Table 1 Summary of included studies

Apinundecha, 2007

To investigate the effect of the intervention to reduce stigma

Socio-economic support for community participation in HIV prevention

Awareness raising, community mobilization and support provision

Thailand

RCT

General population

Changes in knowledge and attitude

Improved knowledge, reduced fear, increased interaction with PLWH

(Pathway 2)

The interventions reduced resource constraints by empowering the community, and providing financial support and this was an effective means of increasing interaction between PLWH and other community members, increasing tolerance and reducing HIV/AIDS stigma. The effectiveness in terms of HIV testing uptake was not reported.

Balfour, 2013

To compare HIV knowledge, stigma and health care seeking behaviours

“On The Ball” program: pictures, question and answers, key statements, group activities, and soccer coaching

Raising awareness

South Africa

RCT

School children

Changes in Knowledge, attitude

Improved knowledge, change attitude

Elementary students who participated in the program reported greater HIV knowledge and lower HIV stigma (p < .001) than those who had not; but the effectiveness in terms of HIV test uptake was not reported

Berendes, 2011

To test that knowledge and self-efficacy would serve as facilitators for testing

Mass-media program and community level activities

Awareness raising

Malawi

Cross sectional

General population

Higher levels of knowledge and intentions to test

Improved knowledge, changed attitude and increased self-efficacy for testing

(Pathway 1)

Effectiveness was not reported in terms of HIV test uptake. A positive association was found between program exposure, and knowledge, low levels of stigma, increased self-efficacy and intentions to test.

Younger age and being educated were more likely to be tested

Blas, 2013

To develop culturally-appropriate messages to motivate MSM to get tested for HIV

Internet and mobile phone-based messaging

Raising awareness

Peru

Qualitative: Focus groups

MSM

Change in knowledge, and reduced fear

Improved knowledge and reduced fear

Effectiveness was not reported in terms of HIV test uptake but provided information on how to make educational message appropriate to overcome fear of testing

Castro, 2005

To assess the relationships between stigma and integrated HIV prevention and care

ART access, VCT access, health education and involvement of PLWH in health care

Raising awareness, health service provision, and community mobilization

Haiti

Literature review with a descriptive case study

General population

HIV knowledge and attitude, HIV test uptake

Improved knowledge, changed attitude

(Pathway 1)

The introduction of quality HIV care can lead to a rapid reduction in stigma, with resulting increased uptake of testing.

Improving quality of health care and increasing health services access increases staff morale, reduce work place stigma and increase HIV test uptake

Chung, 2015

To determine whether knowledge about HIV and self-efficacy associated with stigma

Namibia

Cross-sectional

General population

Stigma reduction

Improved knowledge, changed attitude and increased self-efficacy for testing

Effectiveness was not reported in terms of HIV test uptake.

Stigma tended to decrease with age and years of education

Coates, 2014

To test community-based VCT would be effective

Community testing, post-test support services, community mobilization via social networks and information sessions

Raising awareness, health service provision, community mobilization, and support provision

Thailand, South Africa, Tanzania and Zimbabwe

RCT

General population

Change in attitudes and HIV test uptake

Improved knowledge, changed community norms

(Pathway 1)

Community-based VCT increased testing rates by 25% overall (12–39; p = 0.0003), by 45% (25–69; p < 0·0001) in men and 15% (3–28; p = 0.013) in women. Social norms regarding HIV testing were improved by 6% (95% CI 3–9) in communities in the intervention group.

Logistical barriers influenced the effect

Colchero, 2016

To estimate the impact of the behavioural, biomedical, and structural interventions across a range of outcomes

prevention kits, educational messages, peer-led program, interview and workshops

Raising awareness, and health service provision

Mexico

Quasi-experiment

MSM, transgender, male sex workers, health workers, police officers

Change in knowledge, attitude, behaviour and HIV test uptake

Improved knowledge, reduced stigma, changed behaviour and increased HIV test uptake

(Pathway 2)

Per additional year of program exposure, there was a 7% reduction in stigma/discrimination from healthcare personnel relative to baseline coverage; a 7.5% increase in HIV testing; a 6.3% increase in awareness of HIV status among HIV-positive individuals a 6.7% increase in HIV-positive individuals on treatment.

