ACRIA Raises Concerns About In-Home HIV Testing

OraQuick HIV test. Photo: John Gress/Reuters

In keeping with its history of patient empowerment, the AIDS Community Research Initiative of America (ACRIA) – a leading HIV/AIDS research, prevention, and advocacy organization founded by a group of physicians, activists, and people with HIV – today recognized the importance of Orasure’s new in-home HIV test called OraQuick.  Research has shown that a key roadblock to ending the HIV epidemic is the large number of people who are unaware of their HIV status.  It is estimated that half of all new infections in the U.S. arise from those who are unaware that they have HIV, and one of the best tools available to lower transmission is to make testing broadly available. In-home testing will increase the number of people who are aware of their HIV infection, leading to less transmission.

But in recognizing the value of the new test, ACRIA notes that it is equally important to note its drawbacks, including the lack of counseling and referral to care, misinterpretation of test results, testing for partner screening purposes, and the psychological impact a positive result can have in adverse situations.

Daniel Tietz, R.N, J.D., Executive Director of ACRIA, issued the following statement outlining these drawbacks:

“First and foremost is the lack of counseling tied to the test.  For this very reason, the FDA had been reluctant to approve home HIV tests that provide immediate results.  HIV remains life-threatening and continues to be associated with enormous stigma.  A home user that receives a reactive result, which must be confirmed but which will be taken as positive by many users, with no counselor present for emotional support or to answer questions might be devastated.

“ACRIA is also concerned about the lack of a system for immediate referral to care.  Of the nearly 942,000 people who have tested HIV positive in the U.S., only 75% are in any way linked to care – a percentage that is certain to be lower when no counselor is available to make a referral. ACRIA believes that the strongest reason for offering in-home HIV testing is to get people with HIV into care as soon as possible – HIV testing without providing care defeats its main purpose.

“Finally, and perhaps most concerning, is the likely use of the test to screen sexual partners.  As has been shown by numerous studies, a significant number of individuals avoid condoms by questioning partners about their HIV status or by discriminating on the basis of race or appearance.  All of these methods are deeply flawed and contribute to the stubbornly high number of new HIV infections in the U.S., as well as stigma and discrimination.

“Being able to actually test casual partners for HIV may seem to be a useful solution to this problem, but in reality the test is not at all useful for this purpose.  Newly-infected individuals can take up to six months to create the antibodies that are detected by the OraQuick test, and it is estimated that up to half of all new HIV infections are transmitted by people in this ‘window period’ – people who think they are HIV-negative but who in fact are more able to transmit the virus than at any time in the course of their disease due to extremely high viral loads.

“Of particular concern is the false sense of safety that a negative test will engender.  A negative test will at best make it more difficult to adhere to safer sex guidelines, and many may see it as a license to dispense with them altogether.

“Perhaps most critical is the effect on casual partners who have a reactive result.  A study of 27 gay men who were given testing kits to use with casual partners produced stories such as this:

[I asked him], “Would you like to test with me?” [He said,] “Cool, that would be great.” And then he got the [positive] result [laughter] – he had no idea, I guess. He’s like, “What do you mean?” … And he got pretty upset, you know, it was hard to see that. I said. “Listen, I’ll go with you, if you want to go to another clinic and get retested.” He just said, “You know, I’d really like to just kind of take some time alone.”

Of the 101 casual partners tested in the study, ten tested positive and six were unaware of their HIV status – a very high rate.  The study provided no information on the eventual effect of the result on those six individuals or if they were able to access the counseling and care they needed.

“Even in cases where the test is used with long-term partners, significant concerns remain, not the least of which is domestic violence.  This is not limited to physical violence, but also includes emotional abuse and eviction.

“ACRIA urges OraSure and all those involved in setting public health policy to recognize and discuss both the pros and cons of the test.  It must be emphasized that the proper use of the OraQuick test is solely for private testing of oneself, and that it should not be used to screen casual partners.  Anyone using the test should be urged to consider the possibility of a positive result, as well as the relatively high rate of false negative results, and what steps should be taken if that occurs. The possibility of a positive result must be considered beforehand, and planning who to speak with and where to get care in that event is absolutely essential.”

ACRIA was founded as the Community Research Initiative on AIDS (CRIA) in December 1991 by a group of physicians, activists, and people living with HIV who were frustrated by the slow pace of government and academic AIDS research. Since that time, they have contributed to the development of more than a dozen medications that have received FDA approval, helping countless thousands of HIV-positive people live longer, healthier lives.

ACRIA’s accomplishments over the past two decades include: enrolling a diverse range of participants, including women and people of color, in clinical trials for HIV drugs; releasing groundbreaking research on HIV/AIDS in older adults; launching an HIV Health Literacy Program that gives people living with HIV the knowledge they need to take an active role in their own healthcare; publishing a wide range of health literacy booklets on topics including women’s treatment issues, older adults and HIV, and drug side effects; and, with GMHC, jointly publishing the influential magazine ACHIEVE, an HIV prevention, treatment and politics quarterly.