You are on page 1of 24

Body &

Article Society
2015, Vol. 21(4) 24–47
ª The Author(s) 2014
Rapid Home HIV Reprints and permission:
Testing: Risk and the DOI: 10.1177/1357034X14528391

Moral Imperatives of
Biological Citizenship

Jonathan Banda
University of Texas Medical Branch, Texas, USA

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 that
while 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’s
own 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 intent
expressed 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. The
new public health effort to test the population at large has given rise to a new ‘risky’
population: the untested bodies.

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

On 3 July 2012, the US Food and Drug Administration (FDA), the
government 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 infectious
disease approved by the FDA, was said upon its release to be as easy
to use as a home pregnancy test and was heralded as a ‘positive step

Corresponding author: Jonathan Banda. Email:
Extra material:

Downloaded from at b-on: 00400 Univ. da Beira Interior on March 7, 2016

Banda 25

forward’ in controlling the HIV/AIDS epidemic (McNeil, 2012a).
The FDA approval of this test is a significant development, since
for over twenty years the process of testing and returning HIV
results in the US has remained under the jurisdiction of health care
professionals and other authorized counselors. In addition, it has
great potential for improving health outcomes via early detection
and treatment.
Employing technology that has been utilized in medical set-
tings in the US since 2004, the OraQuick test works via a mouth
swab, which is placed in a vial of developer soution. After wait-
ing 20 minutes, users read the results: one pink line indicates
negative results, and two indicate that the test results are posi-
tive. Because it checks for HIV antibodies, there is a window-
period after infection during which the test will not accurately
detect HIV.1 Hence, some have expressed concern about the
‘small, but open, portal to risk’ should the test be used to con-
firm status before engaging in activity that could transmit the
virus (Fischer, 2012: 389). While material concerns about accu-
racy are crucial, the more provocative questions involve how this
test, and home diagnostics in general, emerge in the market, and
how they empower subjects at the individual and societal levels.
If we take seriously Foucault’s claim (1982) that power is produc-
tive and generative, it becomes clear how these tests can indeed be
empowering - self-diagnostics produce new forms of subjectivity,
corporeal realities and practices of biocitizenship. While these tests
have the potential to allow people more insight into their bodies
outside of the medical setting, as Barbara Cruikshank notes: ‘the
will to empower is neither clearly liberatory nor clearly repressive’
(1999: 72). In other words, empowerment is a form of radically
conditioned agency that can be enabling and/or transformative,
while at the same time shaped by discourse and medical authority.
Hence, the question I am concerned with is not whether self-
diagnostics are empowering, but instead what kinds of power they
produce and support.
Via a discursive analysis of literature, product packaging, and mar-
keting and public health rhetoric surrounding the home rapid HIV test,
this article identifies several contested spaces that emerge within the
context of the capitalist imperative of the United States bioeconomy.
While home HIV testing appears to represent a de-medicalization of

Downloaded from at b-on: 00400 Univ. da Beira Interior on March 7, 2016

2008). My analysis draws specifically from the work of Nikolas Rose (2007) on the biological citizen. therefore. but also their partners. shaping the way they see their bod- ies and their obligations to themselves and those around them. The biocitizen appears to be actively involved in forming him/herself from below. I wish to address a particular form of biocitizenship that is often ignored: the inactive citizen. 2016 .com at b-on: 00400 Univ. while other self-testing and monitoring devices. the self-test for HIV is further framed as a moral obligation. self-care and collectivizing action (2007: 144). Much of the literature to date on biocitizenship in relation to HIV emphasizes its collecti- vizing. while entailing responsibilities to others. have also been framed within the context of consumer choice and empowerment. it also expands the reach of medical authority into the home while constituting new practices of biocitizenship. such as those for pregnancy. da Beira Interior on March 7. as a tool for not only monitoring one’s body. This form of citizenship emphasizes the biological understanding of the body and human existence and the ways that understanding links individuals and distinguishes them from others. via self-education. see Nguyen. is expected from each biological citizen. a closer analysis of the HIV self-test reveals that underneath its democratic impulse lies the potential to reinforce social stratification. but for managing risk within intimate relationships and for society as whole. both at the individual and populations levels. nor is it the first time that individuals can receive their HIV test results anonymously at home. Health promotion and education. In addition. active force and the formation of politically motivated bioso- cieties (for example. However.26 Body & Society 21(4) HIV testing. also serves as a dividing practice: one that divides the HIV negative from the positive and the tested from the untested. While the market is presumed to be democratic insofar as it is open to all. my interests situate HIV self-testing as an individualizing act that. The home rapid HIV test represents the vanguard of a new form of self-diagnosis and monitoring – one that directly implicates not only the tested. Downloaded from bod. How- ever. in their various forms. constitute efforts to construct citizens from above. The HIV self-test is not the first home diagnostic. Continuous monitoring and optimization of one’s health. In addition. Rose also notes that biological citizens are not solely constructed from above. 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.sagepub. Hence.

in effect. The case of the US is important in considering how the uptake of these tests may occur elsewhere. 2006: 438). the American Medical Association.4 The FDA responded two years later by issuing guidance for acceptance of applications for HIV tests. it is less clear what impact home testing will have internationally. the FDA held the first public hearings to consider home HIV tests. Because these tests are not yet widely available to the general public in other countries. and even gay. AIDS activists disseminated copies of an obituary of a man who committed suicide by jumping off the Golden Gate Bridge in San Francisco after learning he had HIV (Wright and Katz. 2013: 11). The general consensus was that citizens were not equipped to test Downloaded from bod. 2010) and biocitizenship litera- ture (Rose. prohibiting home testing. representatives from the Centers for Disease Control and Prevention (CDC). While it has been suggested that unregulated tests are available in certain African and Asian countries (Pai et al. In addition. my analysis outlines theoretical possibilities that have not been fully supported by primary sources and user experience.. lesbian. at the time of this analysis the US is currently the only country in which an approved rapid home test is widely avail- able. Public response was overwhelmingly against home testing: several members of the US Congress.Banda 27 Because of the relatively recent advent of this home test. and it relies heavily on aspects of bio- medicalization theory (Clarke et al. 2006). da Beira Interior on March 7. To highlight the latter con- cern. 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. 2007).sagepub.5 In 1989. empirical and ethnographic data regarding the actual prevalence of its use and impact on public health is limited. however. this article’s focus is limited to the potential use of the HIV self-test in the United States. since the US approval has the potential to influence a new wave of home testing in other countries.3 Home HIV Tests and the Construction of Biological Citizens The concept of home HIV testing was first proposed to the FDA in 1986 (Millenson. while acknowledging their limitations.. 2016 . restricting their use to health care settings and requiring that results be returned with appropriate counseling by health care professionals.2 at b-on: 00400 Univ.

