J Viral Hepat. 2019;00:1–23. wileyonlinelibrary.com/journal/jvh
|
1 Received:30January2019|
Revised:24May2019|
Accepted:26June2019DOI: 10.1111/jvh.13182
O R I G I N A L A R T I C L E
Hepatitis B and C testing strategies in healthcare and
community settings in the EU/EEA: A systematic review
Lauren M. K. Mason
1| Irene K. Veldhuijzen
2| Erika Duffell
3| Ayla van Ahee
1|
Eveline M. Bunge
1| Andrew J. Amato‐Gauci
3| Lara Tavoschi
3Abbreviations:DBS,driedbloodspot;DBS,driedbloodspot;GPs,generalpractitioners;HBV,hepatitisBvirus;HCV,hepatitisCvirus;MSM,menwhohavesexwithmen;OST,opioid substitutiontherapy;PLHIV,peoplelivingwithHIV;PWID,peoplewhoinjectdrugs;RCT,randomizedcontrolledtrial;SIGN,ScottishIntercollegiateGuidelinesNetwork;STI,sexually transmittedinfection. 1PallasHealthResearchandConsultancy B.V.,Rotterdam,TheNetherlands 2TheNetherlandsNationalInstitute forPublicHealthandtheEnvironment, Bilthoven,TheNetherlands 3EuropeanCentreforDiseasePrevention andControl,Stockholm,Sweden Correspondence LaurenM.K.Mason,PallasHealthResearch andConsultancyB.V.,Rotterdam,The Netherlands. Email:laurenmasonboersma@gmail.com Present address LaraTavoschi,UniversityofPisa,Pisa,Italy Funding information EuropeanCentreforDiseasePrevention andControl,Grant/AwardNumber: ECDC/2016/027
Abstract
Anestimated9millionindividualsarechronicallyinfectedwithhepatitisBvirus(HBV) andhepatitisCvirus(HCV)acrosstheEuropeanUnion/EuropeanEconomicArea(EU/ EEA),manyofwhichareyettobediagnosed.Weperformedasystematicreviewto identifyinterventionseffectiveatimprovingtestingofferanduptakeintheEU/EEA. Originalresearcharticlespublishedbetween1January2008and1September2017 wereretrievedfromPubMedandEMBASE.SearchstringscombinedtermsforHBV/ HCV,intervention,testingandgeographicterms(EU/EEA).Outof8331recordsre-trieved,93studieswereselected.Includedstudiesreportedontestinginitiativesin primaryhealthcare(9),hospital(12),otherhealthcaresettings(31)andcommunityset-tings(41).Testinginitiativestargetedpopulationgroupssuchasmigrants,drugusers, prisoners,pregnantwomenandthegeneralpopulation.Testingtargetedtopopula-tionsathigherriskyieldedhighcoverageratesinmanysettings.Implementationof novel testing approaches, including dried blood spot (DBS) testing, was associated with increased coverage in several settings including drug services, pharmacies and STIclinics.Community‐basedtestingserviceswereeffectiveinreachingpopulations athigherriskforinfection,vulnerableandhard‐to‐reachpopulations.Inconclusion, ourreviewidentifiedseveralsuccessfultestingapproachesimplementedinhealthcare andcommunitysettings,includingtestingapproachestargetinggroupsathigherrisk, community‐basedtestingservicesandDBStesting.Combiningadiversesetoftesting opportunitieswithinnationaltestingstrategiesmayleadtohigherimpactbothinterms oftestingcoverageandintermsofreduction,ontheundiagnosedfraction. K E Y W O R D S Europe,hepatitisB,hepatitisC,screening,testing ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium, providedtheoriginalworkisproperlycited.1 | INTRODUCTION
AcrosstheEuropeanUnion/EuropeanEconomicArea(EU/EEA),an estimated4.7millionpeoplearechronicallyinfectedwithhepatitis Bvirus(HBV)and3.9millionarechronicallyinfectedwithhepati-tisCvirus(HCV).1HBVandHCVcanbothcauseacuteandchronic hepatitis,potentiallyleadingtothedevelopmentofcirrhosis,liver cancerordeathofinfectedpatients.2,3 Earlydiseaseanddevelop-mentofliverdamageareoftenasymptomatic,4‐6meaningthatHBVand HCV infection may go undetected for many years7 and many
infectedpeopleremainundiagnosed.8
Transmission of HBV and HCV can occur sexually, through blood‐to‐blood contact or vertically (mother‐to‐child). Over the past decades, there have been shifts in the patterns of transmis-sion in Europe, due to various factors, including improvements in bloodtransfusionandhealthcaresafetystandards,HBVvaccination programmes,harmreductionprogrammestargetinginjectingdrug use,aswellassignificantchangesinpatternsofinjectingdruguse andimmigration.However,anumberofpopulationgroupsarestill potentiallyathighriskorhaveahighburdenofHBV/HCVinEU/ EEAcountries,includingpeoplewhoinjectdrugs(PWID),menwho havesexwithmen(MSM),peoplelivingwithHIV(PLHIV),peoplein prisonandmigrantsfromcountriesofhighendemicity.9-11
As highly effective treatment options have become available
for HBV and HCV,12,13 it is crucial that an informed public health
responseisinplacetailoredtothelocalepidemiologicalsituation, whichwillensurethat those infectedarediagnosed andlinkedto care.Estimatesoftheundiagnosedfractioninthegeneralpopula-tioninEU/EEAcountriesrangefrom40%to85%forHBVand20%
to 91% for HCV, with large variability between countries.11 The
WHOhasformulatedanactionplantoeliminateviralhepatitisasa publichealththreatintheEuropeanregionby2030,settingtargets of50%ofpeoplewithchronicinfectiondiagnosedby2020and90%
by 2030.14 To this end, testing programmes must be scaled up in
ordertoreducetheundiagnosedfraction.
Testing can occur through a number of methods and in vari-oussettings,dependingonthepopulationgrouptargetedandthe localepidemiologyandhealthcareinfrastructure.Testinginhealth caremaytakeplaceacrossarangeofdifferentsettingsinprimary healthcareandhospitalsaswellasotherhealthcaresettingssuch assexuallytransmittedinfection(STI)clinics,antenatalservicesand pharmacies.Outsideofformalhealthcarefacilities,settingswithin the community, such as homeless shelters, migrant services and community‐based drugs services can offer testing services which areadapted,targetedandmadeaccessibletothepopulationsthat frequentthem.15Outreachtesting,forexampleusingmobileunits, streetoutreachbycommunityhealthworkers,orsatelliteservices basedatotheragenciescanbeusedtoreachpeoplewhoarenotin contactwithotherhealthservices.16Commontestingstrategiesfor hepatitisBandCincludeuniversalscreening,birthcohorttesting ortestingtargetedtowardsthoseatincreasedrisk.Inrecentyears, newtechnologiessuchasself‐testingkits,andstrategiesfortesting implementationhavebeendeveloped,whichmaybeconsideredfor incorporationincountries'nationaltestingpoliciesandprogrammes. Evidencearoundtheeffectivenessofdifferentinterventionsinre-lationtouptakeandpositivityratescouldhelpinformcountriesin decidingwhichstrategicapproachestoincorporateinnationaltest-ingprogrammes. AsystematicreviewcoveringHBVandHCVtestingstudiesin keypopulationsintheEuropeanregionuntilJune2013foundthat, althoughalargenumberofstudiesontestingexisted,thesewere unevenly distributed across Europe and that large gaps existed in certain key populations including migrants, people in prison and
MSM.17 Previous systematic reviews on testing interventions
fo-cused solely on either HBV or HCV,18-23 specific key populations
or settings,19,21,22,24 targeted testing interventions18,23 or included
comparativestudiesonly.25
Finally,acomprehensivereportonhep-atitis testing policies and activities in EU/EEA countries revealed substantialgapsintestingcoverageandtestingofferstargetingspe-cificallyhigherriskgroupsacrosstheregion.8 Thescopeofthisstudywastoprovideanoverviewofdifferent effectivetestingstrategiesforhepatitisBandCandtheiroutcomes intheEU/EEA,coveringallrelevantpopulationgroupsandsettings. Asystematicreviewwasperformedtocollect,synthesizeandanalyse availabledataonHBV/HCVtestingoutcomesandacceptabilitymea-suresfromEU/EEAcountries.Thisstudywasconductedaspartofa largerprojecttodevelopanintegratedEuropeantestingguidancefor HBV,HCVandHIV,coordinatedbytheEuropeanCentreforDisease PreventionandControl(ECDC).
