Will Gay and Bisexually Active Men at High Risk of Infection Use Over-the-Counter Rapid HIV Tests to Screen Sexual Partners?

Abstract

The Food and Drug Administration may license OraQuick^™, a rapid HIV test, for over-the-counter (OTC) sale. We investigated whether HIV-uninfected, non-monogamous gay and bisexual men who never or rarely use condoms would use the test with partners as a harm-reduction approach. Sixty participants responded to two computer-assisted self-interviews, underwent an in-depth interview, and chose whether to test themselves with OraQuick^™. Over 80% of the men said they would use the kit to test sexual partners or themselves if it became available OTC. Most participants understood that antibody tests have a window period in which the virus is undetectable yet saw advantages to using the test to screen partners; 74% tested themselves in our offices. Participants offered several possible strategies to introduce the home-test idea to partners, frequently endorsed mutual testing, and highlighted that home testing could stimulate greater honesty in serostatus disclosure. Participants drew distinctions between testing regular versus occasional partners. Non-monogamous MSM who never or rarely use condoms may nevertheless seek to avoid HIV. Technologies that do not interfere with sexual pleasure are likely to be used when available. Studies are needed to evaluate the advantages and disadvantages of using OTC rapid HIV tests as one additional harm-reduction tool.

Introduction

Early in the AIDS epidemic in the United States, HIV testing was voluntary, conducted in clinics, and required written consent and pre- and post-test counseling (Centers for Disease Control, 1987). These conditions have progressively changed. In 2006, the CDC recommended routine testing for patients and pregnant women in all health-care settings unless they opted out of HIV screening; written consent and prevention counseling were no longer required (Branson et al., 2006). Furthermore, HIV tests became available that allowed specimen collection at home with results provided later at a clinic or over the phone, and these options were no longer as controversial as before (Branson, 1998). Researchers believed that home testing could be valuable “in empowering individuals to manage their HIV risks; in helping couples to learn their partners’ HIV status before the initiation of sexual relations; and in addressing the three principal barriers to wider HIV-test acceptance: stigma, convenience, and privacy” (Walensky & Paltiel, 2006, p. 461). More recently, plans were announced to seek Food and Drug Administration (FDA) approval for over-the-counter (OTC) sale of an oral fluid HIV test that would allow individuals to self-administer the test at home, obtain the results in about 20 minutes, and interpret such results following written instructions without the need of external help, phone calls, or clinic attendance (Richmond, 2005; Whellams, 2008; Wright & Katz, 2006).

As soon as the news of a possible OTC HIV test became known, speculation arose that single individuals who were dating or those with multiple partners might avail themselves of this new tool to screen sexual partners and decide, based on the test results, whether to engage in intercourse and whether to use condoms. At the same time, concerns grew that people might overlook the window period of an HIV-antibody test, the period in which the absence of antibodies make an HIV-infected individual appear to be uninfected (Harris, 2005). Although this concern merits attention, mathematical modeling has shown that even taking into account the increased risk posed by the window period, the use of home testing can result in lower rates of transmission than inconsistent or no condom use in areas of high prevalence (Ventuneac et al., 2009; also see comment by Leu, Ventuneac, Levin, & Carballo-Diéguez, 2012).

Prior studies have shown that gay and bisexual men at high risk of HIV transmission (i.e., those who never or seldom use condoms) are nevertheless interested in avoiding HIV infection (Carballo-Diéguez & Bauermeister, 2004). The present study was designed to investigate whether these men would be interested in testing themselves and their partners prior to sexual intercourse as a harm reduction approach and the strategies that they would use.

Method

Our study was conducted in New York City, USA, following approval by the Institutional Review Board of the New York State Psychiatric Institute. Recruitment advertisements indicated that researchers were studying possible uses of a rapid HIV home test. Recruitment took place at gay community organizations, testing sites, events such as Gay Pride, and online dating sites. Eligibility criteria included: man; 18 years of age or older; who engages in receptive anal intercourse (RAI) with other men at least three times per month on average; HIV-negative by self report; not involved in a monogamous relationship at the time of enrollment; who uses condoms on 20% or fewer of the RAI occasions; aware that unprotected RAI may lead to HIV transmission; and fluent in English or Spanish.