and manufacturer representatives) joined to testify before the FDA Blood Products Advisory Committee (BPAC) in support of rapid home tests (Wright and Katz. Consequently. women’s health organizations made arrangements to expand access to pregnancy testing outside of the doctor’s office and to make it more affordable.28 Body & Society 21(4) or receive results on their own. In fact. 2006: 327). 2006: 325). In the seven years following. Leavitt explains: ‘women found ways around these strictures and increasingly demanded access to private.p. The first clearance of a rapid self-diagnostic. it was meeting a demand that was clearly evident (Leavitt. OraQuick. send it to a lab for analysis. 2008: 6). In 2005. The result. da Beira Interior on March 7. While many doctors and health officials dismissed the need for home pregnancy tests in the 1960s and early 1970s. given the intense stigma and rela- tively limited advancement in treatment and outcomes. OraSure Technologies worked with the FDA to conduct required clinical trials and adapt product design to obtain approval for its product. while private interests seem to have played a larger role in bringing the HIV self-test to market. the landscape of HIV testing and treatment in the US has changed considerably. GLBT activists. pub- lic health officials. personal. the FDA reversed its stance and approved an over-the-counter home collection kit.t. is currently the only rapid home test for HIV in the US approved by the FDA. when Warner-Chilcot submitted its applica- tion for the ‘ at b-on: 00400 Univ. In 1996. members of the Chicago Women’s Liberation Union conducted pregnancy testing at various locations in the early 1970s outside of the clinical setting (Kline.’ (Early Pregnancy Test) to the FDA in 1976. and non-judgmental health care. It would appear that the home pregnancy test emerged as part of a citizen-driven movement. the home pregnancy test. In the over two decades since. Once abortion was made legal across the nation in 1973. 2006: 437). Melissa Whellams (2008) notes that Downloaded from bod.sagepub. a coalition including many of the same interest groups that lob- bied against home testing in 1989 (physicians. was issued by the FDA in 1976. in a crit- ical assessment of corporate involvement in establishing FDA guide- lines for rapid home HIV tests. of which the pregnancy test was a part’ (Leavitt. whereby users would collect a blood sample. informed. and receive results and counseling over the phone. For example. 2016 . 2010: 79). Historian Sarah Leavitt has linked the development and FDA approval of the home pregnancy test in the late 1970s to the women’s health movement. with appropriate referrals for positive results (Whellams.

During the open ‘public’ hearing section of the meeting. 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. academic institutions and religious groups expressed Downloaded from bod. which advocates for a greater role of private industries in what had traditionally been considered ‘public’ goods (Buse and Walt.Banda 29 evidence of consumer demand was not a factor in deliberations. non-profit entities. in comparison with the pregnancy test. Hence. Yet the logics and motivations at work in these entanglements do not blend seam- lessly. universities. designed to give the public a voice in FDA decisions. How- ever. this turn. private and public entities have converged in partnerships that seek medical innovations and new markets for these products. state public health departments. the case of the home rapid HIV test can illuminate potential responses. 2016 . This has been tied to the growing influence of neoliberal thought since at least the early 1980s. 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? How are ‘private’ interests implicated in the moral and ethical landscape that biocitizens negotiate? While the answers to these questions are open to debate. it seems that there was minimal demand for the product. must grapple with their potential benefits as well as their social costs. da Beira Interior on March 7.). at least at the time of her analysis. What are we to make of the differences between how these two tests emerged? It is true that the dramatic shift in support for home HIV testing since the 1980s stems in part from advancement in treatments and the framing of HIV as a ‘chronic’ disease. partic- ularly in the realm of medical devices and drugs. nor do they necessarily coincide. as well as the public health push for the routinization of testing as I discuss below.sagepub. She argues that while proponents of rapid home HIV tests claimed that they were responding to consumer desire. govern- ment agencies. it may no longer be possible to distin- guish between corporate interests and public health at b-on: 00400 Univ. community activist groups. 2000). Glob- ally. therefore.g. etc. Critical analyses of self- diagnostics. individuals from organizations that ranged from HIV/ AIDS advocacy groups to medical associations. also demon- strates the proliferation of alliances between private (for-profit) entities and public interest groups (e.

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 will empower them to learn their HIV status in the comfort and privacy of their own home. The idea here is that expanding testing options would increase the number of people who are aware of their status. 2012: 207. Second. the expansion of testing options is also inexorably linked to the relationship of bio- citizens to medical authority. The ‘moral obligation’ is two-fold. while any restriction of choice is framed as undesirable. some have suggested that it would have been viewed as paternalistic and as denying choice or freedom (Whellams. a non-pathological condition).com at b-on: 00400 Univ. consumer choice and autonomy is framed as a univer- sal good. and educational grants. In addition to framing the home test as offering more choice and control to consumers. but this strengthening of consumer choice is also in line with neolib- eral ideology that aims to open markets and promote private profits (McGregor.5 Downloaded from bod. Of the 24 people who spoke.30 Body & Society 21(4) overwhelming support for the approval of the test. Nevertheless. Upon its approval. an infectious disease vs. Symbolic Demedicalization Despite the very different implications of HIV testing and pregnancy testing (i. 2016 . italics mine). pregnancy. research part- nerships. 2008: 9). as I will discuss further below. Refer- encing the ‘breakthrough’ of HIV home rapid testing. 2006: 325). the moral and social responsibility of HIV testing implicates biocitizens who are expected to self-monitor in order to improve their own health and to minimize the risk posed to others.sagepub. First.e. the home pregnancy test was heralded as a ‘breakthrough in home diag- nostics’ and ‘a private little revolution’ (Leavitt. 2001: 87). rang- ing from payment of travel costs to fiscal sponsorship. 13 disclosed financial relationships with OraSure. it is remarkable how similarly these home tests have been framed by the manufacturer and the media. one representative from an AIDS activist group noted: ‘We are morally obligated – morally obligated – to bring these tests to market and stop the spread of HIV’ (BPAC. da Beira Interior on March 7. if not unethical. If the FDA had refused to approve the test based on concerns about user competence.

