Surveillance The contribution of HIV point-of-care tests in early HIV diagnosis: community-based HIV testing monitoring in Catalonia, 1995 to 2018 Laura Fernàndez-López1,2, Juliana Reyes-Urueña1,2, Anna Conway1,3, Jorge Saz⁴ , Adriana Morales⁵ , Jaime Quezadas⁶ , Jordi Baroja⁷ , Anna Rafel⁸ , Ander Pazos⁹ , Anna Avellaneda10 , Mercè Meroño11 , Lorena Andreo12 , Lluís Romero13 , Anna Lara14 , Araceli Otón15 , Benet Rifà16,17 , Rosa Mansilla16,17 , Joan Colom17 , Jordi Casabona1,2,18 1. Centre for Epidemiological Studies on Sexually Transmitted Infections and HIV/AIDS of Catalonia (CEEISCAT), Catalan Health Department, Barcelona, Spain 2. Centros de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Spain 3. The Institute for Health Science Research Germans Trias i Pujol (IGTP), Badalona, Spain 4. BCN Checkpoint, Barcelona, Spain 5. Stop Sida, Barcelona, Spain 6. Associació Ciutadana Antisida de Catalunya (ACASC), Barcelona, Spain 7. Centre Jove d’Atenció a les Sexualitats (CJAS), Barcelona, Spain 8. Associació Antisida de Lleida, Lleida, Spain 9. Gais Positius, Barcelona, Spain 10. Actuavallès, Sabadell, Spain 11. Fundació Àmbit Prevenció, Barcelona, Spain 12. CAS/ARD Lluís Companys, Creu Roja Barcelona, Barcelona, Spain 13. Assexora’Tgn (Associacio Comunitària de Salut Sexual del Camp de Tarragona), Tarragona, Spain 14. Associació Comunitària Anti Sida de Girona (ACAS), Girona, Spain 15. Creu Roja Tarragona, Tarragona, Spain 16. Section for Surveillance, Prevention and Control of Sexually Transmitted Infections and HIV, Public Health Agency of Catalonia, Barcelona, Spain 17. Programme for Prevention, Control and Treatment of HIV, STIs and Viral Hepatitis, Public Health Agency of Catalonia, Barcelona, Spain 18. Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain Correspondence: Laura Fernàndez-López (lflopez@iconcologia.net) Citation style for this article: Fernàndez-López Laura ORCID icon, Reyes-Urueña Juliana ORCID icon, Conway Anna , Saz Jorge , Morales Adriana , Quezadas Jaime , Baroja Jordi , Rafel Anna , Pazos Ander , Avellaneda Anna , Meroño Mercè , Andreo Lorena , Romero Lluís , Lara Anna , Otón Araceli , Rifà Benet , Mansilla Rosa , Colom Joan , Casabona Jordi. The contribution of HIV point-of-care tests in early HIV diagnosis: community-based HIV testing monitoring in Catalonia, 1995 to 2018. Euro Surveill. 2020;25(43):pii=1900424. https://doi.org/10.2807/1560-7917.ES.2020.25.43.1900424 Article submitted on 28 Jun 2019 / accepted on 25 Mar 2020/ published on 29 Oct 2020 Background: Community-based HIV testing services tests was found in people who inject drugs followed by combined with the use of point-of-care tests (POCT) MSM. The contribution of community-based HIV test- have the potential to improve early diagnosis through ing to the overall total notified cases in the Catalonia increasing availability, accessibility and uptake of HIV HIV registry has gradually increased, reaching 37.9% testing. Aim: To describe community-based HIV testing in 2018, and 70% of all MSM cases. In 2018, the per- activity in Catalonia, Spain, from 1995 to 2018, and to centage of individuals with a reactive screening test evaluate the impact of HIV POCT on the HIV continuum who were linked to care was 89.0%. Conclusion: Our of care. Methods: A community-based network of vol- study reinforces the important role that community- untary counselling and testing services in Catalonia, based HIV POCT has on the diagnosis of HIV in key Spain has been collecting systematic data on activity, populations. process and results since 1995. A descriptive analysis was performed on pooled data, describing the data Introduction in terms of people tested and reactive screening test In recent years, efforts to reach the 90–90–90 targets results. Results: Between 1995 and 2018, 125,876 (90% of all people living with HIV knowing their HIV HIV tests were performed (2.1% reactive). Since the status, 90% of all people diagnosed with HIV receiving introduction of HIV POCT in 2007, a large increase in antiretroviral therapy and 90% of all people receiving the number of tests performed was observed, reach- antiretroviral therapy having viral suppression) advo- ing 14,537 tests alone in 2018 (1.3% reactive). Men cated by the Joint United Nations Programme on HIV/ who have sex with men (MSM), as a proportion of all AIDS (UNAIDS), have led to an improvement in acces- people tested, has increased greatly over time reach- sibility and coverage of testing programmes. This, in ing 74.7% in 2018. The highest percentage of reactive turn, has reduced the number of people living with www.eurosurveillance.org 1 undiagnosed HIV infection and increased early diagno- in developing, implementing and evaluating national ses [1]. Monitoring and evaluation (M&E) is an essential policies [13]. component of any effective