In the Culture of NOW
The Arrival of the OraQuick Rapid HIV Test
Since the advent of the TV dinner, American culture facilitated a necessity for everything in our society to be fast and easy. We complain when our Internet service slows. We gnash our teeth at dryers when our clothes need another thirty minutes to dry. And, somehow in the last one hundred years, time began to move more quickly over American soil, and we no longer have that extra hour to cook a fresh dinner. Amongst other problems in the 21st century, Americans are the most obese people in the world. What have we learned from all this? Faster and easier are not always the best solutions to our problems.
In January 2001, the CDC published a document entitled "HIV Prevention Strategic Plan through 2005." In it, they outlined an overarching goal to decrease new HIV cases from 40,000 annually to 20,000 by 2005. While this seemed lofty, it also seemed possible. To achieve this, they provided four goals to attain the desired outcome. They included "[decreasing] by at least 50% the number of persons in the United States at high risk for acquiring or transmitting HIV infection by delivering targeted, sustained, and evidence-based HIV prevention interventions; increase from the current estimated 50% to 80% the proportion of HIV-infected people in the United States who are linked to appropriate prevention, care, and treatment services; and through voluntary counseling and testing, increase from the current estimated 70% to 95% the proportion of HIV-infected people in the United States who know they are infected," in other words, mass testing.
In November 2002 the FDA approved a new HIV testing device. It is a rapid test. In just 20 to 40 minutes, a person can know his or her HIV status, sort of. (I will cover that later.) The most common one being pushed presently by the federal government is the OraQuick test, which utilizes a drop of blood obtained via finger stick. In cities all over the country, the CDC funded a project called PCRS (Partner Counseling and Referral Services) Rapid HIV Testing Demonstration Project. As OraQuick is simple to perform, agencies around the country are being trained and funded to add rapid testing to their scopes of service.
To many service providers, it seems as though we are pushing forward with rapid testing without considering all the possible ramifications. One problem facing the development of rapid testing programs involves the legality of it. Many states have yet to approve the use of OraQuick rapid testing. In Illinois, for example, the state testing law requires a confirmatory test to be performed prior to giving a client a positive result. With OraQuick, a negative is a negative is a negative, if your client is not within his or her window period. However, a positive is a preliminary positive. What does that mean? Although the OraQuick is 99.6% accurate, a false positive is possible.
Because a false positive is possible, testing counselors must tell a client that his or her result is a preliminary positive and a confirmatory test must be performed. "I will never, ever, ever, ever trust the OraQuick rapid test again," stated Jaime Dircksen of Chicago. In the beginning stages of the current CDC project, she received an OraQuick rapid test with a preliminary positive. In the days awaiting her confirmatory test result, she spent several sleepless, tear-filled nights considering what a positive result would mean for her. The testing counselor told her that the test is 99.6% accurate, so the chances of it being wrong were nil. When she returned for her confirmation test result, she received a negative result. Her OraQuick test yielded a false positive. (It should be noted that the testing counselor read five tests that day as preliminary positive -- all of which returned negative. Most likely, the number of false readings rested with the testing counselor and not the test itself.)
For present and future clients receiving positive results from OraQuick, the PCRS project funded by the CDC requires that participating agencies offer partner notification services to newly diagnosed clients. While this service is voluntary, several issues present themselves. At what point are you offering a voluntary service versus coaxing the information out of the client? Where does this information go? If the client engaged in risky behavior with only one person in the last year, will the client reveal another person's status, thereby committing an infringement on the AIDS Confidentiality Act?
"No court is ever, ever going to say that cooperating with government partner notification is a violation of the AIDS Confidentiality Act," said Ann Fisher, the Executive Director of the AIDS Legal Council of Chicago. Still, she noted for partner notification to work, a client must trust the person or government to whom he or she is providing such sensitive information. She concluded by saying, "People don't trust the CDC the way they once did, since they've allowed themselves to become so politicized."
Providers' concerns over distraught clients and legal complications are valid; however, an agency must not forget the overwhelming task of implementation. Where does an agency start? Charles Martin, the Executive Director of JAATF (Julius Adams AIDS Task Force), one of seven agencies in Florida piloting the use of OraQuick, spoke on implementation and utilization. OraQuick now comprises 95% of their testing program. In regard to implementation, he gave one big piece of advice. "The most important thing with OraQuick is the counselors. A counselor must be very adept." In Mr. Martin's opinion, many providers share a common misconception; clients need the waiting time to prepare for a possible positive result. He observed that clients do not need that time. Instead, counselors need that time to prepare. After all, a testing counselor learns the preliminary positive result as the client learns it. Therefore, he suggested that agencies ensure that each counselor is fully prepared for his or her task. He added that a counselor should never feel that his or her job is threatened if that counselor feels uncomfortable performing rapid tests.
After all is said and done, discussed and processed, introduced and implemented, local government agencies coordinate the PCRS project. What outcomes -- positive and negative -- do they anticipate? Andrew Delicata, PCRS Coordinator for the Chicago Department of Public Health, illuminated one of these. "Setbacks will occur mostly on the provider's side, being that this is a huge shift in the way that we do testing and counseling." When asked what, if any, good he expects to come from rapid testing, he said, "I expect there to be more acceptability of HIV testing in general. I expect people who test to have a more positive experience." Granted, he was unfamiliar with Jaime Dircksen's experience. In addition, he anticipates an increase in testing numbers as well as an increase in people who return for their results.
Clearly, a host of both negative and positive thoughts present themselves with the introduction of rapid testing. As we examine the CDC's HIV Prevention Plan, are the negative thoughts dispelled? Our infection rate continues to hover at 40,000/year. The CDC hopes to increase the number of people who know their status from 70% to 95%, hopefully decreasing accidental transmission. With those 95%, they want to increase the number of those receiving care from 50% to 80%. Looking at the numbers, the CDC has something really fabulous going here, but is it feasible?
Once we know everyone who is HIV-positive, what are we going to do with them? Nine state AIDS Drug Assistance Programs continue to maintain a waiting list, denying life saving medications to HIV-positive people in need. The federal government refuses to increase domestic funding for HIV services to the level the community needs. Many people do not trust doctors. Many people do not trust the government. Many people still have little or no access to care.
Overall, rapid testing is still a good idea. If more people know their status, then hopefully transmission numbers will decrease. Hopefully more HIV-positive people will gain access to appropriate care. Hopefully, people will begin to make educated decisions about their treatment and sexual health. Unfortunately, that is a lot of hoping. Hope provides no medication, medical care, case management or community support. Until our society renovates and improves the systems of care with which we operate now, rapid testing will only create more problems than it helps. We need to look before we leap, for once, and solidify those systems already in place.
In my home growing up, my father used to say, "There's your way, my way, and the right way." I believe that may be the best way to look at rapid testing. Charles Martin's agency serves a primarily African-American community. According to Mr. Martin, in Florida, one in forty-six African-Americans is HIV-positive. His community finds rapid testing very beneficial to curbing disease transmission. For those who receive a negative result without the stressful waiting period, Andrew Delicata is correct. They will most likely have a more "positive" experience. However, we wish neither to forget nor to invalidate the experience of Jaime Dircksen. For those unlucky few who receive a false positive, many of them will endure days of agony, thinking they contracted HIV.
In the end, one thing is for certain. Rapid testing is here to stay. Whether it is appropriate for you and your community is for you and your community to decide. It is a conversation in which we all need to participate.
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