Secondary Logo

Journal Logo


Experiences using and organizing HIV self-testing

Qin, Yilua,b,*; Han, Larrya,c,*; Babbitt, Andrewa; Walker, Jennifer S.d; Liu, Fengyinge; Thirumurthy, Harshaf; Tang, Weiminga,e; Tucker, Joseph D.a,g,h

Author Information
doi: 10.1097/QAD.0000000000001705



Despite the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 targets [1], only an estimated 60% of people living with HIV globally knew their status in 2016 [2]. This disappointment has spurred interest in expanding decentralized testing strategies [3,4] such as HIV self-testing (HIVST) [5]. The WHO defines HIVST as an individual collecting their own test specimen, performing an HIV test, and interpreting the result [5]. HIVST offers confidentiality and convenience, which may expand access among those who would not otherwise test [6]. Mathematical models [7] and several implementation pilots suggest that HIVST could expand HIV testing and save money. The WHO now recommends that HIVST be offered as an additional HIV testing approach [5].

However, there are unresolved questions about how self-testing can be scaled up in countries with diverse environments [8]. Adverse outcomes related to the social context of HIVST may influence the overall effectiveness of the approach [9]. These lingering doubts about HIVST have contributed to policies in Germany [10] and elsewhere [11] making HIVST explicitly illegal. Although many countries are re-examining policies now, only 40 countries currently have national policies that support HIVST [12].

Much of the existing HIVST social science research has focused on perceptions of self-testing [13–19] that may not reflect experiences. Examining HIVST experiences is important for three reasons. First, HIVST is more decentralized compared with facility-based testing, increasing the number of settings and potential risks of testing. Second, the unsupervised nature of HIVST introduces the possibility for coercion [20,21]. Third, HIVST social science research can capture experiences from marginalized individuals who may not be reached by conventional surveys [22].

A qualitative systematic review brings together data collected from individual qualitative research studies [23]. This method has been used to synthesize qualitative data and inform WHO guidelines [24–28]. This systematic review appraises and synthesizes qualitative research evidence on experiences using or organizing HIVST.


Our methods were informed by methodology described in the Cochrane Handbook [29]. Our reporting of items is based on PRISMA guidelines [30].

Search strategy

A comprehensive literature search was performed to identify qualitative studies of HIVST. The search was initially conducted in seven primary databases from each database's inception through 30 November 2015: MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, the Cochrane Library, Global Health, and Scopus. Additional searches were conducted on 25 February 2016 for gray literature and unpublished reports in Conference on Retroviruses and Opportunistic Infections, International AIDS Society, OpenGrey, and EThOS (British Library). An updated search was conducted in all resources on 17 November 2016. The search strategy was developed with input from members of the research team, and an experienced librarian conducted the searches. A more detailed search algorithm with subject headings and keywords can be found attached in supplementary material (S1,

Screening and selection process

All citations were screened by two independent reviewers. Full texts were assessed for eligibility based on standardized inclusion criteria: presented primary research data, used qualitative methodology, evaluated direct experiences with HIVST, published in English, and not a thesis or dissertation. Discrepancies during each stage of screening were resolved after discussion and final input by a third reviewer. For the purposes of this review, direct experience with HIVST meant that study participants themselves received an HIVST or organized a program that provided HIVST services to other people.

Data extraction

Basic study descriptors were extracted: study setting, year of study, population researched, research aims, study design, type of data collection, and study context (whether HIV self-test was performed outside of or within research context). Conclusions, themes, and primary data were extracted from articles. Data on hypothetical concerns, preferences, and perspectives were excluded.


A framework thematic synthesis approach was used to analyze and synthesize the data [31]. All extracted data were collected in a spreadsheet and subjected to open coding using line-by-line analysis to develop preliminary descriptive themes. Inductive analysis of all themes developed into an axial coding framework with first, second, and third order themes. Each review finding was assessed using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach [24,32]. The CERQual approach provides a transparent method for evaluating qualitative evidence syntheses, similar to the GRADE approach for quantitative systematic reviews [33].