Volunteers were invited to come to our research offices. After signing a form consenting to participate in the study, they completed a baseline computer-assisted self-administered interview (CASI), were interviewed in depth by a researcher, were offered the possibility of testing themselves using a rapid HIV test and finally, completed a follow-up CASI. Those who elected to test themselves subsequently interpreted their results under the monitoring of the interviewer.

Measures and tests

Baseline CASI

This assessment sought to characterize the sample. It included questions on sociodemographic characteristics, sexual practices, substance use, and sexually transmitted infection (STI) history. It also included a structured item requiring ranking of experienced priorities in a sexual encounter (When I am about to have sex with a guy, the most important issues for me are…, followed by eight possible answers presented in random order to different participants: Not getting HIV; sexually satisfying my partner; having a good time, enjoying sex and getting sexually satisfied; making sure we use condoms; not getting a sexually transmitted disease (STD) or infection (by this we mean STDs other than HIV); that my partner will like me; communicating our thoughts and feelings with each other; not passing a sexually transmitted disease (STD) or infection or HIV to my partner).

In-depth Interview

The purpose of the semi-structured interview was to understand if and how participants might use the OTC test to screen sexual partners. The interview followed a guide that covered the following topics: knowledge of rapid HIV tests; motivations to use it; advantages and disadvantages of rapid home testing of sex partners; participants’ perceived self-efficacy in utilizing such a test in a variety of scenarios; whether the participant would propose mutual testing to a partner; the effect of substance use on likelihood of using the home test; and their anticipated reactions to partner refusal, hostility, or eventual HIV-positive test results.

HIV Test

To verify whether individuals who expressed interest in testing themselves would actually do it, at the end of the in-depth interview, participants were offered the opportunity to test themselves using the OraQuick^™ (OraSure Technologies, Inc., Bethlehem, PA) rapid HIV test, which provides a result in less than 20 minutes. The interviewer observed silently as the participant followed written instructions and only interrupted in case of error. To mimic the circumstance of OTC acquisition of the test, no training on its use or further explanations were offered.

Follow-up CASI

After the participants had tested themselves for HIV (or declined to do it), we asked them, When a rapid HIV home test becomes available over-the-counter, how likely is it that you will use it to test yourself at home? Possible responses were: There is no way I will use it; it’s unlikely; it’s likely; I will definitely use it. The same question was posed regarding testing sexual partners.

Statistical Analyses

Quantitative CASI data were analyzed using Statistical Package for the Social Sciences software (SPSS Inc., Chicago, IL) to calculate frequencies and test for significant differences. Those who took the test in front of the interviewer were compared to those who did not on various demographic and sexual history variables. For continuous variables, t-tests or Mann-Whitney tests (for variables with skewed distributions) were used. For categorical variables, chi-square tests were conducted.

To analyze the qualitative data, which constitutes the main data source for this study, audio recordings were transcribed, and transcriptions were checked against the former for accuracy. A first-level codebook was developed following the major topics covered in the interview. Using the software package NVivo (QSR International, Inc., Cambridge, MA), three independent coders reviewed transcripts, identifying data that fell under these codes. Intercoder comparisons were made on the first ten transcripts until consensus was reached, and the codebook was amended and expanded for clarity. The remaining 47 transcripts were independently coded by two coders and disagreements resolved in consultation. Next, four investigators read the coded material and independently developed second-level codes based on the topics discussed by the participants. The independent codes were unified in a single codebook with definitions and examples. These second-level codes focused on aspects of initiation of the invitation to use home tests with a new partner, such as “Where and when, ” “Triggers,” “Verbal style,” “Challenges,” and “Partner hesitation or refusal.” Finally, code reports for secondary codes were generated, and quotes from respondents were selected by the first author.

Results

Four hundred and sixty-one men telephoned for screening over a nine-month period. The first 60 to meet eligibility criteria were enrolled. Three participants were eliminated, in two cases due to inconsistencies that cast doubt on the honesty of their reporting, and in the other case due to failure to complete study procedures. This resulted in a sample of 57 participants.

Baseline CASI

Table 1 presents the sociodemographic characteristics of the sample.

Table 1.