testing programme. While strategic information should guide the design of test- Community-based testing started in Catalonia with ing initiatives, M&E permits continuous evaluation of only a few sites offering traditional testing, where a targets and programme effectiveness, efficiency and nurse was required to perform venepuncture and send impact. Such data can prove invaluable in planning the blood sample to a laboratory. Traditional testing improvements [2]. was replaced with HIV POCT in 2007, which allowed the expansion of testing programmes in the community. Catalonia is an autonomous community located in the Since 2007, more sites have been offering HIV POCT, north-east of Spain. In 2018, it had a population of and the number of tests performed has increased 7,543,825 inhabitants. This region has a low-level HIV exponentially [5]. epidemic, where high levels of infection are found only in specific groups, particularly men who have sex with Catalonia has experience in the scaling up of CBVCT men (MSM). As of 31 December 2017, Catalonia had a interventions using HIV POCT with linkage to care, rate of 8.1 HIV diagnoses per 100,000 inhabitants, with support and treatment services, within a solid M&E 53.6% of all diagnoses in 2017 attributed to MSM [3]. framework. Here, our aims are to describe HIV testing activity among those CBVCT services participating in In Catalonia, HIV testing M&E forms part of the the DEVO (an abbreviation of ‘voluntary detection’ in Integrated AIDS/HIV/STI Surveillance System of Catalan) network from 1995 to 2018 in order to evalu- Catalonia (SIVES) [4] and is based on two main sources ate HIV POCT contribution in the HIV continuum of care. of information: (i) the network of public hospital labo- ratories, primary healthcare centre laboratories and Methods private laboratories (HIVLABCAT), which have volun- tarily reported diagnostic HIV testing and results since Settings 1992; and (ii) the network of community-based volun- In 1995, the Catalan Health Department (currently, the tary counselling and testing (CBVCT) services, which Public Health Agency of Catalonia, ASPCAT) funded a has offered free, anonymous, voluntary and confiden- network of CBVCT services to offer free, voluntary and tial counselling and testing since 1995 [5]. This report confidential HIV testing in the region. The purpose of will focus on the data collected by the CBVCT network. the DEVO network was to complement existing facil- ity-based HIV testing. The DEVO network has since CBVCT services are considered an effective strategy expanded from four CBVCT services in 1995 to the cur- for HIV testing, especially for key populations [6,7], rent 12 (becoming six organizations in 2001, seven in and have expanded in the European Union/European 2003, eight in 2004, 10 in 2008 and 12 in 2010), mainly Economic Area (EU/EEA) since 2010 through a variety operated by NGOs and serving the general population of service delivery models [8]. This strategy has been or, in some cases, key populations: MSM, sex workers proven to increase the availability, accessibility and (SW), young people (under 30 years old), and people uptake of HIV testing in order to reduce the number of who inject drugs (PWID). The participating organisa- people who do not know their HIV status or who are tions of the network are all CBVCT services providing diagnosed late [9], impacting the first 90 target set by HIV testing by trained lay providers through community UNAIDS [10]. In addition, this strategy increases the and outreach services. In addition to providing HIV test- proportion of first-time testers, increases the propor- ing, most organisations perform syphilis and hepatitis tion of participants who undertook follow-up CD4 tests C testing and additional HIV prevention activities. One after diagnosis, detects patients at an earlier stage of of the organisations also offers other STI tests. Peers infection, increases the number of new HIV diagnoses, and other lay providers have been trained to perform and potentially reduces the stigma and discrimination and interpret rapid diagnostic tests with finger-prick faced by key populations [6]. blood samples. A systematic review found that the use of HIV point- Every person who receives a preliminary reactive test of-care tests (POCT) as part of CBVCT interventions, is referred to a laboratory or to an infectious disease combined with behavioural interventions either at specialist who conducts a confirmatory test. The diag- individual or community level, has the potential for nosed clients are then linked with appropriate special- enormous impact on the HIV epidemic [11]. Scaling up ist services. the CBVCT service model was thought to increase the likelihood of achieving the 90–90–90 target by 2020 Data collection [12], but the scale up in Europe has been impacted