2 | METHODS
2.1 | Search strategy and selection criteria
OriginalresearcharticleswereretrievedfromPubMedandEMBASE databaseson1September2017.PICOquestions(Patient/problem,
Intervention,ComparisonandOutcome26)wereformulated(listed
in Supporting information). Search strategies combined controlled (MeSH/Emtreeterms)andnaturalvocabularyontermsforHBVand HCVwithtermsforinterventionandtestingandgeographicterms (EU/EEA)(detailedinSupportingInformation).Thesearchstrategy employedalsoincludedtermsforlinkagetocare,however,forthe purposesofthisarticle,methodsandresultsapplyingtoapproaches toimprovetestingcoveragearepresentedonly.Onlystudiespub-lished between 1 January 2008 and 1 September 2017 were in-cludedinthesearch.ArticlesinallEU/EEAlanguageswereincluded. OnlyarticlesreportingdatafromEU/EEAcountrieswereincluded. Publications were included which described approaches to improve coverage of testing and reported any of the following outcomes of interest:offeroftest,uptakeandcoverageoftesting,positivityrate, acceptabilityandfeasibilityoutcomes.Studiesonunlinkedanonymous testingtodetermineprevalenceandstudiesdescribingthesensitivity/ specificity of laboratory tests were excluded. The full inclusion and exclusioncriteriaarelistedinTableS3.Onlyoriginalresearcharticles (ienotreviews)andconferenceabstractswereincludedinthisreview; however,thereferencelistsofrelevantsystematicreviewsretrievedin
theliteraturesearchwerecheckedmanuallyforadditionaloriginalar-ticlesnotcapturedbytheliteraturesearch.Conferenceabstractsfrom theInternationalLiverCongressorretrievedinthesystematicliterature search,reportingrelevantquantitativedataandpublishedsince2015, wereincludedasgreyliterature.Additionalpublicationscapturedwere subjecttothesameinclusionandexclusioncriterialistedabove. Tworeviewersreviewedtitlesandabstractsofretrievedpubli-cations.Initially,arandomsampleof5%wasscreenedinduplicate; the results were then compared and used to refine the inclusion andexclusioncriteria.Furtherroundsofduplicatereviewwerecon-ducteduntilalevelofconcordanceofmorethan95%wasachieved, afterwhichtheremainingpublicationsweredividedbetweenre- viewersandscreeningcontinuedinEndNote.Thefulltextsofse-lected articles were subsequently screened by two reviewers, of whicharandomsampleof20%wasscreenedinduplicateandthese reachedmorethan95%concordance.Theremaining80%ofpubli-cationsweredividedbetweenthereviewersandscreened.Articles wereincludedincaseofuncertaintyaboutinclusionorexclusionif thiswasnotresolvedafterdiscussionbetweenthereviewers.
2.2 | Definitions
Primaryhealthcarewasdefinedashealthcareprovidedbygeneral practitioners (GPs). Hospital settings included all hospital depart-mentsincludinginpatients,outpatients,medicaladmissionsunitsand infectiousdiseaseunits.Otherhealthcaresettingsincludedanyformal healthcaresettingsoutsideofprimaryhealthcareorhospitaldepart-ments,forexampleSTIclinics,pharmaciesandprisons.Community‐ basedtestingwasdefinedasanyprogrammeorserviceofferingHBV/ HCVtestingoutsideofformalhealthfacilities.Drugsserviceswere definedasservicesofferingprevention,support,detoxandtreatment foraddictiontodrugsoralcohol,eitherembeddedinhealthcareset-tings or set in the community. Outreach activities were defined as testingactivitiestakingplaceinthecommunitywithoutafixed‐site facility,includingmobileunitsorvans,streetoutreachbycommunity healthworkersandregularsatelliteservicesbasedatotheragencies. Testingofferratewasdefinedastheproportionofpeopletargeted byatestingprogrammewhowereofferedtesting,whiletestingcov-eragewasdefinedasthepercentageofpeopletargetedbyatesting programme that received testing. Positivity rate was defined as the percentageofpeopletestingpositiveforHBsAgandanti‐HCVforHBV and HCV, respectively. When other markers were reported instead, thesedatawereextracted,andthemarkerwasspecifiedintables.2.3 | Data extraction and quality assessment
Relevantdatawereextractedfromincludedarticlesandrecorded inadataextractionfileinMicrosoftExcel.Apredefinedsetofvari-ables covering study characteristics, study population details and outcomes was extracted per study. The complete list of variables isprovidedinTableS5.Theunitfordataextractionwasstudy,not article.Astudyisdefinedasareportofdataonatestingapproachor F I G U R E 1 PRISMAflowdiagramforthesystematicreview
10895 records retrieved prior to deduplica on
Pubmed: 3714
Embase: 7184
8331 records aer deduplica on
Records excluded
based on tle and/or
abstract (n = 7961)
Records included for full-text screening (n = 370)
Full-text ar cles assessed for eligibility (n = 373)
Ar cles added from
other sources (n = 3)
Ar cles with no full
text available (n = 21)
Full text ar cles
excluded, with reasons
(n = 290)
Ar cles with data on tes ng ini a ves included
for data extrac on (n = 62)
linkagetocareapproachforHBVorHCV,inadefinedcountry,over adiscreteperiodoftime.Therefore,onearticlemaycontainmore thanonestudy.Ifastudywascapturedbytwodifferentarticles,the studywasextractedonceandthearticlewiththemostdetailused asareference. Thequalityofincludedpeer‐reviewedliteraturewasassessedusing checklistsdevelopedbytheScottishIntercollegiateGuidelinesNetwork (SIGN)27thatincludethemostimportantcriteriaonpublicationquality fromthePRISMAandSTROBEguidelines.Usingthesechecklists,an overallqualityscorewasassignedperstudy:high(++),acceptable(+) andlow(−).Assomeoftheincludedpublicationsconcernedstudyde- signsforwhichnochecklistsexist,alist(providedinTableS6)wascom-piledofrelevantaspectsfromstandardchecklists,regardingthelevelof detailandclarityofthestudy,appropriatenessofstudypopulation,data collectionanddenominator,andtherepresentativenessofthesample, whichwereansweredwithyesornoperstudy.Usingthechecklist,it wasnotpossibletocalculateanoverallqualityscoreforthesestudies; therefore,allrelevantarticleswereincludedregardlessoftheirquality, buttheresultsoftheassessmentweretakenintoconsiderationininter-pretingtheresults.Articleswereexcluded,however,whenthemethods and/orresultsprovidedaninsufficientlevelofdetailsmakingitnotpos-sibletoaccuratelyextractdata.Noqualityassessmentwasperformed onincludedgreyliteraturepublications. Asetofdetailedsummarytablesweredevelopedpersetting(pro-vided in Tables S7‐S11), containing the following information: study reference,country,studyperiod,studydesign,studypopulationand specificsetting,samplesize,outcomes(testoffer,coverageandpos-itivity rate, acceptance rate and patient and provider indicators of acceptabilityandfeasibility),criticalappraisalandcomments.Within each table, findings are ordered by virus, study population, country andyearofpublication.
3 | RESULTS
The literature search retrieved 8331 unique publications, of which 370wereselectedbasedontitleandabstractandwereassessedin fulltextforeligibility.Ofthese,62articleswereretrievedthatformed theevidencebasefortheeffectivenessoftestinginitiativesandin-terventions(Figure1).Reasonsforexclusionofpublicationsarelisted inTableS4.Theincludedpublicationscomprised93studiesintotal, eachdetailinganinterventiondesignedtoimprovecoverageofHBV orHCVtestinginacertainsetting.Atotalof78studieswerefrom peer‐reviewedpublicationsand15concernedconferenceabstracts.A formalqualityassessmentwasperformedfor19peer‐reviewedstud-ies;theremainderhadstudydesignswhichprecludedthis.Detailed informationofeachincludedstudyisprovidedinTablesS7‐S11.
