The human immunodeficiency virus (HIV) continues to devastate populations throughout the world, and poses as one of the most vexing public health problems of the twentieth and twenty-first centuries. As of December 2007, UNAIDS estimates that about 33.2 million people are currently living with HIV infection. Furthermore, the organization estimates that during 2007 about 2.5 million were newly infected with HIV, while about 2.1 persons died of AIDS. It is likely that up to 95 percent of the HIV infected persons worldwide do not know they are harboring the virus. The figures for 2007 were revised downward by UNAIDS, who now base more of their findings on population-based surveys rather than sentinel surveillance of risk groups.
Are there alternatives?
In 1994, Professor Ralph Frerichs suggested the creation of a simple screening test, using saliva, to detect HIV in the privacy of the home. He reasoned that this would help susceptible persons avoid becoming infected. The idea was immediately criticized and fiercely resisted by many HIV/AIDS professionals and activists who focused more on protecting infected persons from social harm rather than susceptibles from the virus.
Then between 1996 and 1999, Frerichs attempted to address various aspects of the HIV epidemic in South- and Southeast Asia where he served as a consultant. His postings were presented in SEA-AIDS, an electronic network organized by UNAIDS to provide information support services for people living or working with HIV/AIDS in the Asia-Pacific region.
As a public health educator, Frerichs' intention was to provide an epidemiological and public health point of view on HIV related issues. Some of his 78 postings generated controversy and occasional rage, reflecting strong feelings about HIV in the international arena. Postings that respond to listed comments are cited in light blue.
Issues discussed between Professor Frerichs and colleagues include early detection, personal screening, widespread HIV screening, mandatory and routine HIV testing, HIV normalization, partner notification, breastfeeding, and much more. These issues were also discussed at a Manila conference in 1997 in a tumultuous evening talk "Confronting HIV in India" and in a more staid daytime talk "Issues in Home HIV Testing" (see below). In late 2002, the United States government approved a rapid finger-prick HIV blood test, overcoming arguments that have long hindered early detection. CDC formalized the announcement in the MMWR. The rapid testing device, however, initially came with restrictions which fortunately later were later removed. In April 2003, the CDC urged HIV testing of all pregnant women, rather than relying upon them to volunteer. In November 2003, De Cock and colleagues suggested a serostatus-based HIV prevention and care program for use in Africa (but also applicable in Asia). More recently in 2006, Washington DC, site of the highest rate of new AIDS cases in the United States, launched a campaign urging every resident between the ages of 14 and 84 to be tested for HIV. The campaign features oral swabs that delivers results in 20 minutes.
For personal HIV screening or screening of potential sexual partners, a test using saliva is the most appropriate. Following more than a decade of saliva testing, the US Food and Drug Administration finally approved the first rapid saliva test in March 2004. While simple to use, the FDA is not allowing the saliva HIV test to be sold directly to consumers for personal assessment, although this position may change. The struggles for a home HIV test were well-described in 2006. Until the matter is resolved, the impression remains that protecting susceptible persons from becoming infected is less valued with this single disease than safeguarding the rights of HIV infected persons to remain free from detection.
In 2006, the United States CDC re-iterated its public health view by stating: CDC's overarching HIV-prevention goal is to reduce the number of new HIV infections and to eliminate racial and ethnic disparities by the promotion of HIV counseling, testing, and referral and by encouraging HIV prevention among both persons living with HIV and those at high risk for contracting the virus. To this end, CDC now recommends widespread testing -- i.e., routine HIV screening of all persons aged 13-64 in health care setting. This prevention goal and approach remains equally relevant in the developing world.
Active debate continues in the United States on testing requirements and partner notification, with CDC in the fore. The California Supreme Court has also entered the affray by ruling in mid-2006 that HIV infected persons who do not inform their partners can be held liable for transmitting the disease, providing additional incentive for partner notification.
The concept of rights is often raised by persons addressing HIV/AIDS, although they appear to overlook the indifference of the virus to such thinking. Yet while many focus on what humans ought to do, more recently in 2007 some are employing the "rights" perspective to state what humans need to do in order to avoid continued infection. Dixon-Mueller and Germain provided helpful guidance in The Lancet when they wrote that they ..."propose a reorientation of testing policies based on the premise that everyone needs to know their HIV status and that of their sexual partner to make informed sexual and reproductive decisions." Perhaps others will recognize that the right to avoid infection is paramount to survival, and will consider the importance of pre-marital or pre-relations testing.
Being an infectious disease that moves slowly from person to person by direct contact, HIV should be easy to prevent. The experiences of Uganda during the 1990s show that HIV can be prevented in the developing world, even with low-cost intervention strategies. The Ugandan Ministry of Health conducted a successful HIV-prevention campaign with slogans such as ''Love Carefully,'' ''Love Faithfully'' and ''Zero Grazing'' - all aimed at partner reduction. Cited below are details of this program, the ensuing controversies voiced at the 15th International AIDS Conference in Bangkok (2004) and thereafter, and the on-going abstinence efforts in Uganda.
As noted by commentaries, many international agencies have been slow to react to the Ugandan experience, favoring instead traditional approaches that feature blood donation testing, harm reduction (i.e., promotion of condoms and avoidance of shared needles), and the increasingly dim promise of future vaginal microbicides and vaccines.
Cost-effectiveness of Screening
In United States, both public health officials and policy analysts are recognizing the importance of early HIV detection efforts, including widespread routine screening in medical care settings. Three articles on this topic appeared in February 2005 in the New England Journal of Medicine, available below.
Experimentation and Innovation
HIV/AIDS remains a terrible disease, but one that can be addressed. The intent of this site is to present public health strategies for developing countries that rely on knowledge of the virus, rather than idealistic or fearful visions of the disease in society.
Technical articles by Professor Frerichs and colleagues are cited in the following table, describing HIV testing with saliva, personal screening programs and community surveillance systems.