Community-Based Rapid Testing for HIV in Europe and Central Asia: A Narrative Review of Models, Effectiveness, and Implementation Challenges

Introduction

HIV remains a major public health concern across Europe and Central Asia (ECA) despite substantial advancements in antiretroviral therapy (ART) and prevention.^1–3 Persistent gaps in early diagnosis and equitable access to testing remain central obstacles to achieving regional and global HIV elimination targets.^1–6 Individuals and communities most affected by HIV often face structural, social, and legal barriers that limit engagement with conventional, facility-based health services.^2–4 Addressing these barriers is essential to reduce late diagnosis, stop onward transmission, and ensure timely linkage to prevention and care.

In this context, Community-Based Testing (CBT), also known as Community-Based Voluntary Counselling and Testing (CBVCT), has emerged as a key component of differentiated service delivery models aimed at closing these gaps.^3,7,8 By offering testing outside traditional clinical settings, often in “low-threshold”, peer-led environments such as Checkpoints, CBT provides a flexible, inclusive, and stigma-reducing alternative that has demonstrated high acceptance among underserved groups.^3,7,9 These approaches align with global recommendations emphasising decentralisation, integration with multi-disease screening (including viral hepatitis and Sexually Transmitted Infections (STIs)), and task sharing with trained lay providers.^1,2,7 Beyond enhancing accessibility and normalising testing, CBT enhances community trust, contributes to earlier diagnosis, and improves linkage to care.^1,10

Over the past decade, CBT in ECA has evolved substantially, incorporating a wide range of service models and technological innovations, including rapid tests, HIV Self-Testing (HIVST) and self-sampling, mobile and outreach services, and integrated screening for HIV, viral hepatitis, and STIs. At the same time, implementation has remained unequal across the region, reflecting differences in epidemiological patterns, legal frameworks, health system organisation, and the extent to which communities are empowered to lead service delivery. As the 2030 targets approach there is a clear need to synthesise current evidence on how CBT contributes to HIV responses in ECA, as well as to identify remaining gaps and implementation challenges.

The objective of this narrative review is to critically examine the current landscape of CBT in ECA by: i) describing the main models and modalities currently implemented in the region; ii) summarising evidence on their effectiveness in reaching key populations, identifying first-time testers, supporting early diagnosis and facilitating linkage to care; iii) and analysing structural, regulatory, and operational barriers that continue to limit the scale-up and integration of CBT into national strategies. By consolidating evidence from academic literature, surveillance data, and European initiatives, this review aims to clarify the contribution of CBT to regional HIV responses and to inform policy and programme development needed to accelerate progress toward ending AIDS as a public health threat by 2030.

Methodology of the Review

This narrative review synthesised academic and grey literature describing community-based rapid HIV testing in ECA between 2012 and 2025. Geographical scope followed the WHO/UNAIDS definition of the ECA region.

Evidence was identified through structured searches of PubMed/MEDLINE, Embase, Scopus, Web of Science, and repositories of major institutional stakeholders, including the European Centre for Disease Prevention and Control (ECDC), UNAIDS, and World Health Organization (WHO). Additional sources included conference materials and documents produced by community-based organisations as well as websites of European initiatives and projects. The search terms combined concepts related to HIV, rapid or point-of-care testing, community-based services, and ECA. The representative academic search string used was: (“HIV” OR “human immunodeficiency virus”) AND (“rapid testing” OR “point-of-care” OR “POC”) AND (“community-based” OR “community health services”) AND (Europe OR “Central Asia” OR Armenia OR Azerbaijan OR Georgia OR Kazakhstan OR Kyrgyzstan OR Tajikistan OR Turkmenistan OR Uzbekistan).

Documents were included if they reported empirical findings or relevant contextual information regarding community-based rapid or point-of-care HIV testing in the ECA region during the study period. The exclusion criteria included studies unrelated to HIV testing and analyses limited exclusively to hospital-based testing, opinion pieces, and media reports.

The academic search identified 91 articles, of which 15 were excluded because they did not meet defined time period, did not focus on HIV testing, or were conducted outside the ECA region. The grey literature yielded 53 documents: 28 were guidelines, reports, recommendations, or policy briefs from UNAIDS, WHO, and ECDC, and 25 were conference abstracts, articles published in non-peer-reviewed journals, and reports or presentations from projects or NGO websites.

In total, 129 documents were considered for the narrative review. In addition, 14 further documents (12 academic papers and 2 guidelines/recommendations) were added as references when discussing topics not directly linked to the main search, such us the effectiveness of early diagnosis and ART, POC tests, and the COVID-19 pandemic and war in Ukraine.

Findings were synthesised narratively, with attention paid to patterns across service delivery approaches, populations served, regional differences, and structural facilitators and barriers. Quantitative data were summarised descriptively and no meta-analysis was conducted. Grey literature (apart from reports, guidelines/recommendations from WHO, ECDC, UNAIDS) was used mainly to expose examples or particular cases of community-based testing models.

Background and Regional Context

Epidemiology and the Challenge of Late Diagnosis

Epidemiological trends across ECA highlight the need for more tailored CBT approaches. The distribution of new HIV diagnoses differs by subregion, affecting the key population groups in a different way.

In Western Europe, Men who have Sex with Men (MSM) remain the group most affected by new HIV diagnoses and represent the largest share of reported cases.^1,3,11 Overall, MSM account for a stable proportion of reported transmission modes across the wider region (26%), yet they continue to dominate new infections in this sub-region.^1,3,11

In contrast, in Eastern Europe and Central Asia (EECA), the epidemic is increasingly driven by heterosexual transmission and disproportionally affects People Who Inject Drugs (PWID) and their sexual partners.^1,3,11 In addition, increasing numbers of infections among sex workers and their clients have been documented, particularly in EECA.^1,2,4,9,12

Across the European Union/European Economic Area (EU/EEA), migrants account for more than half of new HIV diagnoses, and face significant structural barriers such as insecure legal status, restricted access to services, and fear of criminalisation or deportation.¹

Overall, these regional patterns reflect persistent gaps in prevention coverage, testing uptake, and access to health services among key and marginalized populations.