3.1 | Testing initiatives in primary
healthcare settings
Nine studies that reported outcomes on testing initiatives
per-formedinprimaryhealthcaresettingswereretrieved28‐36(Table1). HBV/HCVtestofferrates,coverageandpositivityrates,wherere-ported,rangedwidelybetweenstudies.Thehighestofferrateand coveragereportedwas70%and100%,respectively,inastudytar-getingmigrants.30VeryhighpositivityratesforHCVwerereported ininitiativestargetingPWID(70%)andhomelesspeople(26%).29,33 TwoinitiativestargetingmigrantsreportedHBVandHCVpositivity ratesof0%.30,32
One comparative study on HCV risk group testing in PWID reported testing coverage of 24.8% among PWID in GP practices exposedtotheintervention,comparedto0.3%ofPWIDtestedin
comparablecontrolpractices.29
Inacomparativestudyonbirthco-horttestingforHCVtestinginanareaofhighprevalenceofHCV andintravenousdruguse,72%of30‐to54‐year‐oldswereoffered testing, compared to 0% in a control practice in the same area
wherebirthcohorttestingwasnotimplemented.28Inanadditional
comparativestudy,thenumberoftestsperformedincreasedfrom 5421beforeto10117duringanationaltestingprogrammewhich involved awareness‐raising activities for GPs and those at higher
risk.34 Another comparative study found a significant increase in
the number tested when a public awareness campaign was com-bined with additional educational brochures and training for GPs, whichresultedinthreetimesmorepeoplebeingtested,compared toacontrolgroupinwhichonlythecampaignwasimplementedand
testingratesincreasedby1.4times.31
Two studies provided data on the acceptability and feasibility oftestinginprimaryhealthcaresettings.Testingacceptancerates
were56%amongPWID29and70%amongmigrants.30AmongPWID
interviewed about a testing intervention, all responded positively about the acceptability of provider‐initiated HCV testing. Staff viewedtheinterventionasanopportunitytofacilitateidentification
andsubsequentreferral.29
3.2 | Testing initiatives in hospital settings
Twelve studies were identified on the effectiveness of testing
ini-tiativesandinterventionsinhospitalsettings34,35,37‐41(Table2).Test
offerrates,coverageandHBV/HCVpositivityratesvariedwithhigh offerrates(83%and100%)intestinginitiativestargetedatmigrants
and psychiatric patients.37,40,41 Coverage was highest (88.4%) in a
studyreportingonauniversaltestinginitiativeconductedatasingle emergencydepartment.38 Aseparateuniversaltestinginitiativecon-ductedinmultipleemergencydepartments,however,yieldedamuch loweroverallcoverageof27%,althoughwithvariationsamongtesting sites.39 PositivityratesforHBVandHCVwerehigherinstudiesreport-ingoninitiativestargetedatkeypopulations(2.2%‐7.8%forHBVand 0.3%‐8.7%forHCV)thanthoseaimedatthegeneralpopulation.37,40,41 Onecomparativestudyreportedonimplementationoforalsam-plingforHCVtestingbetween2011and2014.35Overthisperiod, coverageincreasedfrom9.1%to22%andpositivityratesincreased from 0.5% to 4.5%. In another comparative study, a national pro-grammeinvolvingawareness‐raisingactivitieswasassociatedwith anincreaseinnumberofteststakeninhospitalsfrom10536tests
TA B L E 1 Evidencebasefortheeffectivenessoftestinginitiativesinprimaryhealthcaresettings Intervention
Studies included
Quality of evidence Target population Test offer
Coverage/number of
tests/testedb Positivity rate
Riskgroup testing HBVN=3studies30,32,36 Quality: 3studiesNA Migrants(n=3)(samplesize: 47‐560a) 100% Numbertested/tests:2223 Coverage:2.3%and70% 0%‐6.7% HCV N=4 studies29,30,32,33 Quality: 1studylow 3studiesNA PWID(n=1)(samplesize:inter-vention485,controlNR) 52% intervention Coverage:24.8%inter-vention,0.3%control Comparativestudy: 70%intervention, 22%control Homeless(n=1)(samplesize: NR) Numbertested/tests: 460 26% 9.6%newlydiagnosed Migrants(n=2)(samplesize:47 and560) 100% Coverage:2.3%and70% 0% Birthcohort testing HCV N=1study28 Quality: Acceptable 30‐to54‐year‐olds(n=1) (samplesize:Intervention584, controlNR) Comparative study:72% intervention; 0%control Comparativestudy:cov- erage:20%interven-tion;0%control Comparativestudy: 13%intervention;NA control Novel testing HCV N=2studies33,35 Quality: 2studiesNA Generalpop(n=1)(samplesize: 600‐29600) Coverage(oral): 9.1%‐22% 0.4%‐4.5% Homeless(n=1)(samplesize:
NR) Numbertested/tests(oral):460 26%9.6%newlydiagnosed
Education HBV N=1study30 Quality: NA TargetedatGPs Migrants(n=1)(samplesize: 47) 100% Coverage:70% 0% HCV N=2studies30,31 Quality: 1studylow 1studyNA TargetedatGPs Migrants(n=1);generalpop. (n=1)(samplesize:47a) 100% Coverage:70% Comparativestudy: numbertested: campaign+education (intervention):57tests before;172during; campaign(control):86 testsbefore;118during ORoftheincreaseinter-ventionvscontrol:2.2 (95%CI1.5‐3.3) 0% Comparativestudy: campaign+educa-tion(intervention): 0%before;1.7% during;campaign (control):1.7%be-fore;0.8%during Campaign HCV N=2studies31,34 Quality: 1studylow 1studyNA Targetedatpublic
Generalpop.(n=1)(nosample) Comparativestudy:numbertested/tests:
campaign+education (intervention):57tests before;172during; campaign(control):86 testsbefore;118during ORoftheincreaseinter-ventionvscontrol:2.2 (95%CI1.5‐3.3) Comparativestudy HCV:campaign+ed- ucation(interven-tion):0%before; 1.7%during;cam-paign(control):1.7% before;0.8%during TargetedatGPs/riskgroups Generalpop.(n=1)(nosample) Comparativestudy:num-berHCVtested/tests: before5421tests;dur-ing10117tests Comparativestudy HCV:before9.6%; during6.8% Abbreviations:HBV:hepatitisBvirus;HCV:hepatitisCvirus;HIV:humanimmunodeficiencyvirus;NA:notapplicable;NR:notreported;oral:oral sampling;PWID:peoplewhoinjectdrugs;TB:tuberculosis aDenominatornotreportedforallstudies. bNumberoftestsisonlyreportedhereifnodataoncoverageareavailable.
T A B LE 2 Ev id en ce b as e fo rt he e ff ec tiv en es s of te st in g in iti at iv es in h os pi ta ls et tin gs Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Se tti ng; ta rg et p op ul ati on Te st o ff er C ove ra ge/ nu m be r o f t es ts / te ste d a Po sit iv it y r at e Ri sk g ro up te st in g H BV N = 3 s tu di es 37 ,4 0,4 1 Q ua lit y: 3 st ud ie s N A O th er h os pi ta ld ep ar tm en ts (n = 3 ) (s am pl e si ze :1 05 ‐3 22 6) M ig ra nt s (n = 2 ); ps yc hi at ric p at ie nt s (n = 1 ) M ig ra nt s: 1 00 % Ps yc hi at ric p at ie nt s: 8 3% C ov er ag e m ig ra nt s: 2 8. 7% a nd 61 % C ov er ag e ps yc hi at ric p at ie nt s: 54 % M ig ra nt s: 2 .2 % a nd 7 .8 % Ps yc hi at ric p at ie nt s: 7 .0 % H C V N = 3 s tu di es 37 ,4 0,4 1 Q ua lit y: 3 st ud ie s N A O th er h os pi ta ld ep ar tm en ts (n = 3 ) (s am pl e si ze :1 05 ‐3 22 6) M ig ra nt s (n = 2 ); ps yc hi at ric p at ie nt s (n = 1 ) M ig ra nt s: 1 00 % Ps yc hi at ric p at ie nt s: 8 3% C ov er ag e m ig ra nt s: 2 8. 7% a nd 61 % C ov er ag e ps yc hi at ric p at ie nt s: 54 % M ig ra nt s: 0 .3 % a nd 3 .6 % Ps yc hi at ric p at ie nt s: 8 .7 % Un iv er sal te st ing H BV N = 2 s tu di es 38 ,39 Q ua lit y: 2 st ud ie s N A ED o nl y (n = 2 )( sa m pl e si ze :78 07 a nd 10 0 00 ) G en er al p op ul at io n (n = 2 ) C ov er ag e: 2 7% a nd 8 8. 4% 0. 5% a nd 0 .7 % 0. 2% a nd 0 .5 % n ew ly d ia gn os ed H C V N = 2 s tu di es 38 ,39 Q ua lit y: 2 st ud ie s N A ED o nl y (n = 2 )( sa m pl e si ze :78 07 a nd 10 0 00 ) G en er al p op ul at io n (n = 2 ) C ov er ag e: 2 7% a nd 8 8. 4% 1. 8% a nd 5 % 0. 6% a nd 0 .7 % n ew ly d ia gn os ed No ve lt es tin g H C V N = 1 s tu dy 35 Q ua lit y: NA O th er h os pi ta ld ep ar tm en ts (n = 1 (s am pl e si ze :6 00 ‐2 9 60 0) G en er al p op ul at io n (n = 1 ) C om pa ra tiv e st ud y: c ov er ag e (o ra l): 9. 1% (2 01 1) 14 % (2 01 2) 16 .9 % (2 01 3) 22 % (2 01 4) C ompa ra tiv e st ud y: 0. 5% (2 01 1) 0. 5% (2 01 1) 0. 4% (2 01 3) 4. 5% (2 01 4) Ed uc at io n H BV N = 1 s tu dy 40 Q ua lit y: NA Ta rg et ed a tm ig ra nt s M ig ra nt s (n = 1 )( sa m pl e si ze :3 22 6) 10 0% C ov er ag e: 2 8. 7% 2. 2% H C V N = 1 s tu dy 40 Q ua lit y: NA Ta rg et ed a tm ig ra nt s M ig ra nt s (n = 1 )( sa m pl e si ze :3 22 6) 10 0% C ov er ag e: 2 8. 7% 0. 3% (Co nt in ue s)
3.3 | Testing initiatives in other healthcare settings
Thirty‐one studies were included relating to other healthcare
set-tings34,35,42‐64 (Table 3), which included antenatal services, clinics
for people with no health insurance, drug services (embedded in healthservices),migrantclinics,pharmacies,prisons,publichealth clinicsandSTIclinics.Testingcoverageduringorafterinterventions were found to vary widely between and within settings, with the
highestcoveragelevelsreportedbystudiesinItalianmigrantclin-ics (87%‐91.4%),48,54 clinics for people with no health insurance
(71%‐98.2%)44,57 and public health clinics (90% and 98%).51 Four
studies on novel testing initiatives yielded high coverage levels whendriedbloodspot(DBS)samplingorrapidtestswereused(upto 98.2%forrapidtestingandupto96.6%forDBS).44,50,64Thehighest positivityratesforbothdiseaseswerereportedinstudiestargeting drugusersorPWID(upto48%anti‐HBcpositiveforHBVandupto 61%forHCV).43,51,52,59,62,64 Nostudiesconductedinotherhealth-caresettingsreportedtestofferrates.
