© 2007 Future Drugs Ltd ISSN 1473-7159
Oral fluid-based rapid HIV
testing: issues, challenges and
‘… it is hoped that detection of [HIV-infected] individuals
with high-quality, rapid, accurate point-of-care oral HIV
tests will enable provision of early, timely and highly
effective ART or expedite triage to care and prevention.’
Nitika Pant Pai
McGill University Health Centre,
Division of Infectious Diseases
& Immunodeficiency Service, Montreal
Chest Institute, 3650 St Urbain Street,
Montreal, Quebec, H2X 2P4, Canada
Tel.: +1 514 889 9604
Expert Rev. Mol. Diagn. 7(4), 325–328 (2007)
Global efforts to scale-up HIV testing
The HIV pandemic continues to take a heavy
toll on developing countries, where the Joint
United Nations Programme on HIV/AIDS
(UNAIDS) estimates suggest that less than
one in ten people are aware of their HIV sero-
status [1,2]. In an effort to scale-up detection of
HIV and enhance preven-
tion and treatment pro-
grams, agencies such as
the UNAIDS and WHO
suggest a shift from the
HIV testing approach to a
provider-initiated testing and counseling
(PITC) . With the PITC approach, health-
care professionals actively encourage clients to
get tested for HIV, thereby enabling treat-
ment, care and prevention services to be pro-
vided. It is hoped that PITC will help in the
detection of individuals with undiagnosed
HIV and improve the uptake of antiretroviral
treatment (ART) services now available in
many resource constrained settings [1,2].
By contrast, in resource-rich settings, such
as the USA, the Centers for Disease Control
and Prevention (CDC) estimates that appro-
ximately 250,000–312,000 individuals are
unaware of and living with undiagnosed HIV
infection . In addition, approximately 40%
of adults chose to get tested only in the late
stages of infection, which increases morbidity
as well as healthcare costs . The CDC
recently published revised guidelines on testing
in order to increase early detection in undiag-
nosed individuals and patients who present
late, establish linkages to treatment and care,
and reduce the stigma associated with HIV
testing . These guidelines recommend rou-
tine opt-out testing of all individuals (i.e., ado-
lescents, pregnant women
and adults between 13–64
years of age), and does not
require pretest counseling
or informed consent .
Thus, agencies such as the
CDC are making concerted efforts to scale-up
HIV testing and make testing accessible and
Rapid point-of-care HIV tests & use of
To expedite screening and accurately diag-
nose HIV infection, rapid point-of-care HIV
tests have been a breakthrough of sorts.
Although, the majority of these rapid tests
utilize whole blood, plasma and finger stick
blood specimens, a few tests employ non-
conventional specimens, such as saliva, oral
mucosal fluid and urine [4,5]. Oral fluid-based
rapid tests have potential advantages over
blood-based rapid tests because of their con-
venience, noninvasiveness, ease of specimen
collection, cultural acceptance, high accuracy
and rapidity [4,6–8].
‘To expedite screening and
accurately diagnose HIV
infection, rapid point-of-care
HIV tests have been a
breakthrough of sorts.’
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Expert Rev. Mol. Diagn. 7(4), (2007)
Although salivary and oral fluid-based tests have been in devel-
opment for the past 20 years, it is only recently that oral fluid-
based, rapid point-of-care tests have increased in popularity .
Oral fluid tests are based on a salivary component, the oral
mucosal transudate or crevicular fluid, an interstitial transudate
rich in IgG antibodies, used for diagnosing HIV infection [4,5,9].
Currently, only two commercial oral fluid-based rapid tests
exist, with variants sold under different names [4,6,8,10]:
• OraQuick® Advance (OraSure Technologies Inc., PA, USA;
a US FDA-approved, Clinical Laboratory Improvement
Amendments-waived test) and OraQuick RAPID HIV1/2
test (available in developing countries)
• Calypte Vanguard HIV® (Calypte Biomedical Corp., OR,
USA) and Calypte Aware® HIV1/2 is awaiting FDA
All these rapid point-of-care tests utilize oral mucosal fluid,
and test results are available in less than 30 min [5,11,12].
Since the emergence of salivary and oral fluid tests nearly two
decades ago, over 60 studies on conventional and rapid point-
of-care oral fluid tests have been conducted in various settings
worldwide (>90 studies if salivary tests are also counted). These
studies have evaluated various outcomes, such as diagnostic
accuracy, client preference, acceptability, uptake and cost- and
time-effectiveness [13–17]. It is now an estab-
lished fact that diagnostic accuracy of oral
rapid point-of-care tests is high and that
their test results are consistent across devel-
oped and developing countries [7,13,18].
However, although accuracy is very high,
oral fluid test results are considered prelimi-
nary. Therefore, the results of oral fluid tests
require confirmatory testing with conven-
tional tests, such as ELISA and/or western
blot . The growing use of oral fluid HIV testing has raised
certain issues and challenges, and these are discussed later.
Concerns regarding nonreactive, false-positive & false-negative
As with any rapid point-of-care test, there is a possibility of
false-positive, false-negative or nonreactive results with oral
fluid tests. For example, in 2005, there were reports of false-
positive results with the oral OraQuick test from selected clin-
ics in New York city and San Francisco in the USA . How-
ever, subsequent investigations by the CDC were unable to
clarify whether the quality of kits or inadequate quality control
was responsible for the false-positive results [7,18]. By contrast,
more recently, a study from India showed 100% sensitivity and
specificity of the oral fluid-based OraQuick RAPID HIV1/2
test, demonstrating excellent performance of oral fluid testing
even in a rural setting in India . Thus, it is unclear why some
studies report higher than usual rates of false-positive results.