Late HIV diagnosis remains one of the most persistent challenges in ECA. More than half of individuals newly diagnosed with HIV across the WHO European Region (52.4%) are identified at a late stage, typically defined as a CD4 count below 350 cells/mm³ or the presence of an AIDS-defining event.^1,3,4,12 Recent surveillance data indicates that approximately one third present with advanced HIV disease (33.6%), reflecting gaps in timely testing and access to prevention services.¹ Substantial geographical differences persist: late diagnosis rates are highest in Eastern and Central subregions and remain significant even in Western Europe and the EU/EEA.¹

Some groups are disproportionately affected. Older adults (≥50 years) consistently report the highest levels of late presentation, with approximately two-thirds diagnosed at a late stage.^1,13 Heterosexual individuals, particularly men, also show elevated rates, and migrants from sub-Saharan Africa and Asia, along with PWID, continue to be overrepresented among late presenters.^1,3,12 In contrast, MSM exhibit the lowest proportion of late diagnoses, likely reflecting higher risk perception and more frequent testing behaviours.^1,3

Late diagnosis is associated with increased morbidity, mortality, delayed treatment initiation and an increased risk of onward transmission.¹⁴ Evidence indicates that CBT plays an important role in mitigating this burden, with individuals tested in community settings being more often diagnosed earlier and with higher median CD4 counts than those diagnosed in traditional healthcare facilities.^7,9,15,16 This suggests that CBT can help reach populations who might otherwise be tested only after symptom onset or disease progression.

Global and Regional Strategic Frameworks

CBT remains a central pillar of the international HIV response as efforts transition to the 2025 milestones toward the 2030 goal of ending AIDS as a public health threat.¹⁷ Beyond achieving the 95-95-95 targets, global strategies increasingly emphasise the UNAIDS 30-80-60 commitments, which mandates that 30% of testing and treatment services and 80% of prevention programs for key populations are led by the community.^17,18

The WHO strongly recommends community-based HIV testing services, highlighting their important role in reaching populations underserved by conventional health systems and ensuring a timely linkage to prevention, care, and treatment.^7,19–21 The framework of differentiated service delivery, central to WHO guidance, adapts testing approaches to population needs and local contexts, emphasizing several strategic components:⁷

• Task sharing, which authorises trained lay providers and peers to independently perform rapid diagnostic tests, helping extend testing beyond clinical settings.
• Technological innovations, including HIVST and network-based approaches, to reach individuals less likely to access traditional healthcare services.
• Integrated, person‑centred care, promoting multiplex testing (eg dual HIV/syphilis), and combined screening for HBV, HCV, STIs, and tuberculosis.
• Adherence to the 5 Cs of HIV testing services: Consent, Confidentiality, Counselling, Correct results, and Connection to care.

Within the WHO European Region, the Regional Action Plans for HIV, viral hepatitis, and STIs (2022–2030) provide a unified framework that positions community-based services as essential to ending epidemics.²² The ECDC’s recommendations are aligned with those of the WHO, advocating for the integration of community-led and community-based testing into national health systems, the removal of regulatory restrictions on who may perform HIV tests, and the scaling-up of diversified testing approaches.^12,14,23

Recent policy developments, including the European Standards of HIV Prevention and Care (2025), set a higher bar for implementation efforts.¹³ These standards recommends that all national strategies include CBT for at least one key population and incorporate self-testing and self-sampling.¹³ They also prioritise linkage to care, recommending that a confirmatory test be offered within five working days of a reactive result.¹³

Trends in Coverage and Implementation in Europe and Central Asia

CBT has evolved into an important pillar of national HIV strategies, accounting for an increasing proportion of new diagnoses among populations disproportionately affected by HIV, including MSM, migrants, sex workers, PWID, and transgender individuals.^3,4,24 Data from the COBATEST network and other regional initiatives indicates that a substantial percentage of HIV tests are now delivered outside traditional clinical settings through community centres, mobile units, and outreach programs.^3,25,26

According to the recent ECDC and WHO monitoring, the availability of CBT has increased significantly over the past decade. The percentage of countries in the WHO European Region providing community testing has increased from 35% in 2018 to 51% in 2022, but it has not improved since then, with the same number of countries reporting CBT in 2024.^3,4,12 Coverage within the EU/EEA is even higher, with 86% of countries reporting community-provided testing.^3,12 By 2024, 44 countries in the wider region had implemented some form of CBT, and in several settings community-led approaches were growing faster than clinic-based provider-initiated testing.^3,4

Despite these encouraging trends, implementation remains highly heterogeneous. CBT is widely established in Western and Southern Europe, but it remains severely underutilised in Eastern Europe, where only five countries reported providing such services as of 2022.^3,4 Furthermore, while CBT is increasingly available, traditional clinic-based interventions still maintain a higher overall coverage and are currently the most implemented testing modality across ECA.⁴

Although there is growing political commitment to diversified testing strategies, including self-testing and lay provider testing, most testing in the region still takes place in traditional clinics.

Key Implementation Gaps in Europe and Central Asia

Despite clear progress in expanding CBT across ECA, major implementation gaps continue to limit its full-scale implementation and effectiveness.^2,4,13

A key barrier is the slow adaptation of the national HIV testing guidelines. Nearly half of the national policy documents are now more than five years old, and many no reflect innovations, such as lay provider testing, indicator-condition testing, HIVST, or integrated screening for viral hepatitis and other STIs.^2,4,12 As a result, national frameworks frequently remain behind WHO recommendations, which have supported task-sharing and lay provider testing since 2015 as essential strategies for improving access among underserved populations.²⁷

Legal and regulatory constraints have limited the expansion of community-led models. Thirty-three countries across the region still restrict HIV test administration to medical personnel, and in the EU/EEA specifically, 22 countries prohibit trained lay providers from conducting rapid tests independently.^4,12 These restrictions significantly limit the scale-up of peer-driven services, which is crucial for engaging populations that are unlikely to use traditional healthcare facilities. Although many countries now allow lay providers to administer tests, the number remains substantially lower than those authorising CBT performed by medical professionals (in the EU/EEA, 20 countries versus 25, respectively), highlighting a persistent implementation gap.¹²