The protocol for this study was registered on PROSPERO, the International Prospective Register of Systematic Reviews (CRD42015027607).


Initial screening yielded 1266 potential articles, from which 185 were selected for full text review (Fig. 1). The 18 included studies examined research conducted in eight countries (USA, UK, Ethiopia, Malawi, South Africa, Canada, Kenya, India) with 15 studies focused on adults [34–48] and three on youths [49–51]. Seven studies were focused on key populations: six on MSM [34–37,41,46] and one on transgender individuals [40]. Four studies looked at the special population of healthcare workers (HCWs) [38,42,43,47], one study evaluated pregnant women [45], and five studies investigated partner-testing among couples [34,35,37,39,41]. Seventeen studies reported experiences using HIVST and one study reported experiences organizing HIVST [36]. Five studies were conducted in low-income countries (LIC) [38,39,42,47,48], two in a middle-income country (MIC) [43,45], 10 in high-income countries (HICs) [34–37,40,41,46,49–51], and one study spanned three countries (two LIC, one MIC) [44].

Fig. 1:
Study flow diagram.

Table 1 presents a classification of HIVST themes based on synthesis of qualitative evidence. First-order themes were primarily descriptive and coded directly from the text line-by-line. Second-order and third-order themes provided higher level analysis that grouped findings into logical classifications.

Table 1:
Emerging themes from direct experiences with HIV self-testing.

Results are grouped under three main findings: first, HIVST increased capacity to reach priority populations; second, HIVST provides expanded opportunities for service delivery; and third, social and ethical considerations for implementation and scale-up of HIVST. Table 2 summarizes the review findings and the confidence rating of each finding. Study characteristics are presented in Table 3.

Table 2:
Summary of qualitative findings and Confidence in the Evidence from Reviews of Qualitative Research assessments.
Table 3:
Characteristics of included studies.
Table 3:
(Continued) Characteristics of included studies.

Increased capacity to reach priority populations

HIVST demonstrated increased capacity to reach priority populations in a wide variety of settings. Most individuals noted that HIVST was more convenient and more confidential than facility-based testing.

More convenient than facility-based testing

Individuals were able to employ HIVST in a way that catered to their own schedules and testing needs, offering a customized HIV testing experience that allowed for greater control over location and time [46]. MSM [46], transgender women [40], youths [50], and pregnant women [45] commonly described HIVST as convenient. To some, convenience meant no longer having to wait in lines, make appointments, or travel long distances to clinics [38,39,44,47,49–51]. To others, convenience came in the form of greater control over the speed, efficiency, and location of testing [37,39,43,45,46,49–51]. Individuals who organized HIVST for MSM similarly observed that these attributes reduced barriers to testing and allowed people from regions where getting HIV testing is difficult (e.g. rural areas) to access it [36].

More confidential than facility-based testing

MSM [41,46], transgender women [40], youths [49–51], HCWs [38,42,43,47], and lay users [44] commented on better protection of privacy with HIVST compared with facility-based testing. In particular, HCWs [38,42,47] in Africa and transgender women [40] in the United States of America wanted to avoid the stigma of testing in a public context, with the former being concerned about workplace discrimination and the latter about gossip within the relatively small transgender community. Individuals from LICs [39,44], MICs [44,47], and HICs [40,51] described being judged for seeking out HIV testing at a facility. Facility-based testing in Scotland was sometimes associated with connotations of immorality, promiscuity, and living with HIV. Individuals organizing HIVST confirmed that sexual health service facilities continue to be stigmatized, and thus HIVST reached new populations that do not traditionally test because of fear [36].