while from another view they seemingly reinforce medicalization. An alternative method involves defining (or redefining) such tests as non- medical. those who purchase home kits are conferred the right to collect and test their own samples. several companies claimed that their genetic tests were not medical tests. Rapid HIV testing in the privacy of one’s home represents a new option for the biological citizen. in the form of either an abortion. but ‘personal genetic services’. 2012: 383). However. Thus. a contested space has evolved with the emergence of home and direct to consumer diagnos- tics: from one perspective they appear to relocate subjects outside of medical control (i. is that they help consumers to become more self-directed and active in evaluating and managing their health (Greaney et al. On the other hand. we cannot speak of rights within the context of neoliberal biocitizenship without recognizing that these rights come deeply entangled with obligations to one’s own body and to society. in response to cease and desist letters from the California and New York public health departments. if the home pregnancy test has taught corpora- tions anything. The pregnancy test is the Downloaded from bod. evident from their marketing materials. this phe- nomenon occurs within the FDA and state regulatory framework. in the case of some negative results.Banda 31 This framing. In the US. and prenatal care in the late twentieth century involved more and more testing and more incursions of technology. the supposition underlying self-diagnostic tests in general. were able to operate without direct invol- vement of physicians (Pollack. or. 1992: 226). is not unique to pregnancy tests or home HIV tests. one might claim that these movements represent demedicalization (Conrad. Therefore. da Beira Interior on March 7. effectively assuming the role of clinicians and public health workers. In her study of the med- icalization of reproduction.sagepub. and as at b-on: 00400 Univ. Sarah Leavitt’s analysis arrives at a similar conclusion: The pregnancy test does not reduce their reliance on doctors. assisted reproduction technologies. in light of the previous restriction to the clinical or counseling domain. The evolution of biological citizenship involves a gradual extension of rights whereby processes traditionally seen as part of medical control and authority are relocated outside of that domain. it is that consumers will pay for a technology that empowers them to enter medical care earlier. Now.. 2008). of course.e. 2016 . prenatal care. the home pregnancy test led users to seek medical intervention. Andrea Tone (2012: 325) argues that instead of reversing medicalization. demedicalization). For example.

. consumers are not paying for a definitive diagnosis – instead they are paying for the feeling of knowing and being empowered that self-testing provides. or other professionals. midwives. Clarke and her colleagues recognize this as ‘stratified biomedicaliza- tion’. 2016 . price. this was a concern raised at the initial 2005 FDA hearings (Campbell and Klein. but rather that additional testing should be done in a med- ical setting. In theory. The home pregnancy test relocates the beginning of the long relationship with doctors that a pregnancy brings. by nature of their design.32 Body & Society 21(4) first step: each positive result will lead to the woman’s interaction in some manner with the health-care establishment. italics mine) In a similar way. . and while some protest excessive biomedica- lization intervention into their lives. As in the case of HIV testing. therefore. 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. da Beira Interior on March 7.’ Furthermore. demographic fit. the packaging clearly indicates: ‘A positive result with this test does not mean that you are definitely infected with HIV. the methods for doing this are not accessible to all. This is unlikely. 2010: 61). it specifies: ‘A negative result with this test does not mean that you are definitely not infected with HIV. the hope is that the point of contact with the health care system and biomedical intervention will be moved to the earliest point possible after HIV infection. The home rapid HIV test does not move the subject outside of medical authority or public health surveillance.’ In the home HIV test. Nevertheless. the movement of HIV testing to the privacy of the home represents what Conrad terms ‘symbolic demedicalization’ (1992: 225). . others impacted unevenly. It is conceivable that a subject would attempt to ‘escape’ the public health surveillance apparatus by testing at home. or other factors. Technoscientific developments target specific popula- tions. par- ticularly when exposure may have been within the previous 3 months. 2006). however. this will improve health outcomes for the biological citizen. . In fact. others lack basic care’ (Clarke et al. nurses. whether doctors.sagepub. Thus. certain bodies and identities are seen as needing technologies by virtue of their ‘risky’ behaviors and Downloaded from bod. the message is clear: like the pregnancy test. (2006: at b-on: 00400 Univ. by which they mean that ‘many people are completely bypassed.

