TitleTranslation of "at-home" HIV testing: response to Katz et al. and Hurt and Powers.
Publication TypeJournal Article
Year of Publication2014
AuthorsCatania, JA, Fortenberry, D, Orellana, R, Dolcini, MM, Harper, G
JournalSexually transmitted diseases
Date Published06/2014
Full Text

Katz et al.1 and an accompanying commentary by Hurt and Powers2 provide considerable insight into the assumptions we make about the implementation of new innovations in sexual health. Although we concur with many of the comments of Hurt and Powers and appreciate the cautions raised by Katz et al. regarding an overreliance on any one method of HIV testing, there are other significant issues that deserve consideration. In particular, there are significant limitations in how self-implemented HIV testing (SIT) has been translated to the public, so potential positive impacts on HIV identification and treatment may be impossible to assess accurately.

Recent work by our group has found that OraQuick is perceived to have a number of benefits over clinic-based testing by at-risk low-income African American urban youth and young adults.3,4 We found that OraQuick has the potential to supplement clinic-based testing by reducing social stigma and privacy concerns, increasing convenience, and facilitating normalization of HIV testing in the community. Similar benefits have been identified for adults in other contexts.5

These are important and potentially powerful outcomes that address limitations of current HIV venue-based testing. Moreover, these outcomes should contribute to public health goals by increasing HIV testing, repeat testing, and partner testing. However, our research has identified a number of specific barriers that could blunt OraQuick’s potential benefits including the high retail cost (>US$40/unit in pharmacies). In addition, we have identified instructional and procedural challenges that reflect poor fit with some young low-income African American consumers in terms of comprehension of technical language and sociocultural factors (e.g., an instructional video that is perceived to be a poor fit in terms of socioeconomic status). Hurt and Powers observe that sensitivity for OraQuick is lower in the hands of consumers than when administered by a trained provider (92.9% vs. 99.3%), providing further evidence of the challenges faced in translating SITs to the public. Together, these findings suggest that OraQuick kit instructions and training videos may need additional enhancements for consumers to reach fidelity levels comparable with that of trained providers.

In addition to issues of poor fit, there are also concerns about current SIT dissemination methods (i.e., commercial pharmacies and Internet purchases) and whether these approaches will reach high priority populations.3,4 Alternative dissemination approaches such as distribution through nontraditional sites with untrained personnel, supplemented by enhanced consumer education efforts, could be beneficial in reaching at-risk populations.

We recognize that SITs require a proactive consumer who seeks confirmatory testing, conducts repeat testing, and, when positive, obtains treatment. However, these are also issues consumers confront in clinical and other venue-based test settings. Linkage-to-care programs have only recently been implemented in clinic venues, and the success of these programs in real-world settings is not fully known. Similarly, it remains unclear if persons testing positive through SIT require the same or different linkage-to-care services.

Without a doubt, the “test and treat” strategy is complex from a consumer’s perspective. HIV SIT may offer very real advantages to marginalized and stigmatized persons who may otherwise avoid testing. Without multiple channels for testing diverse at-risk populations, it is difficult to see how we will achieve the national goal of testing 90% of HIV positives by 2015.6