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Background Antiretroviral therapy (ART) initiation in the community and outside of a traditional health facility has the potential to improve linkage to ART, decongest health facilities, and minimize structural barriers to attending HIV services among people living with HIV (PLWH). We conducted a systematic review and meta-analysis to determine the effect of offering ART initiation in the community on HIV treatment outcomes. Methods and findings We searched databases between 1 January 2013 and 22 February 2021 to identify randomized controlled trials (RCTs) and observational studies that compared offering ART initiation in a community setting to offering ART initiation in a traditional health facility or alternative community setting. We assessed risk of bias, reporting of implementation outcomes, and real-world relevance and used Mantel-Haenszel methods to generate pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals. We evaluated heterogeneity qualitatively and quantitatively and used GRADE to evaluate overall evidence certainty. Searches yielded 4,035 records, resulting in 8 included studies-4 RCTs and 4 observational studies-conducted in Lesotho, South Africa, Nigeria, Uganda, Malawi, Tanzania, and Haiti-a total of 11,196 PLWH. Five studies were conducted in general HIV populations, 2 in key populations, and 1 in adolescents. Community ART initiation strategies included community-based HIV testing coupled with ART initiation at home or at community venues; 5 studies maintained ART refills in the community, and 4 provided refills at the health facility. All studies were pragmatic, but in most cases provided additional resources. Few studies reported on implementation outcomes. All studies showed higher ART uptake in community initiation arms compared to facility initiation and refill arms (standard of care) (RR 1.73, 95% CI 1.22 to 2.45; RD 30%, 95% CI 10% to 50%; 5 studies). Retention (RR 1.43, 95% CI 1.32 to 1.54; RD 19%, 95% CI 11% to 28%; 4 studies) and viral suppression (RR 1.31, 95% CI 1.15 to 1.49; RD 15%, 95% CI 10% to 21%; 3 studies) at 12 months were also higher in the community-based ART initiation arms. Improved uptake, retention, and viral suppression with community ART initiation were seen across population subgroups-including men, adolescents, and key populations. One study reported no difference in retention and viral suppression at 2 years. There were limited data on adherence and mortality. Social harms and adverse events appeared to be minimal and similar between community care and standard of care. One study compared ART refill strategies following community ART initiation (community versus facility refills), and found no difference in viral suppression (RD -7%, 95% CI -19% to 6%) or retention at 12 months (RD -12%, 95% CI -23% to 0.3%). This systematic review was limited by there being overall few studies for inclusion, poor-quality observational data, and short-term outcomes. Conclusions Based on data from a limited set of studies, community ART initiation appears to result in higher ART uptake, retention, and viral suppression at 1 year compared to facility-based ART initiation. Implementation on a wider scale necessitates broader exploration of costs, logistics, and acceptability by providers and PLWH to ensure that these effects are reproducible when delivered at scale, in different contexts, and over time., Author(s): Ingrid Eshun-Wilson 1,2,*, Ajibola A. Awotiwon 2,3, Ashley Germann 4, Sophia A. Amankwaa 2, Nathan Ford 5, Sheree Schwartz 4, Stefan Baral 4, Elvin H. Geng 1 Introduction Initiating [...]