are often excluded or deemed morally deficient (Rose. OraQuick tests are currently available online and in 30.. the OraQuick test was priced at approximately $40. that’s not going to be a net positive’ (Duncan. a major concern is that the rapid home HIV test will exclude a large section of that population because the cost will be prohibitive. 2012). While an analysis of the full OraQuick marketing plan is outside the scope of this article. HIV testing is unique in that the people at highest risk and thus at greater need for testing may be populations that have the least resources to pay for it. and people with recent high-risk exposure (Walensky and at b-on: 00400 45% would not pay more than $20 for the test (Willyard.Banda 33 lifestyles (Clarke et al. 2006: 440). and Wal-Mart) throughout the US (www. While the manufacturer of the OraQuick test aims to market to those perceived at higher risk. those who do not participate. A 2006 editorial in Annals of Internal Med- icine identified specific groups to which the authors believed the test would appeal: the affluent. they argue that the FDA should have considered price as a specific criterion for approval. As Paltiel and Pollack (2010) observe. 2007: 25). Upon its release. Even within these ‘risky’ groups. 2010: 83). intravenous drug users and commercial sex workers) at greater rates. 2012). in theory available anywhere to anyone. grocery stores.000 new HIV cases and avert 4000 new infections each year in the US (Willyard. in the technologies of health. 2010).oraquick. Analysis presented to the FDA BPAC in 2012 claimed that the OraQuick home test could potentially detect 45. new couples. 2012a). 2016 . 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 worry if they’re infected. 2012). While historically the HIV/AIDS epidemic in the US has affected MSM (men who have sex with men) and other ‘high-risk’ groups (e. including gay men and minorities (McNeil. it is worth noting that Magic Johnson. former professional basketball star and HIV Downloaded from bod.sagepub. the ‘worried well’. recent studies have shown that it currently disproportionately affects economically impoverished urban populations (Denning and DiNenno. Thus. A more recent study presented at a 2012 meeting showed that in a sample of 108 men who have sex with men. 2006). da Beira Interior on March 7. 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. instead of focusing only on accuracy and safety. for whatever reason.g.000 outlets (including pharmacies. perhaps requiring a subsidy or tiered pricing system to ensure that benefits are maximized.

and. most notably.. 2012). the alternative interpretation is that everyone is at risk. practices of Downloaded from bod. the contemporary meaning of ‘risk’ as ‘danger’ permeates public health discourse and serves as ‘an effective Foucauldian agent of surveillance and control that is difficult to challenge because of its manifest benevolent goal of maintaining standards of health’ (1993: 432–433). In 2006. ‘everything potentially is a source of ‘‘risk’’ and everyone can be seen to be ‘‘at risk’’’ (1996: 195).sagepub. removed the requirement for pre. 2006). 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. Rose summarizes the dilemma: ‘not all have equal citizenship in this biological age’ (2007: 132).com at b-on: 00400 Univ. has shifted to testing the general population in order to reduce transmission by earlier treatment and identification of seropositive individuals.g. The focus of contemporary public health efforts to reduce the incidence of HIV. and those at risk. if many of those deemed at risk for HIV cannot purchase this test due to limited resources. if indeed this results in stratified biomedicalization. under the guise of achieving ‘health for all’. The current guidelines state: ‘the effec- tiveness of using risk-based testing to identify HIV-infected persons has diminished’ (Branson et al. testing of all pregnant women unless they opt out. However. da Beira Interior on March 7. levels of risk. However. it recommended general screen- ing of patients in health care settings. The discourse sur- rounding HIV is ripe with references to risk. While this revision may appear to reduce the role of risk in HIV public health discourse. instead. This expansion of the at-risk population serves both the interests of organizations charged with protecting public health (e. therefore. 2016 .and post-test counseling. the CDC revised its recommendations in an effort to routinize HIV testing. Specifically. The framework of biological citizenship traditionally emphasizes the active nature of the neoliberal subject.7 Risk and the Untested Body As Deborah Lupton has observed. the CDC) and companies that manufacture these tests.34 Body & Society 21(4) activist. there will be a sig- nificant disconnect between the claims that justified its approval and its actual effects in reducing the incidence of HIV/AIDS and detecting new cases. has been hired as a spokesperson in an effort to target the African American community (Anderson.

2007: 154). However. unprotected sex or needle sharing). it is probable that a large sector of this class of biocitizens will find the cost prohibitive.g. those who have not fulfilled their duties as biological citizens in actively monitoring their status. The efforts to reach these untested bodies can be seen as an attempt to rehabilitate biological citizens. da Beira Interior on March 7.) to mini- mize the risk of contracting HIV. While those who test negative (and society in general) are encouraged to take specific steps (e. the test would the- oretically reach those who for whatever reason have not submitted to a clinical test (e. a paradox emerges: while discourse regarding the untested bodies emphasizes their rehabilitation via self-testing.g. to bring them back into the fold of the ‘regime of self’ as actively taking responsibility for their health (Rose. those who do not divulge risky practices to their doctors. informed biological citizens who are aware of their status. These untested bodies are simultaneously at risk while pos- ing a risk. practicing safer sex.g. It is within this context that the involvement of cor- porate capitalism and its fusion with biomedicine and public health gets caught up with the shaping of citizen practices and moral Downloaded from bod. beginning antiretroviral treatment. 1996: 70). 2016 . Thus.Banda 35 biocitizenship are not uniform. These subjects comprise a specific category of biocitizens: the ‘untested bodies’. While the population in general has been identified as at risk for HIV. in a sense. the untested citizens pose a threat to the community of active. 2012).com at b-on: 00400 Univ.g.sagepub. disclosing status to partners) (Petersen and Lupton. 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 people in the US who have HIV do not yet know it. Yet when we consider the potential for stratification of access to HIV self-tests. avoiding sharing needles. those with limited access to health care. 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 it on to others (e. etc. thus returning to the status of the ‘untested’. or those in rural areas without HIV testing centers) (Arnold. the most ‘risky’ bodies now are those who have not been tested. One may test negative and then engage in a risky activity (e. By not monitoring their HIV status and abandoning the obligation to constantly assess and improve their health. practice safer sex. awareness of one’s HIV status is simply the beginning stage of a self-maintenance regime. The status of the ‘untested body’ may be transi- tory.

