HIV detection on demand

by on November 6, 2005 at 5:26 am in Medicine | Permalink

Ms. Brown would get her results in just 20 minutes, thanks to one of
two new tests that AIDS workers say have revolutionized testing for
H.I.V…

On Thursday, the Food and Drug Administration’s Blood Products Advisory
Committee heard testimony on whether to recommend over-the-counter
sales of the rapid test for home use. The agency approved a home
testing kit in 1996, but users have to mail a blood sample to a
laboratory and wait for results by telephone.

Proponents say
rapid testing in the home will reduce the stigma and other obstacles
that prevent many people, including one in four of the nearly one
million Americans who are infected with H.I.V., from getting tested and
starting treatment. Research shows that people who learn they are
infected are less likely to infect others.

Here are the details, note that test is an easy oral swab.  I am not much worried about immediate suicides ("The most emotional responses come from negatives," says the article).  But what are the further ramifications?

1. The test is in the hands of the individual, and the kit presumably does not issue a credible AIDS-free certificate.  So perhaps we return to a greater reliance on trusting the word of the individual — "don’t worry, I tested negative a few weeks ago."  Formal certificates of health might become less expected.

2. Will lovers-to-be ask for an on-the-site test?  There is a stigma attached to asking a partner about his or her status.  It suggests you often sleep with people whose health status you are unsure about; the alternative impression is "of course I’ve never done this before, and I bet you haven’t either.  I’m not used to asking.  HIV, what’s that?"  And how much fun is it to watch a potential partner waiting for the results?  Do you bring little consolation cards in case the test turns out badly?  The resulting unwillingness to pry may further increase the reliance on verbal assurances.  Again, the presence or lack of a certificate — however dated — may provide a clearer focal point and thus greater information and clarity.

3. How often should you test yourself?  Given the signaling point from #2, what should you tell your next partner?  That you test yourself every year?  Every month?  Every day?  Which frequency would you find most reassuring in a potential partner?  Keep in mind the probability of a lie or false result. 

You can spin this one either way.  You might assume that someone who self-tests every day has dangerous habits.  Alternatively, you might assume (at least in pure theory) that the previous partners have been monitoring the test results, and that you don’t need to.  "Hey, if two hundred people have slept with you in the last year, a few of them must have checked you out."  Don’t you usually find the presence of other "customers" reassuring?

4. Say you test yourself after every new partner.  You have a better sense of who infected you, which in turn identifies a greater number of infected agents in advance and also deters self-recognized infectors.  Therefore people will test themselves less often than is socially optimal.  The main benefits from testing may accrue to others, not to yourself.

Hmm…it’s not so simple after all.  But I still believe this test is likely a positive development.  Comments are open…

p.s. We thank Robin Hanson for his guest blogging!

Alex November 6, 2005 at 8:52 am

Well, I think the main payoff is in the sex industry where people know they are engaging in high risk activities and where premia are paid out for not using protection. This is a godsend, especially if it’s cheap and rolled out in poorer countries’ sex industries.

ryan November 6, 2005 at 1:03 pm

Don’t most of the ramifications above suggest positive externalities and potential (non-monetary) costs to the self-tester? In these cases, the number of self-tests will be sub-optimal, which further suggests that the current number of self-tests (zero) is even more sub-optimal, right? The only downside apparent to me is if the positive externalities of a professionally administered test are greater (which is likely) and the costs less (which seems unlikely). There would have to be a situation where (a) the costs and benefits to society as a whole weigh in favor of a professionally administered outcome, (b) the costs and benefits to the testee weigh in favor of home-testing, and (c) the benefits of either test outweigh the costs for the individual, so that absent the alternative, the individual would have been tested professionally. (A) is possible, even likely. (B) is also plausible (note, however, that the criticism leveled in the NYT article mentions counseling — most likely a benefit to the individual). But how likely is (c)? Are there going to be very many people who otherwise would have gotten the professional test but now will use the home-test? How large could this cost possibly be, weighed against the benefit of an increase in total testing?

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