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R.R.
Frerichs Posting
Slowly with time, individuals change, as new ideas are introduced and
debated, and found to have value.
In the heat of the moment -- common in the world of HIV -- people often
forget the important roles that are played both by those who introduce
the ideas and those like editors of SEA-AIDS who diffuse the ideas to the
greater society. Since I have been actively involved in one such drama
(i.e., personal HIV screening), it might be illustrative to SEA-AIDS members
to learn how the process takes place, requiring persistence, a willingness
to debate, dedication to the clarity of the written and spoken word, and
time.
Four years ago, I wrote a viewpoint "Personal screening for HIV in developing
countries" in The Lancet that generated much heat and extensive discussion.
In one section of the article, I focused on the use of HIV home tests for
couples planning to be married or join in a long-term sexual relation.
This section was considered controversial at the time, and because it illustrates
the nature of the diffusion process, I am repeating it here.
From Frerichs RR. "Personal screening for HIV in developing countries,"
The Lancet 343, 960-962, 1994.
... "If inexpensive HIV home tests are available, the couple has another
option. They could screen each other for the presence of HIV antibodies
and then act on the findings.
A screening test should be an important component of partner selection
so that marriage can start as a union between two uninfected persons. Such
screening would prevent men from marrying HIV- infected women who return
home after spending several years as a commercial sex worker. It would
also prevent women from marrying men who have experimented in their youth
with illicit intravenous drugs, anal intercourse with other men, or the
services of prostitutes." ...
Much discussion followed this article, both in the pages of The Lancet,
at international AIDS meetings in Berlin and Vancouver, regional AIDS meetings
in Chiang Mai and Manila, and in internet discussion groups, including
SEA-AIDS. The exchanges were sometimes heated and occasionally personal,
but slowly opinions started to change, most evident in the early stages
among academicians and fellow public health professionals.
The most recent
indication of how far we have come in the United States in our attitudes
towards personal screening comes from an excellent review article on new
testing technologies that is found at HIV
Insite, the web location for
HIV related issues of the University of California at San Francisco (UCSF). While
I encourage everyone to visit the UCSF site and read the entire article,
I was especially interested in two concluding sections that address personal
screening. Although the UCSF article focuses primarily on gay couples in the
United States, the points seems applicable as well to heterosexual couples
who fuel the epidemic in many countries where SEA-AIDS members live and
work.
Concluding sections, "New Testing Technologies Impact on Prevention
Strategy." by Nicolas Sheon (HIV InSite Prevention Editor), HIV InSite,
June 6, 1998. Note: Dr. Bernard Bransen, mentioned in the article, is with CDC.
... In the Near Future... Two men exchange glances across a crowded
dance club. They meet on the dance floor and then shimmy to the bar for
a drink. Ready for action, they decide to leave for the privacy of a nearby
apartment. But before leaving, one of them sheepishly glances at a candy
jar sitting on the bar, filled with small foil packages. You are thinking,
"thank goodness for a well placed stash of condoms," right? What if the
foil packages contained easy to use rapid HIV tests? Whatever the test
results and ethical issues inherent in this scenario, it is reasonable
to assume that test results available within minutes would have a far greater
effect on the men's behavior that night, than if they tested at a clinic
and waited two weeks for the results.
Accurate, low cost, rapid tests are
already in use outside the United States. Home testing kits (as opposed
to home collection kits) are already available from fly by night vendors
over the internet, but these tests are not approved by the FDA. The biomedical
giant, Abbott, has recently acquired companies that produce rapid HIV tests
and pregnancy tests, and appears poised to develop the next generation
of rapid HIV tests for the US market by the millennium. These simple to
use HIV tests are small strips of paper that would change color within
minutes when antibodies are detected in whole blood or urine. Pending FDA
approval, these new tests would eliminate the main obstacles to testing
in the existing system access to the clinic, laboratory turn around time,
and fear of needle sticks.
If testing becomes an even more integral part
of courtship rituals or even sexual foreplay between casual partners, prevention
messages encouraging universal condom use may have to change their approach
to account for the availability of "real-time" testing for sero- status.
Bernard Bransen, a long time advocate for wider use of rapid HIV tests,
believes that advances in testing technology and improved access will make
condom-centered prevention messages less and less relevant. The assumption
is that people will choose sero-concordant partners, take into account
the 6-12 week antibody window period, and opt to have unprotected sex.
Implications for Prevention Programs
Clearly, both testing and treatment technologies have advanced more
rapidly than prevention strategies. If over-the-counter home testing and
testing by outreach workers using rapid tests plays a larger role in prevention
strategies, we must rethink the role of clinic-based test counseling as
well as prevention messages that fail to take into account the behavior
of sero-concordant couples. If these alternative testing modalities can
help more people learn their sero-status, the CDC should consider ways
to subsidize and distribute test kits among high-risk populations.
Partnerships
between test distributors and public health agencies should be forged so
that new testing technologies are appropriately targeted and not misused
to test people without consent or simply to profit from the "worried well."
Legal protections for confidentiality and consent should also be revised
to reflect the availability of home testing technologies.
The potential abuses of the home testing must also be addressed through
social marketing campaigns that explain the complex issues raised by rapid
home tests. Instead of a "one size fits all" message based on consistent
condom use, complex strategies that take into account local community norms
and individual needs within sero-concordant relationships should be encouraged.
Most importantly, the effectiveness of testing modalities depends on their
seamless integration with other services such as early clinical intervention,
support services, and prevention counseling for both positives and high-risk
negatives.
THE END
Good advice for those who are now willing to listen. The process of
diffusing innovative ideas has been well studied. At first there is a tendency
to reject new ideas. Regarding personal HIV screening, such rejection came
from all sectors, extending from the largest international organizations,
down to government and non-governmental organizations (NGOs), and finally
to individuals in talks or discussions. At first, barriers were identified,
solidified, and eventually made to appear so formidable that few could
overcome them. Even experimentation was not considered acceptable, because
the notion had so little social or political support. Then slowly with
persistent pressure to change, the new idea started catching on. To many
personal HIV screening was no longer an alien notion, but rather an innovative
new idea for detecting HIV among those who might otherwise not know of
their HIV status. As the diffusion process continues, more people will
begin to accept the idea and then as memory fades, begin to wonder what
all the concern was about. Such wondering is now occurring in the United
States.
With time, the notion of personal HIV screening will also be revisited
by health professionals in many regions of the developing world, followed
by acceptance. But it will take time, and there is still much dissemination
to be done and barriers to be overcome.
The
HIV InSite article shows, at least, that the diffusion process is
well underway.
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