it seems that there is no valid excuse not to be tested. campaigns against sexually transmitted diseases – often turn into ways of dividing American soci- ety. 2012). wide avail- ability. Surveillance and Acts of Biocitizenship Techniques for self-surveillance have proliferated in recent years. 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. Because of its apparent ease of use. 2016 . it’s not a white thing. Neither the home pregnancy test nor direct-to-consumer genetic testing can claim the same moral urgency. A recent national TV ad for the test declared: ‘It’s not a black at b-on: 00400 Univ. 2011).36 Body & Society 21(4) systems. While many of the untested reported that they would use a home rapid test if it were available. (1997: 1015) The vital moral obligation to oneself and others of HIV testing makes the moral divide between the tested and untested even more concerning and is what differentiates the HIV home test from other over-the-counter diagnostics. drug wars. it’s not a straight thing. Testing for HIV is everyone’s thing’ (OraSure. . da Beira Interior on March 7. then they may be fur- ther ostracized due to their seeming dereliction of citizenship duties. immediate results. from online risk-assessment tools to more dynamic self-monitoring Downloaded from bod. . Consequently. However. even among those with low intentions to get tested (MacKellar et al. and privacy. Apparent efforts to improve public health – alcohol prohibition. cost was not factored into the question. Now. cor- porate capitalism appears to eschew a moral valence in its pursuit of profit. While the biomedical and public health endeavors may claim their goal as the objective promotion of human well-being. . an ostensibly democratiz- ing technology may reinscribe social stigma on these bodies because it is priced outside of their range. it’s not a gay thing. If indeed many of the untested cannot afford to self-test (and have not found other means of testing feasible). of sorting out the moral us from the threatening them.sagepub. 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 rates among untested MSM. the home rapid HIV test is positioned as a tech- nology that can be understood and used by anyone. this assemblage has the potential of reinforcing a moral system that already deems the untested as irresponsible bioci- tizens..

and men- strual cycles (Bethge. you’re kidding me. Though not advertised by the manufacturer as a potential use. forming new networks and associations. she didn’t trust him. Anti- smoking campaigns have urged citizens to not only stop smoking themselves. da Beira Interior on March 7. in which self-trackers discuss their experiences monitoring minute details such as weight. who works as a comedian. 2000: 108).’ said Nai- at b-on: 00400 Univ. Yet as Annemarie Mol points out.Banda 37 systems and online communities such as the ‘Quantified Self’. 2012). 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. she argues. Apparently. Downloaded from bod. some have advo- cated using the test to screen potential partners. calories. heart rates. but to monitor others.’’ for example by insisting that others do not smoke inside one’s house’ (Petersen and Lupton. For exam- ple. ‘(medical) science does not have the power to impose its order on society’ (2002: 62). illustrates this dynamic: Dan Nainan had never heard of a home test for HIV until a prospec- tive girlfriend insisted that he take one. while hegemonic health discourse may seem totaliz- ing. Instead. The experience reported in a US news outlet shortly after the release of the HIV self-test. The purpose of this surveillance of others is both self-interest and the interest of the community. even those considered to be ‘risky’ domains. public health discourse is not only concerned with self-development and self-surveillance – pro- tecting one’s health also involves the surveillance of others. if it succeeds. The author concludes: ‘A socially and sexually ‘‘deviant’’ group were policing themselves to ensure members did not deviate from the ‘‘liberal’’ rhetoric of health promotion’ (Pryce.sagepub. 1996: 69). to protect ‘the masses from ‘‘other people’s smoke. 70% indicated that they would definitely or very likely use it in this manner (McNeil. Of the 4000 partici- pants in the clinical trials conducted before OraQuick’s approval. 2012b). blood pressure. Rapid over-the-counter HIV tests may also serve as a tool by which consumers can ‘police’ others while acting out of self-interest. 31. but she’s really suspicious. it is because actors in society take it up (or adopt what suits their needs). Health monitoring of others has entered private spaces and rituals. ‘I’m like. 2016 . in a European study of the effects of safe-sex promotion (Pryce. ‘I’m not some sleaze bag. unsafe) practices.’’’ The test became a sticking point in their budding relationship. However. ‘‘Come on.

While the authors claim that ‘very few prob- lems occurred’. Sub- jects were given test kits to use before sexual encounters and were monitored for three months. 2016 . Partner testing arises from more than the need for self- protection.. This ethical responsibility.’ Nainan said. Partner screening for HIV has a complex history of practice. therefore.38 Body & Society 21(4) ‘I didn’t feel I had anything to be worried about. The Downloaded from bod. ‘but she didn’t want to proceed. 1989). . . one that. 1995). da Beira Interior on March 7. 2012) One recent study conducted in New York City (Carballo-Diéguez et al. . HIV testing in its myriad forms entails a particular form of ethics of personhood and the body. 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 they are’ (2007: 27). requires that cit- izens take up practices not only individually. 2012) investigated the utility of partner screening with the new rapid HIV test in a population (N ¼ 27) of HIV-negative men who have sex with men (MSM) who regularly had unprotected sex with multiple partners. subjects would refrain from unprotected sex. they also note that using the OraQuick kit to test part- ners is problematic. but in relation to others. by looking for Kaposi’s sarcoma lesions and evaluating muscle tone for signs of wasting (Aveline. A study conducted in Montreal in the early 1990s described the process of inspection that par- ticipants employed to screen partners for HIV status.’ He finally gave in and took the test his girl- friend foisted on him. in par- ticular among MSM who engage in casual unprotected sex. for example.sagepub. a conduct which Rose terms ‘somatic ethics’ (2007: 257). The expectation was that if a potential partner tested positive for HIV. In a New Zealand study reported in the late 1980s (Horn and Chetwynd. 100 part- ners were tested and 10 tested positive (6 of whom were previously unaware of their status). it is deeply embedded within the ethical conduct that has emerged against the backdrop of biopower and biocapital in the neoliberal era. since it may not accurately detect HIV antibodies until after the three-month window period (Carballo-Diéguez et al. certain he’d test negative. Partner screening with over-the- counter rapid HIV tests constitutes a similar form of knowledge produc- tion. During the course of the study.’ Nainan said. one participant described how he would feel under the partner’s arms for swollen lymph glands to assess HIV status. ‘I felt like I was taking a pregnancy test. with the credibility that technoscientific innovations provide. (Halperin. Indeed. 2012: 1753).com at b-on: 00400 Univ.