Reduced test-associated stigma

In several studies in which HIVST kits were provided for participants to bring home, dissemination in public places normalized HIV testing across multiple settings. One pilot program in the United States of America used vending machines to dispense kits, delivering them along with other nonstigmatized products and through a local vending machine [46]. Among heterosexual couples in Malawi that were given free access to HIVST kits, participants often described self-test kits as toothbrushes, normalizing the testing kits within their daily routines [39]. Peer and social networks played an important role in influencing youths to self-test [46]. Positive experiences with HIVST led HCWs in South Africa [43] and MSM in the United States of America [46] to say they would recommend HIVST to friends, colleagues, family, and partners. Individuals that recommended HIVST to partners commented that in some instances, the physical presence of self-test kits served as an ‘ice-breaker’ that facilitated discussions about health, fidelity, and HIV-related concerns that were otherwise difficult to raise [35,39]. Some MSM felt that they were more likely to stick together with partners that had agreed to self-test [37].

Expanded opportunities for service delivery

HIVST facilitates a new testing paradigm in which the testing experience is uncoupled from a strictly medical environment, which provides opportunities for innovative and targeted service delivery.

HIV self-testing brought HIV testing into new settings and contexts

Self-test kits could be obtained from a number of diverse venues, including vending machines [46], community centers [47], bars/clubs [35,49], pharmacies [43], and online [46]. HIVST was also used at a number of diverse locations, including at home [39,43,46,47,49], the supermarket [35], bars/clubs [35], in cars [37,46], at partners’ homes [35,37,51], and at work [35,37,42,51]. Some individuals took to carrying test kits with them regularly so they could be used at anytime, or ‘on the go’ [35,37,51]. HIVST was used amidst new contexts, such as prior to casual sexual encounters, or ‘hookups,’ among MSM in the United States of America [34] and antenatal screening for HIV among first trimester pregnant women supervised by auxiliary midwives in rural India [45].

HIV self-testing facilitated partner-testing

Secondary distribution of HIVST kits to casual or long-term partners was explored among several populations: MSM [34,35,41], transgender individuals [40], heterosexual couples [39], youths [51], and HCWs [38,47]. This method was generally well received and allowed partners to provide support during HIVST in the United States of America, sometimes by providing a comforting presence before or while waiting for results [40] and other times after receiving a positive result [41]. The social support offered by testing with a partner was identified as a motivating factor to get tested for HIV [39,51], seek confirmatory testing [35], and adhere to ART [39]. Women in Malawi contrasted the ease with which they could encourage their husbands to self-test with unsuccessful attempts to get their husbands to attend facility-based HIV testing [39]. Serodiscordant couples used HIVST kits as monitoring devices [39]. Distribution of HIVST kits to partners was noted even in studies in which participants were not explicitly asked by researchers to distribute test kits to partners [40,46,47].

HIV self-testing supplemented existing resources in the community and clinic to improve HIV care

HIVST supplemented existing resources in the community to provide a range of HIV services, including mental health counseling [35,41], confirmatory testing or retesting [34,35], and starting or re-entering ART [39]. Peer networks, community organizations, and LGBT groups were important for both promoting HIVST and encouraging follow-up care after HIVST among MSM [34,35,41], youth, [51], and heterosexual couples in Malawi [39]. Youths, in particular, indicated that there was a strong influence of people in their lives (peer, intimate partner, and family referents) on their decision to self-test [49,51]. HIVST programs in Malawi [39], Kenya [47], and India [45] trained community health workers to promote and support HIVST. The program in India collaborated with an antenatal clinic to provide HIV screening for pregnant women in their first trimester [45].

Lay persons were trained to correctly operate and teach HIV self-testing

HIVST programs in HICs [35,40,46,49–51], MICs [43–45], and LICs [39,44,47] successfully trained lay people to either operate or teach HIVST. Operating HIVST refers to the process of unpackaging, appropriately collecting the specimen, and correctly interpreting the test result. This was particularly welcomed in countries where a lack of adequate trained human resources impedes access to HIV testing [45,47]. Members of the local communities in Kenya, Malawi, and South Africa were videotaped using oral and blood-based specimen HIVST kits and each type was described as easy to use [44]. Most participants correctly interpreted negative and positive HIVST results. HIVST kits were also described as easy and simple to use by youths [49,51], HCWs, pregnant women [45], MSM [35,46], transgender women [40], and heterosexual couples in Malawi [39]. High-quality instructions, such as clear wording, local translations (where necessary), pictorial aids, or live demonstration, were valued and facilitated correct operation of self-test kits [44,45,47,51].