The DEVO network has been collecting systematically by limited funding, poor integration with national HIV standardized data on activity, process and results programmes and regulatory barriers. There is a need since 1995. Since 2014, the DEVO network has formed for guidance to address these implementation chal- part of the community-based testing (COBATEST) net- lenges, including M&E, and a need to assist countries work, a European network of CBVCT services based on the DEVO network experience [8,14]. Since then, all 2 www.eurosurveillance.org Figure 1 Number of HIV tests performeda and percentage of reactive tests by year, Catalonia, Spain, 1995–2018 (n = 129,117) 16,000 10.0 15,000 9.0 14,000 13,000 8.0 12,000 11,000 7.0 10,000 Number of tests % of all HIV tests 6.0 9,000 8,000 POCT 5.0 implementation 7,000 4.0 6,000 5,000 3.0 4,000 3,000 2.0 2,000 1.0 1,000 0 0.0 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 Year Number of tests Percentage of HIV reactive tests DEVO: voluntary detection; POCT: point-of-care test. a Only HIV tests performed within the DEVO network were included. except one of the CBVCT services use the COBATEST repeat testers and recording the correct number of indi- data collection tool (which is based on the DEVO data viduals tested. collection tool) and COBATEST web-based data entry tool through which data can be extracted and analysed Test used in collaboration with the Centre for Epidemiological From 1995 to 2007, a conventional laboratory test Studies on Sexually Transmitted Infections and HIV/ with phlebotomy was used, from 2007 to 2012 the AIDS of Catalonia (CEEISCAT) as part of the Public Determine HIV–1/2 rapid test (Abbott Laboratories, Health Agency of Catalonia (ASPCAT). One of the Abbott Park, IL, United States) was used, and since CBVCT services uses their own data collection tool, 2012 the new Alere Determine HIV–1/2 Ag/Ab Combo and shares the minimum agreed data with CEEISCAT. (Abbott Laboratories) test has been used. With both For monitoring and evaluation purposes, the network POCTs, the results were obtained in 15–20 min (15 min currently uses the standardised core indicators defined for Determine HIV–1/2 rapid test and 20 min for Alere in the COBATEST network [15], aligned with UNAIDS, Determine HIV–1/2 Ag/Ab Combo), and test accuracy World Health Organization (WHO) and European Centre is very high (Determine HIV–1/2 rapid test: sensitivity for Disease Prevention and Control (ECDC) recommen- 99.6% (95% CI: 99.2–99.8), specificity 99.9% (95% CI: dations [16-18]. 99.8–100.0) [19,20]; Alere Determine HIV–1/2 Ag/Ab Combo: sensitivity 99.9% (95% CI: 99.4–100.0), speci- Data collected in the DEVO network include basic demo- ficity 99.8% (95% CI: 99.5–99.9) [21]. graphic information on the tester, test location, testing history, risk behaviour and results of HIV, syphilis and Data analysis hepatitis C testing. Since 2014, services in the DEVO The descriptive analysis was performed on pooled network have used a unique identifier for each client, data from 1995 to 2018 and included: (i) the whole ensuring anonymity while allowing the identification of time period 1995–2018; (ii) each year individually; (iii) the percentage of people tested distributed by gender, www.eurosurveillance.org 3 4 Table a Number of HIV tests performeda, people tested and reactive tests by gender, age group, origin and transmission group, Catalonia, Spain, 1995–2018 (n = 129,117) Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total All tests Test performed 725 1,011 899 1,034 811 631 1,025 915 949 1,144 1,576 1,858 3,757 4,653 6,806 8,317 8,875 10,168 9,654 10,867 11,705 12,371 13,432 14,537 129,117 People tested NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 9,197b 10,536b 9,815b 10,076b 10,894b NA Gender (n = 112,732)b Men 423 633 583 615 497 358 581 563 582 734 945 1,162 2,553 3,108 4,690 5,702 6,288 7,275 6,953 7,947 8,091 8,119 8,404 9,117 86,837 Women 292 372 305 417 312 273 442 350 366 403 627 691 1,111 1,420 1,709 1,946 1,772 1,741 1,528 1,436 1,536 1,528 1,524 1,563 24,135 Transgender 0 0 0 0 0 0 0 0 0 0 0 0 77 113 111 115 162 129 120 146 192 182 157 205 1,713 Age group (years) (n = 112,410)b ≤24 265 414 370 466 338 314 434 334 307 354 470 470 794 1,053 1,376 1,644 1,629 1,639 1,580 1,933 2,081 2,057 2,119 2,541 25,209 25–34 304 447 372 399 337 220 433 434 456 527 744 889 1,839 2,210 3,093 3,573 3,681 4,019 3,695 3,939 3,925 3,811 3,910 4,300 48,270 35–44 52 106 119 125 101 78 123 110 144 196 273 360 825 984 1,474 1,793 2,036 2,475 2,355 2,494 2,507 2,514 2,561 2,499 26,625 ≥ 45 36 32 36 44 32 18 35 37 36 67 87 136 287 377 546 760 883 1,013 971 1,163 1,306 1,345 1,387 1,543 12,306 Origin (n = 121,087)c Local NA NA NA NA NA NA NA 673 667 755 1,046 1,147 2,341 3,019 4,203 4,976 5,227 5,899 5,576 6,097 6,096 5,851 5,889 6,035 66,346 