Sociodemographic Characteristics of Male Participants (N=57)

Sociodemographic Characteristics	Mean (SD) (range)
Age	34.28 (11.93) (18–62)
Income (in thousands)	26.30 (22.06) (0–100)
	n (%)
Education
High school graduate or less	13 (23%)
Partial college	24 (42%)
College graduate or more	20 (35%)
Race/Ethnicity
White	12 (21%
Latino	22 (39%)
Black	18 (32%)
Asian/Pacific Islander	4 (7%)
Refuse to answer	1 (2%)

By eligibility criteria, all participants had been sexually active with more than one partner in the prior year. Table 2 presents the sexual risk behavior and substance use reported by the participants during the prior three months as well as their lifetime history of STIs. Seventy-one percent of participants had been tested for HIV within the past two years (not shown in Table).

Table 2.

Sexual Risk Behavior, Substance Use, and History of STIs (N = 57)

Sexual risk behavior in the prior three months	Mean (SD)	Median (range)
Number of male partners	11.12 (11.39)	7 (1–70)
Unprotected receptive anal intercourse occasions (URAI)	9.80 (13.90)	5 (0–69)
Unprotected insertive anal intercourse occasions (UIAI)	6.44 (12.02)	2 (0–60)
	n (%)	Mean occasions
Alcohol or Substance use in the prior three months
Alcohol	50 (89%)	4.05
Marijuana	24 (44%)	2.78
Poppers	19 (34%)	1.93
Other	22 (39%)	1.28
Lifetime history of STIs
Ever had an STI	33 (58%)
Syphilis	11 (19%)
Pubic lice	10 (18%)
Gonorrhea	8 (14%)
Chlamydia	7 (12%)
Other	15 (26%)
Number of people reporting having had 1 STI in the past	21 (37%)
Number of people reporting having had 2 STIs in the past	7 (12%)
Number of people reporting having had 3 or more STIs in the past	3 (4%)

Table 3 presents the rankings that participants gave indicating the most important issue for them when they were about to have sex.

Table 3.

Ranking of Priorities When Having Sex (N = 50)

Top priority when having sex	n (%)
Having a good time	29 (58%)
Not getting HIV	12 (24%)
Communicating our thoughts	3 (6%)
Sexually satisfying my partner	2 (4%)
Making sure we use condoms	1 (2%)
Not getting an STD	1 (2%)
Not passing on an STD	1 (2%)
Having my partner like me	1 (2%)

In summary, this was a sample of educated adult men of diverse ethnic background who had multiple male sexual partners, frequently engaged in unprotected anal sex, consumed alcohol and, to a lesser extent, used recreational drugs. The majority had had at least one STI in the past. These men valued enjoyment of sex above avoidance of HIV and STIs.

In-depth Interviews

At the onset of the interview, participants were asked if they would consider using a rapid home test to screen sexual partners. Initially, approximately half the participants considered use of a home test to be most appropriate with new partners (i.e., online hookups and one-night stands), while the other half mostly considered it appropriate for partners with whom they had ongoing sexual relationships. However, about one fifth of participants said at the beginning of the interview that they would not use the test with any partner.

Knowledge of rapid HIV tests

Many participants knew about the existence of rapid HIV tests, and some had even been tested for HIV with OraQuick^™ in clinic settings. When informed by the staff that the manufacturer of the test was seeking licensing for OTC sale, most felt enthusiastic about the possibility of easy access to the test although some expressed concerns about its possible cost.

I think having the option available is a no-brainer. I think, you know, whether or not people use it under different circumstances, that’s ultimately going to be up to them anyway. But I think it would be important to have it available. (#018, Latino, 23)

When, where, and how to discuss rapid home tests with a sexual partner

In response to the interviewer’s question, participants discussed the possibility of using home tests to screen sexual partners, particularly in the context of mutual testing. Some participants speculated that it would be easier to do it with one-night stands than with steady partners and pondered where and when to raise the issue. A few men felt that meeting someone online provided a perfect scenario to discuss rapid home testing.