Social and ethical considerations for implementation and scale-up

HIVST led to feelings of empowerment through control of one's own testing experience and diagnosis. However, in the context of partner testing, this increased agency rarely was associated with coercion to test.

HIV self-testing generally promoted agency, but sometimes generated coercion

HIVST was described as empowering for MSM [41,46], transgender individuals [40], HCWs [43,47], pregnant women [45], youths [51] and the general population in Kenya, Malawi, and South Africa [44]. Among youth populations, many had never previously used HIVST, stating that they would have gotten tested sooner if they knew it were an option [50] and that completing the process provided positive reinforcement [49,51]. Transgender women and MSM in the United States of America felt that HIVST allowed them to take ownership of their own serostatus through self-diagnosis and increased agency by providing a tool that allowed for continued self-monitoring [40,46]. Lay users in Kenya, Malawi, and South Africa similarly indicated that they planned to use HIVST for routine monitoring in the future after having a good first experience [44]. Increased agency also manifested as increased testing of partners, notably among MSM [35,37]. For women in relationships with underlying sex and power imbalances, the ability to bring HIVST into the household facilitated partner testing [39]. The introduction of HIVST allowed some couples to discuss topics that were previously difficult to bring up, such as fidelity, health, sexually transmitted infections, and HIV serostatus [35,37,39]. In several instances, HIVST led to disclosure of HIV status between participants and their partners [35,38,47]. At the same time, this increased agency was rarely associated with coercive testing. One study in Malawi noted that women were pressured by their husbands to receive HIVST [39]. These instances of coercive HIVST were situated in underlying sex power imbalances.

HIV self-testing informed sexual decision-making

Many individuals liked that HIVST provided a mechanism to detect the HIV status of their partners [34,35,37,39–41]. MSM [34,35,37,41] and transgender women [40] used HIVST to screen partners and inform decisions about condom use. They also used HIVST to assess fidelity in their partners, a function also used by heterosexual couples in Malawi. Many individuals reported that their HIVST experience raised awareness about various aspects of sexual behavior, HIV knowledge, and general health and wellness [34]. HIVST created self-awareness about one's membership in a group at increased risk for HIV [43].

Positive HIV self-testing results did not lead to adverse outcomes (suicide, violence), but in certain contexts had strong emotional impact

Studies that explored adverse outcomes resulting from HIVST examined violence during partner testing [35] and psychological distress associated with self-testing [35,41–43,46,50,51]. For instance, in one study in Kenya [47], ‘while health workers expressed concern about potential abuse of the self-test kit, by for example testing minors or housekeepers without their consent, no such incident was reported’. Anxiety associated with HIV testing itself in Malawi [42] and suicidality associated with an HIV-positive diagnosis in the United States of America and South Africa [41,43] often blended with and carried over to discussions of HIVST, but participants did not specifically distinguish between self-testing and facility-based testing or attribute these emotions specifically to HIVST. Generally, participants described HIVST as a low stress experience compared with facility-based testing [46,50].


Forward progress to achieve 2020 UNAIDs targets will require development of HIV testing services that are adaptable to a wide range of priority populations. HIVST priorities are likely to differ on the basis of HIV prevalence, with higher prevalence settings requiring more investment in services farther along the HIV care continuum. HIVST has been shown to reach populations that had not previously tested, with one study in Africa showing that between 20 and 30% of self-testers were first-time HIV testers [52]. Although individual user experiences varied, unifying themes applicable to many HIVST programs were identified.