Foreign national NA NA NA NA NA NA NA 242 280 389 527 706 1,408 1,615 5,135 5,911 6,121 6,431 5,931 3,390 3,631 3,583 4,123 4,775 54,741 Transmission group (n = 106,992) PWID 42 214 158 115 118 32 160 118 104 141 72 65 131 149 154 159 194 158 121 95 45 49 53 71 2,734 MSW 0 9 7 5 2 1 10 7 18 18 31 64 140 157 208 215 255 238 197 327 384 332 337 221 3,201 MSM 167 218 220 219 167 141 196 172 145 214 219 380 1,201 1,445 2,856 3,687 4,131 5,079 5,060 6,179 6,569 6,853 7,231 7,988 61,154 FSW 1 22 19 21 52 16 114 73 62 64 157 232 247 285 291 401 454 383 278 284 398 382 271 254 4,890 HM 260 260 218 338 231 237 267 220 245 277 404 379 897 900 1220 1,443 1,426 1,470 1,322 1,510 1,266 1,045 939 1,034 17,929 HW 213 250 231 302 224 177 259 220 235 286 466 466 709 989 1,159 1,292 1,070 1,100 1,042 1,134 1,130 1,136 1,243 1,132 17,084 DEVO: voluntary detection; FSW: female sex worker; HM: heterosexual men; HW: heterosexual women; MSM: men who have sex with men; MSW: male sex worker; NA: not available; PWID: people who inject drugs. a Only HIV tests performed within the DEVO network were included. b From 2014 to 2018 the disaggregated data refer to people tested instead of number of tests performed. c Foreign national: person born in country other than Spain; local: person born in Spain. www.eurosurveillance.org Table b Number of HIV tests performeda, people tested and reactive tests by gender, age group, origin and transmission group, Catalonia, Spain, 1995–2018 (n = 129,117) Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total Reactive tests HIV reactive 29 33 30 35 31 16 34 31 36 46 36 48 79 129 185 217 236 247 233 258 259 228 226 191 2,848 tests Gender (n = 2,923) www.eurosurveillance.org Men 25 23 22 30 25 13 27 21 31 40 28 41 68 111 166 204 215 228 224 241 240 210 210 179 2,646 Women 4 10 8 5 6 3 7 8 8 5 8 7 9 9 11 10 9 12 6 5 4 4 4 4 169 Transgender 0 0 0 0 0 0 0 0 0 0 0 0 5 9 8 3 12 7 3 12 15 14 12 8 106 Age group (years) (n = 2,909) ≤ 24 5 2 4 6 5 7 10 6 4 7 8 3 10 16 21 27 32 18 34 44 34 24 27 38 394 25–34 13 23 18 18 17 5 19 15 17 21 16 29 31 75 88 111 105 130 97 122 108 111 114 85 1,405 35–44 4 4 8 8 9 3 5 8 12 14 7 14 29 30 63 55 79 62 81 69 90 61 58 44 823 ≥ 45 3 1 0 3 0 1 0 2 3 4 5 2 9 7 12 23 20 36 21 23 27 31 27 24 287 Origin (n = 2,711) Local NA NA NA NA NA NA NA 14 15 21 18 21 30 59 93 101 114 139 120 123 138 108 83 60 1,272 Foreign national NA NA NA NA NA NA NA 17 21 25 18 27 49 70 91 116 122 107 113 135 121 119 143 131 1,439 Transmission group (n = 2,786) PWID 5 16 12 17 17 8 19 17 15 26 6 11 5 12 14 4 11 9 4 1 1 4 3 1 240 MSW 0 0 1 2 0 0 0 1 2 4 7 7 9 14 15 15 21 22 19 40 36 34 26 13 288 MSM 17 9 10 8 7 4 6 5 7 7 7 16 40 70 132 174 180 186 191 205 213 181 191 168 2,050 FSW 0 0 1 0 2 0 2 0 4 1 4 2 4 4 2 2 2 1 2 3 1 0 0 0 39 HM 4 3 4 3 1 1 4 2 1 0 1 3 3 3 7 6 6 9 6 2 5 4 3 5 86 HW 2 4 2 5 4 2 2 2 2 2 2 1 2 4 4 5 3 7 3 7 3 3 3 4 83 DEVO: voluntary detection; FSW: female sex worker; HM: heterosexual men; HW: heterosexual women; MSM: men who have sex with men; MSW: male sex worker; NA: not available; PWID: people who inject drugs. a Only HIV tests performed within the DEVO network were included. b From 2014 to 2018 the disaggregated data refer to people tested instead of number of tests performed. c Foreign national: person born in country other than Spain; local: person born in Spain. 5 Figure 2 Gender, age, origin and transmission group of (A) all people tested for HIV (n = 112,732a) and (B) HIV reactive tests (n = 2,848), Catalonia, Spain, 1995–2018 A. People tested B. HIV reactive cases Origin Tranmission group Origin Tranmission group HW HW HM HM FSW FSW MSM MSM MSW MSW PWID PWID Foreign Foreign national national Local Local ≥45 ≥45 (years) (years) 35–44 35–44 Age Age 25–34 25–34 ≤24 ≤24 Gender Gender Transgender Transgender Women Women Men Men 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% % of all HIV tests % of all HIV reactive tests DEVO: voluntary detection; Foreign national: person born in country other than Spain; FSW: female sex worker; HM: heterosexual men; HW: heterosexual women; local: person born in Spain; MSM: men who have sex with men; MSW: male sex worker; PWID: people who inject drugs. a Only people tested within the DEVO network were included. Before 2014 disaggregated data refers to number of tests instead of people tested. age, nationality and transmission group; (iv) the per- Linkage to care was defined as ‘entry into healthcare centage of individuals with a confirmed positive test or follow-up by a HIV specialist or a HIV unit after a before 2007 and the percentage of individuals with a reactive or confirmatory HIV test at a community test- reactive screening test after 2017 distributed by gen- ing facility’ according the definition established in der, age, nationality and transmission group. Variables the Euro HIV EDAT project, co-funded