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Article

Rapid Home HIV

Testing: Risk and theMoral Imperatives of Biological Citizenship

Jonathan BandaUniversity of Texas Medical Branch, Texas, USA

Abstract

This article examines the home rapid HIV test as a new practice of US biociti-zenship. Via an analysis of discourse surrounding self-diagnostics, I conclude thatwhile home HIV tests appear to expand consumer rights, they are in fact the van-guard of a new form of self-testing that carries a moral urgency to protect one’sown body and to manage societal risk. In addition, these tests extend biomedical

authority into the private domain, while appearing to do the exact opposite.Furthermore, access to these tests may be stratified, contradicting the intentexpressed by the manufacturer to reach populations in need of it most and reinfor-cing stigma against them. Lastly, diagnostics such as the rapid home HIV test rep-resent new obligations for surveillance of one’s own health and that of others. Thenew public health effort to test the population at large has given rise to a new ‘risky’population: the untested bodies.

Keywords

biopolitics, biotechnology, citizenship, health promotion, HIV, medicalization

On 3 July 2012, the US Food and Drug Administration (FDA), thegovernment agency that regulates drugs and medical devices,announced approval of a rapid home HIV test, OraQuick by

OraSure Technologies. This test, the first self-test for an infectiousdisease approved by the FDA, was said upon its release to be as easyto use as a home pregnancy test and was heralded as a ‘positive step

Corresponding author: Jonathan Banda. Email: [email protected]

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HIV testing, it also expands the reach of medical authority into thehome while constituting new practices of biocitizenship. In addition,

home HIV testing is part of a growing trend to identify the population

that now poses the most risk – those who are unaware of their status.While the market is presumed to be democratic insofar as it is open toall, a closer analysis of the HIV self-test reveals that underneath its

democratic impulse lies the potential to reinforce social stratification.The HIV self-test is not the first home diagnostic, nor is it the first timethat individuals can receive their HIV test results anonymously athome. The home rapid HIV test represents the vanguard of a new formof self-diagnosis and monitoring – one that directly implicates not only

the tested, but also their partners. Hence, while other self-testing and monitoring devices, such as those for pregnancy, have also beenframed within the context of consumer choice and empowerment, the

self-test for HIV is further framed as a moral obligation, as a tool for not only monitoring one’s body, but for managing risk within intimate

relationships and for society as whole.My analysis draws specifically from the work of Nikolas Rose

(2007) on the biological citizen. This form of citizenship emphasizesthe biological understanding of the body and human existence and the ways that understanding links individuals and distinguishes them

from others. Continuous monitoring and optimization of one’shealth, therefore, is expected from each biological citizen. Health

promotion and education, in their various forms, constitute effortsto construct citizens from above, shaping the way they see their bod-

ies and their obligations to themselves and those around them. How-ever, Rose also notes that biological citizens are not solelyconstructed from above. The biocitizen appears to be activelyinvolved in forming him/herself from below, via self-education,

self-care and collectivizing action (2007: 144). Much of the literatureto date on biocitizenship in relation to HIV emphasizes its collecti-vizing, active force and the formation of politically motivated bioso-cieties (for example, see Nguyen, 2008). However, my interests

situate HIV self-testing as an individualizing act that, while entailing

responsibilities to others, also serves as a dividing practice: one thatdivides the HIV negative from the positive and the tested from theuntested, both at the individual and populations levels. In addition,

I wish to address a particular form of biocitizenship that is oftenignored: the inactive citizen.

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Because of the relatively recent advent of this home test, empiricaland ethnographic data regarding the actual prevalence of its use and

impact on public health is limited.2 Therefore, my analysis outlines

theoretical possibilities that have not been fully supported by primarysources and user experience, and it relies heavily on aspects of bio-medicalization theory (Clarke et al., 2010) and biocitizenship litera-

ture (Rose, 2007), while acknowledging their limitations. In addition,this article’s focus is limited to the potential use of the HIV self-testin the United States. While it has been suggested that unregulated tests are available in certain African and Asian countries (Paiet al., 2013: 11), at the time of this analysis the US is currently the

only country in which an approved rapid home test is widely avail-able. The case of the US is important in considering how the uptakeof these tests may occur elsewhere, since the US approval has the

potential to influence a new wave of home testing in other countries.Because these tests are not yet widely available to the general public

in other countries, however, it is less clear what impact home testingwill have internationally.3

Home HIV Tests and the Construction of Biological

Citizens

The concept of home HIV testing was first proposed to the FDA in1986 (Millenson, 2006).4 The FDA responded two years later byissuing guidance for acceptance of applications for HIV tests,

restricting their use to health care settings and requiring that results

be returned with appropriate counseling by health care professionals,in effect, prohibiting home testing.5 In 1989, the FDA held the first public hearings to consider home HIV tests. Public response was

overwhelmingly against home testing: several members of the USCongress, representatives from the Centers for Disease Control and Prevention (CDC), the American Medical Association, and even gay,lesbian, bisexual and trans-sexual (GLBT) activists strongly opposed

it over concerns about accuracy and potential suicides as a result of

learning of HIV positivity on one’s own. To highlight the latter con-cern, AIDS activists disseminated copies of an obituary of a man whocommitted suicide by jumping off the Golden Gate Bridge in San

Francisco after learning he had HIV (Wright and Katz, 2006: 438).The general consensus was that citizens were not equipped to test

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or receive results on their own, given the intense stigma and rela-tively limited advancement in treatment and outcomes.