Eleven comparative studies reported on interventions in other healthcaresettings.Inpharmacies,HCVtestingcoveragewas30% amongdrugusersreceivingopioidsubstitutiontherapy(OST)when DBS testing was offered, compared to 13% in pharmacies which did not offer DBS. Furthermore, DBS testing coverage was 36% in
pharmaciesinwhichpharmacist‐ledcarepathwayswereusedcom-paredto24%whenconventionalcarepathwayswereused.58,59 One
randomized controlled trial (RCT) found that offering DBS testing forHCVindrugclinicsandprisonssignificantlyincreasedcoverage rates in intervention sites with a 14.5% increase compared to
con-trolsites49;however,anotherRCTinwhichDBStestingforHCVwas offeredinprisonsfoundanORof0.86(95%CI:0.71‐1.06)fortheef-fectoftheinterventionontestingrate.45Anothercomparativestudy reportedadoublinginthenumberoftestsperformedinprisonsand STIclinicsduringanationaltestingprogrammewhichinvolvedaware-ness‐raisingactivities.34 Point‐of‐carerapidtestinginclinicsforpeo-plewithouthealthcarecoveragewasfoundtosignificantlyincrease testing coverage to 98.2%, compared to standard serology testing
performedelsewherewhichhad64.2%coverage.44Onestudywhich implementedtestingofhouseholdcontactsofHBV‐positivepregnant womenthroughnurse‐ledat‐homeDBStestingreportedasignificant increaseincoveragefrom62%to97%inantenatalservicesinwhich theinterventionwasimplemented,comparedtocontrolsiteswhere therewasnoincreaseobservedinthesametimeframe.50Another comparativestudycompareduniversalandrisk‐basedHCVscreening forpregnantwomeninantenatalservicesandreportedapositivity rateof1.7%foruniversalscreeningcomparedto1.3%fortargeted screening;thedifferencewasnotsignificant.47Informationsessions
and peer education increased coverage from 7% to 20% in a drug
clinic,althoughthisdifferencewasnotsignificant.42Introductionofa clinic‐specificguidelineinanSTIclinicledtoanincreaseincoverage from4.7%to13.6%.53Onecomparativestudyreportedonaclinical decision‐makingtoolinitiativewhichincludedcomputer‐assistedself/ personalinterviewingvspaper‐and‐peninterviewsinSTIclinics.Both Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Se tti ng; ta rg et p op ul ati on Te st o ff er C ove ra ge/ nu m be r o f t es ts / te ste d a Po sit iv it y r at e C ampa ig n H BV N = 2 s tu di es 39, 40 Q ua lit y: 3 st ud ie s N A Ta rg et ed a tp at ie nt s G en er al p op .( n = 1) (s am pl e si ze : 78 07 ) C ov er ag e: 2 7% 0.7 % 0. 5% n ew ly d ia gn os ed Ta rg et ed a t‐ ris k gr ou ps M ig ra nt s (n = 1 )( sa m pl e si ze :3 22 6) 10 0% C ov er ag e: 2 8. 7% 2. 2% H C V N = 3 s tu di es 34 ,3 9, 40 Q ua lit y: 3 st ud ie s N A Ta rg et ed a tp at ie nt s G en er al p op .( n = 1) (s am pl e si ze : 78 07 ) C ov er ag e: 2 7% 1. 8% 0. 7% n ew ly d ia gn os ed Ta rg et ed a t‐ ris k gr ou ps G en er al p op .( n = 1) (s am pl e si ze :N R) M ig ra nt s (n = 1 )( sa m pl e si ze :3 22 6) 10 0% C ompa ra tiv e st ud y: b ef or e 10 5 36 te st s; d ur in g 12 1 70 C ov er ag e: 2 8. 7% C om pa ra tiv e st ud y: 9 .9 % b ef or e; 7. 9% d ur in g 0. 3% A bb re vi at io ns :E D ,e m er ge nc y de pa rt m en t; H BV ,h ep at iti s B vi ru s; H C V, h ep at iti s C v iru s; H IV ,h um an im m un od ef ic ie nc y vi ru s; N A ,n ot a pp lic ab le ;N R ,n ot re po rt ed ;o ra l, or al s am pl in g. aN um be ro ft es ts is o nl y re po rt ed h er e if no d at a on c ov er ag e ar e av ai la bl e. T A B LE 2 (Co nti nue d)
HBVandHCVtestingcoveragewerehighest(24%and9%,respec-tively)aftercomputer‐assistedpersonalinterviewing.60 Acceptabilityandfeasibilityoftestinginitiativesinotherhealth-caresettingswerereportedbythreestudies.44,58,60Onestudyon rapidDBStestingforHCVinpharmaciesshowedthatpatientsfound thepharmacyagoodplacetobetested,butsomepatientsweresus- piciouswhenofferedtestingduetopreviousexperienceofdiscrim-inationatpharmacies.58Amongpharmacystaff,rapidDBStesting forHCVwasfoundtobesimpletoperform.Rapidtestinginaclinic forpeoplewithnohealthinsurancewaspreferredoverserological testsby76%oftheparticipants,withreasonsincludinglessstress with same‐day results and more practical use. Half of the clinical
staffsaidthatrapidtestingsimplifiedtheirconsultation.44Astudy
that compared computer‐assisted interviewing to paper‐and‐pen interviewsinSTIclinicsfoundthatcomputer‐assistedinterviewing
encouragedthedisclosureofsexualrisk‐takingbehaviourmore.60
3.4 | Testing initiatives in community settings
Forty‐onestudieswereretrievedthatformedtheevidencebasefor
theeffectivenessoftestinginitiativesandinterventionsincommu-nitysettings.34,43,64‐90Resultsofinitiativesperformedincommunity
settingsarepresentedinTable4.Resultsforallinterventiontypes arepresentedfirst,stratifiedbysettingtype.
Coverage rates above 80% were reported by two testing
ini-tiatives conducted in community drugs services,64,65 although the
othersixstudiesconductedinthissettingreportedlowercoverage.
HCVpositivityrateswerehighinthissetting.34,64,70,75,77,81Outreach
testing activities and testing initiatives conducted in fixed commu-nitysitesyieldedcoverageratesofupto83.3%and71.1%,respecti
vely.66,69,72‐74,76,79,80,82,83,85,86,88,89Ingeneral,onlinetestinginitiatives
reported somewhat lower coverage rates relative to other settings
(4.4% and 16.2%),78,90 as well as low positivity rates for HBV (0%
and 0.2%). Across all settings, novel testing initiatives yielded rela- tivelyhighcoverageratesingeneral,witheightoutoffourteenstud-ies that reported coverage testing more than 50% of the targeted
population.34,43,64,65,67‐69,73‐75,80,81,85,87,88
Twocomparativestudiesreportedonnoveltestinginitiativestar-getedtoriskgroups.Incommunitydrugservices,onsiteoralsampling ofdrugusershadareportedcoverageof100%,comparedto7.4%for standard serological testing which was performed offsite, at an STI
clinic.65Anotherstudycomparednurse‐deliveredoutreachscreening atasaunaandself‐sampledDBSpostaltestingkitstostandardscreen-ingatanSTIclinicforMSMandreportedcoverageratesforthefirst30 usersofeachservice:83.3%foroutreach,53.3%forDBSpostalkitsand 100%forstandardscreening.Positivityrateswerehigherforoutreach (4%hadaclearedHBVorHCVinfection)andDBSpostalkits(25%hada clearedHBVorHCVinfection),comparedto0%forthosetestedinSTI clinics.Inaddition,almostallSTIclinicusershadbeentestedpreviously, comparedtojustoverhalfofsaunaandpostalkitusers.88 AnRCTcomparedoutreachtestinginsheltersforunderprivileged people,involvinggroupeducationsessionsandindividualconsultations duringwhichsubjectswereofferedtesting,eitheratahealthcentreor onsite.Coveragewas42.8%athealthcarecentresand59.7%onsite. Coverageinacontrolgroupthatreceivednointerventionduringthe sametimeperiodwas1.5%.79 EducationalsessionsforPWIDattend-ingharmreductioncentrescontributedtoanincreasedcoveragefrom 44%to85%,comparedtoanincreaseof51to78%inacontrolgroup
that received no educational intervention.77 During an HCV action
planinScotland,implementationofDBStestingandawarenessactivi-tiesresultedina3‐foldincreaseinHCVtestingcoverageincommunity drugservices(RR3.5,P<0.001)anda12‐foldincreaseinpositivetest results(RR=12.1,P<0.001).InEngland,anationalframeworkofactiv-itiestoimproveprevention,diagnosisandtreatmentofHCVledtoan increasefrom26%coveragein2000(priortothenationalprogramme) to62%coveragein2008.34,70Lastly,acommunicationandtechnology HBVtestinginitiativeinvolvingInternet‐basedrecruitmentofmigrants forscreeningyieldedcoverageof43.5%‐46.0%,althoughcomparison between different strategies (behavioural tailoring, behavioural plus
