Fifth of five student guest posts by Jonathan Yuska

The saying, “The more you know, the more you can control,” is no more meaningful than when used in the context of HIV detection and prevention. Public health advocates endlessly stress the need for knowing one’s status; and one would assume that any way in which the most amount of people can be tested would be beneficial for the population1. The Food and Drug Administration shared this same idea when they overwhelmingly approved the first ever over-the-counter (OTC) HIV testing kit in 20052; which in theory, sounds like a promising way to reduce the possible 350,000 HIV cases that remain undiagnosed in this country3. Though, some medical staff are still weary of this type of diagnostic method for reasons such that it breaks the linkage between the patient and long-term care. The debate on whether HIV testing should be—shall we say—left only to the professionals or put in the hands of everyday citizens is only just beginning; though, here are some points you may want to consider when making your own opinion on HIV home testing.

The OraQuick ADVANCE is one example of an in-home testing kit that provides the user with an accurate (sensitivity of 99.3% and specificity of 99.8%) and rapid means of HIV detection with nearly no invasiveness. In just 20 minutes and a swab of the mouth, individuals who may have been living their entire life unaware they are HIV positive, now can take that knowledge as empowerment to manage their health safely and finally receive the appropriate care they may desperately have needed. Supporters of in-home kits believe it offers a choice of what to do with the knowledge of being diagnosed and dismisses possible stigmatizations associated with being tested since testing can be done in the privacy of one’s own home. Proponents also feel that HIV home testing may become the new norm before engaging in intimacy and suggest testing kits come in boxes of two so partners can test each other4. The OTC HIV testing kits are hoped to slow down the more than 40,000 new infections3 that occur every year in the United States; though, some that believe kits such as OraQuick will make little difference in reducing the HIV infection crisis in the populations that need it most.

The HIV home testing kit is hoped to attract those at highest risk including young, low-income and education, non-white males who neither frequent medical care facilities nor are tested regularly on their HIV status5. Surveys conducted by the National Center for Health Statistics have shown that 79% of persons in these types of populations would indeed use home HIV tests if available; though, when participants in the survey were told the price of testing kits was $40, the approval rate of the kits dropped to 40%2. This raises some speculation on whether OTC kits will actually access these sorts of populations without first lowering the price to purchase them.

Rather than accessing those at highest risk, some naysayers anticipate the tests will predominantly appeal only to those “worry well” or hypochondriac individuals who continually test negative or new couples that want to verify their HIV statuses before sexual intimacy begins. Though, what one does with the knowledge of having tested negative for HIV is still under question. It may be seen that negative results actually promotes more risky sexual behaviors—since they were able to “get away” with it in the past—such as having intercourse without protection. This sort of risky behavior may expose the individual to a whole host of other sexually transmitted diseases2.

Issues with the proper usage of kits may also pose a problem in accurately diagnosing those who have been recently infected with HIV which could lead to false-negative results. Individuals participating in unsafe practices may be unaware of the 8-week “window period” needed for in-home tests to detect HIV antibodies (human antibody component is needed to determine HIV status in at-home tests [RNA tests commonly used by clinics can detect HIV within 9 to 11 days post infection]) and unwittingly spread their infection to others6.

False-positive results from in-home tests may also cause a great deal of damage to the validity of proven HIV detection methods as well as the likelihood of individuals to repeat HIV testing after receiving highly upsetting untrue news. False positive outcomes from tests are most common in populations with a low occurrence of disease in the first place—like in HIV—where the occurrence of unknown cases is roughly 0.2%. The ability to perfectly detect such a small percentage of people infected even with a test that is highly sensitive and specific is extremely unlikely and the predictive value of the test will be noticeably low2.

Lastly and most obviously is the disconnect from care that occurs from in-home diagnostic kits. Public testing focuses on linking HIV-positive patients with counseling and treatment; though, when this diagnosis is done in private, a person’s anxiety may force them to exile where they never seek treatment and may even contemplate suicide1. It is important to note that diagnosing patients is only half of the battle, linking them to the appropriate care is the other half—something home testing inherently does not do.

“The more you know, the more you can control” is a saying that is at the heart of reducing the amount of HIV transmissions person-to-person by knowing one’s status. HIV home testing kits such as OraQuick sounds like a promising way to reduce the number of transmissions since they are quick and convenient for the user, but whether these tests will actually reach those individuals who are at greatest risk is doubtful. At home kits may also promote risky behaviors, increase the numbers of false-positives and –negatives, and deteriorate the linkage to care that is vital to those with new diagnoses.

Will in-home HIV testing kits be the assistance needed in decreasing the HIV transmission concern—some professionals are questionable. Now after reviewing the facts on HIV home testing, what is your stance on the subject?

Sources:

1. Chesney, Margaret A., and Ashley W. Smith. “Critical Delays in HIV Testing and

Care.” American Behavioral Scientist. Apr. 1999. 17 Feb. 2013             <http://abs.sagepub.com/content/42/7/1162.short>.

2. Walensky, Rochelle P., and David Paltiel. “Rapid HIV Testing at Home: Does It Solve

a Problem or Create One?” Annals of Internal Medicine (2006): 459-562.

3. Fleming, P. L. “HIV Prevalence in the United States, 2000.” Feb. 2002. 18 Feb. 2013

<http://stdpreventiontraining.jhmi.edu/docs/Fleming%20et%20al_HIVPrev_Seattle_CROI_2002.pdf>.

4. McNeil, Donald G. “Another Use for Rapid Home H.I.V. Test: Screening Sexual

Partners.” The New York Times. 5 Oct. 2012. 18 Feb. 2013 <file:///Users/ska020/Desktop/Another%20Use%20for%20Home%20H.I.V.%20Test%20-%20Screening%20Partners%20-%20NYTimes.com.webarchive>.

5. Phillips, Kathryn A. “Potential Use of Home HIV Testing.” The New England Journal

of Medicine. 11 May 1995. 18 Feb. 2013 <http://www.nejm.org/doi/full/10.1056/NEJM199505113321918>.

6. “Possible Exposure to HIV?” How long it takes to test HIV positive after infection.

Stop AIDS Project. 18 Feb. 2013 <http://stopaids.org/resources/possible-exposure-hiv/time-it-takes-test-positive>.