In the over two decades since, the landscape of HIV testing and

treatment in the US has changed considerably. In 1996, the FDAreversed its stance and approved an over-the-counter home collectionkit, whereby users would collect a blood sample, send it to a lab for

analysis, and receive results and counseling over the phone, withappropriate referrals for positive results (Whellams, 2008: 6). In2005, a coalition including many of the same interest groups that lob-

bied against home testing in 1989 (physicians, GLBT activists, pub-lic health officials, and manufacturer representatives) joined to

testify before the FDA Blood Products Advisory Committee (BPAC)in support of rapid home tests (Wright and Katz, 2006: 437). In theseven years following, OraSure Technologies worked with the FDA

to conduct required clinical trials and adapt product design to obtainapproval for its product. The result, OraQuick, is currently the only

rapid home test for HIV in the US approved by the FDA.The first clearance of a rapid self-diagnostic, the home pregnancy

test, was issued by the FDA in 1976. Historian Sarah Leavitt has linked the development and FDA approval of the home pregnancy test in thelate 1970s to the women’s health movement. While many doctors and

health officials dismissed the need for home pregnancy tests in the1960s and early 1970s, Leavitt explains: ‘women found ways around these strictures and increasingly demanded access to private, personal,informed, and non-judgmental health care, of which the pregnancy test

was a part’ (Leavitt, 2006: 327). Once abortion was made legal acrossthe nation in 1973, women’s health organizations made arrangementsto expand access to pregnancy testing outside of the doctor’s office and to make it more affordable. For example, members of the Chicago

Women’s Liberation Union conducted pregnancy testing at variouslocations in the early 1970s outside of the clinical setting (Kline,2010: 79). Consequently, when Warner-Chilcot submitted its applica-tion for the ‘e.p.t.’ (Early Pregnancy Test) to the FDA in 1976, it was

meeting a demand that was clearly evident (Leavitt, 2006: 325).

It would appear that the home pregnancy test emerged as part of acitizen-driven movement, while private interests seem to have played a larger role in bringing the HIV self-test to market. In fact, in a crit-

ical assessment of corporate involvement in establishing FDA guide-lines for rapid home HIV tests, Melissa Whellams (2008) notes that





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evidence of consumer demand was not a factor in deliberations. Sheargues that while proponents of rapid home HIV tests claimed that

they were responding to consumer desire, it seems that there was

minimal demand for the product, at least at the time of her analysis.What are we to make of the differences between how these two testsemerged? It is true that the dramatic shift in support for home HIV

testing since the 1980s stems in part from advancement in treatmentsand the framing of HIV as a ‘chronic’ disease, as well as the publichealth push for the routinization of testing as I discuss below. How-ever, this turn, in comparison with the pregnancy test, also demon-strates the proliferation of alliances between private (for-profit)

entities and public interest groups (e.g. non-profit entities, govern-ment agencies, universities, community activist groups, etc.). Glob-ally, private and public entities have converged in partnerships that

seek medical innovations and new markets for these products. Thishas been tied to the growing influence of neoliberal thought since

at least the early 1980s, which advocates for a greater role of privateindustries in what had traditionally been considered ‘public’ goods(Buse and Walt, 2000). Hence, it may no longer be possible to distin-guish between corporate interests and public health discourse, partic-ularly in the realm of medical devices and drugs. Yet the logics

and motivations at work in these entanglements do not blend seam-lessly, nor do they necessarily coincide. Critical analyses of self-diagnostics, therefore, must grapple with their potential benefits aswell as their social costs. What are the implications of these assem-

blages that now bring self-diagnostics to market? What contested spaces do they open up and what does this mean for the role of cor-

porations in generating desire for the conduct of biocitizenship? Howare ‘private’ interests implicated in the moral and ethical landscape

that biocitizens negotiate? While the answers to these questions areopen to debate, the case of the home rapid HIV test can illuminate

potential responses.Testimony before the FDA BPAC in 2012 prior to the final recom-

mendation of approval of the OraQuick test demonstrates the blur-

ring of the private and public. During the open ‘public’ hearingsection of the meeting, designed to give the public a voice in FDAdecisions, individuals from organizations that ranged from HIV/

AIDS advocacy groups to medical associations, state public healthdepartments, academic institutions and religious groups expressed