Problem Although most primary hepatocellular cancers (HCCs) are attributable to chronic viral hepatitis and largely preventable, such cancers remain a leading cause of cancer-related mortality wherever chronic hepatitis B is endemic. Approach Many HCCs could be prevented by increasing awareness and knowledge of hepatitis B, optimizing the monitoring of chronic hepatitis B and using antiviral treatments--but there are gaps In the implementation of such strategies. Local setting The 'B Positive' programme, based in Sydney, Australia, Is designed to Improve hepatitis-B-related health outcomes among immigrants from countries with endemic hepatitis B.The programme offers information about disease screening, vaccination and treatment options, as well as optimized access to care. Relevant changes The B Positive programme has been informed by economic modelllng.The programme offers culturally tailored education on chronic hepatitis B to target communities and their health practitioners and regular follow-up through a population- based registry of cases. Lessons learnt As the costs of screening for chronic hepatitis B and follow-up are relatively low and less than one in every four cases may require antiviral drugs, optimizing access to treatment seems an appropriate and cost-effective management option.The Identification and accurate staging of cases and the judicious use of antiviral medications are predicated upon an Informed and educated health workforce. As establishing community trust Is a lengthy process, delaying the Implementation of programmes against chronic hepatitis B until antiviral drugs become cheaper is unwarranted. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Probleme Bien que la majorite des cancers hepatocellulaires primaires (CHC) soient attribuables aux hepatites virales chronlques et qu'ils puissent etre evites en grande partie, ces cancers restent une des principales causes de mortalite liee au cancer partout ou l'hepatite B chronique est endemique. Approche De nombreux CHC pourraient etre evites par une sensibilisation et une connaissance accrues de l'hepatite B, l'optimisation du suivi des hepatites B chroniques et i'utilisation de traitements antiviraux--mais il existe des lacunes dans la mise en ceuvre de ces strategies. Environnement local Le programme <>, base a Sydney en Australie, est concu pour ameliorer l'etat de sante lie a l'hepatite B chez les immigrants venus de pays ou l'hepatite B est endemique. Le programme offre des informations sur le depistage de la maladie, la vaccination et les options de traitement, alnsi qu'un acces optimise aux soins. Changements significatifs Le programme <> a ete elabore par modelisation economique. Le programme offre un enseignement sur l'hepatite B chronique culturellement adapte pour cibler les communautes et leurs professionnels de sante, et un suivi regulier via un registre de cas base sur la population. Lecons tirees Puisque les couts de depistage et de suivi de l'hepatite B chronique sontrelativementfaiblesetquemoinsd'unmaladesurquatre peut avoir besoin de medlcaments antiviraux, l'optimisation de l'acces au traitement semble etre une option de gestion appropriee et rentable. Identification des cas, leur triage precis et l'utilisation judicieuse des medlcaments antiviraux s'appuient sur un effectif de sante informe et eduque. Letablissement de liens de confiance avec les communautes est un processus long. Par consequent, il n'est pas justifie de retarder la mise en ceuvre de programmes de lutte contre l'hepatite B chronique jusqu'a ce que les medicaments antiviraux deviennent plus abordables. [TEXT NOT REPRODUCIBLE IN ASCII] Situacion Aunque la mayoria'de carcinomas hepatocelulares (CHC) primarios se atribuyen a la hepatitis virica cronica y son evitables en gran parte, ese tipo de canceres sigue siendo una de las principales causas de la mortalidad relacionada con el cancer en aquellos lugares en los que la hepatitis B cronica es endemica. Enfoque Muchos CHC podrian evitarse con un aumento de la concienciaclon y el conocimiento sobre la hepatitis B, la optimizacion de la supervision de la hepatitis B cronica y el uso de tratamientos antiviricos, pero existen lagunas en la puesta en practica de estas estrategias. Marco regional El programa'B Positive' con sede en Sidney, Australia, se ha disenado para mejorar los resultados sanitarios relacionados con la hepatitis B entre los inmigrantes procedentes de paises en los que la hepatitis B es endemica, y ofrece Informacion acerca dela deteccion de la enfermedad, la vacunacion y las opciones de tratamiento, asi como un acceso optimizado a la atencion. Cambios importantes El programa 'B Positive' se fundamenta en modelos economicosy ofrece educacion culturalmente adaptada sobrela hepatitis B cronica para llegar a las comunidades y sus medicos, y realizar un seguimiento regular a traves de un registro poblacional de casos. Lecciones aprendidas Puesto que los costes de deteccion y seguimiento de la hepatitis B son relativamente bajos y menos de uno de cada cuatro casos requiere medicamentos antiviricos, la optimizacion del acceso al tratamiento parece ser una opcion de gestion adecuada y rentable. La identificacion y clasificacion correcta de los casos y el uso acertado de los medicamentos antiviricos se apoya en una personal sanitario Informado y formado. El establecimiento de la confianza de la comunidad es un proceso muy largo, por lo que retrasar la ejecucion de programas contra la hepatitis B cronica hasta que los medicamentos antiviricos se abaraten no tiene justificacion alguna., Problem In May 2010, the Sixty-third World Health Assembly adopted a resolution calling for a comprehensive approach to the prevention and control of all forms of viral hepatitis--which kills over [...]