2016 .Banda 39 OraQuick packaging clearly states that one should not use the test ‘to make decisions based on behavior that may put you at risk for HIV’ given the possibility of a false negative. Hence. sometimes even transforming them to meet their needs. the lead researcher noted that when subjects were asked whether they understood that the result might not be accurate given the window period. Drawing from Foucault in her work on the democratic citizen. the biological citizen is not a passive recipient of health discourse. citizens are made and therefore sub- ject to power even as they become citizens’ (1999: 20). Clarke et al. . to fit their own needs and circumstances in order to protect themselves from HIV infection and fulfill a societal at b-on: 00400 Univ.sagepub. performances of biocitizenship. (BPAC. some of those who choose to test partners are negotiating the use of a med- ical technology. These are biocitizens who. They feel much more empow- ered when they have a test that they can use to test someone. In testi- mony to the FDA in reference to the study on MSM described above. 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. we misread partner testing if we assume that users believe that these tests are infallible. 2012: 148) Partner testing is not simply an imposition ‘from above’ of a new medical technology as a tool for surveillance. Yet. Viewed in this way. . and the uncertain knowledge it produces. da Beira Interior on March 7. As noted previously. Cruikshank argues that ‘it is to be in a tangled field of power and knowledge that both enables and constrains the possibilities of citizenship . while embodying norms. but as something to be self-tested at the deepest Downloaded from bod. Those desires and convictions are still framed within contempo- rary discourses of risk and contribute to the economic bottom line of corporations. via this performative act. they all responded in the affirmative. (2010: 56) argue that processes of bio- medicalization are contingent on how individuals negotiate them. nor is it adopted blindly. so probably you’re not infected. They demonstrate the con- viction that biotechnology can provide an objective evaluation instead of relying on visual assessments or the partner’s word. however. These acts of biocitizenship have the potential to usher in new forms of subjectivity and ways of becoming intimate. may no longer simply view the body as a potential object of examination by medical authority. However. can also be acts of agency.

biological citizens construct themselves while negotiating the use of these tests. Now that the FDA has Downloaded from bod. it reinforces medicalization by bringing consumers into contact with health authority as early as possible. For some. the biotech industry. Conclusion Rose notes that ‘strategies for making up biological citizens ‘‘from above’’ tend to represent the science itself as unproblematic’ (2007: 142). 2016 .sagepub. this is not merely an example of pervasive biopower. in other words. That is. It is hoped that this will translate into earlier treatment and better outcomes for HIV patients. have created a new cate- gory of biocitizens: the untested bodies. and the material needs of a population. sometimes in contradiction to their stated use. Third. while it is framed as promot- ing citizen choice and autonomy. Stratification of access may further the moral stigma against this population. This unproblematic representation is also reflected in marketing and public health discourse surrounding the rapid home HIV test. The deployment and moral valences associated with this test carry a number of significant implications for biological citizens. In addition. corporate marketing. as this analysis has shown. this is part of a life-long process of such examination. according to public health discourse. As I have demonstrated. the responsibility of health surveillance has been extended to monitoring others. It is from the complex networks of health discourse. and indi- vidual material needs that such practices emerge. need it most. efforts to test the general popu- lation. as the methods by which biocitizens are able to test themselves and others proliferate. including govern- ment agencies. rapid home HIV testing represents ‘symbolic de-medicalization’. scientific technologies are not neutral. of which the new test is a component. Second.40 Body & Society 21(4) molecular level. societal obligations. it may be inaccessible to certain populations who. However. at b-on: 00400 Univ. the over-the-counter rapid HIV test in the US emerged from a unique assemblage of actors. and self-testing contributes to the moral and social fabric through which contemporary citizenship practices are woven. 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 immediate decisions based on that result. da Beira Interior on March 7. Yet. stratification of access may contradict the reasoning behind releasing the test. HIV/AIDS activist groups and non-profits.

In other words. they can potentially improve health outcomes. that underneath the liberatory rhetoric used to promote these medical technologies. and other factors. South Africa.67%. African Americans. A recent review Downloaded from bod. It is important to recognize. and Lati- nos. which included approximately 5000 participants. and Australia vocalized support for the approval of rapid home testing kits in their own countries (Kretowicz. I would also like to thank the anonymous reviewers and editorial board at Body & Society for their close review and critique of previous versions of this article. and in particular Professors Rebecca Hester and Arlene Macdonald for their encouragement and feedback throughout the review process. as well as for relations of power in society. other infectious diseases and conditions will likely encounter relatively uncomplicated tracks to approval. Practices of biological citizenship. however. Wallace. Even within the same locality. which the manufacturer attributes to the antibody window period or user error (FDA. 2012).Banda 41 approved home rapid testing for HIV. are not homogeneous globalized phenomena. when someone is HIV negative. 2016 . Yet in positive individuals.98%. Shortly after the announcement of FDA approval. da Beira Interior on March 7. 3. 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. their performance is highly dependent on local context and power dynamics. 2012. In addition. and specificity was 99. the test is nearly 100% accurate. limited only by available technology. due to stratification. 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. sensitivity was 91. there are important consequences for the way we understand and monitor our own bodies and those of others. Canada. there would be approx- imately one false negative out of every 12 tests. In the Phase III (Unobserved Use Study) trial of the test. Notes 1. specific practices are widely variable. 2. UNAIDS. consumer choice. however. 2012). advocates in the United Kingdom. with higher acceptability among youth (age 18–24). A recent acceptability study in New York concluded that over half of the adults surveyed said they would use a home rapid test. regulatory at b-on: 00400 Univ. but that its use may be limited by cost (Keller. 2012.sagepub. 2012).