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overwhelming support for the approval of the test. Of the 24 peoplewho spoke, 13 disclosed financial relationships with OraSure, rang-

ing from payment of travel costs to fiscal sponsorship, research part-

nerships, and educational grants. In addition to framing the home testas offering more choice and control to consumers, one representativefrom an AIDS activist group noted: ‘We are morally obligated – morally obligated – to bring these tests to market and stop the spread of HIV’ (BPAC, 2012: 207, italics mine). The ‘moral obligation’ istwo-fold. First, consumer choice and autonomy is framed as a univer-sal good, while any restriction of choice is framed as undesirable, if not unethical. If the FDA had refused to approve the test based on

concerns about user competence, some have suggested that it would have been viewed as paternalistic and as denying choice or freedom(Whellams, 2008: 9). The idea here is that expanding testing options

would increase the number of people who are aware of their status, but this strengthening of consumer choice is also in line with neolib-

eral ideology that aims to open markets and promote private profits(McGregor, 2001: 87). Second, as I will discuss further below, themoral and social responsibility of HIV testing implicates biocitizenswho are expected to self-monitor in order to improve their own healthand to minimize the risk posed to others. Nevertheless, the expansion

of testing options is also inexorably linked to the relationship of bio-citizens to medical authority.

Symbolic Demedicalization

Despite the very different implications of HIV testing and pregnancytesting (i.e. an infectious disease vs. pregnancy, a non-pathological

condition), it is remarkable how similarly these home tests have beenframed by the manufacturer and the media. Upon its approval, the

home pregnancy test was heralded as a ‘breakthrough in home diag-nostics’ and ‘a private little revolution’ (Leavitt, 2006: 325). Refer-encing the ‘breakthrough’ of HIV home rapid testing, the CEO of OraSure noted:

for the first time ever individuals will be able to use the same test that

healthcare professionals have used and trusted for years and this willempower them to learn their HIV status in the comfort and privacy of

their own home.5





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This framing, of course, is not unique to pregnancy tests or homeHIV tests; the supposition underlying self-diagnostic tests in general,

evident from their marketing materials, is that they help consumers to

become more self-directed and active in evaluating and managing their health (Greaney et al., 2012: 383). Therefore, a contested space hasevolved with the emergence of home and direct to consumer diagnos-

tics: from one perspective they appear to relocate subjects outside of medical control (i.e. demedicalization), while from another view theyseemingly reinforce medicalization. Rapid HIV testing in the privacyof one’s home represents a new option for the biological citizen, in lightof the previous restriction to the clinical or counseling domain. Now,

those who purchase home kits are conferred the right to collect and testtheir own samples, effectively assuming the role of clinicians and publichealth workers. However, we cannot speak of rights within the context

of neoliberal biocitizenship without recognizing that these rights comedeeply entangled with obligations to one’s own body and to society. The

evolution of biological citizenship involves a gradual extension of rights whereby processes traditionally seen as part of medical controland authority are relocated outside of that domain. In the US, this phe-nomenon occurs within the FDA and state regulatory framework. Analternative method involves defining (or redefining) such tests as non-

medical. For example, in response to cease and desist letters from theCalifornia and New York public health departments, several companiesclaimed that their genetic tests were not medical tests, but ‘personalgenetic services’, and as such, were able to operate without direct invol-

vement of physicians (Pollack, 2008). Thus, one might claim that thesemovements represent demedicalization (Conrad, 1992: 226).

On the other hand, if the home pregnancy test has taught corpora-tions anything, it is that consumers will pay for a technology that

empowers them to enter medical care earlier. In her study of the med-icalization of reproduction, Andrea Tone (2012: 325) argues thatinstead of reversing medicalization, the home pregnancy test led usersto seek medical intervention, in the form of either an abortion, prenatal

care, or, in the case of some negative results, assisted reproduction

technologies. Sarah Leavitt’s analysis arrives at a similar conclusion:

The pregnancy test does not reduce their reliance on doctors, and

prenatal care in the late twentieth century involved more and more

testing and more incursions of technology. The pregnancy test is the

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first step: each positive result will lead to the woman’s interaction in

some manner with the health-care establishment, whether doctors,

midwives, nurses, or other professionals. . . . The home pregnancy

test relocates the beginning of the long relationship with doctorsthat a pregnancy brings. (2006: 330, italics mine)

In a similar way, the movement of HIV testing to the privacy of thehome represents what Conrad terms ‘symbolic demedicalization’

(1992: 225). It is conceivable that a subject would attempt to ‘escape’the public health surveillance apparatus by testing at home. In fact,this was a concern raised at the initial 2005 FDA hearings (Campbell

and Klein, 2006). This is unlikely, however. The home rapid HIV testdoes not move the subject outside of medical authority or publichealth surveillance; the packaging clearly indicates: ‘A positiveresult with this test does not mean that you are definitely infected with HIV, but rather that additional testing should be done in a med-

ical setting.’ Furthermore, it specifies: ‘A negative result with thistest does not mean that you are definitely not infected with HIV, par-ticularly when exposure may have been within the previous 3

months.’ In the home HIV test, therefore, consumers are not payingfor a definitive diagnosis – instead they are paying for the feeling of knowing and being empowered that self-testing provides. Thus, the

message is clear: like the pregnancy test, the hope is that the pointof contact with the health care system and biomedical interventionwill be moved to the earliest point possible after HIV infection. Intheory, this will improve health outcomes for the biological citizen.