A punitive legal environment can worsen these challenges. The criminalisation of HIV transmission, sex work, and drug use discourage key populations from accessing testing and prevention services because of fear of legal repercussions, stigma, and discrimination. These structural barriers reduce CBT uptake, contribute to late diagnosis, and perpetuate gaps in linkage to care.^4,12

Overall, while CBT is now widely recognised as a critical component of HIV testing strategies in the region, its potential remains constrained by regulatory obstacles, policy inertia, and stark regional differences in implementation. Addressing these gaps through updated national guidelines, the removal of legal restrictions on lay provider testing, and reforms to reduce the impact of punitive laws will be essential to harness the full benefits of community-based approaches and advance progress toward ending AIDS as a public health threat by 2030.^12,17,18,22

Models and Modalities of Community-Based Testing

In ECA, the landscape of HIV testing outside traditional medical environments is characterised by a variety of terminologies and operational modalities designed to reach key populations and overcome barriers to care.

Terminology and Definitions

The terminology used to describe testing delivered in community settings has evolved significantly. Early initiatives focused mainly on offering voluntary counselling and testing outside hospitals or clinics. Over time, as services diversified and community leadership became increasingly important, the vocabulary evolved to reflect new operational realities, levels of community governance, and technological advances in testing.

Community-Based Voluntary Counselling and Testing (CBVCT) was one of the earliest standardised terms. Before 2010, definitions varied widely across countries. A regional consensus, developed during the HIV-COBATEST project and published in International Journal of STD & AIDS (2015), established CBVCT as

Any programme or service that offers HIV counselling and testing on a voluntary basis outside formal health facilities, and that has been designed to target specific groups of the population most at risk and is clearly adapted for and accessible to those communities. Moreover, these services should ensure the active participation of the community with the involvement of community representatives either in planning or implementing HIV testing interventions and strategies.¹⁵

This definition became a key reference for European practice and remained one of the most standardised terms for describing community-delivered HIV testing.

As testing technologies and community-led models advanced, organisations such as the COBATEST Network expanded the definition. The updated formulation includes testing for STIs and viral hepatitis, incorporates a wider range of testing methods, and emphasises accessibility, adaptation to community needs, and meaningful community participation (Table 1).²⁸

Table 1 Definitions of Key Terms

Over time, new terms have been adopted to describe different models, including community-led services, peer-led testing, lay provider testing, low-threshold services, and home-based testing. The expansion of self-testing and self-sampling has diversified the conceptual landscape. Today, CBT is understood not as a single model but as a range of approaches that prioritise accessibility, person-centred design, and reducing health inequities. The terminologies identified are presented in Table 1.

Heterogeneity in Community-Testing Models

CBT services in ECA differ widely in their organisation, staffing models, size, target population, delivery model, setting, and level of integration with formal health systems.¹⁵ Rather than following a single model, these services range from highly medicalized structures to fully community-led approaches.¹⁵ This variation reflects not only differences in national legal frameworks that determine who can perform HIV testing, but also the level of medical involvement within each service.^12,14,15 Centres offering comprehensive check-ups, extended infection screening, or confirmatory testing require more specialised personnel and operate more like community clinics, whereas others maintain a low-threshold, community-centred model focused on rapid testing alone.^{15,29,30,36,38} Figure 1 shows a conceptual diagram of the different models, mapped according to their degree of medicalisation and community involvement.

Figure 1 Conceptual diagram of models of Community-Based Testing in Europe and Central Asia, organised by level of medicalisation and degree of community leadership.

Typologies of Services

Following the definition of key terms, Table 2 presents a structured classification of CBT services in two dimensions: the delivery model and service setting. This framework differentiated fixed-site models from outreach and mobile approaches, as well as home-based and individual modalities and more integrated or network-driven models, capturing the operational diversity of CBT and highlighting how each modality adapts to the needs and contexts of key populations.

Table 2 Classification of the Different Modalities of CBT According to the Delivery Model and the Service Setting

Technologies Enabling Community-Based Rapid Testing

Rapid Testing Technologies

Rapid diagnostic tests (RDTs) are the core technology for CBT, specifically designed for ease of use and immediate results.^7,24,40 These immunoassays provide results in less than 30 min using non-invasive specimen collection, such as oral fluid or finger-stick capillary blood.^7,41 Most RDTs currently implemented are either third-generation (detecting antibodies) or fourth-generation (detecting both antibodies and the p24 antigen), the latter of which can identify more recent infections.^7,42,43 The WHO recommends that RDTs used in these settings achieve at least 99% sensitivity and 98% specificity.⁷ As they do not require a clinical laboratory or venipuncture, these tests are highly suitable for task sharing with trained lay providers and peer educators.^4,7,24,40,44

In community-based models, a single RDT typically serves as a “Test for Triage” (A0), and a reactive result is considered preliminary and must always be followed by confirmatory testing using the full national testing algorithm.^7,42

Multiplex technologies now enable combined testing for HIV and syphilis or integrated screening for hepatitis B and C, supporting more routine testing and better use of resources.^7,8,34,45

Beyond rapid testing alone, more medicalised community-based models, often supported by doctors, nurses, or formal links with hospitals, offer a wider set of clinical services tailored to the needs of key populations.¹⁵ Many of these services include nucleic acid amplification testing for asymptomatic pharyngeal and rectal gonorrhoea and chlamydia, infections that are often missed with standard urethral screening.³⁸ In high-prevalence settings, these “one-stop-shop” sites may also provide on-site CD4 cell count and viral load monitoring to allow for rapid ART initiation and monitor treatment effectiveness.³⁴ Furthermore, some medicalised initiatives normalise HIV screening by integrating it into general health checks, including measurements of blood pressure, body mass index, and blood glucose.^7,46 This broader approach not only helps identifies underlying non-communicable diseases, but also improves the detection of co-infections such as tuberculosis, improving overall health outcomes for marginalised groups who tend to avoid traditional clinical settings.³⁴