Despite concerns about the availability of counseling and mixed views on the ability of HIVST to secure confirmatory testing and follow-up care, the preference for HIVST over facility-based testing was clear. Respondents consistently showed dissatisfaction with testing at clinics due to concerns about access and confidentiality. HIVST expanded access by providing greater autonomy over test conditions, including the timing, location, and setting. Although increased confidentiality brought in more individuals who might not otherwise test, it also presented challenges in educating patients who test negative about avoiding risky behaviors and informing patients who test positive about the importance of care and treatment.

We found that HIVST was associated with less test-associated stigma compared with facility-based testing. HIVST kits brought the experience of HIV testing into people's lives and homes, normalizing it and decreasing test-associated stigma. Given the importance of stigma as a barrier to expanding HIV testing around the world [53,54], this could facilitate scaling up HIV testing in many locations, especially low and middle-income countries that have substantial HIV test-associated stigma. Persistent stigma associated with the physical presence of HIVST kits may be further minimized by anonymizing kit packaging and incorporating user preferences.

Although HIVST generally increased agency, it was not commonly associated with coercive testing. This risk increased in the context of sex power imbalances in heterosexual couples [39]. This finding is consistent with quantitative studies from Malawi [22] and China [20,21] showing rare instances of HIVST-associated coercion. Our data suggest the potential for coercion directly related to HIVST, contrasting the interpretation of evidence from the WHO HIV Self-Testing Guidelines [5]. Further research on coercive testing is needed to better understand this potential harmful outcome. This emphasizes the need for accurate adverse event reporting among testers and their partners.

Our qualitative evidence synthesis has several limitations. First, many studies in our review were from heterosexual couples, MSM, and transgender individuals in HICs. At the same time, CERQual transparently reports data adequacy for each review finding (Table 2), allowing the reader to draw their own inferences about transferability. Further HIVST research among other vulnerable populations such as sex workers will be important to understand coercive testing. Second, only one of the identified studies included data from individuals organizing HIVST programs. Third, none of the identified qualitative studies assessed linkage to care. A previous quantitative systematic review of HIVST [55] also found no existing literature on issues related to seeking linkage to care. Fourth, none of the identified studies reported the price of HIVST kits. Finally, none of the identified qualitative studies assessed participant knowledge of the limitations of HIVST in the window period between HIV infection and the detection of antibodies. Future qualitative studies should consider follow-up of participants post-HIVST to examine outcomes along the entire cascade of HIV care.

Our systematic review has implications for research, policy, and programs. From a research perspective, our findings suggest the need for more extensive research on coercive HIVST and linkage to care. From a policy perspective, this systematic review can be used to inform the development of local and national HIVST guidelines. Given the WHO HIV Self-Testing Guidelines [5], many policymakers are now re-evaluating HIVST policies. In July 2017, the WHO announced that 40 countries have now incorporated HIVST in their national policies, with 48 other countries currently developing new HIVST policies. This represents significant progress from only 16 countries supporting HIVST 2 years ago [12]. A system to collate test results into a national repository will help governments better assess the role of HIVST in national HIV prevention and treatment programs. From the perspective of HIVST programs, our data may be useful for optimizing pilot HIVST sites, service delivery models, and strategies. At the same time, implementers should be certain that HIV rapid diagnostic test kits for self-testing are approved by regulatory authorities and quality-assured. There will unlikely be a single ‘one-size-fits-all’ HIV testing approach and the natural advantage of HIVST is that it could be adapted to a wide range of different settings. Our review findings provide practical details to enhance HIVST in diverse settings.

The current systematic review provides synthesized data on experiences of using and organizing HIVST. The advent of the self-test will usher in new opportunities and challenges for HIV testing programs. Our data confirm the importance of self-testing as a new tool that normalizes testing, decreases test-associated stigma, and expands HIV testing.


We thank all staff members at SESH Global and the Guangdong Provincial Center for Skin Diseases and STI Control for their contributions. We thank Chongyi Wei for helpful edits on the article.