Nevertheless, access to this improvement may not be uniform.

Stratified Biomedicalization

While every biological citizen is expected to participate actively in mon-itoring and improving his or her body, the methods for doing this are notaccessible to all. Technoscientific developments target specific popula-tions, by nature of their design, price, demographic fit, or other factors.

Clarke and her colleagues recognize this as ‘stratified biomedicaliza-

tion’, by which they mean that ‘many people are completely bypassed,others impacted unevenly, and while some protest excessive biomedica-lization intervention into their lives, others lack basic care’ (Clarke et al.,

2010: 61). As in the case of HIV testing, certain bodies and identities areseen as needing technologies by virtue of their ‘risky’ behaviors and





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lifestyles (Clarke et al., 2010: 83). Even within these ‘risky’ groups, thosewho do not participate, for whatever reason, in the technologies of health,

are often excluded or deemed morally deficient (Rose, 2007: 25). While

the manufacturer of the OraQuick test aims to market to those perceived at higher risk, including gay men and minorities (McNeil, 2012a), amajor concern is that the rapid home HIV test will exclude a large section

of that population because the cost will be prohibitive. While historicallythe HIV/AIDS epidemic in the US has affected MSM (men who have sexwith men) and other ‘high-risk’ groups (e.g. intravenous drug users and commercial sex workers) at greater rates, recent studies have shown thatit currently disproportionately affects economically impoverished urban

populations (Denning andDiNenno, 2010). As Paltiel andPollack (2010)observe, HIV testing is unique in that the people at highest risk and thus atgreater need for testing may be populations that have the least resources

to pay for it. Thus, they argue that the FDA should have considered priceas a specific criterion for approval, perhaps requiring a subsidy or tiered

pricing system to ensure that benefits are maximized, instead of focusingonly on accuracy and safety.

Testimony presented during a 2005 FDA advisory meeting cited a pilot study that showed $15 was the upper price limit to purchase a rapid test in a sample of 240 patients with HIV (Wright and Katz, 2006: 440).

A more recent study presented at a 2012 meeting showed that in a sampleof 108 men who have sex with men, 45% would not pay more than $20for the test (Willyard, 2012). Upon its release, the OraQuick test was

priced at approximately $40. A 2006 editorial in Annals of Internal Med-

icine identified specific groups to which the authors believed the testwould appeal: the affluent, the ‘worried well’, new couples, and peoplewith recent high-risk exposure (Walensky and Paltiel, 2006). The chief executive of amfAR commented: ‘If the people who go out and pay for

this test end up being sorority girls who had a one-night stand and worryif they’re infected, that’s not going to be a net positive’ (Duncan, 2012).Analysis presented to the FDA BPAC in 2012 claimed that the OraQuick home test could potentially detect 45,000 new HIV cases and avert 4000

new infections each year in the US (Willyard, 2012). OraQuick tests are

currently available online and in 30,000 outlets (including pharmacies,grocery stores, and Wal-Mart) throughout the US (www.oraquick.com),in theory available anywhere to anyone. While an analysis of the full

OraQuick marketing plan is outside the scope of this article, it is worthnoting that Magic Johnson, former professional basketball star and HIV

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activist, has been hired as a spokesperson in an effort to target the AfricanAmerican community (Anderson, 2012). However, if many of those

deemed at risk for HIV cannot purchase this test due to limited resources,

if indeed this results in stratified biomedicalization, there will be a sig-nificant disconnect between the claims that justified its approval and itsactual effects in reducing the incidence of HIV/AIDS and detecting new

cases. Rose summarizes the dilemma: ‘not all have equal citizenship inthis biological age’ (2007: 132).7

Risk and the Untested Body

As Deborah Lupton has observed, the contemporary meaning of ‘risk’ as ‘danger’ permeates public health discourse and serves as

