Home HIV testing: Why not in Canada?

FDA-approved home testing for HIV infection has been available in the United States since 1996. Test kits can be purchased anonymously from pharmacies, by mail order or through the Internet. Home testing is really home specimen collection: the patient takes a capillary blood sample at home and mails it to a private laboratory. The result is retrieved a few days later by telephone from trained counsellors who provide information on interpreting the results, seeking follow-up and preventing disease transmission. The cost to obtain results in 3 business days is US$55; in 7 business days, US$44.1

In March 2000, Health Canada finally approved the use of rapid HIV test kits in this country. But it restricts their use to ”the point-of-care by health-care professionals where appropriate HIV counselling is available.”2 Health Canada‚s reasoning is that patients need to be supported through the rapidity of the testing process and to be counselled about the need for confirmatory testing. Few of us would deny the benefits of counselling, but have we also considered the harms? According to clinical practice guidelines, a main component of pretest counselling is ascertainment of risk. Through an exchange more revealing (but less enclosed) than a confession, patients are asked to disclose, among other intimate details of their lives, the last time they had sex with a man and the kinds of sexual activities they engage in.3 People who regard such questions as an invasion of privacy or are ashamed to acknowledge risky behaviour may be deterred from seeking testing.

People who use home testing have a different risk profile than those who use conventional testing. Home testers are more likely to be at risk because of sexual contact with a person who is HIV positive and less likely to be at risk because they are homosexual or use injection drugs.4 A recent national survey in the US revealed that a large proportion of home test kits were purchased by bisexual men and that almost 50% of those who tested positive had never been tested for HIV before.5

The main advantage of home HIV testing is not so much the speed of knowing the results as the fact that it can be conducted in complete privacy. For many years, home pregnancy tests have given women autonomy in obtaining personal health information with the potential to change their lives profoundly. Where the technology exists, why should the public not have the same autonomy and privacy in obtaining other important health information? The public is capable of understanding public health messages about risk factors for HIV. We suspect that most people who are concerned that they may be infected are already aware of the dangers and advantages of testing. The public does not need Health Canada‚s protection or its support for elaborated disclosure. Home testing should be made available in Canada and its use promoted. More HIV infections will be detected earlier, treatments will be started sooner and, we may hope, some potential transmissions will be prevented. — CMAJ