Author contributions: J.D.T., W.T., Y.Q., A.B., L.H., and F.L. conceived the study. J.D.T. and J.S.W. designed the search strategy. Y.Q., A.B., and J.D.T screened and selected articles. Y.Q., L.H., and A.B. extracted and synthesized data. L.H. drafted the article with input from J.D.T., Y.Q., H.T., W.T., A.B., F.L., and J.S.W. All authors critically reviewed and revised the article.

The current work was supported by the National Institutes of Health (National Institute of Allergy and Infectious Diseases 1R01AI114310 to J.D.T.); UNC-South China STD Research Training Centre (Fogarty International Centre 1D43TW009532 to J.D.T.); UNC Center for AIDS Research (National Institute of Allergy and Infectious Diseases 5P30AI050410 to J.D.T.); the UNC Chapel Hill, Johns Hopkins University, Morehead School of Medicine and Tulane University (UJMT) Fogarty Fellowship (FIC R25TW0093 to W.T., F.L.). The listed grant funders played no role in any step of this study.

Conflicts of interest

There are no conflicts of interest.


1. UNAIDS. 90–90–90-An ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014.
2. UNAIDS 2016 estimates.
3. Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, Saltzman AK, et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med 2013; 10:e1001496.
4. Sharma M, Ying R, Tarr G, Barnabas R. Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa. Nature 2015; 528:S77–S85.
5. WHO. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: World Health Organization; 2016.
6. Figueroa C, Johnson C, Verster A, Baggaley R. Attitudes and acceptability on HIV self-testing among key populations: a literature review. AIDS Behav 2015; 19:1949–1965.
7. Cambiano V, Ford D, Mabugu T, Napierala Mavedzenge S, Miners A, Mugurungi O, et al. Assessment of the potential impact and cost-effectiveness of self-testing for HIV in low-income countries. J Infect Dis 2015; 212:570–577.
8. Tucker JD, Wei C, Pendse R, Lo YR. HIV self-testing among key populations: an implementation science approach to evaluating self-testing. J Virus Erad 2015; 1:38–42.
9. Brown AN, Djimeu EW, Cameron DB. A review of the evidence of harm from self-tests. AIDS Behav 2014; 18 (Suppl 4):S445–S449.
10. Karcher HL. HIV home test kit banned in Germany. BMJ 1997; 315:627–1627.
11. HIV self-testing research and policy hub: Policy map. 2017. Available at
12. UNITAID. Market and technology landscape: HIV rapid diagnostic tests for self-testing. 3rd ed.Geneva: WHO; 2017.
13. Bilardi JE, Walker S, Read T, Prestage G, Chen MY, Guy R, et al. Gay and bisexual men's views on rapid self-testing for HIV. AIDS Behav 2013; 17:2093–2099.
14. Ochako R, Vu L, Peterson K. Insights into potential users and messaging for HIV oral self-test kits in Kenya, 3ie grantee final report. Washington, DC: International Initiative for Impact Evaluation (3ie); 2014.
15. Greacen T, Friboulet D, Blachier A, Fugon L, Hefez S, Lorente N, et al. Internet-using men who have sex with men would be interested in accessing authorised HIV self-tests available for purchase online. AIDS Care 2013; 25:49–54.
16. Rosales-Statkus M, Fuente L, Fernández-Balbuena S, Figueroa C, Fernàndez-López L, Hoyos J, et al. Approval and potential use of over-the-counter HIV self-tests: the opinion of participants in a street based HIV rapid testing program in Spain. AIDS Behav 2015; 19:472–484. 413p.
17. van Rooyen H, Tulloch O, Mukoma W, Makusha T, Chepuka L, Knight LC, et al. What are the constraints and opportunities for HIVST scale-up in Africa? Evidence from Kenya, Malawi and South Africa. J Int AIDS Soc 2015; 18:19445.
18. van Dyk AC. Client-initiated, provider-initiated, or self-testing for HIV: what do South Africans prefer?. J Assoc Nurses AIDS Care 2013; 24:e45–e56.