by the European included: gender (men, women, transgender), age, Commission [23], and all linkage to care information nationality (foreign national defined as born in a coun- was collected from patient feedback. try other than Spain, or local defined as born in Spain) and transmission group (constructed as hierarchical, In order to evaluate the contribution of community test- mutually exclusive risk categories in the following ing to the total number of diagnosed cases in Catalonia, order of priority: PWID, male sex workers (MSW), MSM, data from the DEVO network and the Catalonia HIV reg- female sex workers (FSW), heterosexual women (HW), istry were triangulated, considering that reactive tests heterosexual men (HM)). detected in the DEVO network were linked to care and therefore were noted in the Catalonia HIV registry. The For Figures 4 and 5 the MSW group was added to the percentage of HIV cases diagnosed in the community MSM group in order to present all the MSM population and registered in the Catalonia HIV registry was cal- together. culated from 2001 to 2017, the period where Catalonia HIV registry data were available. The lines in Figure 4 chart the evolution of the percent- age of reactive screening tests per year by transmission All percentages were calculated excluding missing val- group and were smoothed using the centred moving ues (which represented less than 5%). A p value below average method. Using this method, data points were 0.001 was considered for statistical significance. Data modified four times, each time the average of raw analysis was performed using PASW Statistics for observations at a given point in time was calculated Windows, version 18.0 (SPSS Inc., Chicago, United using that point, the one immediately prior and the one States). immediately after. This method allows for smoothing out short-term fluctuations and highlights long-term Ethical statement trends or cycles [22]. To test trends in Figures 1 and 4, Ethical approval was not needed at the beginning of a Pearson’s chi-squared test was used. the project in 1995, as no biological samples were pre- served for the study and data collected from the cli- ents were anonymous and part of the routine services 6 www.eurosurveillance.org Figure 3 Distribution by transmission group of (A) all people HIV testeda (n=106,992) and (B) HIV reactive tests (n=2,786), Catalonia, Spain, 1995–2018 A. B. 100% 100% 90% 90% 80% 80% % of all people HIV tested 70% 70% % of HIV reactive cases 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 Year Year PWID MSW MSM FSW HM HW DEVO: voluntary detection; FSW: female sex worker; HM: heterosexual men; HW: heterosexual women; MSM: men who have sex with men; MSW: male sex worker; PWID: people who inject drugs. a Only people tested within the DEVO network were included. Before 2014 disaggregated data refers to number of tests instead of people tested. of CBVCT centres. Since the introduction of POCT, each HIV testing activity differed greatly between CBVCT client taking a POCT gave informed consent stating services, with one organisation, which works only with that they understood the POCT was not a diagnostic MSM, performing on average more than half of the test. Since 2014 when the DEVO network joined the total number of HIV tests in the DEVO network. COBATEST network, the CBVCT services signed an The Table shows the evolution by year on tests agreement ensuring they fulfilled the General Data performed, people tested and number of reactive Protection Regulation, where each client has to sign screening tests disaggregated by gender, age group, an informed consent explaining the use of the data origin and transmission group. collected. Between 1995 and 2018, 77.0% (86,837/112,732) of the Results total people tested at the community sites were men, Between 1995 and 2018, 129,117 HIV tests were per- and 92.9% (2,646/2,848) of reactive tests were in men. formed by the DEVO network, of which 2.1% were reac- In men and women, the age group with the most peo- tive. The increase in the number of tests performed ple tested and most reactive tests was 25–34 years old by the CBVCT services by year was relatively low until (Figure 2). Foreign nationals accounted for 45.2% of the 2006, ranging from 716 in 1995 to 1,849 in 2006 (Figure total number of people tested, and 53.1% of the total 1). number of reactive tests. MSM accounted for 57.2% of all people tested, and 73.58% of the total number of With the introduction of the HIV POCTs at the end of reactive tests. 