Which community-based HIV initiatives are effective in achieving UNAIDS 90-90-90 targets? A systematic review and meta-analysis of evidence (2007-2018)

BackgroundReaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets to end the HIV epidemic relies on effective interventions that engage untested HIV+ individuals and retain them in care. Evidence on community-based interventions through the lens of the targets has not yet been synthesized, reflecting a knowledge gap. We conducted a systematic review and meta-analysis to shed light on successful community-based interventions that have been effective in contributing, directly or indirectly, towards the UNAIDS 90-90-90 targets: knowledge of HIV status, linkage to care/on treatment, and viral suppression. Linkage to care was also included in this review due to the limitations of studies.MethodsWe conducted a systematic review and meta-analysis of the period 2007–2018. Eleven databases were searched to identify community-based interventions designed to improve knowledge of HIV status (in particular HIV testing), linkage to care/on treatment, and/or viral suppression. Eligible studies were classified by intervention, population, country income level, outcomes and success. Success was defined as interventions demonstrating statistical significance between intervention and control group or that reached any target by proportion; 90% testing, 81% linked to care/on treatment and 73% viral suppression.ResultsOf 82 eligible studies, 51.2% (42/82) reported on HIV testing (first 90), 20.7% (17/82) on linkage to care/ on treatment (second 90), and 45.1% (37/82) on viral suppression (third 90). In all, 67.1% (55/82) of studies reported success; 21 studies on the first 90, 9 towards linkage to care/on treatment, and 25 towards the third. By strategies, 36.6% deployed community workers/peers, 22% used combined test and treat strategies, 12.2% used educational methods, 8.5% used mobile testing, 7.3% used campaigns and 13.4% used technology. For HIV testing/linkage, combined test/treat interventions were often used, for viral suppression, educational interventions and technologies were commonly deployed. Our pooled analysis suggested that deployment of community health care workers/peer workers significantly improved viral suppression (pooled OR: 1.40 95% CI 1.06–1.86). Of the studies published after 2014, 50.0% reported metrics aligned with UNAIDS targets.ConclusionsData on linkage to care/on treatment (second target) remained weak, because many studies reported successes on the first and third targets. Stratification by targets and country income levels is informative and guides adaptation of successful interventions in comparable settings. Consistent reporting of clear metrics aligned with UNAIDS targets will aid in synergy of study data with programmatic data that will help reportage. Exploration of innovative interventions, for engagement and linkage and deployment of community/ peer workers is strongly encouraged.研究背景 终结艾滋病流行、达成联合国艾滋病规划署（Joint United Nations Programme on HIV/AIDS, UNAIDS）90-90-90目标，需依托能够动员未接受检测的HIV感染者并使其持续接受诊疗的有效干预措施。目前尚未有从该目标视角出发的社区干预措施相关证据被系统整合，这一现状反映出当前存在相关知识空白。本研究开展了一项系统综述与荟萃分析，旨在阐明能够直接或间接助力达成该90-90-90目标的优质社区干预措施，该目标涵盖HIV感染状况知晓、诊疗衔接/治疗维持以及病毒抑制三个维度。鉴于现有研究存在一定局限性，本综述亦纳入了诊疗衔接相关的结局指标。 研究方法 本研究针对2007至2018年的文献开展系统综述与荟萃分析。我们检索了11个数据库，以筛选旨在提升HIV感染状况知晓率（尤其是HIV检测）、诊疗衔接/治疗维持以及病毒抑制效果的社区干预措施相关研究。符合纳入标准的研究将按干预措施类型、研究人群、国家收入水平、结局指标及干预成功与否进行分类。本研究将干预成功定义为：干预组与对照组间存在统计学差异，或按比例达成任一目标，即90%的检测率、81%的诊疗衔接/治疗维持率以及73%的病毒抑制率。 研究结果 本次共纳入82项符合标准的研究，其中51.2%（42/82）聚焦HIV检测（首个90目标），20.7%（17/82）聚焦诊疗衔接/治疗维持（第二个90目标），45.1%（37/82）聚焦病毒抑制（第三个90目标）。总计67.1%（55/82）的研究报告了干预成功的结果：其中针对首个90目标的研究有21项，针对诊疗衔接/治疗维持的有9项，针对第三个90目标的有25项。按干预策略分类，36.6%的研究采用了社区工作者/同伴干预模式，22%采用了检测与治疗联合策略，12.2%采用了教育干预方法，8.5%采用了移动检测手段，7.3%采用了宣传动员活动，13.4%采用了技术干预手段。针对HIV检测/诊疗衔接环节，研究多采用检测与治疗联合干预；针对病毒抑制环节，则常使用教育干预与技术手段。荟萃分析结果显示，配备社区医护人员/同伴工作人员可显著提升病毒抑制效果（合并优势比OR=1.40，95%置信区间CI：1.06~1.86）。在2014年后发表的研究中，50.0%的研究报告了与UNAIDS目标相符的结局指标。 研究结论 目前关于诊疗衔接/治疗维持（第二个90目标）的数据仍较为匮乏，这是因为多数研究仅报告了首个及第三个90目标的成功结果。按目标维度与国家收入水平进行分层分析可提供有效信息，并可为相似环境下的成功干预措施本土化调整提供指导。持续报告与UNAIDS目标相符的明确结局指标，将有助于研究数据与项目数据的协同整合，进而为相关报告工作提供支撑。本研究强烈呼吁探索用于动员患者及衔接诊疗的创新干预措施，并推广社区/同伴工作人员的应用模式。