culturaltailoringorgenericinformation)showednodifferences.84 Eightstudiesprovideddataonthefeasibilityandacceptability oftestingincommunitysettings.Testacceptanceratesrangedfrom 28.4%to98.2%68,69,74,90 withthehighestratesreportedintwostud-ieswhichdescribedoutreachinitiativestargetingdrugusers,oneof whichusedoralsampling.68,69 Anotherstudyreportingonanout-reachtestinginitiativetargetedatChinesemigrantsreportedthat 100%ofinterviewedrecipientsfoundaninformationsessionprior totestingusefulandjust5%respondedthatthetestcauseddiscom-fort.85Astudydescribinganoralsamplinginitiativeatahomeless shelterreportedthat91%oftheparticipantswouldagreetoscreen-ingorthoughtanoralswabtestwasacceptableformoftesting.80 AnonlineplatformofferinghomesamplingkitsforHBV,HIVand STIsreportedthatofthesamplesreturned,15%wereprovidedin-sufficientbloodand39%ofparticipantsreporteddifficultiestaking bloodsamples.However,95%saidtheywouldusetheonlineservice againand93%wouldrecommendittofamilyandfriends.87Atesting initiativetargetedatuniversitystudentswithanacceptancerateof 37%reportedthattherewasnoindicationorreportsfromstudents orstaffthatthetestingofferandprocesswerestigmatizingorun-desirable.74Lastly,aculturallytargetedscreeningprojectinvolving campaignsandeducationalmeetingsforTurkishmigrantswascon-sideredgoodandunderstandableby97%oftheparticipants.76
3.5 | Testing initiatives in multiple/
unspecified settings
In addition, two studies were retrieved which provided data on initiativesconductedinmultiplesettingsordidnotspecifyresults persetting.OnestudyexaminedtheoutcomesofaFrenchnational HCV prevention programme implemented in 1999 and reported thattestingincreasedfrom2000to2005by45%butdecreasedby 10%in2006.Positivityratesdecreasedfrom4.3%to2.9%.91 Afur-therstudydescribinganationaltestingprogrammewhichinvolved awareness‐raisingactivitiesreportedoutcomesacrossallsettings; 19058testsweretakenbefore;and29045testsweretakenduring theprogrammeandpositivityratesdecreasedfrom9.6%to6.8%.34
TA B L E 3 Evidencebasefortheeffectivenessoftestinginitiativesinotherhealthcaresettings Intervention
Studies included
Quality of evidence Setting/target population Coverage/number of tests/testedc Positivity rate
Riskgroup testing HBV N=6studies48,54,56,57,61,62 Quality: 6studiesNA Migrantclinic(n=2)(sample size:516and4078) Coverage:87%and91.4% 6.0%and7.7% Prisons(n=2)(samplesize:
3468a) Numbertested:160Coverage:65.3% 0%and4.4%1.5%newly
diagnosed Drugservices(n=1)(sample size:287and2024) Coverage:34%and69% 33%and48% (anti‐HBc) Clinicforpeoplewithnohealth insurance(n=1)(samplesize: NR) Coverage:90%whenscreening isproposedduringaprevention interview;71%withoutinterview 6.9% HCV N=15stud-ies43,45,47‐49,51,52,56‐59,61‐64 Quality: 3studiesacceptable 1studylow 11studiesNA STIclinics(n=1)(samplesize: 3365) MSM(n=1) Coverage:69% 0.65% Prisons(n=3)(samplesize: 3468‐3600a) Numbertested:160Coverage:64.6% Comparativestudy(DBS):ORs foreffectoftheinterventionon testingrate:OR:0.86;95%CI: 0.71‐1.06;P=0.153 22.8%and33.8% 1.5%newly diagnosed Drugservices(n=3)(sample size:287‐2566) Coverage:53%‐84.2% 26%‐61% Antenatalservices(n=1)(sam-plesize:4369) 28.3%receivedtargetedscreening Comparativestudy: 1.3%(compared to1.7%universal screening;differ-encebetweenthe twoNS) Migrantclinic(n=1)(sample size:4078) Coverage:90.8% 3.6% Pharmacies(n=2)(sample size:143intervention,561 control;244conventionalcare pathway;262pharmacistcare pathway) Comparativestudy(DBS):30% intervention;13%control.OR: 2.25(95%CI1.48‐3.42) Comparativestudy:24%coverage conventionalcarepathway;36% pharmacistcarepathway Comparativestudy: 25.9%conventional carepathway 26.5%;pharmacist carepathway Drugclinicsandprisons(n=1) (samplesize:6550interven-tion,5800control) Comparativestudycoverage(DBS) intervention:8.4%before,20.6% duringintervention control:7.7%before,5.4%during intervention 32%(overall) Publichealthclinic(n=1)(sam-plesize:81and497) Coverage:90%and98% 60%(overall) Specialistservicesb (n=1)(sam-plesize:1322) 55% Clinicforpeoplewithnohealth insurance(n=1)(samplesize: NR) Numbertested/tests:1196 Coverage:90%whenscreening isproposedduringaprevention interview;71%withoutinterview 5.8% (Continues)
Intervention
Studies included
Quality of evidence Setting/target population Coverage/number of tests/testedc Positivity rate
Universaltesting HCV
N=1study47
Quality: NA
Antenatalservices(n=1)(No
samplesize) Numbertested:4222 Comparativestudy:1.7%
(comparedto1.3% targetedscreening; differencebetween thetwoNS) Noveltesting HBV N=3studies44,50,56 Quality: 1studyhigh 1studyacceptable 1studyNA Clinicforpeoplewithnohealth insurance(n=1)(samplesize: 162intervention,162control) Coverage:64.2%(serology);98.2% (RT) Comparativestudy: 9.6%(serology); 8.1%(RT) Antenatalservices(n=1) (Samplesize:41pre‐interven-tion;58post‐intervention;91 pre‐control;68post‐control) Comparativestudy: Coverage(DBS):62%pre‐interven-tion;97%post‐intervention;40% pre‐control;39%post‐control Comparativestudy: 0%‐3%pre‐inter-vention;3%‐22% post‐intervention; 6%‐8%pre‐con-trol;2%‐9% post‐control Prisons(n=1)(samplesize:NR) Numbertested(DBS):160 0% HCV N=11 studies35,42‐45,49,52,56,58,59,64 Quality: 1studyhigh 4studiesacceptable 1studylow 5studiesNA Clinicforpeoplewithnohealth insurance(n=1)(samplesize: 162intervention,162control) Coverage:64.2%(serology);98.2% (RT) Comparativestudy:3.8%(serology); 2.5%(RT) Drugservices(n=3)(sample size:25‐1123) Numbertested/tests(DBS):266 Coverage(FibroScan):20% Coverage(DBS):84.2% 31.2%and35% Prisons(n=2)(samplesize: 3600a) Numbertested(DBS):160Comparativestudy(DBS):ORsfor effectoftheinterventionontest-ingrate:0.86;95%CI:0.71‐1.06; P=0.153 33.8% Drugclinicsandprisons(n=1) (samplesize:6550interven-tion,5800control) Comparativestudycoverage(DBS) intervention:8.4%before,20.6% duringintervention control:7.7%before,5.4%during intervention 32%(overall) STIclinicsandGPpractices (n=1)(samplesize:29600) Coverage(oral):15.2% 0.6% Specialistservicesb (n=1)(sam-plesize:1322) 55% Pharmacies(n=2)(sample size:143intervention,561 control;244conventionalcare pathway;262pharmacistcare pathway) Comparativestudycoverage(DBS): 30%intervention;13%control. OR:2.25(95%CI1.48‐3.42) Comparativestudycoverage(DBS): 24%conventionalcarepathway; 36%pharmacistcarepathway Comparativestudy: 25.9%conventional carepathway; 26.5%pharmacist carepathway TA B L E 3 (Continued) (Continues)
4 | DISCUSSION
Weundertookacomprehensivesystematicreviewtocollect,syn-thesizeandanalyseavailabledataonHBV/HCVtestingstrategies across the EU/EEA. Available evidence on testing strategies was analysedqualitativelyacrossprimaryhealthcare,hospitalsettings, otherhealthcaresettingsandcommunitysettings. Primaryhealthcareisusuallythefirstpointofcontactthatpa- tientswillhavewiththehealthcaresystem.Therefore,itisanim-portantsettingfortestinganumberofpopulationgroupsthatmay notpresenttoothersettingsandmaybeespeciallyimportantfor specificpopulationgroupsincludingex‐PWID.92However,according toaUKstudy,ofallHCVdiagnostictestsperformedinapoolof
sentinel laboratories, only 16% were requested by GPs.93 Overall,
theevidenceretrievedontheeffectivenessoftestinginterventions toimproveHBVandHCVtestingcoverageinprimaryhealthcare waslimited,largelyrestrictedtoWesternEuropeancountries,and focused mainly on targeted test offer to risk groups such as mi-grants,PWIDandhomeless.Apreviousmeta‐analysisassessingthe effectiveness of targeted HCV testing interventions found these strategiestobeeffectiveindiagnosingcasesandincreasinguptake