2006, there was a 102.9% increase in the number of HIV tests performed in 2007 compared to 2006 (anal- Figure 3 describes the contribution of each transmission ysis published in a previous study [5]). In 2018, the group to the total number of people tested, and the number of HIV tests peaked at 14,537, of which 1.3% total number of reactive tests between 1995 and (n = 191) were reactive. From 2006 to 2018 there was 2018. It shows that MSM as a proportion of all people an increase of 686.2% in number of tests performed tested has increased greatly over time, reaching 74.7% (from 1,858 tests performed in 2006 to 14,537 in 2018), (7,988/10,700) in 2018. The opposite trend is visible with an average annual increase of 21.1%. In the past among PWID. Each year between 1996 and 2004, PWID 10 years, the percentage of reactive tests has been were the transmission group with the highest number decreasing (statistically significant trend, p < 0.0001), of reactive tests. Since 2005, the proportion of this from 2.8% (129/4,653) in 2008 to 1.3% (191/14,537) in group has gradually diminished, reaching the lowest 2018. value (0.7%; 71/10,700) in 2018. In the same period, the proportion of all reactive tests for MSM (MSM plus www.eurosurveillance.org 7 Figure 4 (191/10,894) were reactive. Of these reactive tests, Percentage of HIV reactive tests by transmission group 94.8% (181/191) had a confirmatory test, of which per year, Catalonia, Spain, 1995–2018 (n people tested = 106,992a; n reactive tests = 2,848b) 100% were confirmed as positive. Of the total num- ber confirmed positive, 93.9% (170/181) were linked to care. The percentage of individuals with a reactive 18.00 screening test who were linked to care was 89.0% 16.00 (170/191). This percentage has not varied considerably % of HIV reactive tests 14.00 since these data were available (81.7% in 2014, 95.0% 12.00 in 2015, 89.5% in 2016, and 92.7% in 2017). 10.00 8.00 6.00 Discussion This study shows the contribution of community-based 4.00 2.00 HIV POCT in improving early HIV diagnosis in Catalonia 0.00 over time, especially among key populations, and 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 demonstrates that the collected data are an impor- Year tant source of strategic information to be included into the Integrated AIDS/HIV/STI Surveillance System of PWID FSW HM HW MSM+MSW Catalonia (SIVES). DEVO: voluntary detection; FSW: female sex worker; HM: In Catalonia, community-based HIV testing has been heterosexual men; HW: heterosexual women; MSM: men who monitored and has formed part of HIV Surveillance have sex with men; MSW: male sex worker; PWID: people who inject drugs. since 1995. The DEVO Network has made it possible to collect standardised data on each person tested in a Only people tested within the DEVO network were included. CBVCT services. The collected data complement stra- Before 2014 disaggregated data refers to number of tests tegic information on key populations and thus make it instead of people tested. possible to improve HIV prevention strategies aimed b Only HIV reactive tests performed within the DEVO network were at these key populations. The continual monitoring included. performed by the DEVO Network has improved public health decision-making at the Public Health Agency of The lines were smoothed using the moving average method. Catalonia by detecting changes in HIV testing uptake, in HIV tester profiles and in HIV test-seeking behav- MSW) increased, accounting for 95.0% of the total iours [5]. number of reactive tests detected in 2018. The DEVO Network succeeded in scaling up HIV test- The highest reactivity rate in each transmission group ing among key populations, with the number of tests during the whole period of study was found in PWID performed in the year following the implementation of (ranging between 1.1% (1/95) in 2014 and 25.0% (8/32) POCT increasing by 103% from the previous year [5]. in 2000), followed by MSM plus MSW (ranging between 2.2% (181/8,209) in 2018 and 10.2% (17/167) in 1995) HIV POCT have the potential to increase the number of (Figure 4). Nevertheless, in recent years the reactiv- people who know their HIV status [24]. The POCT that ity rate in the PWID group has gradually decreased. meet the WHO’s ASSURED (affordability, sensitivity, This decrease is not statistically significant, due to specificity, user-friendly, rapid and robust, equipment- the low number of PWID tested. The reactivity rate in free and deliverable) criteria [25] follow a simple pro- MSM plus MSW has shown a statistically significant cedure involving a limited number of steps and are decrease (p < 0.001), especially in the past 10 years, equipment-free, ensuring they can be performed out- reaching 2.2% (181/8,209) in 2018. For the rest of the side traditional laboratory settings by staff with no groups, no significant trend was observed. formal laboratory training [24]. Additionally, both pro- viders and clients prefer rapid tests over traditional Figure 5 shows the increase of the contribution of HIV tests [26,27]. Several studies have shown the efficacy POCT in the community to the overall total number of