19. Kabiru CW, Sidze EM, Egondi T, Osok D, Izugbara CO. Understanding perceived social harms and abuses of oral HIV-self-testing in Kenya: key findings of a cross-sectional study, 3ie Grantee Final Report. Washington, DC: International Initiative for Impact Evaluation (3ie); 2014.
20. Qin Y, Tang W, Nowacki A, Mollan K, Reifeis SA, Hudgens MG, et al. Benefits and potential harms of human immunodeficiency virus self-testing among men who have sex with men in China: an implementation perspective. Sex Transm Dis 2017; 44:233–238.
21. Ong JJ, Li H, Dan W, Fu H, Liu E, Ma W, et al. Coercion and HIV self-testing in men who have sex with men: implementation data from a cross-sectional survey in China. J Acquir Immune Defic Syndr 2017; [Epub ahead of print].
22. Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, et al. Uptake, accuracy, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study. PLoS Med 2015; 12:e1001873.
23. Boeije HR, van Wesel F, Alisic E. Making a difference: towards a method for weighing the evidence in a qualitative synthesis. J Eval Clin Pract 2011; 17:657–663.
24. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12:e1001847discussion e1001847.
25. Hall BJ, Sou K, Beanland R, Lackey M, Tso LS, Ma Q, et al. Barriers and facilitators to interventions improving retention in HIV care: a qualitative evidence meta-synthesis. AIDS Behav 2017; 21:1755–1767.
26. Ma Q, Tso LS, Rich ZC, Hall BJ, Beanland R, Li H, et al. Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence. J Int AIDS Soc 2016; 19:21166.
27. Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, et al. Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review. AIDS 2016; 30:1639–1653.
28. Li H, Marley G, Ma W, Wei C, Lackey M, Ma Q, et al. The role of ARV associated adverse drug reactions in influencing adherence among HIV-infected individuals: a systematic review and qualitative meta-synthesis. AIDS Behav 2017; 21:341–351.
29. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 [updated March 2011]. In. Higgins J, Green S: editors. Cochrane Collaboration; 2017. Available at
30. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Med 2009; 6:e1000100.
31. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8:45.
32. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gulmezoglu M, et al. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Med 2015; 12:e1001895.
33. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328:1490.
34. Balán I, Carballo-Diéguez A, Frasca T, Dolezal C, Ibitoye M. The impact of rapid HIV home test use with sexual partners on subsequent sexual behavior among men who have sex with men. AIDS Behav 2014; 18:254–262.
35. Carballo-Dieguez A, Frasca T, Balan I, Ibitoye M, Dolezal C. Use of a rapid HIV home test prevents HIV exposure in a high risk sample of men who have sex with men. AIDS Behav 2012; 16:1753–1760.
36. Flowers P, Riddell J, Park C, Ahmed B, Young I, Frankis J, et al. Preparedness for use of the rapid result HIV self-test by gay men and other men who have sex with men (MSM): a mixed methods exploratory study among MSM and those involved in HIV prevention and care. HIV Med 2017; 18:245–255.
37. Frasca T, Balan I, Ibitoye M, Valladares J, Dolezal C, Carballo-Dieguez A. Attitude and behavior changes among gay and bisexual men after use of rapid home HIV tests to screen sexual partners. AIDS Behav 2014; 18:950–957.
38. Kebede B, Abate T, Mekonnen D. HIV self-testing practices among healthcare workers: feasibility and options for accelerating HIV testing services in Ethiopia. Pan Afr Med J 2013; 15:50.
39. Kumwenda M, Munthali A, Phiri M, Mwale D, Gutteberg T, MacPherson E, et al. Factors shaping initial decision-making to self-test amongst cohabiting couples in urban Blantyre, Malawi. AIDS Behav 2014; 18 (Suppl 4):S396–S404.
