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Frerichs, R.R. Thoughts on home testing. SEA-AIDS Network, April 8, 1996

Posted in response to:

Anonymous to Frerichs, March 23, 1996

The following message was sent to me personally. I have deleted all identifiers to preserve the anonymity of the writer. His or her message, however, reflects general interest in home testing, to which I have tried to respond.

As a XXXXXXX who does some work for the group that distributes the family "heads in sand" posters, and like most people who are concerned about preventing hiv/aids, I found your posting in response to the Philippines conference of great interest.  It would certainly be empowering to have simple "home kit" preliminary testing available at reasonable cost. I've heard about this through and sea.aids, and I know WHO are currently checking a quick test developed by an Israeli company. Do you have more information on all this? It would certainly be worthwhile pushing for simple quick tests. 

The "worried well" and people most at risk would benefit in different ways. It would also provide people with some confidence to check themselves. Some public and private clinics in Southeast Asia have absolutely no counseling (pre- or post-test), many are not anonymous, and people are sometimes treated worse than "criminals" ! This does not mean that there are not some very good organizations out there, but it does suggest there is a lot more that needs to be done. I'd like to discuss this some more.

R.R. Frerichs Posting

I liked very much the poster you referred to. It uses humor in the most effective way, to gently move people in a positive direction.  The home test issue has been debated for quite some while. At present the Food and Drug Administration (FDA) in the United States has refused to consider any tests that are not administered in a clinical setting, with available counseling. They have not accepted the concept of screening, and do not seem to recognize the potential public health importance of simple  screening devices. Many other governments have accepted the United States FDA as a standard, and will not act on their own. This lack of independence is a curious phenomenon, but that is another issue for another time.

Your comments about public and private clinics seem right on the mark.  Because of the close identification in the world literature of HIV with prostitution, homosexuality, and drug addiction, many view HIV infection as proof that someone has been "sinful." Thus when people come for testing, instead of addressing their problems in a caring, professional manner, they treat them as sinners. Clearly this objectionable attitude is not what is needed.

What I have tried to do in my writings is emphasize that HIV must be viewed as a viral disease, similar to other microbial infections (a recent example is: Frerichs RR. HIV Winners and Losers. Epidemiology 6(3): 329-331, 1995). We must encourage both society and members of the medical community to address HIV as they would any other life-shortening disease, with compassion, support and care. I refer to this process of viewing HIV as a disease rather than a sin as "normalization" of HIV. We also must bring HIV out in the open where the problem can be addressed in a more forthright manner. To do this requires widespread testing with governmental and non-governmental agencies, and the people themselves, working together to detect the virus at an early stage of infection. Since the ultimate concern of most people is their own health, I favor home testing of self and spouse or lovers (their most likely source of infection). My ultimate goal, however, is to encourage likely-infected persons to enter the health care system. My theory is that people would come forward for confirmatory testing after self-screening with HIV indicators in the privacy of the home.

Notice that I have emphasized "theory" since this notion has not been evaluated. I have put on my "advocate" hat to stimulate public health colleagues to consider the merits of the idea and to evaluate its effectiveness. When this occurs, I will once again switch to my"epidemiology" hat and welcome unbiased research on this important intervention and prevention strategy.

While I have strong opinions about the need for early detection, widespread testing and normalization of HIV, I am less knowledgable about the various manufacturers of screening tests. Here in the United States there are two companies that make saliva collection devices (Epitope, Inc. and Saliva Diagnostic Systems, Inc.). Epitope has linked their saliva collector with the Organon Teknika EIA and has approval from the FDA for use in a clinical setting. No other US company has a licensed saliva test. SDS has developed a simple serostrip test (i.e., uses serum rather than whole blood or saliva) that has been evaluated in Mexico, Brazil, Myanmar, and Thailand, as well as by CDC in Atlanta. It works very well. They have recently developed a fingerstick test that uses whole blood, and can be used at home. I have not seen any field evaluation of this whole blood test, however, and cannot say if it is as accurate as their serostrip test. They are currently developing a saliva strip test that also can be used at home. Two other US companies, Johnson and Johnson and Chemtrak, also have home collection devices that are linked to laboratory for testing. Both would allow people to anonymously submit blood spots for testing, but neither are licensed in the United States. Finally, I have heard of the Israel company you mentioned, and of another in Ireland staffed by people who used to work at Epitope.  Unfortunately, I know little about their products and have seen nothing in the scientific literature about them.

My attempt at this point is to get those who are concerned with public health to recognize the importance of early detection, both for prevention and treatment of infection. If we agree that early detection is an important goal, then we need next to influence the regulatory agencies to license various home screening tests (i.e., HIV indicators) or home collection devices. Once companies see that there is a market for such products, they will start to compete with one another and the prices will come down to an acceptable level.

Thanks for the opportunity to share these thoughts with you and others.