CBVCT strategies using HIV POCT to improve HIV of cases registered in the Catalonia HIV registry. The testing uptake in populations at higher risk of expo- percentage of positive cases in the Catalonia HIV sure to HIV [6,7,9]. The DEVO Network has shown to be registry which were first detected in the DEVO network successful in providing testing to at-risk populations. has gradually increased, from 4.5% (34/763) in 2001 to In the period 1995–2018, 57.2% of tests were per- 37.9% (219/578) in 2017. In the case of MSM plus MSW, formed on MSM, 7.6% on SW (FSW plus MSW), 2.6% on this contribution is higher, reaching 70.0% of total HIV PWID, 1.5% on transgender people and 45.2% on for- diagnosed cases in the Catalonia HIV registry among eign nationals (including migrant population). A recent MSM in 2018. study showed that in Catalonia, 12.3% of those living with HIV were still undiagnosed, and this proportion In 2018, a total of 14,537 tests were performed in the was higher in migrants [28]. Therefore, in Catalonia, DEVO network on 10,894 individuals, of which 1.8% providing access to HIV POCT in the community is 8 www.eurosurveillance.org Figure 5 Number of HIV reactive screening tests from the DEVO network, total number of cases registered in the Catalonia HIV registry and the percentagea of tests recorded in the Catalonia HIV registry first detected in the DEVO network for (A) all people tested (n = 2,483 in DEVO network, n = 13,004 in HIV registry) and (B) men who have sex with men and male sex workers only (n = 2,099 in DEVO network, n = 5,660 in HIV registry), Catalonia, Spain, 2001–2017 A. All people tested B. MSM + MSW Number of HIV reactive tests/ HIV Number of HIV reactive tests/ HIV % of reactive tests/ % of cases % of reactive tests/ % of cases 1,000 80.00 900 1,000 80.00 registry notifications registry notifications 70.00 900 800 70.00 60.00 800 700 60.00 50.00 700 600 50.00 600 500 40.00 500 40.00 400 30.00 400 30.00 300 300 20.00 20.00 200 200 100 10.00 100 10.00 0 0.00 0 0.00 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Year Percentage of Catalonia HIV HIV reactive tests All Catalonia HIV registry cases first detected in DEVO from DEVO registry cases DEVO: voluntary detection; MSM: men who have sex with men; MSW: male sex worker. a Percentage calculated as number of reactive tests obtained by DEVO community testing divided by number of total cases recorded in the Catalonia HIV registry. important, especially for populations facing barriers to acute HIV infection [31]. This, coupled with their pre- accessing the healthcare system, such as the migrant exposure prophylaxis (PrEP) service in the framework population. of research studies, has broadened the portfolio of pre- ventive services available to users of the Checkpoint. The low number of PWID tested in the DEVO network In England, the incidence of new HIV infections in MSM can be explained by the fact that most PWID are tested attending sexual health clinics fell by 55% in 2016 and in harm reduction centres. In Catalonia there is a net- 2017 [32,33], and was attributed to an increase in HIV work of harm reduction programmes run by mobile testing, earlier initiation of HIV treatment and the scale units, street teams or facility-based centres. The facil- up of privately purchased generic PrEP in England from ity-based centres are located in areas of drug traffick- late 2017 onwards. ing and drug consumption, or in drug treatment clinics [29]. In Catalonia, universal treatment (treatment independ- ent of CD4+cell count for patients newly diagnosed with Linkage to care and treatment for those with a reac- HIV) has had a positive impact on the dynamics of the tive test in the DEVO network is high (89%). A recent viral load in people living with HIV [34]. This, along systematic review and meta-analysis of studies in the with increasing testing and linkage to care as part WHO European Region [30] showed a pooled estimate of a combined prevention strategy, can explain the of 85% (95% CI: 75–93) of people with reactive tests decrease in the percentage of new HIV diagnoses in the linked to care within 3 months. Linkage of those with a DEVO network. The increase in number of sites offer- reactive test to appropriate specialist services is a key ing HIV testing thanks to the introduction of HIV POCT step in the HIV continuum of care, as immediate ini- has increased the proportion of community detected tiation of treatment has substantial benefits in reduc- HIV cases in the overall number of HIV cases reported ing the risk of patient morbidity, as well as reducing in Catalonia, increasing from 4.5% in 2001 to 37.9% onward transmission [30]. in 2017. The impact of introducing HIV POCT was even larger for MSM, where 70% of all new HIV diagnoses In the past 10 years, a statistically significant decreas- in 2017 