HIV treatment and care begins with diagnosis. In recent years, there has been an increase in the uptake of HIV testing, but a majority of people living with HIV do not know their status (WHO 2010). An estimated 30% of people living with HIV in Canada (Boulos 2006) and 90% worldwide (UNAIDS 2007) are not aware of their diagnosis. Delays in diagnoses may lead to lost opportunity for HIV prevention and treatment which may result in poorer health outcomes. Low use and uptake of HIV testing and treatment in populations at elevated risk for HIV infection further exacerbates the problem. Evidence suggests that low use and uptake of HIV testing is associated with limited access to services (Ochan‐Lokol 2004), logistical problems such as transport and costs (Helleringer 2009)  and with HIV related stigma (Obermeyer 2007;  UNAIDS 2007; Vidanapathirana 2009), fear and denial (Foster 2007). In high income countries where services for diagnosis and treatment are readily available, stigma has appeared as a strong barrier for utilizing the available services (Vidanapathirana 2009).  Also, lack of social support within communities, particularly, among marginalised groups such as women, immigrants, Aboriginal peoples, is widely reported as a major determinant of low uptake of HIV testing and treatment (Obermeyer 2007; Coovadia 2000; Ochan‐Lokol 2004). Delayed access to HIV screening and treatment for immigrants and refugees is a concern in several immigrant‐ and refugee‐receiving countries.

Streamlined pretest counselling (less than five minutes’ duration with a brief description of risk and benefits of testing) has been promoted as part of screening procedures, but without evidence of relative effectiveness. Risk‐reduction counselling has been shown to be most effective when targeted to reduction in high‐risk sexual behaviour (Pottie (in press)).The meta analysis by Weinhardt and associates on behaviour change showed decreases in high‐risk sexual behaviour in HIV‐positive women and men, with HIV positive patients reporting less unprotected intercourse and more condom use (Weinhartd 1999).  There is concern that vulnerable and low income populations in both high income and low income countries are less likely to return for counselling and treatment than high income patients.

Rapid HIV tests produce quick and accurate results. Obtaining results from these tests takes 10‐20 minutes compared to the standard laboratory HIV testing that requires at least a week and have a sensitivity and specificity of >99%  (Malonzaa 2003; Webber 2000; Nagamine 2009). Rapid tests, using saliva, urine or finger‐prick blood, are user friendly and can be performed outside laboratory settings. These technologies do not require invasive procedures, specialized equipment or laboratory technicians (WHO 2008).  This technology is particularly significant in low and middle income countries (LMIC), where advance testing infrastructures are lacking (Beteganya 2009). The tests with this technology may be performed in homes, in mobile clinics (reaching populations including sex workers, truck‐drivers, or factory workers), public places and community facilities.

The literature concerning the role of rapid testing versus conventional testing, particularly in high income country settings, shows conflicting results.  For example, some research suggest that since most disease screening programs are designed around conventional laboratory testing, rapid tests in community settings may not always be cost‐effective as they require additional equipment, manpower, logistic supports and follow‐up (de la Fuente 2009; White 2009). However, other evidence suggests that in groups at elevated risk for HIV infection, rapid testing linking to treatment are cost‐effective and can improve the effectiveness of current HIV screening programs (King 2001; Branson 2006).  Literature also suggest that rapid testing technology is feasible (Celentano 2008), and requires less time to deliver HIV testing especially for hard‐to‐reach, high‐risk populations including populations with little access to clinical care (McNamara 2009). A recently published randomised controlled trial in Ghana has shown that rapid HIV testing for tuberculosis patients was more acceptable and more efficacious than conventional testing; for example, the patients who used rapid testing were more likely to return for risk reduction counselling and treatment than those who used conventional testing (Appiah 2009).

How can we effectively improve the uptake of testing, diagnosis, risk reduction counselling and treatment for HIV? Recent research suggests that involving marginalized and persons at elevated risk for HIV in designing and delivering testing services and utilizing newly developed, rather than conventional technology can enable alternative facilities (CHAIC 2006) (such as mobile/rapid HIV testing) to improve the uptake of rapid HIV testing and treatment (CDC 2006). Rapid HIV testing is already being used in multiple US emergency departments and this has been an increasingly common strategy in the US as well as in resource‐limited settings.  However, the test performance has been questioned in both settings, due to low background HIV prevalence which increased risk for false positives in low prevalence countries and due to risk of false negatives in resource‐limited settings (Bassett 2011; Claassen 2006; Gray 2007; Aghokeng 2009). In these contexts, our understanding is still limited on the effectiveness of these alternative testing approaches. We, therefore, propose to critically review and synthesize comparative evidence to assess the impact of rapid testing on testing uptake, false positive rates, and ability to link sero‐positive individuals to counselling and treatment in community and facility settings.

Internationally, many different testing strategies have emerged to improve the uptake of testing, reaching out to infected individuals and slow the HIV epidemic. In a study from Uganda, researchers assessed and compared costs and outcomes of four HIV counselling and testing (HCT) strategies at reaching key population groups: stand alone, hospital based, household member and door‐to‐door (Menzies 2009). These strategies vary in effectiveness depending on health system infrastructure, population group, testing site ‐ facility vs. community, and the use of laboratory vs. rapid testing technology.

One way to normalize HIV testing is through universal screening and routine (opt‐out) approaches (Khumalo‐Sakutukwa 2008) which are linked with health services. This approach primarily uses laboratory rather than rapid testing (Sanders 2008). It is also found that the likelihood of testing among individuals at elevated risk for HIV‐infection increases with anonymous rather than conventional testing approaches. However, the gains are counterbalanced by the number of lost follow‐ups with infected individuals (Fisman 2004; Spielberg 2003). It is also reported by several studies that HIV counselling and testing is found to be cost‐effective if HIV prevalence is over 0.1% (Marseille 2002; Paltiel 2005; Sanders 2005; Sanders 2008).

As mentioned above, of the HIV‐related barriers, stigma, fear, denial and logistical problems are major impediments to promoting counselling and testing. Understanding and measuring these barriers is essential from patients’ and practitioners’ perspectives (Vidanapathirana 2009). These impediments may be reduced by adjusting the testing approaches to align with the respective cultural values and the social context (Logie 2009; Vidanapathirana 2009). In many social contexts, HIV infections are assumed to be sinful (Campbell 2007; Simbayi 2007) thereby resulting in high stigma, fear and denial. Studies show that these testing barriers were not only correlated with lack of social support, poor mental health, lower income and younger ages (Campbell 2007; Simbayi 2007; Foster 2007; Obermeyer 2007) but also interact with structural inequities (e.g. racism, homophobia), gender roles, negative attitudes and discrimination by health care providers and by society in general (Higgins 2006; Campbell 2006). Subsequently, people fear positive HIV test results, breaching of privacy and confidentiality, and discrimination (e.g. barriers to housing, jobs and insurance) –these fears can delay HIV testing and treatment and risk reduction counselling.