Self-Testing

HIVST has become an important innovation to broaden access to HIV diagnosis by allowing individuals to test privately and at their convenience.^2,7 Its implementation has grown significantly in the WHO European region, with the number of countries reporting HIVST availability increasing from 17 in 2018 to 31 in 2022.^4,12 While HIVST empowers users and reduces structural barriers, a reactive self-test result is not a definitive diagnosis and requires confirmation by a trained provider.^2,7 Self-sampling approaches, in which individuals collect samples at home and send them to a laboratory, offer an additional option for those seeking privacy while still ensuring laboratory-validated results.⁹

By 2025, CBT services have become key settings for implementing these technologies, moving beyond on-site testing to provide broader support for self-managed HIV care.^3,13 CBT programmes contribute to the effective roll-out of HIVST through several mechanisms. First, CBT sites act as complementary access points, offering trusted, non-medicalised environments in which individuals who avoid conventional healthcare can receive hands-on support on using self-testing or home-sampling kits.^3,13 CBT organisations are increasingly taking the lead in digital HIVST by combining online kit distribution with social media outreach, virtual counselling, and telehealth support.^7,47–49 Programmes such as Moldova’s MyLife+ app or Milan’s EasyTest integrate ordering, result reporting, and peer-based virtual support within a single platform, improving accessibility for people facing legal, social, or geographic barriers.^47,50

Reaching populations traditionally missed by health systems has become central to CBT strategies. By using approaches like vending machines in gay saunas, mobile outreach for sex workers, and integration within harm-reduction services, CBT providers broaden access to HIVST for first-time testers, people with irregular working hours, and those who rarely use health facilities.^26,51 Finally, robust referral and linkage pathways remain a core responsibility for CBT services, ensuring that people who self-test, particularly those with reactive results, are supported and guided to confirmatory appointments.^7,13

By combining the privacy of self-testing with the trust and navigation support of CBT, these integrated models are essential for closing the remaining testing gaps and achieving the 2030 goal of ending the AIDS epidemic.^1,2

Effectiveness of Community-Based Testing in Europe and Central Asia

Figure 2 summarize the main effectivity data of CBT in ECA detailed in this section.

Figure 2 Summary figure on Effectiveness of Community-Based HIV testing in Europe and Central Asia.

Uptake, Positivity Yield, Identification of First-Time Testers

Across ECA, CBT has proven to be an acceptable and effective strategy for reaching populations at high risk who may avoid traditional healthcare settings.^29,52 Global systematic reviews report acceptance rates close to or above 85% for community-based approaches, including rapid testing, index testing, and self-testing.¹⁰

Evidence from across the region shows that HIV positivity rates in community-based settings (0.2–1.4%) are higher than in traditional healthcare settings (0.01–0.5%), suggesting greater access to populations at higher risk and with lower healthcare engagement.^12,26,53 The “checkpoint” model has consistently shown high diagnostic yield and substantial public health impact, with significant declines in HIV incidence in cities where it has been fully implemented, such as the 62% reduction documented by BCN Checkpoint in Barcelona.^24,54–56

CBT is particularly successful in identifying first-time testers, a critical step in reducing the undiagnosed fraction.^26,46 Standardised data from the COBATEST Network show that 35–36% of individuals tested in community settings had never previously taken an HIV test.^25,26,30,57 National and local projects reinforce this pattern: a demonstration project in Italy reported 45.2% first-time testers, while a pilot in Rotterdam achieved a rate of 52.3%.^46,52 Targeted outreach activities, such as those conducted in sex-work venues, migrant centres, or nightlife spaces, continue to reach meaningful proportions of individuals testing for the first time.^16,46 Detecting HIV among first-time testers, even at relatively low positivity rates (eg 0.6% in nationwide Italian initiatives), represents an important step in reducing the number of undiagnosed infections and reducing onward transmission.⁵²

Visibility, accessibility, and anonymity are key drivers of uptake. Street-based testing in urban areas has been shown to attract people with no prior testing experience simply due to the high visibility and convenience of the service.⁵⁸ Similarly, outreach testing on university campuses or in multicultural neighbourhoods reaches younger people, heterosexual men and women, and people with low perceived risk, groups that are frequently under-represented in facility-based testing data.^9,59

Reaching Key Populations

CBT plays a key role in reaching populations disproportionately affected by HIV in ECA, helping to overcome structural, social, and legal barriers that limit access to traditional healthcare settings.

Among MSM and transgender women, peer-led community services, often based on the “Checkpoint” model, are the most widespread approach in Europe, with around 80% of community services specifically targeting MSM, according to a survey published in 2015.¹⁵ These queer-affirming spaces reduce stigma, enhance trust, and effectively reach individuals with low testing patterns or higher risk behaviours, such as those frequenting saunas or sex-on-premises venues.^1,3,15,35

Outreach-based CBT, delivered through mobile units, street-based teams and peer navigation models, is vital for engaging PWID, who often experience socially marginalisation and limited contact with formal healthcare.^9,26,34 Several examples showed high acceptability and feasibility of HIV and HCV rapid testing integration into harm-reduction settings (needle-syringe programmes, opioid agonist therapy units, or “one-stop-shop” centres)^29,34,44 These integrated services support immediate screening and facilitate trusted relationships that are crucial for linkage to care.³⁴

Similarly, sex workers benefit from CBT approaches delivered directly in workplaces, such as brothels, or through dedicated mobile outreach, which help overcome the effects of criminalisation and severe stigma.^4,60,61 Evidence shows that up to one in four sex workers reached through brothel-based testing are first-time testers, underscoring the importance of providing services in their own environments.⁹ Further expansion of tailored services remains a priority in EECA, where HIV transmission among sex workers and their clients has increased substantially over the past decade.^3,4,17,61