[There is] a wonderful application on iPhone and BlackBerry, Grindr, where you have a location of gay people that are near you and their profile or whatever they want to send you. So in that instance, if I were doing that, and I was going specifically for a hookup, then it [the mention of home testing] would be at the beginning. It would be, you know, “Are you clean?” “Are you STD free?” “What’s going on?” […] Because some of those profiles will say “disease free” and stuff. (#063, White, 28)

Others felt that a phone conversation or a face-to-face meeting at a public place would be more appropriate to discuss home testing. For example, an HIV-counselor said:

I guess before we leave the bar, like, so, Are you a top? Are you a bottom? Oh, you’re bottom, great, I’m a top. That’s good. HIV negative? Positive? […] Negative? Cool. You’re not going to feel funny about me asking you to take the test, right? Because you know, I got -- I went to [DRUGSTORE] last night and I bought a bunch of them so we’ve got to put the bitches to use. I test everybody. Like, one, it’s my living. You know, I work in the field. And then on top of that, I got it here personally, so I’ve got to use them. (#017, Black, 27)

Yet others felt that a public place would not provide sufficient privacy and that a home environment would be the most conducive to discuss home testing. Some participants felt that forewarning was required before a face-to-face encounter if one were to ask a potential sexual partner to use the rapid home test. Interestingly, a few participants thought that the rapid home test could be used after having sex.

So I don’t know if it would be when the clothes were coming off. Maybe it would be after we had sex and then like maybe for the next time. (#023, White, 46)

Different approaches were considered on how to present the idea of rapid home testing. Some felt they could be very blunt.

I would just be very direct about saying, “Well, I’m interested in sexual health, well-being; would you mind taking this, you know, with me?” (#019, Latino, 25)

Others would rather use persuasion.

[I’d] say, “As far as I know, I’m negative, but I do have this kit, it’s really unique, and it’s great. And you know, before we do it, I’d like to get your OK. I’d like to show you my results, it only takes 20 minutes, you just put a Q-tip in your mouth, and you put it in a holder, and we can just talk. And this way, you’ll know, and I’ll know. And it’s very important information. (#058, White, 50)

I will slowly, slowly talk my way into it, or persuade the person to take an interest in it. I probably would do it first so that somebody could feel comfortable with it. (#024, Black, 38)

Several participants said they would try to bring the topic up in a very casual way.

… say oh, you know, I read a news article (laughter) or I saw on the Internet (laughter). You know, that I probably, like, bring it up as casually as I possibly could. (#036, Black, 33)

Special circumstances could be used to propose the use of rapid home tests.

If it was someone who was cheating on someone else, then you have another card to play in the sense that, you know, if you don’t want to get caught and you don’t want to get in trouble, then let’s do that [use the rapid home test]. (#008, White, 40)

I have had partners in the past who say, I don’t have sex with a condom. […] if that was a situation with a new partner […] and I wasn’t in a trusting place, or I’m just smart about it and say well, listen, you know that’s OK. But if that’s the case, then -- and you want to have anal sex, then this is what we’re going to do. I could see that happening, absolutely. (#018, Latino, 23)

Well there was one guy, he was like almost obsessively concerned with catching something. And you know, but he was dying to have sex […] I sort of had to stop myself from laughing because I would’ve said to hell with it. But he was just so --and this might’ve been something to really calm him down. (#005, White, 62)

All these examples focused on new potential sex partners. However, participants also felt that a rapid home test could be used as relationships moved from casual to steady.

This kind of feels like we’re kind of sexual buddies, so I mean, why not get tested together so we could both feel at ease and we don’t have any limitations, we would feel, we’ll feel OK? (#053, Latino, 23)

Finally, some felt that if the rapid home test became a community norm, this would facilitate proposing its use to partners.

Maybe this becomes readily available, and we start doing this with everybody […] The other is if a friend started to, suddenly started to regale me with his conquests, […] I would be more likely to request this of someone that I knew well. (#056, White, 31)

Challenges

The above-mentioned examples come from interviews in which participants felt they could propose to use rapid home tests to screen some of their sexual partners. Yet some participants, at times even the same participants who had an optimistic outlook on home testing, felt that there would be many challenges to using a rapid home test.

A common objection was that taking the test would kill the mood for sex or be incongruent with a sexual situation.

To wait 20 minutes to see what would happen would -- I just couldn’t see -- that would put the brakes on whatever crescendo you’re having with that sexual experience. It’s, it’s a buzz killer as they say, you know? (#008, White, 40)

I’d probably freak out if somebody asked me to take a home sex -- you know, a home kit. Like, what, who are you? Are you trained to do this? Like, who are you? Like, I’m just coming over to fuck you. (#017, Black, 27)

The difficulty in using a rapid home test would be compounded by some of the environments in which sex may take place.