‘an effective Foucauldian agent of surveillance and control that isdifficult to challenge because of its manifest benevolent goal of maintaining standards of health’ (1993: 432–433). The discourse sur-

rounding HIV is ripe with references to risk, levels of risk, and thoseat risk. In 2006, the CDC revised its recommendations in an effort toroutinize HIV testing. Specifically, it recommended general screen-ing of patients in health care settings, testing of all pregnant womenunless they opt out, and, most notably, removed the requirement for

pre- and post-test counseling. The current guidelines state: ‘the effec-tiveness of using risk-based testing to identify HIV-infected personshas diminished’ (Branson et al., 2006). While this revision mayappear to reduce the role of risk in HIV public health discourse, the

alternative interpretation is that everyone is at risk . Petersen and Lup-

ton observe that the new public health focus on the ‘environment’ (as broadly defined) serves to disband the categories of ‘healthy’ and ‘unhealthy’ populations; instead, ‘everything potentially is a source

of ‘‘risk’’ and everyone can be seen to be ‘‘at risk’’’ (1996: 195). Thefocus of contemporary public health efforts to reduce the incidenceof HIV, therefore, has shifted to testing the general population inorder to reduce transmission by earlier treatment and identification

of seropositive individuals. This expansion of the at-risk population

serves both the interests of organizations charged with protecting public health (e.g. the CDC) and companies that manufacture thesetests, under the guise of achieving ‘health for all’.

The framework of biological citizenship traditionally emphasizesthe active nature of the neoliberal subject. However, practices of





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biocitizenship are not uniform. While the population in general has been identified as at risk for HIV, the most ‘risky’ bodies now are

those who have not been tested, those who have not fulfilled their

duties as biological citizens in actively monitoring their status. Thesesubjects comprise a specific category of biocitizens: the ‘untested

bodies’. These untested bodies are simultaneously at risk while pos-

ing a risk. By not monitoring their HIV status and abandoning theobligation to constantly assess and improve their health, the untested citizens pose a threat to the community of active, informed biologicalcitizens who are aware of their status. Much of the impetus and jus-tification for the OraQuick test centered around evidence collected

by the CDC which showed that approximately one in five peoplein the US who have HIV do not yet know it. Thus, the test would the-oretically reach those who for whatever reason have not submitted to

a clinical test (e.g. those who do not divulge risky practices to their doctors, those with limited access to health care, or those in rural

areas without HIV testing centers) (Arnold, 2012). The efforts toreach these untested bodies can be seen as an attempt to rehabilitate

biological citizens, in a sense, to bring them back into the fold of the‘regime of self’ as actively taking responsibility for their health(Rose, 2007: 154). The status of the ‘untested body’ may be transi-

tory. One may test negative and then engage in a risky activity(e.g. unprotected sex or needle sharing), thus returning to the statusof the ‘untested’. However, awareness of one’s HIV status is simplythe beginning stage of a self-maintenance regime. While those who

test negative (and society in general) are encouraged to take specificsteps (e.g. practice safer sex, avoiding sharing needles, etc.) to mini-mize the risk of contracting HIV, those who test positive are directed

by counselors and health care professionals to take steps to minimize

the effects of the disease on their bodies and the chance of passing iton to others (e.g. beginning antiretroviral treatment, practicing safer sex, disclosing status to partners) (Petersen and Lupton, 1996: 70).

Yet when we consider the potential for stratification of access to

HIV self-tests, a paradox emerges: while discourse regarding the

untested bodies emphasizes their rehabilitation via self-testing, it is probable that a large sector of this class of biocitizens will find thecost prohibitive. It is within this context that the involvement of cor-

porate capitalism and its fusion with biomedicine and public healthgets caught up with the shaping of citizen practices and moral

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systems. While the biomedical and public health endeavors mayclaim their goal as the objective promotion of human well-being, cor-

porate capitalism appears to eschew a moral valence in its pursuit of

profit. However, this assemblage has the potential of reinforcing amoral system that already deems the untested as irresponsible bioci-tizens. If indeed many of the untested cannot afford to self-test (and

have not found other means of testing feasible), then they may be fur-ther ostracized due to their seeming dereliction of citizenship duties.Because of its apparent ease of use, immediate results, wide avail-ability, and privacy, the home rapid HIV test is positioned as a tech-nology that can be understood and used by anyone. A recent national

TV ad for the test declared: ‘It’s not a black thing, it’s not a whitething, it’s not a gay thing, it’s not a straight thing. Testing for HIVis everyone’s thing’ (OraSure, 2012). Now, it seems that there is

no valid excuse not to be tested. Public health research conducted in the US prior to OraQuick’s approval pointed to the over-the-

counter rapid HIV test as a promising tool to increase testing ratesamong untested MSM, even among those with low intentions to gettested (MacKellar et al., 2011). While many of the untested reported that they would use a home rapid test if it were available, cost was notfactored into the question. Consequently, an ostensibly democratiz-

ing technology may reinscribe social stigma on these bodies becauseit is priced outside of their range. As James Morone has observed:

The myth of a liberal society makes it easy to overlook moral bound-

aries and the ways we use them. . . . Apparent efforts to improve public

health – alcohol prohibition, drug wars, campaigns against sexually

transmitted diseases – often turn into ways of dividing American soci-ety, of sorting out the moral us from the threatening them. (1997: 1015)

The vital moral obligation to oneself and others of HIV testingmakes the moral divide between the tested and untested even moreconcerning and is what differentiates the HIV home test from other over-the-counter diagnostics. Neither the home pregnancy test nor

direct-to-consumer genetic testing can claim the same moral urgency.

