6% (n=49) had ever received a previous HIV test.24 In another study, 11 651 men in the Dominican Republic and 508 men in Haiti reported to have been tested.25 In Haiti, provider-initiated testing, which included a collaboration between the Haitian Ministry of Health and a non-governmental organisation (Partners in Health), was evaluated; 3787 HIV tests were performed, and it was found that 95 out of 112 (84.8%) were HIV-positive, had prior clinical encounters data available and had obtained a diagnosis at their first encounter with a health professional.26 A majority of MSM in Jamaica (57.7%) reported having ever completed an HIV test, of whom 93% retrieved their results.28 A similar study found that 74.7% of Jamaican MSM who had accepted cash for sex in the past 3 months and 79.9% of MSM who had not accepted cash for sex reported having been tested for HIV.28 There were no significant differences between HIV-negative and HIV-positive MSM who had tested for HIV with regard to income, education and sex work.29 Lastly, 75.7% of TGW reported having ever received an HIV test in Jamaica.30
Late testing (LT) is defined as being diagnosed with AIDS 1 year after having initially tested positive for HIV; higher HIV transmission is a direct result of LT.31 Two articles reported on LT.21 30 In Barbados, 32% of newly infected persons were critically immunocompromised and men were more likely than their female counterparts to be within this group.21 In Puerto Rico, 1582 patient records from year 2000 until 2011 from a retroviral research centre were screened, and it was found that men accounted for 66% of the population while MSM accounted for 29% of those who were late testers for HIV; older men who injected drugs had increased odds of LT.31
Barriers to testing
Six studies reported on barriers to HIV testing.21 24 32–35 Structural barriers such as stigma, discrimination, gender inequality, gender-based violence, criminalisation of sexual practices associated with HIV transmission (specifically for sexual minorities), poverty and human rights abuses were all impediments to HIV testing and treatment.21 Same-sex practices were found to be heavily stigmatised in Barbados and Jamaica; breaches of confidentiality, violent attacks, testing without consent, mistrust of the health system and refusing to provide services were reported in both countries.21 33 Men conveyed the anxiety associated with testing and fear of a positive result as barriers to testing.24 TGW living in Jamaica who engaged in practices that elevate HIV exposure such as substance use and sex while under the influence of drugs were unlikely to report having had an HIV test.32 The majority (87.9%) of non-testers living in Jamaica reported that they were not at risk for HIV and 59.7% had no interest in learning their HIV status.34 Another study conducted among Jamaican inmates cited that stigma was a barrier to testing, as inmates who reported low experiences of HIV stigma were more likely to have tested than those who reported high experiences of stigma.35
Strategies and interventions
Various strategies and interventions were employed in order to assess and promote HIV testing. The strategies included rapid testing, service provider and peer-led programmes. One study reported on couple-oriented counselling (COC).36 COC was successful in increasing partner HIV testing rates in the Dominican Republic, and a higher proportion of partners used COC to test than did standard testing.36
In two articles,37 38 HIV rapid testing (RT) was reported as an HIV testing promotion strategy. Eight of the 11 countries included had policies in place for HIV RT, and all countries were using RT at the main laboratory in the country.37 In the same article, three countries in 2014 reported using oral fluid tests for point-of-care testing versus nine countries that used blood-based test kits.37 HIV RT use was evaluated in Trinidad and Tobago, and an increase in testing from 1652 in 2008 to 5253 in 2010 was reported.38 Overall, 27.1% of testers cited the convenience of getting their results on the same day as a reason for testing.38 Another article reported that participants who expressed a test preference preferred oral fluids testing to fingerprick testing (65.8% vs 34.2%).39
Service provider strategies
Two articles40 41 discussed a training of trainers’ model. The development of a protocol for same-visit testing on behalf of the Ministry of Health in Trinidad and Tobago was also described.40 The training of trainers included a 3-day workshop with 14 hours of classroom instruction and 10 hours of applied training. The training was proven to be effective in increasing HIV testing after an increase from 22 clients tested in July of 2005 to 2323 testers in 2006 who used the same-visit testing service was reported and included an average of 185 trained testers who used the service per month.40 A training of trainers’ voluntary counselling and testing (VCT) programme trained 3489 individuals in order for them to provide counselling and testing in several Caribbean countries; 80% of the trainers were certified in VCT and were successful in the scaling up of services for VCT.41 One study engaged social workers to complete a symptoms checklist in order to identify symptomatic patients during HIV testing and link them to care, and in a 6-month period 11 578 adult patients were tested in 2009 and 1398 patients tested positive for HIV.42
Peer-led HIV testing
Community-based voluntary HIV counselling and testing was implemented in Antigua and Barbuda with the goal of increasing access to HIV testing and was the first peer-based programme in the region.43 Peer outreach workers and employees from laboratories and community organisations were trained to provide counselling after RT. Outreach workers were trained to use a fingerprick RT system that provided test results in 30 min. Similarly, peer educators were engaged to promote testing among incarcerated men in three studies.44–46 A sample population of inmates were offered HIV testing through the recruitment of trained peer educators in a Jamaican penitentiary; testing options included a blood sample or fingerprick using the Determine HIV assay.44 The acceptance rate for testing was 63%.44 In Haiti, ‘Health through Walls’, a peer health intervention, was conducted in a men’s prison in which peer health educators were trained to recruit participants, use a video to explain HIV transmission and prevention, and to answer questions regarding the subject matter. Sixty-four per cent of the 156 inmates who participated in the health sessions with the peer health educators were willing to be tested for HIV.45 In a study of incarcerated men in Jamaica, HIV testing and treatment services were found to be salient and acceptable.46