40. Lippman SA, Moran L, Sevelius J, Castillo LS, Ventura A, Treves-Kagan S, et al. Acceptability and feasibility of HIV self-testing among transgender women in San Francisco: a mixed methods pilot study. AIDS Behav 2016; 20:928–938.
41. Martinez O, Carballo-Dieguez A, Ibitoye M, Frasca T, Brown W, Balan I. Anticipated and actual reactions to receiving HIV positive results through self-testing among gay and bisexual men. AIDS Behav 2014; 18:2485–2495.
42. Namakhoma I, Bongololo G, Bello G, Nyirenda L, Phoya A, Phiri S, et al. Negotiating multiple barriers: health workers’ access to counselling, testing and treatment in Malawi. AIDS Care 2010; 22 (Suppl 1):68–76.
43. Pant Pai N, Behlim T, Abrahams L, Vadnais C, Shivkumar S, Pillay S, et al. Will an unsupervised self-testing strategy for HIV work in healthcare workers of South Africa? A cross sectional pilot feasibility study. PLoS One 2013; 8:e79772.
44. Peck RB, Lim JM, van Rooyen H, Mukoma W, Chepuka L, Bansil P, et al. What should the ideal HIV self-test look like? A usability study of test prototypes in unsupervised HIV self-testing in Kenya, Malawi, and South Africa. AIDS Behav 2014; 18:422–432.
45. Sarkar A, Mburu G, Shivkumar PV, Sharma P, Campbell F, Behera J, et al. Feasibility of supervised self-testing using an oral fluid-based HIV rapid testing method: a cross-sectional, mixed method study among pregnant women in rural India. J Int AIDS Soc 2016; 19:20993.
46. Young SD, Daniels J, Chiu CJ, Bolan RK, Flynn RP, Kwok J, et al. Acceptability of using electronic vending machines to deliver oral rapid HIV self-testing kits: a qualitative study. PLoS One 2014; 9:e103790.
47. Kalibala S, Tun W, Muraah W, Cherutich P, Oweya E, Oluoch P. Knowing myself first: feasibility of self-testing among health workers in Kenya. Nairobi: Population Council; 2011.
48. Kumwenda MK. The influence of masculinity on HIVST community intervention: a qualitative evaluation of empirical evidence from Blantyre, Malawi. International AIDS Society Conference, Durban, South Africa; 2016
49. Brown W 3rd, Carballo-Dieguez A, John RM, Schnall R. Information, motivation, and behavioral skills of high-risk young adults to use the HIV self-test. AIDS Behav 2016; 20:2000–2009.
50. Pant Pai N, Bhargava M, Joseph L, Sharma J, Pillay S, Balram B, et al. Will an unsupervised self-testing strategy be feasible to operationalize in Canada? Results from a pilot study in students of a large canadian university. AIDS Res Treat 2014; 2014:747619.
51. Schnall R, John RM, Carballo-Dieguez A. Do high-risk young adults use the HIV self-test appropriately? observations from a think-aloud study. AIDS Behav 2016; 20:939–948.
52. UNITAID. Stimulating and shaping the market for HIV self-testing in Africa (STAR). UNITAID, 2016.
53. Treves-Kagan S, El Ayadi AM, Pettifor A, MacPhail C, Twine R, Maman S, et al. Gender, HIV testing and stigma: the association of HIV testing behaviors and community-level and individual-level stigma in rural South Africa differ for men and women. AIDS Behav 2017; [Epub ahead of print].
54. Evangeli M, Pady K, Wroe AL. Which psychological factors are related to HIV testing? A quantitative systematic review of global studies. AIDS Behav 2016; 20:880–918.
55. Pant Pai N, Sharma J, Shivkumar S, Pillay S, Vadnais C, Joseph L, et al. Supervised and unsupervised self-testing for HIV in high- and low-risk populations: a systematic review. PLoS Med 2013; 10:e1001414.

* Yilu Qin and Larry Han contributed equally to the article and are cofirst authors.


Confidence in the Evidence from Reviews of Qualitative Research; HIV self-testing; qualitative research; systematic review

Supplemental Digital Content

Copyright © 2018 Wolters Kluwer Health, Inc.