We implemented a pilot home-based HIV testing program to increase access to HIV testing separate from the SARS-CoV2 pandemic; however, its launch coincided with rising SARS-CoV2 cases and the stay-home order in Oregon. We observed rapid uptake of this HIV self-testing service, thus revealing enthusiasm for discreet, free, home-based testing and uncovering an unmet need for HIV testing as clinical and outreach programs shuttered. One-third of program participants had never tested before, a proportion greater than that found in a prior survey of MSM who use apps and in a trial of home HIV self-testing [9, 10]. For almost all, participation in the pilot program was their first introduction to home HIV self-testing.
Program participants represented key demographics of MSM affected by HIV in Oregon [1, 4]: a quarter of our sample was less than 25 years of age; 34% were people of color (25% of Oregon’s population is comprised of people of color) with 17% identifying as Latinx (13% of the Oregon population is Latinx), 4% identifying as Black (2% of the Oregon population is Black) and 3% identifying as Native American (1.2% of the Oregon population is Native American); and, 25% had more than three sexual partners in the prior year. A goal of our statewide home testing program was to reach MSM outside of Oregon’s urban areas; over one-fifth of program participants lived in rural/frontier areas with poorer access to HIV testing . Our pilot testing program was advertised on, and most orders originated from, a single app. Diversification of the apps and websites on which we advertise self-testing may allow us to reach more young, gender diverse, Black, Indigenous, Latinx, and rural MSM in addition to more sexually active MSM.
Based on the feedback provided by participants, home self-testing appears to ameliorate several barriers to accessing an HIV test. First, testing was free to avoid concerns related to cost and insurance coverage. However, public health agencies must find a way to sustain access to free testing, particularly at a time when STD/HIV programs may be underfunded as health departments dedicate substantial resources to responding to the SARS-CoV2 epidemic. Options include prioritizing grant and state/county general funds for home testing programs; billing insurance for HIV tests for those with insurance while continuing to provide free testing for uninsured participants; and/or, allowing participants to donate tests to another participant (a pay-it-forward model). As federal funds account for a substantial source of state and local health department funding for HIV prevention, funders should allow for maximum flexibility in how dollars can be spent for home testing initiatives. Restrictive caps on use of funds and excessively burdensome data reporting requirements should be avoided.
Second, testing was “easy” and “convenient.” It did not require participants to take a day off from work or put other responsibilities on hold for an appointment at a healthcare setting. Third, proximity to local HIV testing resources is less crucial, particularly in rural and frontier areas, when a test can be delivered to one’s door. Fourth, testing can be performed in the safety and privacy of one’s home without fear of judgment or discrimination based on race, ethnicity, sexual and gender identity, and sexual practices. In fact, healthcare providers may judge sexual activity with non-household members quite harshly during stay-home orders. Finally, home HIV testing allowed participants to test without risking exposure to SARS-CoV2 infection in a healthcare setting.
While our data are limited in that they represent a single state experience and, due to technical issues, 64% of the individuals who ordered kits, this pilot program suggests that at-home HIV testing can address existing gaps and barriers in testing in many areas of the United States both in the presence and absence of social distancing measures. In the coming months, we plan to expand the sexual health services offered by our home self-testing program to include the ability to order multiple HIV tests for distribution to social and sexual contacts and the option for comprehensive STI testing, hepatitis C screening, and labs for pre-exposure prophylaxis.