Culturally and linguistically adapted CBT models play an important role in addressing the legal, social and language barriers often faced by migrants in formal healthcare systems.^1,3,62,63 Interventions such as Rotterdam’s general health-check approach and mobile outreach with cultural mediators at migrant support centres have shown high uptake, with substantial proportions of first-time testers.^1,9,34,46,52 However, despite promising case-finding, linkage to care remains a persistent challenge in contexts where undocumented individuals face restrictions on ART eligibility.^4,64,65

Linkage to Care and Referral Pathways

Prompt and effective linkage to care is a core measure of effectiveness in CBT, ensuring that individuals with a reactive result receive confirmatory testing and treatment initiation in a timely manner.^7,9,12,66 Across the WHO European Region, linkage to care is generally defined as attending a clinical service within three months of diagnosis, a standard used for public health monitoring in Europe.^1,4 In the EU/EEA, around 97% of people diagnosed with HIV meet this criterion, indicating strong overall performance but masking persistent disparities among marginalised groups such as PWID and undocumented migrants.^1,3,7

Across ECA, many CBT services have established formal referral pathways with infectious disease clinics, reducing delays and preventing loss to follow-up. Programmes such as Milan’s EasyTest or the Fast-Track City initiative in Turin have reported very high levels of linkage to care, enabled by facilitated appointments, simplified administrative processes, and short waiting times.^8,50 Integrated “one-stop-shop” models in settings such as Minsk, Bălți and Brighton further strengthen this process by offering blood sampling, confirmatory testing and, in some contexts, same-day ART initiation directly within low-threshold community environments, an approach shown to support faster viral suppression than conventional rapid-start protocols.^34,67–71

Peer navigation is a central component of these systems. Trained peers accompany clients to initial appointments, help them navigate administrative procedures, and build the trust required for marginalised groups, such as PWID, migrants, or sex workers, to engage in care.^7,72 Initiatives such as Lisbon’s REACH U project and the Positive Movement in Belarus illustrate how peer-led accompaniment improves engagement and retention in care.³⁴ CBT referral systems are increasingly supported by digital platforms, such us Moldova’s MyLife+ and Ukraine’s Syrex Cloud, which use QR codes, appointment tracking, and real-time feedback to coordinate linkages and support continuity of care.⁴⁷

Some CBT centres have also incorporated point-of-care confirmatory diagnostics, further shortening the time between screening and care. The BCN Checkpoint in Barcelona uses rapid PCR to confirm HIV diagnoses within approximately 90 minutes, while the EasyTest in Milan typically provides confirmatory results within 24 hours and specialist consultations within 48 hours.^9,29,50,73 These accelerated approaches help minimise the risk of disengagement after a reactive test result, however, their implementation remains limited to Western Europe, with no reported adoption in EECA.²² The scale-up of integrated multi-disease testing, covering HIV, HBV, HCV, STIs, and TB in a single visit, improves efficiency, facilitates earlier detection of co-infections, and is consistent with the 2025 European Standards, which stress the importance of strong referral pathways for HIV treatment and prevention, including PrEP and harm-reduction services.^1,13,17,22

Enhanced referral pathways are essential for engaging individuals who might otherwise be lost to follow-up shortly after receiving a reactive result, particularly those facing stigma, housing insecurity, or high mobility. Peer navigation, personalised follow-up, and trust-based relationships rooted in the community setting contribute to more rapid ART initiation and earlier viral suppression.^2,7,46

Economic Benefits and Sustainability

Early diagnosis through CBT is highly cost-effective and helps reduce long-term healthcare costs.^8,42,74 Early diagnosis, with CD4 counts above 350 or 500 cells/mm³, is associated with annual care costs several thousand euros lower than those for people diagnosed at later stages, who require intensive management of advanced disease and opportunistic infections.^8,75

Programmes such as the Turin Fast-Track City initiative have reported savings of more than 3800€ per individual diagnosed early, highlighting the cost-effectiveness of proactive community-based approaches.^8,75 Similar economic evaluations across multiple European cities report costs per reactive test ranging from 1966€ to 9065€, among the lowest documented globally, and routine CBT costs of 41€-113€ per test, figures that compare favourably with many facility-based approaches.⁷⁴

Decentralised testing also reduces the burden on hospitals and laboratories, particularly for the large proportion of negative results that require no additional clinical follow-up.^10,42 Integrated multi-disease screening (HIV, HBV, HCV, STIs, TB) further optimises resources and helps prevent morbidity associated with untreated co-infections.^7,17

Long-term sustainability continues to depend on a transition from donor-funded models to stable national financing. Social contracting, where governments fund community-based organisations to deliver testing and outreach, has proven effective but it still applied at a limited scale.^{8,17,18,22,74} Scaling-up peer-led and lay-provider models can reduce costs and increase reach and acceptability.⁷

Barriers, Challenges, and Structural Factors

Legal and Policy Barriers

Legal and policy frameworks remain among the most significant obstacles to the implementation of CBT across the ECA. Many countries still restrict HIV testing to medical or nursing staff, limiting the scale-up of lay-provider testing despite WHO recommendations since 2015 to demedicalise diagnostics and expand the role of trained non-medical staff.^12,14 Regulations for other infections are even more restrictive, with the majority of EU/EEA countries requiring that Hepatitis B and C tests be performed by healthcare professionals, thereby limiting the implementation of integrated multi-disease screening within community settings.¹² Evidence from countries that have removed these barriers confirms a positive impact on public health.⁷⁶

This challenge is exacerbate by outdated national testing guidelines, as nearly half of the region’s policies are over five years old, and many countries report no plans to update them.¹² As a result, national framework often lack provisions for key innovations, including HIVST, indicator-condition testing, and integrated screening for HBV, HCV and STIs.^3,12

Marked regional disparities remain evident. Western Europe, despite offering a broader range of testing modalities, maintains some of the highest regulatory barriers, with most EU/EEA countries still prohibiting lay-provider testing or requiring clinician oversight.¹² In Central Europe, national guidelines often lack key interventions and show limited integration between HIV and STI services.¹² In EECA, punitive legal environments, including the criminalization of sex work, drug use, HIV transmission, or even HIV exposure, are inconsistent with global HIV testing guidance and continue to limit access to community-led services.^3,12,17