oftreatment,particularlywhenstrategiesinvolvedpractitioners.18
In this review, limited evidence indicated that educational inter-ventionstargetingGPsandcampaignstargetingthepublic,GPsor Intervention
Studies included
Quality of evidence Setting/target population Coverage/number of tests/testedc Positivity rate
Education HCV N=1study42 Quality: High Targetedat‐riskgroups Drugservices(n=1)(sample size:52) Comparativestudycoverage:7% control;20%intervention(NS) WillingnessforHCVscreening: Control:89%;56%;67%(baseline; after1mo;after3mo) Intervention:86%;96%;100%; 77%;100%(baseline;afterinfo; after1mo;after3mo;after FibroScan) Campaign HCV N=2studies34,46 Quality: 2studiesNA Targetedatgeneralpop. Mixedsettings(n=1),STI clinic/Prison(n=1) (samplesize:4200and33667a) Coveragefrommixedsettings: 2.3%‐3.7% Comparativestudy: prison:44.4%be-fore,27.0%during intervention STIclinic:5.2% before,3.5%during intervention 45%‐53%newly diagnosed Guideline HCV N=1study53 Quality: NA STIclinics(n=1)(samplesize: NR) Comparativestudy:Coverage:4.7%before,13.6%after intervention Clinicaldecision‐ makingtools Computer‐as-sistedself/ personalinter-viewing(CASI/ CAPI)vspaper &pen(PAPI, control) HBV N=1study60 Quality: High STIclinic(n=1)(samplesize: 2318) Comparativestudy: Coverage:PAPI:16%;CAPI:24%; CASI:17% Comparativestudy: AnySTI:PAPI:10%; CAPI:11%;CASI: 10% HCV N=1study60 Quality: High STIclinic(n=1)(samplesize: 2318) Comparativestudy:Coverage:PAPI:3%;CAPI:9%; CASI:3% Comparativestudy: AnySTI:PAPI:10%; CAPI:11%;CASI: 10% Abbreviations:BBV,bloodbornevirus;CASI,computer‐assistedself‐interviewing;CAPI,computer‐assistedpersonalinterviewing;CI,confidence interval;DBS,driedbloodspot;GP,generalpractitioner;HBV,hepatitisBvirus;HCV,hepatitisCvirus;HIV,humanimmunodeficiencyvirus;mo, months;MSM,menwhohavesexmen;NA,notapplicable;NS,notsignificant;OR,oddsratio;PAPI,pen‐and‐paperinterviewing;RT,rapidtest;STI, sexuallytransmittedinfection. aDenominatornotreportedforallstudies. bspecialistservicesmainlytargetingPWID. cNumberoftestsisonlyreportedhereifnodataoncoverageareavailable. TA B L E 3 (Continued)
riskgroupsmayhavebenefit,particularlywheneducationandcam-paignsarecombined,andthatofferingHCVtestinginthissetting wasacceptabletopatients.ArecentEU‐fundedprojectinvestigated optionstofurtherexpandtestingopportunitiesformigrantcommu- nitiesinthissettingandhasproducedausefultoolkitthatmaysup-portitsimplementation.94 Hospitalsareanotherimportantlocationfortesting,withmore thanhalfofallHCVtestsperformedinUKsentinellaboratoriesre- questedbyhospital‐basedclinicians,especiallyhepatologyandin-fectiousdiseasedepartments.93However,theevidenceontesting interventionsaimedatimprovingHBVandHCVtestinginhospital settings retrieved was relatively limited. In many studies, testing forHBVandHCVwasperformedaspartofaBBVscreeningtest includingHIVtesting.Specifichospitaldepartmentscouldbestra-tegic settings to capture patients belonging to certain risk groups and encourage and facilitate testing. Targeted testing to individu- alsfromriskgroups(migrantsandpsychiatricpatients)wasimple-mentedinhospitaldepartmentswithgenerallyhighpositivityrates andfairlyhighcoveragelevelsinstudiesinvolvinghospitalinpatients or outpatients attending the hospital for reasons other than test-ing,althoughuptakewaslowerwhenparticipantswereinvitedto cometothehospitalforthesolepurposeoftesting.Thisemphasizes theimportanceofpractitionersconsideringopportunistictestoffer forpatientsthatmaybeatrisk.Twostudiesonuniversaltestingin emergencydepartmentsreportedlowerpositivityratescompared tootherstrategies;however,thiscouldbeanimportantstrategyfor casefindinginareasthatareknowntohaveahighprevalenceor burdenofdisease,orwhereinjectingdruguseisprevalent. Evidencerelatingtootherhealthcaresettingsfoundsimilarvari-ationincoverageandpositivityrateswhichwereoftenhighwhen risk groups were targeted. This suggests that offering testing to groupsathighriskofinfectionatlocationstheyspecificallyattend forhealthpurposes,suchashealthclinicsformigrants,couldbean effective method for case finding. Locations frequently visited by certain groups, where staff are medically trained, present an op-portunitythatcanbeexploitedfortesting.Forexample,individuals receivingOSTaccesspharmaciesonaregularbasistoreceivemedi-cation.PeoplereceivingOSTwerefoundtobemorelikelytoaccept
DBS testing at the pharmacy than testing from other providers.58
Furthermore,pharmaciesinsomecountriescanprovidetreatment
forthosefoundtobeinfected.59Noveltestingapproachessuchas
rapid testing and DBS were frequently employed in testing initia- tivesinthevarioushealthcaresettingsandwerefoundtobeeffec-tiveinincreasingcoverageinanumberofcomparativesettings,as wellasbeinghighlyacceptableamongusersandtestingstaff.Rapid testingallowspoint‐of‐caretesting,simplifyingthetestingprocess asthosetesteddonothavetovisitoutsidetestingcentresorwaitto pickupresults,althoughitiscrucialtoensurethatindividualstesting positivearelinkedtoongoingcare.Anotherstrategyidentifiedthat mayhelptoimprovetestingcoverageinotherhealthcaresettings
included implementation of clinic‐specific guidelines.53 These may
beparticularlyusefulincountrieswherenationalhepatitistesting
guidelinesarenotavailable.8
Community‐based testing services, both fixed‐site and out-reach‐based, represent potential sites to target specific pop-ulation groups and individuals who may be at increased risk of infectionandwhoarenotincontactwithformalhealthservices. Testing in community settings can be adapted and made
acces-sible for these groups in order to maximize testing uptake15;
however,agapinpolicyoncommunityandoutreachtestingwas reportedbysomeEUcountriessuggestingthatitisnotalwaysim-plementedatscale.8 Yet,weidentifiedconsiderableevidencesup-portingtheimplementationofcommunity‐basedtestingservices. Accordingtotheevidence,testingservicesincommunitysettings oftenresultedinhighcoverageandhighpositivityrates,particu-larlywhentargetingMSM,peoplewithmigrationbackgroundand drugusers,althoughinfluencedbytheunderlyingepidemiology. Outreachactivities,includingshort‐termtestingfacilities,mobile testingservicesandstreet‐basedoutreach,werealsoshowntobe highlyeffectiveintargetingthesepopulationgroups,whilebeing highly adaptable. Available evidence also suggested that use of oral sampling and DBS increase testing coverage and oral sam-pling was considered acceptable in community‐based services. Comparedtootherinfectiousdiseases,themarketforHBVand HCV rapid tests is less abundant, and the scale of
implementa-tioniscomparativelylimited.8However,DBSandrapidtestsare
recommendedbytheWHOtofacilitatetestinginsettingswhere
no laboratory is available.95 Finally, educational interventions,
campaignsandnationalprogrammeswerealsofoundtoincrease community‐based testing coverage for HBV and HCV, including among migrant communities. An earlier systematic review on chronic HBV testing in community settings identified common features of successful screening interventions that included strategiestoincreasecommunityawarenessandknowledgeand incorporatedthetargetpopulation'svaluesinthedesignandim-plementationoftheprogrammeandwereabletoprovidelowcost
orfreeaccesstocare.21
