June 24, 1998
Rebecca Firestone, United States
of the major questions surrounding personal screening for HIV is whether or not
the person testing him/herself will know how to handle the results of the
test. The rationale for clinic-based testing is that counseling and referral services can be provided for people
who have just discovered that they
are HIV-positive, and education can be provided to the "worried well."
with HIV-infection is a life-changing event, and as public health professionals,
we have a responsibility to give the people we serve information
and support, so they know how to interpret and respond to their test
results, positive or negative. Clinics are vital for the education and counseling services they can provide, in
addition to testing and treatment.
they act as an entry-point into the public health system, clinics are
a place to ensure that people are receiving complete and accurate information
about HIV. Testing on its own will not necessarily lead to behavior
change, whether the testing happens at home or in a clinic. Education
about HIV/AIDS and the skills to act on received information are necessary
SEA-AIDS members have mentioned cultural context as a reason why personal
screening would not work. I think this gets at the issue of HIV/AIDS
education and access to information. A well-educated, middle-class population in the United States might be
eligible for personal screening, because
this group has had ample access to HIV/AIDS prevention messages, leading
to an awareness of risk, a desire for confidentiality and the ability
to act on the test results (I know I'm generalizing).
remote Cambodian village (which
I believe was one example given for cultural context)
would probably be less eligible. HIV/AIDS prevention messages are less
prevalent, which means less personal perception of risk and a lower demand for testing services. But if a
Cambodian villager used a personal HIV
test, and the results were positive, how can we ensure that this person knows what services are available to him/her
or knows how to prevent further transmission?
Even if the results are negative, this Cambodian villager is clearly
concerned about HIV, so how can we ensure that he/she receives the right information to mitigate those concerns?
Frerichs is right that HIV testing resources could be more wide-spread and accessible, and we should be thinking
about the logistics and costs involved.
But I would like to know how Dr. Frerichs would ensure that the hypothetical
user of a personal HIV test would get the information he/she needs
to respond to the results of that test in a setting where information about HIV may be non-existent or inaccurate.
we want to discuss testing, I suggest that we put greater emphasis on STD prevention and treatment. STDs are a co-factor
for HIV-transmission, but we still
don't have cheap, fast diagnostic tests for several major STDs, and syndromic management can be problematic,
particularly for cases of vaginal discharge.
We need effective behavioral risk assessments for asymptomatic cases
for Health and Gender Equity
Carroll Ave., Suite 430
Park, MD 20912
Kenrad Nelson, Johns Hopkins University
have been reading all of the sea-aids discussion on HIV testing. I think another good reason for testing using
"rapid tests" in very high risk settings
in the US and Europe is the 30% or so of people who come to an anonymous
or other clinic for testing and then don't come back and can't be located
to get their results. Obviously ,any potential benefit of early diagnosis
-- counseling and therapy to prevent transmission and progression may
be lost in this situation. Unfortunately at present there is only one licensed test available in the USA --
although several are available in Europe,
Asia and elsewhere. I think physicians in the US may be reluctant to use a rapid test -- certainly for a
definitive diagnosis -- because of the frequent
problem of non-specific false positive results.
it would certainly be important to find a better way than exists, or is being used ,now to be sure that
everyone who DOES request an HIV test actually
is informed of RELIABLE results quickly.. Unfortunately this isn't always happening now -- even (maybe
especially) in the USA.
I am responding to the thoughtful comments of Rebecca Firestone and
Dr. Kenrad Nelson. They both raise
important issues of human behavior, influencing how we address the HIV/AIDS
epidemic. Like Dr. Nelson and perhaps Ms. Firestone, I too foresee important
uses for rapid tests in clinical settings where blood can be taken for
testing, evaluated and the results are available for immediate discussion
and counseling. Dr. Nelson is correct that clinicians would want to have
at least two brands of rapid tests available so that one could be used
as the screening test and the second (or possibly a third) as the confirmatory
test. While there is much interest in the United States in rapid tests,
we still only have one rapid test that is licensed by the FDA, hindering
the implementation of this "quick diagnosis" plan.
My comments to SEA-AIDS on testing are intended mainly for countries
in Southern Asia, although I recognize that the network extends well beyond
the limits of this region. Dr. Nelson and his colleagues at Johns Hopkins
University have considerable experience in Southeast Asia, providing ground-breaking
work on the epidemiology of the disease in Thailand, and on intervention
or prevention strategies. One such colleague is Dr. Chris Beyrer who has
written a fascinating book about the region, "War in the Blood -- Sex,
Politics and AIDS in Southeast Asia," Zed Books Ltd, New York, 1998. Perhaps
Rebecca Firestone has also worked in the region, possibly in Cambodia with
the villagers she refers to.
As all these individuals know, the situation in Southern Asia with respect
to HIV/AIDS is complex, with no easy solutions in sight. This is why we desperately
need more experimentation, trying different strategies to see
what works and what does not. Mental barriers need to be reduced, however,
before willingness will lead to actual experimentation. This willingness
to experiment is especially important for those who control or influence
funding sources. If their minds are closed to notions such as personal
screening tests, resources for field investigations or demonstration projects
will be hard to come by.
UNAIDS earlier this weeks released a comprehensive account of HIV/AIDS
in the world ("Report on the global HIV/AIDS epidemic). It can be obtained
at their website (www.unaids.org), along with
an appendix and an accompanying spreadsheet that provides country-specific
estimates of HIV prevalence in most countries. In Southern Asia, some countries
based on infection percentages for 15-49 year old adults, could be view
as high prevalence (Cambodia [2.40%], Thailand [2.23%] and Myanmar [1.79%]),
others as medium prevalence (India [0.82%], Malaysia [0.62%], Vietnam [0.22%],
Papua New Guinea [0.19%], Singapore [0.15%] and Australia [0.14%]), while
other could be seen as low prevalence (New Zealand [0.07%), Sri Lanka [
0.07%], Philippines [ 0.06%], China [0.06%], Indonesia [0.05%], Laos [0.04%]
and Bangladesh [0.03%]). Of course these designations are arbitrary and
do not present the variations within each country. No single testing policy
should be employed in all of these countries. The need for testing will
vary from one country to another, depending on the prevalence of the disease,
and from one region within countries to another. Thus having personal screen
tests widely available might be useful in some settings, but not in others.
In an excellent editorial in a recent issue of AIDS ("The demographic
impact of the HIV epidemic in Thailand," AIDS 1998 (12)813-814), Dr. Kenrad
Nelson summed up the situation in Thailand as follows: "In this area [the northern
region], as elsewhere in Thailand, the major transmission
risk has become sexual transmission among married couples and mother-to-infant
transmission. Prevention of HIV transmission among married couples is a very difficult
public health challenge. Regular condom use among married couples is unusual
unless both partners are aware that one is infected with HIV. Diagnosis
of HIV infection in married men or women prior to transmission to their
regular partner is the public health challenge of the future of the control
of the HIV/AIDS epidemic in Thailand."
The challenge that Dr. Nelson writes
of will not be met unless we are willing to experiment with new testing
strategies that are effective at reaching the many people who could benefit
from such knowledge, and are inexpensive and convenient to use. Clinic-based
testing and counseling programs seem reasonable in some settings, but those
who rely on this model alone, will not reach on a regular basis the general
population in Southern Asia. Without such widespread coverage and the knowledge
that ensues, it will be much more difficult to protect married women and
children from becoming infected. This, after all, is what the testing discussion
in SEA-AIDS is all about.