Understanding Reach, Effectiveness, Adoption, Implementation, and Maintenance of home-based comprehensive sexual health care: a Realist Review

Background Testing for human immunodeficiency virus (HIV) and sexually transmitted infections (STI) is increasingly offered outside a clinic-based setting. Among key populations barriers to accessing testing and sexual health care may could be lowered due to home-based testing and care services. This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. Methods A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counselling). PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO databases were searched. Peer-reviewed quantitative and qualitative literature published between February 2012 and February 2023 was examined. The RE-AIM framework was used to systematically assess the (R) reach of key populations, (E) effectiveness of the intervention, and (AIM) effects on the adoption, implementation, and maintenance within routine sexual health care. Results Of 730 uniquely identified records, 92 were selected for extraction. Of these studies, 59% (54/92) reported actual interventions and 41% (38/92) described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/92) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness (E) of most studies was (expected) increased HIV testing. Adoption (A) of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity (I) of the intervention. In terms of maintenance (M), home-based CSH should be institutionalised and complementary to clinic-based sexual health care. Conclusions Five key findings were identified which may enhance implementation of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of HIV testing among key populations. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study is part of the project Limburg4Zero: An integrated approach to reduce the number of HIV and sexually transmitted diseases in Limburg. Previously funded by Aidsfonds Nederland; P-49903 and currently by Maastricht University Medical Centre+ within the Next Step grant. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data sharing is not applicable since no datasets were generated or analysed during this study. * CT : Chlamydia Trachomatis, CSH : comprehensive sexual health care DBS : dried blood spot HBV : Hepatitis B HCV : Hepatitis C HIV : Human immunodeficiency virus MSM : men who have sex with men NG : Neisseria Gonorrhoea RCT : randomized controlled trial RE-AIM : reach, effectiveness, adoption, implementation and maintenance framework STI : sexually transmitted infections WHO : World Health Organisation