Derksen, 2014

Reduce stigma between potential sexual partners and increase HIV testing rates by providing new information about the effect of ART on HIV transmission risk

One health information community meeting in each village about benefits of ART access, ART provision

Raising awareness and health service provision

Malawi

RCT

(Poster)

General population

Change in knowledge, attitude and HIV test uptake

Improved knowledge, changed attitude and increased HIV test uptake

(Pathway 1)

Due to increased ART access, the intervention was reported to increase knowledge, reduce fear and increase HIV test uptake

Doherty, 2013

To compare the effect of home based vs. facility based HIV testing

HBCT mobilizing local counsellors for community mobilization and discussions

Raising awareness, Health service provision, and community mobilization

South Africa

RCT

General population

Change in Knowledge and attitude, stigmatizing behaviours, HIV testing

Improved knowledge, changed behaviours

(Pathway 2)

69% of participants in the home based HCT arm versus 47% in the control arm were tested for HIV (prevalence ratio 1.54, 95% confidence interval 1.32 to 1.81). Participants in the intervention arm were less likely to report stigmatising behaviours.

Intimate partner violence was reduced

Hutchinson, 2007

To examine the effect of intervention in HIV knowledge and attitude, condoms use and HIV disclosure

Mass media and interpersonal communication

Raising awareness

South Africa

Cross-sectional

General population

Knowledge, HIV stigmatizing attitude, HIV testing and disclosure

Improved knowledge

The intervention was not reported to reduce stigmatizing attitude and HIV testing; however, mass media exposure increased the likelihood of talking to someone about HIV

Improvements in the quality and availability of HIV services at the local clinic also influenced the effect on stigma reduction

Jurgenson, 2013

To investigate whether home-based Voluntary Counselling and Testing has an impact on stigma

HBCT by lay counsellors, community mobilization, radio program

Raising awareness, health service provision, and community mobilization

Zambia

RCT

General population

Change in knowledge, attitude and HIV test uptake

Improved knowledge and changed attitude

(Pathway 1)

7% reduction in stigma from baseline to follow-up, due to a reduction in individual stigmatizing attitudes. Being tested for HIV was associated with a reduction in stigma (beta = −0.57, p = 0.030), and there was a trend towards home-based VCT having a larger impact on stigma than other testing approaches (beta = − 0.78, p = 0.080 vs. beta = − 0.37, p = 0.551), possibly explained by a strong focus on counselling and the safe environment of the home.

Jurgensen, 2013

(the 7 C’s)

To investigate the feasibility and acceptance of home-based VCT

HBCT by local counsellors;

Raising awareness, health service provision, and community mobilization

Zambia

Mixed-methods

General population

Change in knowledge, attitude and HIV test uptake

Improved knowledge, changed attitude and change behaviour

(Pathway 1)

Social mobilisation lead to significant reduction in stigma (P < 0.001) in both the intervention and control arms.

Local counsellors ensured community trust in the services

Lapinski, 2008

To assess the effects of the film about an HIV positive man

Film (educational entertainment approach)

Raising awareness

Nigeria

Quasi-experimental

General population

Increase knowledge and intentions to test

Increased knowledge and intentions to test

(Pathway 3)

The intervention changed male participants’ fear of the severity of HIV, less blame to PLWH and intentions to test. Women had negative attitude toward HIV following the intervention

Low, 2013

To assess the effect of HBCT and community leader mobilization on HIV stigma

HBCT: community sensitization program

Raising awareness, health service provision, and community mobilization

Kenya

RCT

General population

Change in attitude and HIV testing

Improved knowledge, changed attitude and changed behaviour

(Pathway 2; and Pathway 3)

Due to its “whole community” approach.,the home-based HIV testing intervention resulted in community leaders reporting lower levels of stigma; however, stigma among community members reacted in mixed ways

Bringing HIV testing closer to an individual reduced social-cultural barrier.

Ma, 2008

To compare the attitudes and acceptance of VCT and levels of HIV knowledge

ART, health care and education, PMTCT, VCT

Raising awareness, and health service provision

China

Cross-sectional

General population

Attitude, acceptance of VCT

Improved knowledge

(Pathway 3)

Urban residents of program area had higher HIV/AIDS knowledge levels than urban residents of the comparison area (p = 0.002) and no significant differences in uptake were found between intervention and control areas

Higher education levels and income influenced the association

Mall, 2013

To assess changes in stigma, knowledge and VCT over time

HIV awareness and education campaign and access to ART

Raising awareness, and health service provision

South Africa

Cross-sectional

General population

Change in knowledge, HIV testing uptake

Improved knowledge, changed attitude and increased HIV test uptake

(Pathway 1)

Overall basic knowledge of HIV/AIDS increased from 2004 to 2008 (p = 0.04) and stigmatisation towards HIV-positive individuals decreased over the same period (p < 0.001); and the proportion of participants who had undergone HIV testing increased from 2004 to 2008 (40 vs. 70%, respectively) and VCT increased from 26 to 43%.

