This posting is in response to Andrew Hobbs from Lusaka, Zambia, appearing
in SEA-AIDS on June 17, 1998. He posed a question, "How exactly will couples
take into account the 6-12 week antibody window period when they are using
their litmus papers in the dark?" The answer, of course, is that they will
not unless they are cautious and test each other twice over a three month
Fortunately, the window period (i.e., when the HIV test is negative
but the person is infective to others) on average lasts only a few months,
a small time when considering the 108-120 months when the potential sexual
partner is HIV infected but shows no sign of the virus. If a couple wants
to be extra safe, they would consistently use condoms until two sets of
tests are negative, done 3-4 months apart.
Some will be able to do this and they will be able over a long life
to have risk-free sexual intercourse with each other. Others will not,
and some of them will become HIV infected.
The second point raised by Mr. Hobbs is more provocative. He mentions,
"Good ideas sometimes spread - profitable ideas (good or bad) always spread."
What will make personal HIV screening profitable in the United States
and Europe is the availability of effective (but usually expensive) therapy.
You cannot treat what you cannot find. Thus the desire of HIV infected
persons in such societies to live will stimulate widespread testing. Since
clinic based testing will be considered too cumbersome, inconvenient or
intrusive for frequent use, personal HIV screening will catch on as a viable
alternative in most developed countries. Those concerned with public health,
however, will also benefit from personal screening, since detection will
likely lead to behavior change, which will reduce secondary transmission.
Thus the good idea of personal screening will spread in wealthier societies,
with the "profit" being financial for drug companies and humanitarian for
public health officials.
In the developing world, the good idea of personal screening may not
spread because there is less incentive on the treatment side for case-finding.
What is most curious in poorer societies is not the reaction of physicians
and their patients to testing, but rather the neglect of testing that occurs
among many in the public health community. The humanitarian benefits of
testing (that is, the good of saving lives by avoiding further transmission)
are the same around the world. Wealthier societies, however, have the added
benefit of financial profit that comes to those who manufacturer or distribute
drugs against HIV. Can public health professionals find satisfaction in
testing to avoid further transmission? If the answer is "yes," then personal
screening will likely be viewed as a viable intervention and prevention
strategy. If the answer is "no" then epidemic will continue as before with
no new options for prevention.
The fundamental question raised by the Hobbs enquiry is, "Will the good
idea of testing to avoid further transmission spread on its own merit,
or will effective therapy be a necessary component before detection is
acceptable?" I leave this to my public health colleagues in the developing
world to answer.