ContacttracingandpartnernotificationforHBVandHCVhave recognized public health benefits, such as controlling the spread, reducingmorbidityandmortality,reachingpeoplewithasymptom-
aticinfectionandpeoplewhodonotpresentfordiagnosis,coun-selling and treatment96 and have been shown to be effective.50
Partner notification may be implemented in different ways,97 and
approachesdesignedtomeetdiversestructural,societalandlegal barriers.However,ourstudyidentifiedverylimitedevidenceonthis approach,possiblyduetoitssuboptimalimplementationinEU/EEA, asreportedinapreviousstudy.98 ArecentWHOguidelinerecommendedthatHCVscreeningin birthcohortsofolderpersonsathigherriskofinfectionandmor-bidity may be applied in populations with overall lower general
prevalence,whereindicatedbythelocalepidemiology.95,99Recent epidemiologicalstudiestoassesstherelevanceofsuchanapproach havebeenperformedinsomeEU/EEAcountries,demonstratingthe growinginterestinthistestingstrategyandsuggestingapossible roleofthisapproachintheeliminationeffort.100-103Theevidence resultingfromourstudy,however,indicatedthattheutilityofbirth
T A B LE 4 Ev id en ce b as e fo rt he e ff ec tiv en es s of te st in g in iti at iv es in c om m un ity s et tin gs Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Ta rg et po pu la tio n Te st o ff er C ov er ag e/ nu mb er o f t es ts /t es ted c Po sit iv it y r at e A ll pe rs et tin g H BV N=1 8 st ud ie s 65 ,6 6, 69 ,7 2‐ 76 ,7 8,7 9, 82 ‐8 9 Q ua lit y: 3 st ud ie s ac ce pt ab le 15 s tu di es N A C om m un ity ‐b as ed te st in g si te s (n = 2 )( sa m pl e si ze :5 12 a nd 7 44 ) C ov er ag e: 3 7% a nd 7 1. 1% 8. 3% a nd 9 .4 % O ut re ac h (n = 1 1) (s am pl e si ze : 30 ‐8 6 00 0) 10 0% N um be rt es te d/ te st s: 2 99 ‐1 09 0 C ov er ag e: 9 .8 % ‐7 6. 2% C om pa ra tiv e st ud y co ve ra ge :1 .5 % c on tr ol ; 42 .8 % in te rv en tio n (o ut re ac h ed uc a-tio n + te st in g at h ea lth c en tr e) ;5 9. 7% in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: C ov er ag e: 5 3. 3% D B S po st al k it; 8 3. 3% n ur se ‐le d sa un a ou tr ea ch te st in g; 1 00 % s ta nd ar d ST Ic lin ic te st in g 0% ‐1 2. 4% C om pa ra tiv e st ud y: 0 % c on tr ol ;2 .1 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;4 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) D ru g se rv ic es / ha rm re du ct io n pr og ra m m es (n = 2 )( sa m pl e si ze : in te rv en tio n 27 ,c on tr ol 2 8; 3 91 ) C ov er ag e: 4 9% C om pa ra tiv e st ud y co ve ra ge :I nt er ve nt io n (o ra l) 92 .6 % ;c on tr ol (r ef er ra l) 7. 4% 20 % (a nt i‐H B c) O nl in e to ol s (n = 3 )( sa m pl e si ze : 26 5 an d 14 00 a) C ov er ag e: 1 6. 2% 43 05 s el f‐ sa m pl in g ki ts re qu es te d; 4 8% o f req ues ted ki ts re tu rn ed C om pa ra tiv e st ud y co ve ra ge :4 3. 9% in te r-ve nt io n (b eh av io ur al ta ilo rin g pl us c ul tu ra l ta ilo rin g) (O R 0. 94 9 5% C I0 .6 9‐ 1. 26 ); 43 .5 % in te rv en tio n (b eh av io ur al ta ilo rin g) (O R 0. 88 9 5% C I0 .6 5‐ 1. 19 )4 6. 0% c on tr ol 0% a nd 0 .2 % H C V N = 2 3 st ud ie s 34 ,4 3,6 4,6 5,6 7‐ 75 ,7 7‐ 83 ,8 8‐ 90 Q ua lit y: 3 st ud ie s ac ce pt ab le 20 s tu di es N A C om m un ity ‐b as ed te st in g si te s (n = 3 )( sa m pl e si ze :3 2‐ 74 4) N um be rt es te d/ te st s: 9 5 C ov er ag e: 3 7% a nd 7 1. 1% 0% ‐6. 3% (Co nt in ue s)
Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Ta rg et po pu la tio n Te st o ff er C ov er ag e/ nu mb er o f t es ts /t es ted c Po sit iv it y r at e O ut re ac h (n = 7 )( sa m pl e si ze : 30 ‐6 5 00 0) 10 0% N um be rt es te d/ te st s: 4 91 ‐5 20 C ov er ag e: 9 .8 % ‐7 6. 2% Compar ativ e study c ov er ag e: 1.5% c on tr ol; 42.8% in terv en tion (outr each educ a-tion + testing a thealth c en tr e); 59.7% in ter -ven tion (outr each educ ation + onsit e test) C om pa ra tiv e st ud y co ve ra ge :C ov er ag e: 53 .3 % D B S po st al k it; 8 3. 3% n ur se ‐le d sa un a ou tr ea ch te st in g; 1 00 % s ta nd ar d ST I cl in ic te st in g 0. 8% ‐3 7. 6% C om pa ra tiv e st ud y: 0 % c on tr ol ;3 .2 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;2 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: H BV /H C V a ct iv e; cl ea re d in fe ct io n 6. 25 % ;2 5% D B S po st al k its 0% ;4 % n ur se ‐le d sa un a ou tr ea ch te st in g 0% ;0 % s ta nd ar d ST Ic lin ic te st in g D ru g se rv ic es /h ar m re du ct io n pr og ra m m es (n = 8 )( sa m pl e si ze : 27 ‐53 99 ) C om pa ra tiv e st ud y: 6 7 te st s be fo re 9 73 du ring C ov er ag e: 4 2%‐ 84 .2% C om pa ra tiv e st ud y co ve ra ge :I nt er ve nt io n (o ra l) 10 0% ;c on tr ol (r ef er ra l) 7. 4% C om pa ra tiv e st ud y: 4 4% in te rv en tio n; 5 1% co nt ro l 18 % ‐53% C om pa ra tiv e st ud y: 1 5% in te rv en tio n; 14 % c on tr ol C om pa ra tiv e st ud y: 1 9. 4% b ef or e; 3 8. 1% du ring O nl in e to ol s (n = 2 )( sa m pl e si ze : 26 5 an d 96 53 ) 15 .3 % C ov er ag e: 4 .4 % a nd 1 6. 2% 4. 5% a nd 4 .6 % C om bi ne d se tt in gs (n = 3 )( sa m pl e si ze :2 40 a nd 5 64 a) 73 % N um be rt es te d/ te st s: 2 66 C ov er ag e: 3 7% a nd 72 % 4. 8% ‐3 5% Ri sk g ro up te st in g H BV N=1 6 st ud -ie s 65 ,6 6, 69 ,7 2,7 3,7 5,7 6,7 8,7 9, 82 ‐8 6, 88 ,8 9 Q ua lit y: 3 st ud ie s ac ce pt ab le 13 s tu di es N A D ru g us er s (n = 3 )( sa m pl e si ze : in te rv en tio n 27 ,c on tr ol 2 8; 3 91 a) 10 0% C ov er ag e: 4 9% ‐7 6. 2% C om pa ra tiv e st ud y co ve ra ge :i nt er ve nt io n (o ra l) 92 .6 % ;c on tr ol (r ef er ra l) 7. 4% 0% 20% (a nt i‐H B c) H om el es s (n = 1 )( sa m pl e si ze :N R) N um be rt es te d/ te st s: 4 91 12 .4 % M ig ra nt s (n = 9 )( sa m pl e si ze : 74 4‐ 65 0 00 a) N um be rt es te d/ te st s: 2 99 ‐1 09 0 C ov er ag e: 9 .8 % ‐7 1. 1% C om pa ra tiv e st ud y co ve ra ge :4 3. 9% in te r-ve nt io n (b eh av io ur al ta ilo rin g pl us c ul tu ra l ta ilo rin g) (O R 0. 94 9 5% C I0 .6 9‐ 1. 26 ); 43 .5 % in te rv en tio n (b eh av io ur al ta ilo rin g) (O R 0. 88 9 5% C I0 .6 5‐ 1. 19 )4 6. 0% c on tr ol 0. 6% ‐8 .7 % T A B LE 4 (Co nti nue d) (Co nt in ue s)
Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Ta rg et po pu la tio n Te st o ff er C ov er ag e/ nu mb er o f t es ts /t es ted c Po sit iv it y r at e M SM (n = 2 )( sa m pl e si ze :3 0‐ 26 5) C ov er ag e: 1 6. 2% C om pa ra tiv e st ud y: c ov er ag e: 5 3. 3% D B S po st al k it; 8 3. 3% o ut re ac h sa un a nu rs e; 10 0% s ta nd ar d ST Ic lin ic 0% Com pa ra tiv e st ud y: H BV /H C V a ct iv e; cl ea re d in fe ct io n 6. 25 % ;2 5% D B S po st al k its 0% ;4 % n ur se ‐le d sa un a ou tr ea ch te st in g 0% ;0 % s ta nd ar d ST Ic lin ic te st in g U nder pr iv ile ge d pe opl e b(n = 1 ) (s am pl e si ze :8 11 c on tr ol ;2 22 inte rv ent io n; 2 43 inte rv en -tio n + on si te te st C om pa ra tiv e st ud y co ve ra ge :1 .5 % c on tr ol ; 42 .8 % in te rv en tio n (o ut re ac h ed uc a-tio n + te st in g at h ea lth c en tr e) ;5 9. 7% in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: 0 % c on tr ol ;2 .1 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;4 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) H C V N = 2 0 st ud ie s 43 ,6 4,6 5,6 7‐ 73 ,7 5, 76 ,7 8‐ 83 ,8 9, 90 Q ua lit y: 2 st ud ie s ac ce pt ab le 18 s tu di es N A D ru g us er s (n = 6 )( sa m pl e si ze : 27‐ 96 53 ) 10 0% N um be rt es te d/ te st s: 2 66 C ov er ag e: 4 9% ‐8 4. 2% C om pa ra tiv e st ud y co ve ra ge :i nt er ve nt io n (o ra l) 10 0% ;c on tr ol (r ef er ra l) 7. 