Correspondence (The Lancet 343, 1294-5, May 21,1994)

Home Testing for HIV

Steven D. Pinkerton, Paul R. Abramson

Department of Psychology, University of California, Los Angeles CA 90024, USA (now 90095)

Sir -- Frerlchs neglects several issues of critical importance for the success of any such program in curtailing the spread HIV.

For testing to have an Impact on HIV transmission rates infected men amid women would have to modify their risk-related activities. Although most studies examining the effect of serostatus knowledge on sexual behaviour of gay American men suggest that positive serostatus motivates behavioral change, reported risk reduction is far from total.[1]  Sex, it seems, is a difficult habit to break.[2] In a recent study, 36% of HIV discordant heterosexual Haitian couples continued to engage in unprotected intercourse.[3] By contrast, a low seroconversion rate was reported for discordant Zairean couples who participated in an intensive psychological counseling program.[4] The effect of counseling in motivating behavioral change should not be underestimated. However, It is precisely this component that is missing from Frerichs' proposal. Because self-test results would be available without mandatory post-test counseling, decreased compliance with recommended behavioral modifications might be expected.

The absence of a post-test counseling component is also troubling from a psychological standpoint. To inform someone who may be intellectually and emotionally unprepared to cope with HIV disease that he or she is infected with the virus, without also providing adequate psychological support services is, or should be, unthinkable.  Acute psychological distress may follow notification of a positive test result, at least, to all positive-testing individuals. 

Clearly, the stated rationale for self-testing (convenience, privacy, cost-effectiveness) would be compromised if in-person notification and counseling were required for all test recipients. Conversely, if only positive-testing individuals were notified in person, this fact would soon become common knowledge and thereafter a summons to the counseling site would carry the same emotional weight as notification of a positive test result. One solution to this dilemma would be to have some pre-designated proportion of negative-testing individuals receive their rest results at the counseling site, along with all those who tested positive. If the ratio of negatives to positives were high, and made known to the public in advance, then a summons to the counseling site could not serve as a surrogate marker for a positive result. Because far more negative than positive-testing individuals would be summoned, most people would probably assume themselves to be among those who tested negative (a case of "optimistic bias"[5]), thereby mitigating the threat of severe psychological distress. Costs, meanwhile, would remain low provided that the ratio was not too great.

Additional concerns that remain to be addressed include the possibility that false-negatives arising from tests conducted during the window period between infection and antibody production might lead to increased risk-taking, and the possibility that the introduction of self-testing, promoted as a means of reducing the risk of becoming infected might provide a false sense of security to individuals who continue to engage In risky activities.

1. Jacobsen PB, Perry SW, Hrisch D-A. Behavioral and psychological responses to HIV antibody testing. J Consult Clin Psychology 1990; 58: 31-37. 

2. Abramson PB, Pinkerton SD. With pleasure: thoughts on the nature of human sexuality. Oxford: Oxford University Press (in press).

3. Pape JW. AIDS: results of current prevention efforts in Haiti. AIDS Res Num Retrovir 1993: 9: S143-45.

4. Kamenga M, Ryder R, Jingu M, et al. Evidence of marked sexual behavior change associated with low HIV-1 serosconversion in 149 mattied couples with discordant HIV-1 serostatus: experience at an HIV counseling center in Zaire. AIDS 1991; 5(suppl 1): 61-67.

5. Weinstein ND. Perceptions of personal susceptibility in harm. In: Mays VM, Albee GW, Schneider SW, eds. Primary prevention of AIDS. Newbury Park, CA: Sage, 1989: 142-67.