Anonymous sex is anonymous sex, and who the hell is going to be walking around with one of those kits on them? If you’re at a damn peepshow booth or whatever, you just want to get off and go about [your] business, you know? […] “Oh, what? You know what, let me check this guy out over here. I don’t need this shit.” (#022, Black, 52)

In the crack house after someone desperately wants a hit, that you know, they’ll clear the room so that these two people can be together so that you can give drugs for sex. And at that point, somebody will let you fuck them, somebody will let you suck them, but you know, whatever. And there’s no discussion of a condom, there’s no discussion of HIV. In fact, it’s the raw degradation of the person that becomes what’s valued. It’s a very sick, sick thing. Depraved… (#002, Black, 57)

Being under the influence of alcohol or drugs may affect the likelihood of using rapid home tests, the efficiency with which it is used, or the possibility of waiting 20 minutes to read the results. Pros and cons were expressed by different participants and summarily presented by one.

Man, if I could meet someone who would smoke a joint with me while getting our test results, that’s a dream boat. (laughter). But I feel like it could possibly impact, I mean, it could affect whether or not you’re doing the test result properly, or it might be even easier to bring up a topic that for some people is hard to talk about if they’ve had a drink in them and they’re a little loosened up and a little more open and understanding. […] Though, on end, getting a positive result while you’re not sober, that could be bad. (#009, Latino, 20)

Most participants who had experience with alcohol or drugs felt that they would be unlikely to use the test if they were high or inebriated.

When I’m high, I don’t care about anything, so I don’t think I would stop to do it, you know. (#040, Latino, 36)

I don’t think when you’re smoking, or rather drinking alcohol, you’re, you’re going to do it because you’re just -- there’s no time when I’ve drank where I’ve asked someone if they’re HIV positive or negative. Or if I have, it didn’t really faze me. It just sort of, you’re in a, you know, in a tipsy trance. (#045, Race unknown, 36)

The type of relationship between the sexual partners may also affect the likelihood of the test being used.

I’m a sex worker, so it’s just, they come and go. My customers wouldn’t want to hear that (#040, Latino, 36)

One participant feared that the invitation to take the rapid home test could be interpreted as racially motivated.

You don’t want to be offending anyone, […] just because you’re African American or you’re Hispanic, like myself, doesn’t mean you have to get tested. “You want [me] to get tested ‘cause I’m black?” (#021, Latino, 18)

Practical matters were also brought up.

Who pays for it? Do we split the 10/10? Do I pay the 20? You know, you’re topping me so you pay for it or I’m topping you so I pay for it? (#021, Latino, 18)

Partner refusal was seen as another possible challenge, although participants tended to assume refusal would be a warning about the potential partner’s positive HIV status or previous sexual risk behavior. This would lead to either not having sex or using condoms.

I would also say that “You know, this is no guarantee because there is that window period, but wouldn’t you feel comfortable knowing for sure?” That’s how I would phrase it. And if the person said, “No, let’s just do it [have sex],” I think that would be like a good break for me to just pull out of the situation. I think this would help me to -- because there is that little gray area where sometimes I do take a risk, and I think if the person was really willing and adamant not to do this [use a home test], I think that would scare me. (#058, White, 50)

Beyond refusal to take the home test, most participants did not anticipate that the invitation to use a rapid home test would generate any violent reactions. Referring to casual partners, many participants stated that they trusted their skills to judge a situation and would not bring up the idea of using home tests if there were a potential for violence. Most participants felt they could handle aggression or violence in the rare event it might occur.

I know this sounds cavalier, but I’m not afraid for my physical -- I mean, I feel like I could defend myself and get out of a situation, even if I’m in somebody’s apartment. (#058, White, 50)

What if the test were positive?

When we asked participants what would happen “if a test came up positive,” many made distinctions based on who was getting the positive test result and how long they had known each other. In the case of finding out that a prospective sexual partner was unknowingly infected, participants frequently anticipated showing empathy and trying to help the man get connected with the appropriate health services.

I’d probably put my arm around them and say, you know, what can I do to help you? Is this a shock? First I’d ask them. If he said yeah, I’d say, Well, let’s see if we can do something. Because I’m sure that’s got to be a terrible thing to hit you, to find out about. (#008, White, 40)

Well, there’s a hundred ways a person can react. If they are devastated, I would try to do all I could to help them, comfort them, talk to them and tell them, Look, your life’s not over yet. They’re doing a lot of great things nowadays. Don’t think that I’m going to jump ship just because you turned out positive. (#028, White, 54)

In very few cases participants said they would disengage immediately from the situation. (I = interviewer, R = respondent)

I: So let’s say you propose this test to somebody and they say yes, and they do it, and they get a positive result.