In 2010.. da Beira Interior on March 7. 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. While it is not in the scope of this article to draw correlations between the populations that cannot afford to self-test and those that may find it difficult to access treatment. The authors also expressed concern that these studies did not demonstrate whether such tests are successful in linking individuals to care in these settings. of the total population diagnosed with HIV in the US. open meeting (1989) Federal Register 50: 7279 (17 February). The first International Symposium on Self-Testing for HIV. especially in low-resource contexts (Pai et al. it is worth noting that access to treatment for HIV and health care in general in the US is also stratified. Blood collection kits labeled for Human Immunodeficiency Virus Type 1 (HIV-1) antibody testing. 2013). individual countries should consider whether there is a ‘better. Available at: http://seekingalpha. While there was general consensus that home self-testing should be encouraged and supported internationally. OraSure Technologies’ CEO presents OraQuick in-home HIV test (Tran- script) (2012) 10 October. 2013).42 Body & Society 21(4) 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. 7. 5. held in April 2013.sagepub. brought together experts from 14 different nations to discuss the issues surrounding home rapid at b-on: 00400 Univ. 2011). 2006). compared to 92% for whites) (Cohen et al. home test kits designed to detect HIV-1 anti- body. com/article/ 917691-orasure-technologies-ceo-presents-oraquick-inhome-hiv-test- transcript?source¼Nasdaq (accessed July 2013). Kenya was the first African country to develop guidelines regarding the sale of self-testing kits for HIV. 6. 25% had not been linked to care within four months after diagnosis. 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. 2016 . it was also recom- mended that before devoting resources to its scale-up. African Americans and Latinos were slightly less likely to receive treatment (86% and 89%. 2013: 18–19). what we may see is an interna- tional stratification of access to home rapid tests depending on the individual assessment of each nation. hence he met with the FDA to discuss the possibility of approval (Millenson. risk-free way’ to achieve the same benefits.. Downloaded from bod. Of those referred to care. While the rapid test had not yet been developed.. 4. Hence. and at least one feasibility study has implemented a program whereby health workers can self-test themselves and partners (Mavedzenge et al. one entrepreneur believed that a home collection kit was technically feasible.

Buse K and Walt G (2000) Global public–private partnerships. Morbidity and Mortality Weekly Report 55: 1–14. and pregnant women in health-care settings. Arnold C (2012) At-home HIV test poses dilemmas and opportuni- ties. AIDS and Behavior 16(7): 1753–1760. Available at: http://www. the first at-home HIV test. 15 May.spie- gel. Campbell S and Klein R (2006) Home testing to detect Human Immunodeficiency Virus: boon or bane? Journal of Clinical Microbiology 44(10): 3473–3476.html (accessed July 2013).com/2012/10/15/magic-johnson-oraqu ick-hiv-home-test-game-changer (accessed July 2013). 5 January. da Beira Interior on March 7.pdf (accessed July 2013). Frasca T.pdf (accessed July 2013). is a game changer.cdc. (2006) Revised recommendations for HIV testing of adults. 2016 . Available at: http://www. Journal of Sex Research 32(3): 201–212. BPAC (Blood Products Advisory Committee) (2012) Transcript of 102nd Meeting of the Blood Products Advisory Committee (BPAC).gov/nchhstp/newsroom/docs/HIVFactSheets/Challenges- 508. Balan I. Available at: at b-on: 00400 Univ. Huffington Post. CDC (Centers for Disease Control and Prevention) (2013) Chal- lenges in HIV prevention – Fact Sheet. Branson B. Carballo-Diéguez AdvisoryCommittees/CommitteesMeetingMaterials/BloodVacci nesandOtherBiologics/BloodProductsAdvisoryCommittee/UCM 309516.Banda 43 References Anderson J (2012) Magic Johnson: usi ng-high-tech-equipment-a-829454.sagepub. The Lancet 380(9847): 1045–1046.fda. Aveline DT (1995) A typology of perceived HIV/AIDS risk-reduc- tion strategies used by men who ‘cruise’ other men for anonymous sex. part 1: a new development in health? Bulletin of the World Health Organization 78(4): 549–561. et al. Available at: http:// www. Bethge P (2012) Tech pioneers track bodily functions day and night. 15 October.huffingtonpost. Downloaded from bod. Spiegel Online. adolescents. Ibitoye M and Dolezal C (2012) Use of a rapid HIV home test prevents HIV exposure in a high risk sample of men who have sex with men.

2016 . Who Hasn’t and Why? Auckland: New Zealand Department of Health. Hu X and Koe- nig LJ (2011) Vital signs: HIV prevention through care and treat- ment—United States. Health. Hall IH. Cohen SM. and Illness in the U. da Beira Interior on March 7.startribune.cdc. Halperin K (2012) Home testing for HIV – reading the lines in do-it- yourself test.44 Body & Society 21(4) Clarke A.html (accessed July 2013). 18 health/161302315. Downloaded from bod. Available at: http://www. Fosket J. Denning P and DiNenno E (2010) Communities in crisis: is there a gen- eralized HIV epidemic in impoverished urban areas of the United States? In: International AIDS conference (vol. 3 July. NC: Duke University Press. Ithaca. Fishman J and Shim J (eds) (2010) Bio- medicalization: (accessed July 2013). Mamo L. Conrad P (1992) Medicalization and social control. Available at: http://abcnews. Star Tri- bune. Duncan I (2012) Drugstores soon will sell tests for HIV.S. Van Handel at b-on: 00400 BloodProducts/ApprovedProducts/PremarketApprovalsPMAs/ UCM312534. ABC News. Horn J and Chetwynd J (1989) Changing Sexual Practices amongst Homosexual Men in Response to AIDS: Who Has Changed. Med- icine.sagepub. Available at: http://www. O’Mathúna D and Scott P (2012) Patient autonomy and choice in healthcare: self-testing devices as a case in point. Durham. 21).pdf (accessed July 2013). Food and Drug Administration (FDA) (2012) Oraquick in-home HIV test summary of safety and effectiveness. Foucault M (1982) The subject and power.fda. Health Care. Annual Review of Sociology 18(1): 209–232.html (accessed July 2013). Branson BM. Greaney A. Fischer W (2012) ‘I think having the option available is a no-brai- ner’: will gay and bisexually active men at high risk of infection use over-the-counter rapid HIV tests to screen sexual partners? Journal of Sex Research 49(4): 388–389. NY: Cornell University go. Available at: http://www. Cruikshank B (1999) The Will to Empower: Democratic Citizens and Other Subjects. Critical Inquiry 8(4): 777–795. and Philosophy 15(4): 383–395. Morbidity and Mortality Weekly Report 60(47): 1618–1623.