One article reported mixed findings on the perceptions of HIV self-testing and willingness to use among Puerto Rican men and transgender FSWs.47
To our knowledge, this systematic review is the first to focus on HIV testing barriers among multiple populations in the Caribbean. Despite increased HIV surveillance and HIV prevention strategies in the region, MSM, TGW, FSWs and incarcerated men are not testing for HIV at a high rate. A number of strategies were implemented and evaluated in different Caribbean countries in an attempt to address the low HIV testing rate. These intervention strategies included but are not limited to RT, same-visit HIV testing programme and provider-initiated testing.40–44
However, stigma, criminalisation of same-sex practices and sex work remain salient barriers to HIV testing uptake; these barriers undermine the efforts of HIV prevention strategies and interventions for groups such as same-sex-loving persons and transgender persons.48 Recent investigation into the reduction of stigma has found six approaches that are of value for interventions: providing information about the manifestations of stigma and its effects on health, skill-building exercises for healthcare providers in regard to reducing stigma, active engagement in interventions alongside members of the stigmatised group(s), provide contact with the stigmatised group(s) in intervention delivery, use of an empowerment approach to improve client coping mechanisms, and including structural or policy changes which redress systems and facility restructuring.49 These strategies are also appropriate for addressing the criminalisation of sex work and same-sex practices in the Caribbean region, specifically the latter approach of included structural and policy strategies. Future research should heed these recommendations to develop interventions which target healthcare professionals and includes the participation of stigmatised and criminalised groups. Because discriminatory laws and gender inequality increase shame, fear and stigmatising attitudes, which discourage HIV testing uptake,50 advocacy for reducing stigma, discrimination and criminalisation of sexual practices for the LGBTQIA+ community is imperative to the uptake of HIV testing and safe-sex practices.
This systematic review is subject to limitations that should be considered. This review includes only the full-text reviews of articles that were written in English. Relevant articles that were not in the target language were excluded. Furthermore, this review aimed to evaluate strategies which effectively increase HIV testing among multiple populations in the Caribbean, but not all studies focused solely on HIV testing. Still, all 27 of the included articles explored HIV testing in some capacity. However, commissioned reports which are kept on file with ministries of health were not included. Assessments for risks of bias were not completed for this review and present a potential issue of studies having been included which may have overestimated the true intervention effects to reported results. Lastly, only articles which were published between 2008 and 2018 were included in this review.
HIV testing interventions should target places where at-risk populations congregate, train laypersons to conduct rapid tests in these settings if professional staff is unavailable, and promote RT and provider-initiated testing when possible. All interventions should specifically target multiple populations and provide safe and inviting testing settings, especially for men, MSM and TGW, late testers, and incarcerated persons. More health education, promotion and regular testing activities need to focus on these groups in all Caribbean countries. Pre-exposure prophylaxis and HIV self-testing should also be included and evaluated in the public health efforts to reduce HIV transmission in the region.
This is the first systematic review to assess HIV testing, barriers and intervention strategies among men, transgender women, female sex workers and incarcerated men in the Caribbean.
Future research should consider that structural barriers such as stigma, discrimination, gender inequality, gender-based violence and criminalisation of sexual practices are impediments to HIV testing.
Future research should also consider that advocacy for reducing stigma, discrimination and criminalisation of sexual practices for the LGBTQIA+ community is imperative to the uptake of HIV testing and safe-sex practices.
Future research should also consider that rapid testing, service provider testing and peer-led testing programmes are acceptable strategies for increasing HIV testing in the region.
Handling editor Jackie A Cassell
Contributors All coauthors have both contributed substantially to the paper and approved the version being submitted.
Funding AH was supported by the Minority Health International Research Training (MHIRT) (grant no T37-MD001448) from the National Institute on Minority Health and Health Disparities, National Institute of Health (NIH). TT was supported by a postdoctoral fellowship supported by Award Numbers T32MH020031 and P30MH062294 from the National Institute of Mental Health (NIMH), and a scholar with the HIV/AIDS, Substance Abuse, and Trauma Training Program (HA-STTP), at the University of California, Los Angeles (R25DA035692). DC was supported by a training grant from NIMH (#R00MH110343) and NHLBI (#5R25HL105444-07). HB was supported by a training grant from NIH/NIMH (1K01MH116737). This work is also partially supported by an ASPIRE grant from the Office of the Vice President for Research at the University of South Carolina. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.