Surveillance and Acts of Biocitizenship

Techniques for self-surveillance have proliferated in recent years,from online risk-assessment tools to more dynamic self-monitoring





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systems and online communities such as the ‘Quantified Self’, inwhich self-trackers discuss their experiences monitoring minute

details such as weight, blood pressure, calories, heart rates, and men-

strual cycles (Bethge, 2012). However, public health discourse is notonly concerned with self-development and self-surveillance – pro-tecting one’s health also involves the surveillance of others. Anti-

smoking campaigns have urged citizens to not only stop smokingthemselves, but to monitor others, to protect ‘the masses from ‘‘other

people’s smoke,’’ for example by insisting that others do not smokeinside one’s house’ (Petersen and Lupton, 1996: 69). The purpose of this surveillance of others is both self-interest and the interest of the

community. Health monitoring of others has entered private spacesand rituals, even those considered to be ‘risky’ domains. For exam-

ple, in a European study of the effects of safe-sex promotion (Pryce,

2000) one interviewee who worked as a bouncer at an S/M leather club noted that staff policy was to exclude members who were

observed engaging in ‘deviant’ (i.e. unsafe) practices. The author concludes: ‘A socially and sexually ‘‘deviant’’ group were policingthemselves to ensure members did not deviate from the ‘‘liberal’’rhetoric of health promotion’ (Pryce, 2000: 108). Yet as AnnemarieMol points out, while hegemonic health discourse may seem totaliz-

ing, ‘(medical) science does not have the power to impose its order on society’ (2002: 62). Instead, she argues, if it succeeds, it is

because actors in society take it up (or adopt what suits their needs),forming new networks and associations.

Rapid over-the-counter HIV tests may also serve as a tool by whichconsumers can ‘police’ others while acting out of self-interest. Thoughnot advertised by the manufacturer as a potential use, some have advo-cated using the test to screen potential partners. Of the 4000 partici-

pants in the clinical trials conducted before OraQuick’s approval,70% indicated that they would definitely or very likely use it in thismanner (McNeil, 2012b). The experience reported in a US news outletshortly after the release of the HIV self-test, illustrates this dynamic:

Dan Nainan had never heard of a home test for HIV until a prospec-

tive girlfriend insisted that he take one. Apparently, she didn’t trust

him. ‘I’m not some sleaze bag, but she’s really suspicious,’ said Nai-

nan, 31, who works as a comedian. ‘I’m like, ‘‘Come on, you’re kidding

me.’’’ The test became a sticking point in their budding relationship.

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‘I didn’t feel I had anything to be worried about,’ Nainan said, ‘but she

didn’t want to proceed.’ He finally gave in and took the test his girl-

friend foisted on him, certain he’d test negative. . . . ‘I felt like I was

taking a pregnancy test,’ Nainan said. (Halperin, 2012)

One recent study conducted in New York City (Carballo-Diéguezet al., 2012) investigated the utility of partner screening with the new

rapid HIV test in a population ( N ¼ 27) of HIV-negative men whohave sex with men (MSM) who regularly had unprotected sex withmultiple partners. The expectation was that if a potential partner tested

positive for HIV, subjects would refrain from unprotected sex. Sub-

jects were given test kits to use before sexual encounters and weremonitored for three months. During the course of the study, 100 part-ners were tested and 10 tested positive (6 of whom were previously

unaware of their status). While the authors claim that ‘very few prob-lems occurred’, they also note that using the OraQuick kit to test part-ners is problematic, since it may not accurately detect HIV antibodies

until after the three-month window period (Carballo-Diéguez et al,2012: 1753). Partner testing arises from more than the need for self-

protection. Indeed, it is deeply embedded within the ethical conductthat has emerged against the backdrop of biopower and biocapital in

the neoliberal era, a conduct which Rose terms ‘somatic ethics’(2007: 257). HIV testing in its myriad forms entails a particular formof ethics of personhood and the body, one that, as Rose notes: ‘con-cerns itself with the self-techniques by which human beings should

judge and act upon themselves to make themselves better than theyare’ (2007: 27). This ethical responsibility, therefore, requires that cit-

izens take up practices not only individually, but in relation to others.Partner screening for HIV has a complex history of practice, in par-

ticular among MSM who engage in casual unprotected sex. In a NewZealand study reported in the late 1980s (Horn and Chetwynd, 1989),one participant described how he would feel under the partner’s armsfor swollen lymph glands to assess HIV status. A study conducted in