R: Man, got to go. [laughter]

I: Yeah, that’s it?

R: That would be it. I mean, people say you can do like condoms and stuff, but I don’t really like the feel of them.

I: So that would be no sex. And what if they were distressed?

R: [laughter] What would that have to do with me? Clearly you need to go check into your past. [laughter] (#059, Black, 21)

Most participants felt that a positive result would kill the mood for sex. Yet, others thought they would still have sex but use protection.

I guess that’s when it comes down to the looks or the perfect man versus the average Joe. If it’s the perfect man, I believe I would still go forward with having sex. I guess I would definitely be more cautious on what I do, how I do it, and just -- it would take away from the enjoyment, but at least now I would know exactly like what I’m getting myself into. If it’s just the average Joe, […] if I’m not that attracted to the person, I guess I would just be like well, mine says negative, yours says positive, we can’t really -- opposites don’t attract. (#012, Latino, 25)

Interestingly, participants felt that the most complicated situations would arise not in casual relationships but in on-going partnerships. In the latter case, a positive test result could signify a breach of agreement either on exclusivity or on condom use with partners outside the relationship. This, in turn, could lead participants to a variety of reactions ranging from support to aggression and violence. Also, if prior to testing the men had had unprotected sex, participants said that they obviously would worry about their own status.

If it was somebody I’ve had a fling with, then I would immediately think did I --was he wearing a condom when I went down on him, or was he wearing a condom when he -- you know. I would just try to backtrack and try to figure out if there’s a possibility that I would be infected. If it was somebody I was close with, then I just, I would ask, “Are you sure?” I guess. But I would worry about my own safety (#035, Asian, 35)

If the positive results corresponded to the participant himself, most said they anticipated they would be very distressed and would not proceed with sex.

I would have the devastated look on my face because I wouldn’t be expecting that. And I’d be apologizing profusely. […] I wouldn’t have sex with someone, that’s for sure. That would be a limit that I would, if I was in someone else’s place, I’d be putting my clothes on and getting out the door. If they were at my place, I would be encouraging them to do the same thing because I would be in no mood for having sex anymore. (008, White, 40)

Some were concerned about confidentiality, whereas others felt that they would have other priorities.

I: And how would it be like for you to have this other person know your status?

R: Kind of scary, like I think I would feel kind of violated in a way, too? Like, you know, like, this person has too much information about me. That just met me. ‘Cause now they know. (015, Black, 39)

I: And how concerned would you be about this person now knowing your HIV status?

R: (pause) I guess you would ideally want to tell [the] people that you want to know, that you have HIV; but news spreads fast, you know, in communities or whatever. I mean, I guess I would have less interest in my reputation than my health. (#019, Latino, 25)

Finally, several participants said that their next step after testing would be to seek confirmatory testing followed by treatment.

HIV Test

Forty-two participants (74%) chose to test themselves in front of the interviewer. Those who decided not to test themselves stated a variety of reasons, such as already having an appointment to do it at a clinic or wanting to do it together with a partner. Most participants who chose to test themselves did so without mistake although many paid little attention to the written instructions and focused instead on a visual card. The most common mistake observed was the participant touching the pad of the testing wand with their fingers. Other mistakes included swabbing the gums multiple times and eating or drinking just before taking the test. One participant, who appeared very anxious about taking the test, immediately after opening the test vial, was bringing the vial to his lips to drink the solution it contained, and was promptly stopped by the interviewer before doing so.

Follow-up CASI

Men who took the test in front of the interviewer (N= 42) were compared to those who did not (N=15) on all of the demographic and sexual history variables reported in the Baseline CASI results section above. A few differences were significant at the .05 level. Those who took the test had lower incomes (Medians = 23,091 vs. 40,000, U = 83.00, p = .037), reported more unprotected insertive anal sex (Medians = 3 vs. 1, U = 207.00, p = .048), were less likely to have had syphilis (12% vs. 40%, χ² = 5.60, p = .027), and were less likely to have had gonorrhea (7% vs. 33%, χ² = 6.28, p = .024).