False-negative test results may occur if testing is performed
after ART is initiated or in acute HIV infection, where sero-
conversion has not occurred . A nonreactive result in a
recently exposed individual is another possibility; therefore,
repeat testing of such high-risk individuals is recommended.
Also, certain medical conditions may produce nonreactive
results, such as IgG gammopathy, multiparity, rheumatoid
arthritis, hepatitis, multiple myeloma, syphilis and lupus. Fur-
thermore, certain substances may interfere with test perform-
ance, such as heparin, bacterial contamination, sodium citrate
and elevated bilirubin .
To reduce erroneous results, quality assurance and quality con-
trol procedures laid down by the CDC should be met . These
include maintaining kits at the recommended temperature,
maintaining temperature logs, running controls at regular inter-
vals and performing external and internal control checks . In
addition, healthcare professionals must avoid using kits beyond
the expiration date and discard poorly performing lots of kits.
Overall, users of oral fluid tests must anticipate errors in test
performance and carefully follow manufacturers’ instructions
and the CDC recommended guidelines on rapid HIV testing
. Furthermore, even if accuracy is high, predictive values of
any test depend on disease prevalence and can vary across popu-
lations. This often ignored fact must be kept in mind while
interpreting results of any test in any setting.
Cultural acceptance of oral fluid HIV testing
It is well known that blood specimen col-
lection is a sensitive issue in some countries
and racial/ethnic groups. For example,
rural Indians do not like to give blood spec-
imens because they perceive it will further
worsen their health or make them weaker.
A recent study in rural India found high
preference for oral fluid vis-à-vis blood-
based finger stick HIV testing . This
study suggests that, in certain settings, non-
invasive specimens, such as oral fluids and urine, should be fur-
ther studied owing to their potentially higher acceptance and
greater feasibility even for large-scale population surveys.
Populations where oral fluid HIV testing can have an impact
Because oral fluid HIV tests are accurate, feasible, noninvasive
and culturally acceptable, they have the potential to make an
impact in several high-risk, vulnerable populations. For exam-
ple, oral fluid tests can be used in the labor room and emergency
room settings in both developed and developing countries to
expedite provision of interventions that can reduce mother-to-
child HIV transmission . They may also be helpful in testing
marginalized populations, (i.e., sex workers, immigrants, intra-
venous drug users, and the homeless and incarcerated) living
with undiagnosed HIV infection [21,22]. Targeted testing in these
populations can help detect HIV early and reduce high-risk sex-
ual practices/behavior, preventing further HIV transmission.
Healthcare workers in developing countries are at risk of con-
tracting HIV due to occupational exposure . In such occupa-
tional settings, oral fluid rapid tests can greatly help in providing
cost- and time-effective postexposure prophylaxis .
‘… diagnostic accuracy of
oral rapid point-of-care tests is
high and … their test results
are consistent across
developed and developing
countries. However, … oral
fluid test results are
Oral fluid-based rapid HIV testing
Although a few studies have evaluated the cost–effectiveness
of oral fluid testing in comparison with conventional tests, the
cost of the tests is a concern for its widespread use in develo-
ping countries . In an effort to scale-up prevention and treat-
ment linkages, the costs of these oral fluid tests must be kept
affordable for people in developing countries that bear the
brunt of the HIV epidemic and need them the most.
Future research directions
Although oral fluid HIV tests are highly accurate, the actual clin-
ical and public health impact of the use of these tests in improv-
ing patient care and treatment outcomes are
yet to be fully determined. Therefore, large-
scale, pragmatic studies are needed in real-
life settings, especially in high-risk, vulnera-
ble populations. These studies should not
focus on accuracy, but focus on applicability
and impact on long-term patient outcomes.
For example, will the introduction of routine
oral fluid-based rapid testing in a labor ward
in India or Africa actually help expedite the
delivery of interventions to reduce perinatal HIV transmission?
There is also a need to determine whether innovative approaches
using oral fluid rapid tests can help in preventing transmission of
HIV by modification of risk behavior. For example, will the easy
availability of rapid oral fluid tests enhance voluntary testing
among commercial sex workers and their clients?
In developed countries, there is a steadily growing demand
for home-based HIV tests (along the lines of home-based
pregnancy testing). Oral fluid tests are ideally suited for
home-based self-testing because of their high accuracy, sim-
plicity and ease of use. The FDA is considering the possibility
of approving over-the-counter tests for HIV, but concerns
remain about the lack of adequate pre- and post-test coun-
seling. Data are lacking on the feasibility of home-based HIV
self-testing and diagnostic trials are needed to evaluate them for
In conclusion, given the large numbers of individuals living
with undetected HIV infection worldwide, it is hoped that
detection of such individuals with high-quality, rapid, accurate
point-of-care oral HIV tests will enable provision of early, timely
and highly effective ART or expedite triage
to care and prevention. However, through-
out the testing process, ensuring privacy
and confidentiality of test results, ensuring
quality control and following quality assur-
ance procedures at all times will help gener-
ate high-quality test results, leading to
increased confidence in test results and
encourage more individuals to come for-
ward for HIV testing. Thus, rapid oral
fluid-based point-of-care HIV tests can produce substantial cost
savings and reduce the global burden of HIV infection.
Conflict of interest
Nitika Pant Pai is supported by a fellowship from the Canadian
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• Nitika Pant Pai, MD, MPH, PhD
Canadian HIV Trials Network Fellow,
McGill University Health Centre, Division of
Infectious Diseases and Immunodeficiency
Service, Montreal Chest Institute, 3650 St
Urbain Street, Montreal, Quebec, H2X 2P4,
Tel.: +1 514 889 9604