Personal screening for HIV in developing countries

Response to Correspondences (The Lancet 343, 1506, June 11,1994)

Personal Screening for HIV in Developing Countries

Ralph R. Frerichs

Department of Epidemiology, School of Public Health, Los Angeles, CA 90094, USA (now 90095-1772).

Sir -- My intent in my viewpoint (April 16, p 960) was to stimulate debate among colleagues in developing countries who face HIV/AIDS on a daily basis. The resolve to control the HIV/AIDS epidemic is slowly being eroded as programs face frustration and shortfall in such varied locations as Africa, Asia, and South America. Existing control strategies seem to be based more on hopes and dreams rather than on proven effectiveness. This point was made by Soderlund and colleagues [1] in their evaluation of prevention strategies in developing countries. Although they were able to derive cost data, they noted that measures of effectiveness with prevented HIV or AIDS as the outcome were hard to find in any studies.

Mertens and colleagues (May 21, p 1293) address what they believe to be the objective of screening: early detection of disease. They focus on assisting those who are already infected with the virus. Although their concern and that of Pinkerton and Abramson (p 1294) with the wellbeing of HIV-infected persons is understandable, they surely must accept Joseph's clear admonition that "protecting the uninfected is the first duty" of public health.[2] The main objective of home screening is to prevent HIV transmission as well as to promote early detection.

Prevention of HIV starts and often ends with the family. Over time, one partner or other becomes infected through sexual contact or by contaminated blood, and brings the virus home. The spouse, unaware of the partner's infection, continues to have unprotected sex. Although the probability of viral transmission per coitus may be low, the cumulative number of coital events that occurs in marriage greatly raises the risk of infection.

Inexpensive tests for HIV are now being developed, with saliva holding the most promise for home testing.[3, 4] With additional changes in the marketplace, family members would send or take numbered specimens to a local laboratory and receive anonymously the results within a few days. If the cost is reasonable, the screening test could be widely sold in the private sector at pharmacies, food stores, or medical clinics, similar to the distribution network for condoms or that being proposed for vaginal microbicides.[5] HIV testing should be done whenever a new adult member plans to join the family through marriage or less formal bonding. Home testing should also be done at intervals -- infrequently by those practicing mutual monogamy but more commonly if there is sexually transmitted diseases or other signs of promiscuity. If couples are discordant for HIV, they will need sensitive and effective family counseling to discuss both their sexual and reproductive behavior, and their reproductive outlook. There are many options to prevent further transmission, including abstinence from penetrative sexual intercourse, use of condoms, spermicides, and vaginal microbicides, and early treatment of sexually transmitted diseases. If the woman is infected, she needs to be aware of how the disease is transmitted to newborn babies, and offered appropriate family planning services. Finally, all members of the household, should know that HIV is in the family so that they can reinforce the need for preventive behavior.

Personal screening is a promising option. By permitting and encouraging sale of inexpensive HIV home tests in the private sector, we also serve the broader interests of public health.

1. Soderlund N, Lavis J, Broomnberg J, Mills A. The costs of HIV prevention strategies in developing countries. Bull WHO 1993; 71: 595-604.

2. Joseph JC. Dragon within the gates. New York: Carroll and Graf Publishers, 1992: 1-272.

3. Tamashiro H, Constantine NT. Serological diagnosis of HIV infection using oral fluid samples. Bull WHO 1994; 72: 135-43.

4. Frerichs RR, Silarug N, Eskes N, et al. Saliva-based HIV antibody testing in Thailand. AIDS (in press).[8(7), 885-894, 1994]

5. Elias CJ, Heise LL. Challenges for the development of female-controlled vaginal microbicides. AIDS 1994; 8:1-9.