4% 31 .2%‐ 41 % PW ID (n = 3 )( sa m pl e si ze :2 40 a nd 34 63 a) 73 % N um be rt es te d/ te st s: 2 4‐ 20 2 C ov er ag e: 4 2% a nd 72 % 18 % a nd 2 0. 3% H om el es s (n = 2 )( sa m pl e si ze :N R) N um be rt es te d/ te st s: 9 5‐ 49 1 6. 3% a nd 1 3% M ig ra nt s (n = 5 )( sa m pl e si ze : 74 4‐ 65 0 00 ) N um be rt es te d/ te st s: 5 20 C ov er ag e: 9 .8 % ‐7 1. 1% 0. 3% ‐4 .7 % M SM (n = 2 )( sa m pl e si ze :3 0‐ 26 5) C ov er ag e: 1 6. 2% C om pa ra tiv e st ud y: c ov er ag e: 5 3. 3% D B S po st al k it; 8 3. 3% o ut re ac h sa un a nu rs e; 10 0% s ta nd ar d ST Ic lin ic 4. 6% C om pa ra tiv e st ud y: H BV /H C V a ct iv e; cl ea re d in fe ct io n 6. 25 % ;2 5% D B S po st al k its 0% ;4 % n ur se ‐le d sa un a ou tr ea ch te st in g 0% ;0 % s ta nd ar d ST Ic lin ic te st in g U nder pr iv ile ge d pe opl e b(n = 1 ) (s am pl e si ze :8 11 c on tr ol ;2 22 inte rv ent io n; 2 43 inte rv en -tio n + on si te te st C om pa ra tiv e st ud y co ve ra ge :1 .5 % c on tr ol ; 42 .8 % in te rv en tio n (o ut re ac h ed uc a-tio n + te st in g at h ea lth c en tr e) ;5 9. 7% in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: 0 % c on tr ol ;3 .2 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;2 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) Ri sk g ro up s (n = 1 )( sa m pl e si ze : 96 53 ) 15 .3 % C ov er ag e: 4 .4 % 4. 5% T A B LE 4 (Co nti nue d) (Co nt in ue s)
Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Ta rg et po pu la tio n Te st o ff er C ov er ag e/ nu mb er o f t es ts /t es ted c Po sit iv it y r at e No ve lt es tin g H BV N=8 s tu di es 65, 69 ,7 3‐ 75, 85, 87 ,8 8 Q ua lit y: 1 st ud y ac ce pt ab le 7 st ud ie s N A D ru g us er s (n = 3 )( sa m pl e si ze : in te rv en tio n 27 ,c on tr ol 2 8; 3 91 a) 10 0% C ov er ag e (D B S) :4 9% C ov er ag e (F ib ro Sc an ): 76 .2 % C om pa ra tiv e st ud y co ve ra ge :i nt er ve nt io n (o ra l) 92 .6 % ;c on tr ol (r ef er ra l) 7. 4% 0% 20% (a nt i‐H B c) M ig ra nt s (n = 2 )( sa m pl e si ze : 21 0 00 a nd 6 5 00 0) N um be rt es te d/ te st s (D B S) :2 29 ‐1 12 6 8.7 % M SM (n = 1 )( sa m pl e si ze :3 0 pe r gr ou p) C om pa ra tiv e st ud y: c ov er ag e: 5 3. 3% D B S po st al k it; 8 3. 3% o ut re ac h sa un a nu rs e; 10 0% s ta nd ar d ST Ic lin ic C om pa ra tiv e st ud y: H BV /H C V a ct iv e; cl ea re d in fe ct io n 6. 25 % ;2 5% D B S po st al k its 0% ;4 % n ur se ‐le d sa un a ou tr ea ch te st in g 0% ;0 % s ta nd ar d ST Ic lin ic te st in g St ud en ts (n = 1 )( sa m pl e si ze :5 12 ) C ov er ag e (D B S) :3 7% 9. 4% G en er al p op (n = 1 )( sa m pl e si ze : N R) 43 05 s el f‐ sa m pl in g ki ts re qu es te d; 4 8% o f req ues ted ki ts re tu rn ed 0. 2% H C V N = 1 3 st ud ie s 34 ,4 3,6 4,6 5,6 7‐ 69 ,7 3‐ 75 ,8 0, 81 ,8 8 Q ua lit y: 1 st ud y ac ce pt ab le 12 s tu di es N A D ru g us er s (n = 7 )( Sa m pl e si ze : 27 ‐1 12 3) N um be rt es te d/ te st s (D B S) :2 66 C ov er ag e (D B S) :1 3% ‐4 9% C ov er ag e (F ib ro Sc an ): 76 .2 % C om pa ra tiv e st ud y co ve ra ge :I nt er ve nt io n (o ra l) 10 0% ;c on tr ol (r ef er ra l) 7. 4% C om pa ra tiv e st ud y (D B S) :3 ‐f ol d in cr ea se in te st in g (R R = 3. 5, P < 0 .0 01 ) 27 .5 % ‐53% C om pa ra tiv e st ud y (D B S) :1 2‐ fo ld in cr ea se in p os iti ve s (R R = 12 .1 ,P < 0 .0 01 ) PW ID (n = 2 )( sa m pl e si ze :2 40 a) 73 % (o ra l) N um be rt es te d/ te st s (D B S) :2 02 C ov er ag e (o ra l): 72 % 20 .3 % (o ra l) H om el es s (n = 1 )( sa m pl e si ze :N R) N um be rt es te d/ te st s (D B S) :9 5 6. 3% M ig ra nt s (n = 1 )( sa m pl e si ze : 65 0 00 ) N um be rt es te d/ te st s (D B S) :5 20 0. 8% M SM (n = 1 )( sa m pl e si ze :3 0 pe r gr ou p) C om pa ra tiv e st ud y: c ov er ag e: 5 3. 3% D B S po st al k it; 8 3. 3% o ut re ac h sa un a nu rs e; 10 0% s ta nd ar d ST Ic lin ic C om pa ra tiv e st ud y: H BV /H C V a ct iv e; cl ea re d in fe ct io n 6. 25 % ;2 5% D B S po st al k its 0% ;4 % n ur se ‐le d sa un a ou tr ea ch te st in g 0% ;0 % s ta nd ar d ST Ic lin ic te st in g St ud en ts (n = 1 )( sa m pl e si ze :5 12 ) C ov er ag e (D B S) :3 7% 0% T A B LE 4 (Co nti nue d) (Co nt in ue s)
Int er ve nt io n St ud ies in cl ud ed Q ual it y o f e vi den ce Ta rg et po pu la tio n Te st o ff er C ov er ag e/ nu mb er o f t es ts /t es ted c Po sit iv it y r at e Ed uc at io n H BV N=3 s tu di es 76 ,7 9, 89 Q ua lit y: 1 st ud y ac ce pt ab le 2 st ud ie s N A Ta rg et ed a t‐ ris k gr ou ps U nder pr iv ile ge d pe opl e b(n = 1 ) (s am pl e si ze :8 11 c on tr ol ;2 22 inte rv ent io n; 2 43 inte rv en -tio n + on si te te st ) M ig ra nt s (n = 2 )( sa m pl e si ze :1 50 0 an d 63 37 C ov er ag e: 1 1. 2% a nd 3 1% C om pa ra tiv e st ud y co ve ra ge :1 .5 % c on tr ol ; 42 .8 % in te rv en tio n (o ut re ac h ed uc a-tio n + te st in g at h ea lth c en tr e) ;5 9. 7% in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) 1. 1% a nd 2 .8 % C om pa ra tiv e st ud y 0% c on tr ol ;2 .1 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;4 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) H C V N = 4 s tu di es 76 ,7 7,7 9, 89 Q ua lit y: 1 st ud y ac ce pt ab le 3 st ud ie s N A Ta rg et ed a t‐ ris k gr ou ps U nder pr iv ile ge d pe opl e b(n = 1 ) (s am pl e si ze :8 11 c on tr ol ;2 22 inte rv ent io n; 2 43 inte rv en -tio n + on si te te st ) M ig ra nt s (n = 2 )( sa m pl e si ze :1 50 0 an d 63 37 ) PW ID (n = 1 )( sa m pl e si ze :8 8) C ov er ag e: 1 1. 2% a nd 3 1% C om pa ra tiv e st ud y co ve ra ge :1 .5 % c on tr ol ; 42 .8 % in te rv en tio n (o ut re ac h ed uc a-tio n + te st in g at h ea lth c en tr e) ;5 9. 7% in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: 78 % c on tr ol ;8 5% inte rv ent io n 0. 3% a nd 2 .4 % C om pa ra tiv e st ud y H C V :0 % c on tr ol ;3 .2 % in te rv en tio n (o ut re ac h ed uc at io n + te st -in g at h ea lth c en tr e) ;2 .8 % in te rv en tio n (o ut re ac h ed uc at io n + on si te te st ) C om pa ra tiv e st ud y: 1 4% c on tr ol ;1 5% inte rv ent io n C ampa ig n H BV N=4 s tu di es 66, 76, 85 ,8 6 Q ua lit y: 4 st ud ie s N A Ta rg et ed a t‐ ris k gr ou ps M ig ra nt s (n = 4 ) (s am pl e si ze :6 33 7‐ 29 0 00 ) N um be rt es te d/ te st s: 2 99 a nd 1 09 0 C ov er ag e: 1 1. 2% a nd 1 5. 3% 2.8 % ‐8. 7% 2. 9% n ew ly d ia gn os ed H C V N = 3 s tu di es 34 ,76 ,9 0 Q ua lit y: 3 st ud ie s N A Ta rg et ed a t‐ ris k gr ou ps M ig ra nt s (n = 1 )( sa m pl e si ze : 63 37 ) C ov er ag e: 1 1. 2% 0. 3% Ta rg et ed a tG Ps a nd th os e at ri sk G en er al p op .( n = 1) (s am pl e si ze : 53 39) C om pa ra tiv e st ud y nu m be rt es te d/ te st s: 6 7 be fo re ;9 73 d ur in g C om pa ra tiv e st ud y: 1 9. 4% b ef or e; 3 8. 1% du ring Ta rg et ed a tp ub lic G en er al p op . (n = 1 )( sa m pl e si ze :9 65 3) 15 .3 % w eb si te v is ito rs o ff er ed te st in g. C ov er ag e: 4 .4 % 4. 5% N at io na l pro gr am m e H C V N = 2 s tu di es 34 ,7 0 Q ua lit y: 2 st ud ie s N A PW ID (n = 1 ) (s am pl e si ze :3 46 3) C ov er ag e: 4 2% 18 % G en er al p op ul at io n (n = 1 )( sa m pl e si ze: 53 99 ) C om pa ra tiv e st ud y: c ov er ag e be fo re a nd af te rp ro gr am m e: 2 6% (i n 20 00 ); 62 % (i n 20 08) C om pa ra tiv e st ud y: 1 9. 4% b ef or e; 3 8. 1% du ring T A B LE 4 (Co nti nue d) (Co nt in ue s)