Written consent is still a mandatory requirement in several countries, maintaining a state of “HIV exceptionalism” that reinforces stigma and discourages testing, particularly in central and eastern sub-regions.^3,12,36

Structural and Social Barriers

Structural inequities and social dynamics limit the access to HIV testing. Criminalisation and punitive laws increase the fear of prosecution and contribute to the exclusion of key populations, including PWID, sex workers, migrants, and LGBTQ+ communities, from formal healthcare services.^2,4,12,60 In approximately one-third of countries, user fees persist for certain populations or geographic areas, compromising equity of access.^4,12 Administrative requirements such as mandatory identification or advance appointments further exclude undocumented migrants and individuals with unstable housing.^4,77

Stigma remains a major factor contributing to late diagnosis.^{1,3,14,77–79} Concerns about confidentiality and the social consequences of a positive result lead many individuals to avoid formal healthcare services.^2,3 In EECA, this stigma is particularly acute and reinforced by conservative cultural norms.^2,3,11 Low self-perceived risk, especially among heterosexual populations, further limits uptake of regular testing.^46,77

Operational Challenges

Operational barriers continue to limit the scalability and sustainability of CBT. Many services operate under conditions of chronic funding insecurity, with several countries relying heavily on international donors or private foundations rather than stable national public financing.^1,2 This compromise the continuity of outreach, staffing, and long-term planning, particularly in rural and underserved areas.

Training gaps persist in settings where lay-provider testing is permitted but not adequately supported, resulting in variation in service quality and delivery.^7,36 Supply-chain disruptions, including shortages of rapid tests and challenges in procuring integrated HIV/HCV/STI kits, further limit testing capacity.^7,36 Fragmented health information systems and limited interoperability with national surveillance platforms also hinder efficient data reporting and monitoring.^1,17,22,30

Disruptions Caused by Recent Crisis

Large-scale crises have had a substantial impact on HIV testing and surveillance capacity. The COVID-19 pandemic caused major disruptions in testing availability, with over half of countries reporting reduced HIV testing volumes as community-based services were constrained by lockdowns and public health restrictions.^4,80,81 These declines contributed to diagnostic delays and widened existing gaps in early detection.^4,8,80 At the same time, the pandemic accelerated innovation in HIVST, digital counselling, and remote kit distribution, highlighting alternative pathways for maintaining services during periods of disruption.^18,22,82

The Ukrainian War has created additional barriers by interrupting the continuity of care, limiting access to medication and laboratory services, and forcing large-scale population movements.^3,36,83–86 Several community-based organisations rapidly adapted their HIV prevention programs. This included expanding the distribution of prevention materials, scaling-up mobile van services, and shifting counselling activities to online formats where feasible. In parallel, many organisations introduced additional services to respond to the needs of key populations, such as providing humanitarian support (including food, hygiene items, and clothing) and establishing temporary shelters for displaced people.⁸⁷

Host countries have had to rapidly adapt their surveillance, referral, and treatment systems to address the needs of refugees living with or at risk of HIV.^3,36,83–86 These challenges highlight both the vulnerability of community-led services during geopolitical or humanitarian crises and the need for resilient, adaptable systems.

Integrated Testing and Integrated Services/Multi-Disease Approach

European public health guidance strongly supports integrated testing as a standard of good practice. The ECDC and WHO Regional Office for Europe recommend that community-based services routinely offer combined testing for HIV, viral hepatitis, and STIs, especially for key populations at higher risk.^22,30 The 2025 European Standards for CBT further specify that integrated testing should be incorporated into routine service delivery, aligning diagnostic strategies across diseases to maximise early detection and facilitate timely linkage to care.¹³

Several European initiatives have contributed to advancing this approach. The INTEGRATE Joint Action supported its practical implementation by developing tools that demonstrated the feasibility of multi-disease testing in both clinical and community settings.^88–91 More recently, the CORE project has shown that combining HIV, viral hepatitis, and STI testing within community programmes effectively reaches underserved groups and accelerates linkage to care.⁹²

Examples across regions highlight the added value of integration. In Georgia, triple rapid testing for HIV, HCV, and syphilis in low-threshold settings has proven particularly effective for PWID.^7,90 The introduction of multiplex technologies, such as dual HIV/syphilis rapid tests, has further enabled multiple diagnoses from a single specimen and improved case detection among key populations and pregnant women.^7,93–95 Beyond diagnostics, integrated care models implemented in Minsk, Rotterdam, and several programmes in the UK and Portugal provide more comprehensive multi-disease care, including laboratory assessments, liver evaluations, and, in some cases, treatment initiation directly in community settings.^34,46

Despite this progress, integration remains uneven across ECA, with many services continuing to operate in disease-specific silos. According to ECDC monitoring, only a subset of EU/EEA countries (17 of 27) has fully incorporated integrated testing for HIV, HBV, HCV, and STIs into national guidance.^3,12

Monitoring, Surveillance, and Data Integration

Standardised Community-Based Testing Data Collection

Standardising the monitoring and evaluation of CBT is essential for assessing its impact on public health and for integrating these services into national responses. In Catalonia, the long-standing DEVO community testing network has used harmonized indicators and data collection tools since 1995.^24,26 These standardized data have shown that the proportion of notified HIV cases attributed to community services increased form 4.5% in 2001 to 37.8% in 2017, including 70% of new diagnoses among MSM, illustrating the role of robust monitoring in quantifying impact and enabling integration with regional HIV registries.²⁴ The COBATEST network, based on the Catalonian experience, was established to support standardised monitoring and evaluation of CBT practices in ECA. It employs harmonised tools, a shared database, and core indicators aligned with UNAIDS, WHO and ECDC guidance.^15,25,57,96 Standardised data produced through the network facilitate cross-site comparisons and robust analysis, providing evidence to inform policy and improve CBT services.^25,57,97