Montreal in the early 1990s described the process of inspection that par-ticipants employed to screen partners for HIV status, for example, by

looking for Kaposi’s sarcoma lesions and evaluating muscle tone for signs of wasting (Aveline, 1995). Partner screening with over-the-

counter rapid HIV tests constitutes a similar form of knowledge produc-tion, with the credibility that technoscientific innovations provide. The





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OraQuick packaging clearly states that one should not use the test ‘tomake decisions based on behavior that may put you at risk for HIV’

given the possibility of a false negative. Yet, we misread partner testing

if we assume that users believe that these tests are infallible. In testi-mony to the FDA in reference to the study on MSM described above,the lead researcher noted that when subjects were asked whether they

understood that the result might not be accurate given the window period, they all responded in the affirmative. However, as he testified:

They see the possibility of testing partners as something much better

than doing ‘ocular’ virology – if I look at you and I think you look

good, so probably you’re not infected. They feel much more empow-ered when they have a test that they can use to test someone. (BPAC,

2012: 148)

Partner testing is not simply an imposition ‘from above’ of a newmedical technology as a tool for surveillance, nor is it adopted blindly.

As noted previously, the biological citizen is not a passive recipient of health discourse. Clarke et al. (2010: 56) argue that processes of bio-medicalization are contingent on how individuals negotiate them,sometimes even transforming them to meet their needs. Hence, someof those who choose to test partners are negotiating the use of a med-

ical technology, and the uncertain knowledge it produces, to fit their own needs and circumstances in order to protect themselves from HIVinfection and fulfill a societal obligation. They demonstrate the con-viction that biotechnology can provide an objective evaluation instead

of relying on visual assessments or the partner’s word.

Those desires and convictions are still framed within contempo-rary discourses of risk and contribute to the economic bottom lineof corporations, however. Drawing from Foucault in her work on the

democratic citizen, Cruikshank argues that ‘it is to be in a tangled field of power and knowledge that both enables and constrains the

possibilities of citizenship . . . citizens are made and therefore subject to power even as they become citizens’ (1999: 20). Viewed in

this way, performances of biocitizenship, while embodying norms,

can also be acts of agency. These acts of biocitizenship have the potential to usher in new forms of subjectivity and ways of becomingintimate. These are biocitizens who, via this performative act, may

no longer simply view the body as a potential object of examination by medical authority, but as something to be self-tested at the deepest

Banda 39




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molecular level. For some, this is part of a life-long process of suchexamination, as the methods by which biocitizens are able to test

themselves and others proliferate. Partner testing has potential impli-

cations for the configurations of sexual relationships and practices as biocitizens learn of others’ status in the home and make immediatedecisions based on that result. It is from the complex networks of

health discourse, corporate marketing, societal obligations, and indi-vidual material needs that such practices emerge.

Conclusion

Rose notes that ‘strategies for making up biological citizens ‘‘fromabove’’ tend to represent the science itself as unproblematic’ (2007:

142). This unproblematic representation is also reflected in marketingand public health discourse surrounding the rapid home HIV test. Yet,as this analysis has shown, scientific technologies are not neutral, and

self-testing contributes to the moral and social fabric through whichcontemporary citizenship practices are woven. The deployment and moral valences associated with this test carry a number of significantimplications for biological citizens. First, while it is framed as promot-

ing citizen choice and autonomy, rapid home HIV testing represents‘symbolic de-medicalization’. That is, it reinforces medicalization

by bringing consumers into contact with health authority as early as possible. It is hoped that this will translate into earlier treatment and better outcomes for HIV patients. Second, stratification of access may

contradict the reasoning behind releasing the test; in other words, it

may be inaccessible to certain populations who, according to publichealth discourse, need it most. Third, efforts to test the general popu-lation, of which the new test is a component, have created a new cate-

gory of biocitizens: the untested bodies. Stratification of access mayfurther the moral stigma against this population. In addition, theresponsibility of health surveillance has been extended to monitoringothers. However, this is not merely an example of pervasive biopower;

biological citizens construct themselves while negotiating the use of

these tests, sometimes in contradiction to their stated use.As I have demonstrated, the over-the-counter rapid HIV test in theUS emerged from a unique assemblage of actors, including govern-

ment agencies, HIV/AIDS activist groups and non-profits, the biotechindustry, and the material needs of a population. Now that the FDA has





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approved home rapid testing for HIV, other infectious diseases and conditions will likely encounter relatively uncomplicated tracks to

approval, limited only by available technology. These tests present a

significant shift in the way that citizens are able to understand the con-ditions of their bodies outside of the clinical setting. In addition, theycan potentially improve health outcomes. It is important to recognize,

however, that underneath the liberatory rhetoric used to promote thesemedical technologies, there are important consequences for the waywe understand and monitor our own bodies and those of others, as wellas for relations of power in society.

Acknowledgements

I would like to thank the faculty and my fellow students at the Insti-tute for the Medical Humanities for comments on earlier presenta-tions of this work, and in particular Professors Rebecca Hester and Arlene Macdonald for their encouragement and feedback throughout

the review process. I would also like to thank the anonymousreviewers and editorial board at Body & Society for their close review

and critique of previous versions of this article.

