Use of a Rapid HIV Home Test Prevents HIV Exposure in a High Risk Sample of Men Who Have Sex With Men

Alex Carballo-Diéguez; Timothy Frasca; Ivan Balan; Mobolaji Ibitoye; Curtis Dolezal

Disclosures

AIDS and Behavior. 2012;16(7):1753-1760. 

In This Article

Discussion

Besides giving additional support to the findings of the first (hypothetical) stage of our study, the results reported here give proof of concept that HIV-uninfected MSM from diverse ethnic backgrounds who never or rarely use condoms and have intercourse with multiple partners understand the limitations of HT and are willing and able to use HT to screen partners. Most importantly, our results show that use of HT results in prevention of HIV exposure. The high yield of positive results (about 10 % of tested individuals were found to be infected) and the high proportion of partners (60 %) who were previously unaware of their infection show that HT may be a very effective and cost-efficient strategy for HIV detection. Moreover, availability of HT may result in more frequent testing among individuals with high-risk behavior, earlier detection of new infections, and distribution of test kits among network acquaintances presumably also engaging in high-risk sex. This is particularly promising in light of recent studies that have shown high rates of UAI among MSM who serosort based on the assumed serostatus of their partners ("seroguessing") as well as infrequent and low HIV testing rates among serosorters.[29–32]

Beyond actual use, the availability of HT and intention to use it may result in initiation of a discussion of HIV-related concerns and more honest disclosure of HIV-positive status from individuals aware of their infection. While prior studies have shown that MSM are less likely to disclose their HIV-positive status to casual or anonymous sexual partners than to main sexual partners,[33–35] among our sample of MSM who had multiple casual partners, HT use led to several discussions on HIV prevention and prompted two partners to disclose their seropositivity. The method appeared to have ample acceptability not only among White MSM but also among ethnic minority MSM, a population hard hit by the epidemic for which many HIV-prevention approaches have failed and effective interventions are much needed.[36]

The window period of the oral fluid test used in this study remains an issue—one upon which the biggest concerns about using HT to screen sexual partners will be raised. Yet, participants in our study understood and remembered the window period limitations. For instance, only one out of 44 individuals screened for the study was deemed ineligible to participate because he did not understand the concept of the window period. On the other hand, several participants referred to the window period while discussing their sexual behaviors during the in-depth interview at the end of the 3-month study. Furthermore, new tests are being developed that reduce the length of the window period. For example, Determine HIV-1/2 Ag/Ab ComboTM a fourth generation, rapid in vitro immunoassay qualitatively detects HIV p24 antigen as well as antibodies to HIV-1 and HIV-2 in serum, plasma, and whole blood. The p24 antigen is produced during the first few weeks of HIV infection and is detectable 7–9 days earlier than HIV antibodies. Test results can be read in 20 min.[37] Although this test is not yet available in the US, new rapid OTC tests undoubtedly will become available in the future with shorter window periods that could increase the prevention potential of HT.

Another potential barrier to the adoption of HT as a risk reduction strategy is the concern that it might lead users to take additional risk. Similar arguments have been raised in regards to other HIV risk reduction techniques including needle exchange programs—a successful strategy whose implementation was delayed for years despite ample research findings demonstrating its utility.[38–40] Just as the provision of clean needles to injection drug users was once feared to promote substance use, the use of HT to screen sexual partners is at this point a cutting-edge strategy that faces an uphill battle. While some may argue that people will "migrate" from condom use to the less reliable strategy of HT screening thereby increasing their HIV risk, it should be noted that our study was conducted with MSM who never or seldom use condoms. Therefore the adoption of HT among this population would not replace their sporadic condom use but instead provide them with an additional risk reduction option.[17,18]

Use of HT as a screening tool may result in public health savings much needed in times of budget constraints. For example, the current cost of OraQuickTM is less than $20 per kit, depending on the number of units purchased, and NGOs are working to reduce the price of rapid HIV testing kits.[41] By contrast, the estimated yearly cost of using TruvadaTM as PrEP is $10,000 per person/year.[42]

Generalization of our results should be made with caution. Our sample was small. Our eligibility criteria were very strict and resulted in a highly selective sample of MSM with high-risk sexual behavior and history of frequent STIs yet HIV-uninfected; they were recruited based on their stated intention to use HT and their professed self-confidence that they could handle potential violence. Therefore, they may not be representative of other MSM who engage in high-risk sexual behavior. Furthermore, the marginal difference between dropouts and completers in their intention to use HT with partners requires further study; it may indicate an effective opt-out of the technology by those who feel ill equipped to employ HT with partners.

Despite these limitations, our study highlights the important potential of use of HT as an HIV-prevention strategy for MSM who engage in high-risk behavior. If use of HT to screen sexual partners were to become widespread in high-risk sexual networks (e.g., barebackers), it could evolve into a community norm that could facilitate both discussion and use of the test. Guidelines on how to discuss HT with potential sexual partners (e.g., do it before the actual sexual encounter, suggest mutual testing, discuss with partner the resources available if someone tests positive before testing) may decrease the chances of untoward events. Furthermore, since the tactic is peer driven, it may empower individuals to take control of their behavior, develop a non-condom-based approach for communal, shared responsibility to prevent HIV transmission, and ultimately transform serosorting from a guessing game into a strategy based on objective evidence.

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