Of the 57 men in the study, 87% stated that they would be likely to test themselves if the test became available OTC, and 80% said they would be likely to use the kit to test sexual partners at home. Most preferred an oral fluid test over a blood (fingerprick) test. Participants reported their likelihood of using each product on a scale from 1 to 10. The mean rating for the oral fluid test was 9.22 compared to 4.55 for a blood test.

Discussion

We sought to investigate whether high-risk MSM (defined for this study as those with multiple partners, who never or rarely used condoms, and who engaged in RAI at least three times per month on average) would be interested in using an OTC rapid home test, if it were available, to test themselves and their partners prior to intercourse. The results of our study show that most participants were enthusiastic about the possible availability of an OTC home test and thought they could use such a test with their sexual partners. Participants expressed a variety of opinions concerning when to bring the issue up, where, and with what kind of partners. Furthermore, they creatively discussed possible strategies they could employ to approach the discussion. Although using the test before having sex could be seen as intrusive, it was also perceived as opening the gates to freedom and enjoyment.

Nevertheless, many participants also pointed out challenges that could be encountered trying to use home tests with a partner, such as testing killing the mood or being impractical in certain environments, with certain partners, and when individuals are under the influence of alcohol or drugs. Although participants anticipated that some prospective sexual partners might refuse to use a rapid home test, for the most part they did not think that they would face violent reactions or be unable to manage the situations that arose.

Although the possibility of an unanticipated positive result was seen as serious and problematic, participants expected both to react with empathy and to receive support from a casual partner in those circumstances. They felt that a positive result would be more complicated to handle in an ongoing partnership if it implied a breach of previously established rules.

Questions may be raised concerning the predictive validity that responses to our hypothetical scenario (“If the test were available, would you use it to screen sexual partners”) may have for actual use of the test. However, the large proportion of participants who chose to test themselves unassisted in front of the interviewer suggests at least that participants experienced no major barriers to testing themselves. This may increase their confidence to propose testing to a sexual partner.

Another concern has to do with the window period. If MSM chose to avail themselves of the rapid home test and used it to screen sexual partners, would that lead them to forget that an individual who tests negative might be infected or might even be in the highly contagious acute phase, thereby posing a higher risk of HIV transmission? This may be the case. Yet, our participants were already having high levels of unprotected intercourse with multiple partners in circumstances of high risk of HIV transmission. It is likely that potential partners who suspected or knew they were HIV infected but denied it might avoid situations in which they could be asked to take the test. Furthermore, as technologies advance, the window period could be significantly reduced (Branson, 2010; American Association for Clinical Chemistry, 2010; Pandori et al., 2009), thus decreasing this risk.

Other anticipated challenges to the use of home testing (HT) as a partner-screening device are likely to come from the public health establishment. Often, a search for what may be optimum precludes us seeing what may be useful under certain circumstances. Aspiring to find a technology that confers 100% protection may lead us to overlook the potential of HT for high-risk populations like those we tested. Recent developments in biomedical approaches to prevention like vaginal microbicides (Abdool Karim et al., 2010) and pre-exposure prophylaxis (Grant et al., 2010) are only partially effective methods. Yet, they have been rightfully received as important advances in prevention and are being rolled out in demonstration projects (“300 Gay Men in SF”, 2011) in community settings. HT to screen sexual partners will also be only partially effective. Nevertheless, it is a strategy that should not be discarded without further research on its acceptability and effectiveness.

Our study had several limitations. First, participants were a small number of self-selected volunteers who most likely were not representative of the MSM population at large. Second, participation in this research may have led the individuals to overestimate their likelihood of implementing home testing with their partners. Specifically, having an extensive discussion with the interviewers on pros and cons of testing may have affected participants’ reports of likelihood of future use. A second phase of this study is underway in which participants at high risk of contracting HIV are given free test kits to take home with the possibility of choosing to use them with prospective partners during a three-month period, at the end of which an evaluation takes place. Yet, within the above limitations, our study is the first to explore what issues may be raised by the OTC availability of this technology.

Technologies that do not interfere with sexual pleasure during intercourse are likely to be used when they become available. Studies are needed to evaluate the advantages and disadvantages of using OTC rapid HIV tests as a harm reduction strategy.