Lupton D (1993) Risk as moral danger: the social and political func- tions of risk discourse in public health. approval. McNeil D Jr (2012a) OraQuick at-home H. test wins F. Durham. Presented at the FDA Blood Products Advisory Committee Meeting. 2016 . Mavedzenge SN.html (accessed July 2013). Millenson. Available at: http://www. McNeil D Jr (2012b) Another use for home H. nytimes. New York Times. Samuelsen K.V. New York Times. Whalen CC. NC: Duke University Press. Millenson E (2006) Testimony of Elliot J. (2011) Reasons for not HIV testing. The Sydney Morning Herald. Available at: and potential use of an over-the-counter rapid HIV test in an internet sample of men who have sex with men who have never tested for HIV. Downloaded from bod. Leavitt S (2006) A private little revolution: the home pregnancy test in American culture. 8 July. testing intentions. da Beira Interior on March 7.D. smh. Baggaley R and Corbett EL (2013) A review of self-testing for HIV: research and policy priorities in a new era of HIV (accessed July 2013).Banda 45 Keller D (2012) HIV home testing accepted most by those at highest risk.medscape. test: screening partners.A. McGregor S (2001) Neoliberalism and health care.html (accessed July 2013). and Women’s Health in the Second Wave. et al. Reproduction. Available at: http://www. Mol A (2002) The Body Multiple: Ontology in Medical australia-20120707-21nqr.pdf (accessed July 2013).com at b-on: 00400 fda-approval. Kline W (2010) Bodies of Knowledge: Sexuality. Available at: http:// www. Chicago: University of Chicago Press. 10 March 2006.sagepub. Kretowicz E (2012) HIV groups want home testing kit in Australia. Medscape Medical News. Smith A.I. Sexually Transmitted Diseases 38(5): 419–428. Hou S. 5 October. Bulletin of the History of Medicine 80(2): 317–345. 3 slides/2006-4206OPH2_2b. MacKellar DA.I.html (accessed July 2013). International Journal of Health Services 23(3): 425–435. Sanchez T. 26 screening-partners.fda. Available at: http://www. nytimes. Clinical Infectious Diseases 57(1): 126–138. International Journal of Consumer Studies 25(2): 82–89.

self-surveillance. Petersen A and Lupton D (1996) The New Public Health: Health and Self in the Age of Risk. Princeton. Medical Decision Making 30(2): 217–223. Thousand Oaks. Journal of Health Politics. Journal of Sex Research 49(4): 319–327.html (accessed July 2013). OraSure (2012) OraQuick TV ad.unaids. 4 July. Vadnais C. UNAIDS (2012) An HIV test in the privacy of your own home. Downloaded from bod. da Beira Interior on March 7. Shivkumar S. CA: Sage. Nguyen V-K (2008) Antiretroviral globalism. PLoS Med 10(4). Available at: http://www. Oxford: Blackwell. Available at: http:// www. 2016 .46 Body & Society 21(4) Morone JA (1997) Enemies of the people: the moral dimension to public health. Pillay S. Joseph L. Available at: http://www. Power. Walensky R and Paltiel D (2006) Rapid HIV testing at home: does it solve a problem or create one? Annals of Internal Medicine 145(6): 459–462. Rose N (2007) The Politics of Life Itself: Biomedicine.sagepub. Pai N. Available at: http://www. 26 June.nytimes. Sharma J. 1st tre/featurestories/2012/july/20120704hometesting/ (accessed July 2013). Dheda K and Peeling R W (2013) Supervised and unsupervised self- testing for HIV in high-and low-risk populations: a systematic review. performance. New York Times. pp. Toronto Star.html (accessed July 2013). Tone A (2012) Medicalizing reproduction: the pill and home pregnancy tests. 4 26/business/26gene. NJ: Princeton Univer- sity¼player_detailpage&v¼82rV3jg g-Hk (accessed July 2013). and the FDA approval process: the example of home HIV testing. biopolitics. and Sub- jectivity in the Twenty-first Century. 124–144. In: Ong A and Collier SJ (eds) Global Assemblages. Pryce A (2000) Frequent observation: sexualities. December. Policy and Law 22(4): 993–1020. Paltiel A and Pollack H (2010) Price. Pollack A (2008) Gene testing questioned by regulators. and therapeu- tic citizenship. Nursing Inquiry 7(2): 103–111. com/news/canada/2012/07/04/health_canada_mum_on_future_avail- Wallace K (2012) Health Canada mum on future availability of in-home oral HIV test.thestar. confession and the construction of the active at b-on: 00400 Univ.

Willyard C (2012) Recommendation of HIV test brings diagnostic dilemma home.sagepub. Jonathan Banda is a PhD student in Medical Humanities at the University of Texas Medical Branch. Human Rights and Public Health Implications of HIV Self-testing Scale-up. the history of medicine and public health. Ethical. WHO (World Health Organization) (2013) Report on the First Interna- tional Symposium on Self-testing for HIV: The Legal. Wright A and Katz I (2006) Home testing for HIV. His research interests include science and technology studies. gender and sexuality 8_eng. Downloaded from bod. Nature Medicine 18(6): 841. Geneva. Switzerland. da Beira Interior on March at b-on: 00400 Univ. and critical race. Available at: http://apps.pdf (accessed July 2013). New England Journal of Medicine 354(5): 437–440.who.Banda 47 Whellams M (2008) The approval of over-the-counter HIV tests: playing fair when making the rules. Gender. 8–9 April. Journal of Business Ethics 77(1): 5–15. with an emphasis in Social Medicine. 2016 .