were diagnosed in the community setting. This ing trend has been observed in the percentage of MSM suggests that CBVCT services are a valuable element with a HIV reactive test. This trend could be explained of the strategy to increase HIV testing in Catalonia, by the success of different strategies of combined pre- especially for MSM. These estimations are higher than vention in this key population, including increased test- that presented in a 2019 study showing that in several ing frequency and earlier initiation of HIV treatment. southern European countries, 0.2–19.7% of total HIV BCN Checkpoint (the CBVCT service with the largest cases and 0.5–37.0% of HIV cases among MSM were HIV testing activity, particularly among MSM) has gone diagnosed through CBVCT services [35]. further to promote earlier initiation of HIV treatment by introducing qualitative PCR POCT for the detection of www.eurosurveillance.org 9 The longstanding experience of the DEVO Network and Conflict of interest its results has been used as a basis for establishing None declared. the COBATEST Network, a European network of CBVCT services that share standardised data [8,14]. Authors’ contributions There are a number of limitations to this study. Firstly, LFL led the data analysis and drafting of the manuscript sup- the disaggregated data presented in the Table from ported by JRU, AC and JCa. JS, AM, JQ, JB, AR, AP, AA, MM, 1995 to 2013 refers to the number of tests performed, LA, LR, AL, AO provided HIV testing data. BR, RM and JCo while data from 2014 to 2018 refer to the total number contributed to the development of the different drafts. All authors commented on various drafts of the manuscript and of people tested. This is due to improvements made to approved the final version. the data collection system and its integration into the COBATEST network. After 2013 a unique identifier was assigned to each client, allowing detection of repeat References testers, and at the same time ensuring the anonymity 1. Tavoschi L, Hales D. Monitoring of HIV testing services in of people tested. This could have led to an under-esti- the EU/EEA. Euro Surveill. 2016;21(48):30410. https://doi. org/10.2807/1560-7917.ES.2016.21.48.30410 PMID: 27934584 mation of the number of tests in the period 2014–2018, 2. World Health Organization (WHO). Consolidated guidelines on especially in the MSM group as MSM are more often person-centred HIV patient monitoring and case surveillance. repeat testers. Secondly, the number of HIV positive Geneva: WHO; 2017. Available from: https://www.who.int/hiv/ pub/guidelines/person-centred-hiv-monitoring-guidelines/en/ cases from1995 to 2007 refers to HIV confirmed cases 3. Centre d’Estudis Epidemiològics sobres les Infeccions only, as the test offered was the conventional labora- de Transmissió Sexual i Sida de Catalunya (CEEISCAT). tory test. Since the introduction of HIV POCT, the num- Vigilànciaepidemiològica de la infecciópel VIH i la SIDA a Catalunya. Informeanual 2017. [Epidemiological surveillance ber of HIV positive cases refers to reactive cases as of HIV and AIDS infection in Catalonia. Annual report 2017]. in some cases, the information related to referral and Badalona: CEEISCAT; 2018. Catalan. Available from: https:// canalsalut.gencat.cat/web/.content/_A-Z/S/sida/enllasos/ confirmation of the diagnosis is not complete. So the anual_VIH.pdf number of HIV reactive cases in the period 1995–2006 4. Centre d’Estudis Epidemiològics sobres les Infeccions could be higher. Lastly, regarding the number of cases de Transmissió Sexual i Sida de Catalunya (CEEISCAT). Epidemiological Report SIVES 2015.Technical document detected in the DEVO network as a percentage of the nº22, Integrated Surveillance System for STI and HIV in total number of Catalonia HIV registry cases - as it was Catalonia. Badalona; CEEISCAT; 2015. Available from: https://salutpublica.gencat.cat/web/.content/minisite/ assumed that all reactive cases were linked to care and aspcat/vigilancia_salut_publica/vih-sida-its/05_CEEISCAT/ therefore were added to the Catalonia HIV registry, the publicacions-cientifiques/informes/SIVES/SIVES_2015/ sives2015_ENG.pdf contribution could have been overestimated. 5. Fernàndez-Lopez L, Rifà B, Pujol F, Becerra J, Pérez M, Meroño M, et al. Impact of the introduction of rapid HIV testing in the Conclusion Voluntary Counselling and Testing sites network of Catalonia, Spain. Int J STD AIDS.2010;21(6):388-91. PMID: 20606218 In conclusion, our study with a monitoring series of 6. Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, almost 25 years reinforces the important role that com- Saltzman AK, et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta- munity-based HIV POCT has on the improvement of analysis of community-based approaches. 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