Gaps in Surveillance Integration

Despite growing recognition of the value of community-generated data, its integration into national HIV surveillance systems across ECA remains limited and inconsistent. The European Standards of HIV Prevention and Care (2025) set a target of 80% of community HIV testing services to report data through national monitoring systems; however, the lack of harmonised indicators and interoperable digital tools remains a barrier to comparable trend analysis across the region.^1,13 As a result, community organisations, frequently the primary source of information on key populations, frequently report data through informal channels, hindering comparability and limiting visibility of their contribution to national testing coverage.²

Several initiatives have been implemented to address these gaps. The INTEGRATE Joint Action developed core indicators and piloted the integration of CBT data into national surveillance systems in Poland, Serbia, Slovakia, and Slovenia, demonstrating feasibility and public health value.^98,99 Similarly, the COBATEST Network has reinforced standardised CBT data collection across ECA, improving data quality and facilitating alignment with national reporting frameworks.^25,57,100 Since 2018, the Dublin Declaration monitoring process has incorporated specific indicators for CBT, reflecting growing institutional recognition of CBT within regional surveillance systems.¹⁰¹ Some countries, such as Portugal, Ireland, Poland, and Spain, have developed national mechanisms for routine CBT data reporting.^98,102–104

Despite promising developments, the integration of community-generated data into the national surveillance remains incomplete. Strengthening digital infrastructure, adopting standardised indicators, and formalising data-sharing mechanisms between community providers and public health authorities will be essential to fully assess testing coverage, identify gaps, and monitor progress among key populations.

Projects and Research

The scale-up of CBT in ECA has been supported by major EU-funded initiatives and reinforced by community-based research cohorts that have provided evidence on effectiveness, monitoring, and HIV incidence among key populations. Collectively, these projects have contributed to defining core concepts, strengthening evaluation frameworks, and accelerating the adoption of innovative approaches across the region.

Major European Strategic Projects

Early European initiatives laid the groundwork for standardised CBT. The HIV-COBATEST Project (2010–2013) established the first consensus definition of CBVCT and core indicators for monitoring access, positivity, and linkage, highlighting the heterogeneity of CBT models across Europe.^15,96 Building on this, EUROHIVEDAT (2014–2017) refined monitoring tools, improved guidance on early diagnosis and linkage, particularly for MSM and migrants, and explored digital and network-based testing strategies.¹⁰⁵

The ECHOES Survey (2017), implemented under the ESTICOM project, provided the first EU-wide overview of community health workers engaged in supporting MSM, identifying their main roles and core training needs, helping to inform policies and investments in community-led testing capacity.³⁷

The INTEGRATE Joint Action (2014–2020) contributed to broadening CBT by piloting integrated testing for HIV, hepatitis, STI, and TB, scaling-up HIVST, and promoting the inclusion of CBT data within national surveillance systems.^88,98,99,106

More recent EU4Health projects (CORE, BOOST, EXPAND, REACH OUT, 4C) have strengthened community-led and outreach-based models, supporting integrated infectious-disease screening and improving access to migrants, PWID, and sex workers.^107–111

Community-Based Research Cohorts and Incidence Studies

Community-based cohorts are essential for understanding HIV incidence and testing patterns among key populations, providing evidence that is often missing in traditional surveillance systems. The Lisbon Cohort (CheckpointLX) has monitored HIV incidence among MSM since 2011 through biannual peer-led testing, generating real-time evidence on behavioural risk and prevention trends, identifying an HIV incidence of 2.80 per 100 person-years in 2015.^112,113 In Barcelona, the ITACA Cohort (BCN Checkpoint) documented a substantial decline in HIV incidence, from 4.17 to 1.57 per 100 person-years, associated with frequent testing and rapid ART initiation.^56,114 Similarly, the Athens Cohort (Ath Checkpoint) has reported incidence rates of around 4 per 100 person-years, with younger MSM showing significantly higher seroconversion risk.¹¹⁵

Cohorts, including the SEXCHECK Study (Bologna) and longitudinal analyses within the COBA-Cohort, have explored co-infection patterns and behavioural risks.^116,117

Recent analyses from the COBATEST Network show that routine CBT data can be reliably used to estimate HIV incidence without establishing dedicated cohorts, while also highlighting significant disparities across key populations, particularly non-European migrants, MSM, and sex workers.¹¹⁸

Overall Contribution

Together, these projects and community-led cohorts demonstrate the unique value of CBT as both a testing strategy and an epidemiological resource. By capturing data from populations underrepresented in facility-based surveillance, these initiatives have provided critical evidence to support programme design, policy development, and continuous improvement of community-based and community-led testing models across ECA.

Discussion

The evidence synthesised in this narrative review suggest that CBT has become a critical component of HIV-testing strategies across the ECA region. Rather than playing a marginal role, CBT consistently reaches populations underserved by conventional healthcare systems, contributes to earlier diagnosis of HIV, and facilitates timely linkage to care.^1,9,13,119 The diversity of models described reflects the flexibility of community approaches to adapt to different epidemiological contexts, social environments, and population needs.^7,9,29,30,34 The use of innovations such as rapid diagnostic tests (including multiplex HIV/syphilis technologies), HIVST, and digital referral ecosystems further strengthens the capacity of CBT to deliver person-centred, stigma-free services.^7,8,18,30

Evidence from across the region indicates high acceptability of these approaches, higher positivity yields compared with facility-based testing, and a strong capacity to reach first-time testers, who are often among those most at risk of late diagnosis.^{9,10,12,25,26,29,41,50,57} Programmes supported by networks like COBATEST and aligned with policy frameworks such as the WHO Differentiated Service Delivery approach and the ECDC European Standards indicate that CBT is not only clinically effective but also scalable and economically efficient.^{7,9,13,26,30,74}