Notes

1. In the Phase III (Unobserved Use Study) trial of the test, which included

approximately 5000 participants, sensitivity was 91.67%, and specificity

was 99.98%. In other words, when someone is HIV negative, the test is

nearly 100% accurate. Yet in positive individuals, there would be approx-

imately one false negative out of every 12 tests, which the manufacturer

attributes to the antibody window period or user error (FDA, 2012).

2. A recent acceptability study in New York concluded that over half of the

adults surveyed said they would use a home rapid test, with higher

acceptability among youth (age 18–24), African Americans, and Lati-

nos, but that its use may be limited by cost (Keller, 2012).

3. Shortly after the announcement of FDA approval, advocates in the United Kingdom, South Africa, Canada, and Australia vocalized support for the

approval of rapid home testing kits in their own countries (Kretowicz,

2012; UNAIDS, 2012; Wallace, 2012). Practices of biological citizenship,however, are not homogeneous globalized phenomena; their performance

is highly dependent on local context and power dynamics. Even within the

same locality, specific practices are widely variable, due to stratification,

consumer choice, regulatory restrictions, and other factors. A recent review

Banda 41




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of studies on supervised and unsupervised (home) testing concluded that

the evidence is not clear that unsupervised rapid testing has high acceptabil-

ity uniformly across the globe, especially in low-resource contexts (Pai

et al., 2013). The authors also expressed concern that these studies did notdemonstrate whether such tests are successful in linking individuals to care

in these settings. Kenya was the first African country to develop guidelines

regarding the sale of self-testing kits for HIV, and at least one feasibility

study has implemented a program whereby health workers can self-test

themselves and partners (Mavedzenge et al., 2013). The first International

Symposium on Self-Testing for HIV, held in April 2013, brought together

experts from 14 different nations to discuss the issues surrounding homerapid tests. While there was general consensus that home self-testing

should be encouraged and supported internationally, it was also recom-

mended that before devoting resources to its scale-up, individual countries

should consider whether there is a ‘better, risk-free way’ to achieve the

same benefits, and that in lower-resource settings it may be more valuable

to focus resources on improving current programs rather than this new test-

ing method (WHO, 2013: 18–19). Hence, what we may see is an interna-

tional stratification of access to home rapid tests depending on the

individual assessment of each nation.

4. While the rapid test had not yet been developed, one entrepreneur believed that a home collection kit was technically feasible; hence he met

with the FDA to discuss the possibility of approval (Millenson, 2006).

5. Blood collection kits labeled for Human Immunodeficiency Virus Type 1

(HIV-1) antibody testing; home test kits designed to detect HIV-1 anti-

body; open meeting (1989) Federal Register 50: 7279 (17 February).

6. OraSure Technologies’ CEO presents OraQuick in-home HIV test (Tran-

script) (2012) 10 October. Available at: http://seekingalpha. com/article/

917691-orasure-technologies-ceo-presents-oraquick-inhome-hiv-test-

transcript?source¼ Nasdaq (accessed July 2013).

7. While it is not in the scope of this article to draw correlations betweenthe populations that cannot afford to self-test and those that may find it

difficult to access treatment, it is worth noting that access to treatment

for HIV and health care in general in the US is also stratified. In

2010, of the total population diagnosed with HIV in the US, 25% had

not been linked to care within four months after diagnosis. Of those

referred to care, African Americans and Latinos were slightly less likely

to receive treatment (86% and 89%, compared to 92% for whites)(Cohen et al., 2011). A recent CDC (2013) report also noted that lack

of health insurance is a major barrier to accessing HIV treatment

and that lack of insurance is disproportionately higher among African

Americans and Latinos in the US.





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http://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.nytimes.com/2008/06/26/business/26gene.htmlhttp://www.nytimes.com/2008/06/26/business/26gene.htmlhttp://www.unaids.org/en/resources/presscentre/featurestories/2012/july/20120704hometesting/http://www.unaids.org/en/resources/presscentre/featurestories/2012/july/20120704hometesting/http://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://bod.sagepub.com/http://bod.sagepub.com/http://bod.sagepub.com/http://bod.sagepub.com/http://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://www.thestar.com/news/canada/2012/07/04/health_canada_mum_on_future_availability_of_inhome_oral_hiv_test.htmlhttp://www.unaids.org/en/resources/presscentre/featurestories/2012/july/20120704hometesting/http://www.unaids.org/en/resources/presscentre/featurestories/2012/july/20120704hometesting/http://www.nytimes.com/2008/06/26/business/26gene.htmlhttp://www.nytimes.com/2008/06/26/business/26gene.htmlhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hkhttp://www.youtube.com/watch?feature=player_detailpage&v=82rV3jgg-Hk


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