Knowing someone infected, being female and being educated were associated with lower stigma levels

Maman, 2014

To assess attitudinal and behavioural changes in HIV testing norms, discussions, and stigma

Community Mobilization, Increased Access to VCT, Post-Test Support Services

Raising awareness, health service provision, community mobilization, and support provision

Tanzania, Zimbabwe, South Africa and Thailand

Qualitative: in-depth interviews

General population

Increase testing and change in attitude and behaviour

Improved knowledge changed community norms and changed behaviour and HIV test uptake

(Pathway 2)

A change in HIV-related stigma over time was most pronounced in Tanzania and Zimbabwe. Participants in the intervention communities from these two sites attributed community-level changes in attitudes.

Massey, 2012

To assess the effectiveness of the intervention to facilitate knowledge, attitudinal and behavioural change

Peer-led, school-based clubs based raising awareness (Songs, articles, dialogues and other media was used)

Raising awareness, and community mobilization

Senegal

Quasi-experimental

School children

Positive attitudes and intentions related to HIV test-uptake

Improved knowledge and attitude

(Pathway 1)

Students exposed to intervention activities had 1.5 greater odds of intending to get HIV tested compared with students not exposed to the program.

Gender norms in sub-Saharan Africa reinforced and supported higher rates of HIV testing among women

Maughan, 2014

To examine the independent effects HIV- stigma on HIV testing

South Africa

Cross-sectional

General population

Stigma, HIV test uptake

Improved knowledge and reduced fear

Effectiveness was not reported in terms of HIV test uptake

Moshabela, 2016

To understand the social, economic and contextual factors that affect Treatment as prevention program

‘Test and treat program’ and mobilization of local counsellors (traditional healers)

Raising awareness, health service provision, and community mobilization

South Africa

Qualitative: focus groups

PLWH, general population

HIV testing

Improved knowledge, changed attitude, changed behaviour and HIV test uptake

(Pathway 2)

Traditional practitioners were engaged with the home-based testing services and HIV clinics; and specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing.

Witchcraft beliefs and illiteracy

Mukulo, 2013

To assess relationship of negative labeling and social exclusion in and attitudes toward VCT

Mozambique

Cross-sectional

General Women

Attitude towards HIV testing

Improved knowledge and changed attitude and behaviour

A decrease from 50 to 25-points in the score for social exclusion stigma was associated with 1.5 and 1.3-fold increase in odds for past-6-months VCT use and supporting VCT use

Contact with traditional healers were each associated with higher odds of supporting VCT

Murray, 2010

To assess access to VCT among MSM and transgender

VCT (rapid test: mobile units)

Raising awareness, and health service provision

Brazil

Commentary

MSM and transgender

HIV testing

Improved knowledge and changed attitude

Did not report effectiveness of interventions

Partnership between NGOs and public health services was crucial

Pappas, 2008

To examine associations between exposure to serial drama and outcomes related to HIV testing

Radio-based awareness programs, community meetings, messages in local magazine

Raising awareness

Botswana

Cross sectional study

General population

Knowledge and intentions to test

Improved knowledge, changed attitude, intention to test

(Pathway 1)

Positive associations was found between exposure to the program and intermediate outcomes, including lower level of stigmatizing attitudes, stronger intention to have HIV testing, and talking to a partner about testing.

Increased access to HIV testing via national VCT program

Pulerwitz, 2015

To evaluate the relative effectiveness of interventions in reducing stigma

Quality of care policy, staff training, material supplies

Raising awareness, support provision, and regulatory law

Vietnam

Quasi experimental

Health care workers

Knowledge and attitude

Improved knowledge and reduced fear

Effectiveness was not reported in terms of HIV test uptake but, stigma measures had improved significantly for both intervention groups

The Law of HIV/AIDS Prevention and Control, which made HIV-related stigma an offence, and promoted full rights to PLWH

Raoura, 2008

To investigate the interplay between ART scale-up, different types of stigma and VCT uptake

ART and VCT

Raising awareness, and health service provision

Tanzania

Qualitative study: in depth interviews

community leaders, ART clients and health care providers

Knowledge and attitude

Reduced fear and internalized stigma and increased blame and increased HIV test uptake

