Clinical Decision Support Systems to Guide Healthcare Providers on HIV Testing

Mikaela Smit; Carlijn C.E. Jordans; Jitte M. Reinhard; Wichor M. Bramer; Annelies Verbon; Casper Rokx; Alexandra Calmy


AIDS. 2022;36(8):1083-1093. 

In This Article

Abstract and Introduction


Objective: To understand the impact of clinical decision support systems (CDSSs) on improving HIV testing and diagnosis.

Design: An original global systematic review (PROSPERO Number: CRD42020175576) of peer-reviewed articles reporting on electronic CDSSs that generate triggers encouraging healthcare providers to perform an HIV test.

Methods: Medline, Embase, Cochrane CENTRAL and CINAHL EBSCOhost were searched up to 17 November 2020 and reference lists of included articles were checked. Qualitative and quantitative syntheses (using meta-analyses) of identified studies were performed.

Results: The search identified 1424 records. Twenty-two articles met inclusion criteria (19 of 22 non-HIV endemic settings); 18 clinical and four laboratory-driven reminders. Reminders promoted 'universal' HIV testing for all patients without a known HIV infection and no recent documented HIV test, or 'targeted' HIV testing in patients with clinical risk-factors or specific diagnostic tests. CDSSs increased HIV testing in hospital and nonhospital setting, with the pooled risk-ratio amongst studies reporting comparable outcome measures in hospital settings (n = 3) of 2.57 [95% confidence interval (CI) 1.53–4.33, random-effect model] and in nonhospital settings (n = 4) of 2.13 (95% CI 1.78–4.14, random effect model). Results of the clinical impact of CDSSs on HIV diagnosis were mixed.

Conclusion: CDSSs improve HIV testing and may, potentially, improve diagnosis. The data support the broader study of CDSSs in low- and high prevalent HIV settings to determine their precise impact on UNAIDS goals to reach universal HIV testing and treatment coverage.


Timely HIV diagnosis, rapid linkage to care and effective antiretroviral treatment are important to both reduce HIV-related morbidity and mortality,[1] and transmission at population-level.[2] For individuals who are diagnosed early and who have access to effective antiretroviral therapy, HIV has become a chronic condition with a life expectancy close to normal.[3] Recent data suggests that opportunities for timely diagnosis are often missed.[4]

Current guidelines from the European Centre for Disease prevention and Control (ECDC) recommend HIV testing in patients entering care with HIV-related indicator conditions.[5] Although HIV indicator conditions are internationally accepted and defined, many national and international guidelines on specific indicator conditions across the world fail to recommend HIV testing, and thus fail to ensure the timely diagnosis of people with HIV (PWH). Guidelines around testing include a variety of different strategies mostly based on local epidemiology, ranging from routine 'universal' testing to 'targeted' testing, based on risk factor assessment, mostly in low prevalence areas.[6] However, despite these recommendations, many PWH remain unaware of their status, illustrated by the United Nations Joined Programme on HIV/AIDS (UNAIDS) estimations that almost one-fifth of PWH worldwide are unaware of their HIV infection. This falls short of the 90–90–90 target the UNAIDS set for 2020,[7] which strives to diagnose 90% of those living with HIV, put 90% of those diagnosed on antiretroviral treatment and ensure 90% of those treated are virally suppressed.

Clinical decision support systems (CDSSs) have successfully been used across a wide range disease area to improve testing, including for infectious diseases.[8–10] The impact of CDSSs on diagnostic decisions by healthcare providers has been evaluated in three previous systematic reviews.[11–13] Overall, CDSSs were likely associated with a beneficial clinical impact in the adequateness of diagnostic test ordering. Identified benefits were twofold. First, the added value included allowing healthcare providers to classify patients as either 'low' or 'high' risk for certain conditions, enabling healthcare providers to base recommendation for testing on this risk profile.[14] Translating to HIV, risk profiles could help triggering HIV testing in known at-risk populations or diagnosing AIDS in those with consistent diagnosed AIDS-defining illnesses. Second, CDSSs were useful in reminding healthcare practitioners about routine testing,[15] with for HIV this could be helpful when ordering, for example, tuberculosis or STI diagnostic tests.

Despite the potential of CDSSs to improve diagnostic gaps, few studies have evaluated the use of CDSSs to improve HIV testing in healthcare settings, and no study has systematically evaluated whether CDSSs aimed at supporting healthcare providers on diagnostic decision-making have led to an increase in HIV testing and HIV or AIDS diagnosis. In this article, we address this gap by carrying out a systematic review and performing a qualitative and quantitative synthesis of the published literature on the use of CDSSs to improve HIV testing.