Advances in HIV testing technologies over the last decade have resulted in the recent US Food and Drug Administration (FDA) approval of a rapid HIV test (OraQuick, OraSure Technologies, Bethlehem, Pennsylvania, USA) for use by a consumer at home. As described by Myers et al.  in this issue of the journal, the availability of HIV testing at home creates opportunities for expanded HIV screening in the United States that will ideally increase the percentage of those who are living with HIV who are aware of their infection. As public health clinicians, we support this technology as a means to reach persons who might choose to be tested at home due to the increased convenience and confidentiality afforded by this methodology. But as the authors point out, it remains to be seen how home HIV testing will best complement current HIV testing methods. In order to assure that the technology is effective at identifying previously undiagnosed HIV-infected individuals, populations at greatest risk for HIV will need to choose this mechanism of testing. In addition, public and personal health systems must be prepared to respond to characteristics of the new test: misinterpretation of rapid test results, the window period during acute infection, a potentially high out-of-pocket cost per test and the challenges inherent in its use outside of a healthcare setting.
Home HIV testing has the potential to reduce the proportion of people currently living with HIV in the United States who are unaware of their infection, but only for those persons able to afford the test. Of those not currently diagnosed, it is estimated that a greater percentage are youth, black MSM, and other minority , populations that historically comprise a disproportionate share of those on the lower end of the socioeconomic scale. Data from the US National HIV Behavioral Surveillance (NHBS) system suggests that in heterosexual populations poverty is a primary driver of HIV infection . In 2009 NHBS data, 2.3% of heterosexuals living at or under the federal poverty level, which in 2009 was an income of less than US$ 10 830 a year for a single person, were found to be HIV infected compared with 1% for those persons with incomes above the federal poverty level. Myers et al.  speculate that in the first year of public availability, 2800 000 individuals will utilize the home rapid HIV test based on an FDA constructed Monte Carlo Model. This estimate may prove to be true, but uptake is likely to skew in the direction of persons with fiscal means to pay for the test, not necessarily those at greatest risk.
Public and personal health systems should not consider the availability of home testing to be a panacea. Until we have a better understanding of who will utilize this new technology, we must assure that safety net screening services are readily available for those often found on the lower end of the socioeconomic scale who are at most risk. In fact, public and free HIV testing sites need more visibility in the community. Not only will these facilities be a common setting for confirmatory HIV testing after a positive home test, but individuals seeking out home testing who cannot afford the test kit will need readily available, user friendly and low-cost or free alternatives to the home test. Resources currently supporting low-cost or free HIV screening services should not be radically redirected until the reach of home testing is better understood.
More importantly, a shift to home testing necessarily mandates expanded public health resources to identify people testing positive and link them into HIV care. According to data from the NHBS, most MSM choose to be screened regularly already, 89% having ever been screened and 61% screened in the past year . Although marginal increases in diagnoses could potentially be seen in MSM populations through the use of this new technology, expanded home testing will shift the site of these diagnoses away from the controlled environment of our clinics to the less structured setting of a patient's living room.
There is an urgent need to quickly develop and ramp-up linkage to care services for people screening positive at home. The Centers for Disease Control and Prevention estimates that only 72% of those persons testing positive for HIV through current clinical screening programs are successfully linked into care within 4 months . Home testing may be more confidential, but will result in more people testing positive who may not know what their next step should be or how they begin to navigate our byzantine healthcare systems. Although the manufacturer has thoughtfully developed a call center to link people into care, passive referral systems have been shown to not be as effective as active referral mechanisms .
We in public health must implement programs that actively reach out to persons in the community who will be in need of confirmatory testing and linkage to HIV-care: relationships must be established, marketing plans developed, websites created, and staff trained to navigate local health systems and facilitate linkage to care for persons newly diagnosed with HIV. Testing is one part of a much larger cascade . Although patients testing at home might reduce transmission risk through an adjustment in risk behavior, this risk will only truly be minimized once a patient is linked into HIV care, retained in care, on medications and their virus is suppressed. Despite the fact that these are critical components of the engagement in the HIV care cascade, none of these care milestones are attainable by someone without knowledge of their HIV infection. HIV diagnosis initiates the cascade and is the critical first step to allow complete engagement in care.
There is an excellent opportunity right now to ride the wave of media attention on home HIV testing in order to promote and (hopefully) continue the destigmatization of HIV testing and HIV infection. In addition to these potential societal benefits, we welcome the opportunities this evolution in HIV screening offers to consumers, but see home testing as complementary to – not supplanting – current testing efforts. As such, we recommend safety net screening services continue to be supported and linkage services be developed to assure that all persons, regardless of economic status, have easy access to HIV testing and the HIV care services vital to achieving a suppressed HIV viral load.
Conflicts of interest
There are no conflicts of interest.
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