(Pathway 1)

The intervention reported a substantial increase in VCT uptake due to normalization of HIV but it also increased blaming attitude that can reduce VCT uptake

Beliefs on witchcraft

Semugoma, 2012

To investigate the potential health effects of the proposed anti homosexuality law among MSM

Uganda

Commentary

MSM and transgender

Fear of testing

Effectiveness was not reported in terms of HIV test uptake

Anti-homosexuality law and mandatory reporting of sexual identity and HIV positive test results by health workers increased fear and stigma

Uys, 2009

To assess the impact of stigma reduction intervention among the nurse and PLWH

Workshop: (1) sharing information, (2) increasing contact with the affected group, and (3) improving coping through empowerment

Raising awareness, and support provision

Lesotho, Malawi, South Africa, Swaziland, and Tanzania

Mixed methods: Multiple-case study design

A group of PLWH and nurses

Change in attitude and behaviour, HIV testing uptake

Reduced stigma among PLWH, but not among nurses; increased mutual support between nurses and PLWH

(Pathway 3)

No change in stigma was reported among nurses but a significantly higher percentage of the nurse were tested for HIV; stigma experience of PLWH can be decreased, but that the stigma experiences of nurses are less easy to change

van Royaan, 2016

To assess the impact of intervention on HIV testing, disclosure, stigma and discrimination

Family-based counselling and testing, behavioural intervention, mobilization of community local counsellors, training

Raising awareness, health service provision, and community mobilization

South Africa

Qualitative: In-depth interviews, focus groups

General population

Changes in Knowledge, attitude, HIV testing

Improved knowledge and changed attitude, and increased HIV test uptake

(Pathway 1)

The family-based intervention encouraged HIV testing of adults, children, and adolescents and disclosure of HIV status. Intergenerational communication was identified as the key causal pathway to improve testing, linkage to care, disclosure, and reduced stigma for this group.

Hierarchical relationships between generations, inability to discuss sex across generations, and poor communication skills and sex as a taboo

Weihs, 2014

To provide a better understanding of employees´ experiences of a VCT

Lottery incentive scheme for testing

Awareness raising, and support provision

South Africa

Quasi-experimental study

Staffs General population

Increased knowledge attitude and HIV test uptake

Improved knowledge, reduced fear, reduced work place discrimination and increased HIV test uptake

(Pathway 2)

Lottery induced excitement facilitated social interactions pertaining to HCT that mitigated the burden of HIV stigma in the workplace and created open discussions.

Weiser, 2006

To assess knowledge and attitude toward testing, and prevalence and correlates of testing

Radio TV messages, and routine testing

Raising awareness, and health service provision

Botswana

Cross-sectional

General population

Change in Knowledge, attitude, HIV test uptake

Improved knowledge

Effectiveness was not reported in terms of HIV test uptake; routine testing appears to be widely supported and may reduce barriers to testing

White, 2013

To qualitatively assess service provider and user attitudes of the quality of the various services

Integrating HIV and RH services, and community mobilization

Raising awareness, and health service provision

Cambodia

Qualitative: In-depth Interviews

Pregnant women

Stigma reduction, HIV testing

Increased knowledge and attitude, c hanged behaviour and HIV test uptake

(Pathway 2)

Success stories of home based counselling team and integrated approach may reduce stigma and increase HIV testing, increase closeness to HIV testing

Increased visibility of HIV and family support influenced HIV test uptake

Wu, 2008

To reduce stigma and increase level of comfort working with PLWH for service providers in China

Mass media and a community advisory board involving PLWH and local people

Raising awareness

China

RCT

Health service providers

Change in Knowledge and fear

Improved knowledge and reduced fear among health care workers

Effectiveness was not reported in terms of HIV test uptake, but the intervention was successful to reduce stigma and discrimination among health care workers

Mandatory reporting of positive HIV test

Young, 2010

To determine the efficacy of community-based voluntary counselling and testing

Community-based HIV mobile voluntary counselling and testing, community mobilization, and post-test support services

Raising awareness, health service provision, community mobilization, and support provision

South Africa

Cross-sectional analysis of data from a RCT

General population

Change in Knowledge, attitude and HIV testing

Improved knowledge, changed community norms related to HIV, and enhance social support

Effectiveness was not reported in terms of HIV test uptake; however previous testing was found to be effective to reduce HIV stigma

Older generation, females and more educated people were more likely to have been tested.