However, progress is still constrained by legal and regulatory restrictions. In particular, limitations on lay providers testing, written consent requirements, and punitive laws affecting key populations (including sex workers, PWID, migrants, and LGBTQ+ communities), continue to challenge the expansion of evidence-based community models.^{2,3,12,14,17,120} Many national HIV testing guidelines remain outdated, failing to incorporate key innovations, such as HIVST, indicator-condition testing, integrated screening for HIV, hepatitis B/C, and STIs, or task-sharing approaches essential to reaching the 95-95-95 goals.^12,14 These policy gaps reinforce regional differences, with Western Europe offering a broader set of yet regulated service options, while structural barriers continue to limit implementation across much of EECA.^1,3,17

Structural and social determinants such as stigma, fear of criminalisation, administrative barriers, or lack of healthcare entitlements for undocumented migrants, remain key drivers of delayed diagnosis and inconsistent engagement in prevention and care.^{2,3,12,14,17,78,79,119} Overall, these dynamics emphasise the importance of community-led, culturally competent, low-threshold approaches that can build trust, ensure confidentiality, and reduce bureaucratic and psychological obstacles to testing.^{1,18,26,34,62,79}

An important gap identified in this review is the limited integration of community-generated data into national HIV surveillance systems.^1,13,30 Despite progress through harmonised indicators, digital tools, and EU-funded projects, such as INTEGRATE, only a subset of countries have established routine mechanisms to incorporate CBT indicators into national monitoring frameworks.^1,2,13 This lack of systematic data integration means that community-generated data are not consistently captured, impeding accurate assessments of testing coverage, positivity yields, linkage to care, and trends among key populations, ultimately limiting the evidence available for policymaking and resource allocation.^12,14,121 Strengthening interoperability, digital infrastructure, and standardised monitoring systems is essential for the consolidation of CBT within national testing systems.^12,22

This review also highlights the increasing relevance of accelerated linkage pathways, including peer navigation, proactive referral systems, and in some settings point-of-care confirmatory PCR.^26,34,73 These models reduce loss to follow-up after a reactive result and support faster initiation of ART, aligning with emerging European practices and WHO recommendations.^7,13 The integration of multiple infections (HIV, HBV, HCV, syphilis, STIs, and tuberculosis) in CBT further enhances efficiency, reduces missed opportunities for diagnosis, and reflects a shift toward more comprehensive, people-centred care.^{7,13,17,18,22,30}

From an economic standpoint, CBT has been shown to be cost-effective, particularly through the early diagnosis of HIV, which reduces long-term treatment costs, and through service models that help decongest facility-based health systems.^7,8,29,74 However, long-term sustainability requires transitioning from donor-dependent initiatives to stable domestic financing, including social contracting mechanisms in which governments fund community-led organisations to deliver testing, outreach, and linkage services.¹⁷

The COVID-19 pandemic and war in Ukraine have further exposed the vulnerability of HIV services while also creating opportunities for innovation. Disruptions in testing volumes were accompanied by rapid expansion of self-testing, digital counselling, remote distribution of test kits, and adaptive models to ensure continuity of care in the country and for displaced populations.^17,18,22,87 These experiences demonstrate both the resilience and adaptability of community-based approaches and highlighting the need for crisis-responsive frameworks capable of sustaining testing and linkage services during emergencies.

This narrative review has several limitations that should be acknowledged. First, the available evidence is unevenly distributed across the region, with a marked predominance of studies and programme examples from Western Europe. This reflects gaps in the published literature and may restrict the transferability of some findings to other contexts. In addition, a proportion of the cited work derives from projects in which the author has been directly involved, some of which were developed within the COBATEST Network, which the author leads. This has resulted in a relatively high level of self-citation rate and raises the possibility of bias associated with reviewing evidence from one’s own professional sphere. This potential limitation is acknowledged, and efforts were made to situate those findings within the wider body of available literature and to reflect the range of approaches reported across different settings.

Implications for Practice and Policy

Overall, the findings underscore that CBT is fundamental to achieving early diagnosis, advancing equity, and strengthening HIV response across ECA. To fully realise the impact of CBT, national strategies must prioritise an enabling policy, financial, and structural environment that allows these services to operate at scale.

The first priority is to remove regulatory barriers by updating national policies to align with WHO/ECDC standards. This includes authorising trained lay providers to perform HIV testing, eliminating unnecessary written consent requirements, and removing legal and punitive frameworks that discourage key populations from seeking testing and care. Such reforms are essential for expanding access and ensuring that CBT models function effectively.

Second, countries should prioritise strategic integration by scaling up person-centred models that combine HIV, hepatitis B/C, syphilis, and STI testing, supported by robust referral pathways, peer navigation, and timely linkage to care. Incorporating HIVST and multiplex diagnostics across community settings can further enhance uptake and diagnostic efficiency.

Third, strengthening monitoring and evaluation systems is critical. Supporting networks, such as COBATEST, and investing in interoperable digital infrastructure will enable the systematic incorporation of community-generated data into national surveillance. High-quality data are critical for improving programmes, guiding, targeted resource allocation, and monitoring progress toward the 2030 goals.

Fourth, securing sustainable financing, particularly through social contracting, will reduce reliance on donor support and ensure long-term operational stability, allowing community-led organisations to expand their reach and maintain service continuity.

Finally, countries must actively address structural inequities, including stigma, criminalisation, migration-related barriers, and gender disparities, through targeted interventions and legal reforms.

Future Research Priorities

Future studies should focus on implementation science for integrated testing models, evaluation of digital and hybrid service modalities, optimisation of post-self-testing linkage pathways, and deeper investigation into structural and legal barriers that continue to limit reach among populations at the highest risk. Advancements in multiplex rapid diagnostics, remote sampling, and real-world economic evaluations are also essential for scaling-up.

Overall Conclusion

This review shows that CBT has become an essential component of HIV responses in ECA, particularly for reaching populations that remain insufficiently served by standard healthcare settings.

Further progress will depend less on generating additional evidence of effectiveness than on creating the conditions for long-term integration, including supportive regulation, stable financing, and routine inclusion of community-generated data in national surveillance. Without these changes, the contribution of community-led testing to ending AIDS as a public health threat by 2030 is likely to remain constrained.