THE ISSUE

The human immunodeficiency virus (HIV) is a deadly, difficult foe.  Similar to cholera which struck England in the 1800s.  The disease caused by HIV infection -- AIDS -- has brought fear, loathing and death during recent decades. Yet different from historical cholera, we know the causative agent of AIDS (i.e., HIV) and the transmission pathways (i.e., sexual contact, blood, and mother to child).  Yet this knowledge has not helped us stop the epidemic.  Scientific experts have much research available, but still differ greatly on views of appropriate and feasible intervention or prevention strategies.  

In John Snow's time (1854), as a way to prevent cholera transmission Snow advocated taking the handle off the Broad Street pump. This action was questioned by experts and politicians but it was taken nevertheless, providing an enduring symbol of public health activism.  In modern times public health officials continue to debate disease control actions, not always knowing for sure what works, but often being willing to "remove the pump handle." 

In the mid-1990s, a new control strategy to address HIV was proposed by Professor Ralph Frerichs for developing countries.  His intent was to use widespread HIV testing and normalization of infection to reduce HIV transmission.  He reasoned that susceptible people will act in their own self-interest if they know that potential sexual partners are HIV infected. Since cost is a major issue in developing countries, Frerichs proposed the use of inexpensive personal screening tests featuring saliva in a viewpoint in The Lancet.  His publication generated five communications in The Lancet, four of which were critical, not accepting widespread testing and normalization as "removing the pump handle."  These communications as well as Frerichs' responses are included here. The points and counterpoints address a new philosophy which evolved during the 1990s in public health circles.  Rather than the earlier focus on protection of susceptible populations, the new philosophy emphasized patient autonomy (i.e., independent of government intrusions) and individual rights. The debate in The Lancet reflects the two points of view regarding HIV/AIDS. 

The material provides a contemporary view of the sorts of debate that faced John Snow in the mid-1800s.  Along with posting in the HIV controversies section, this material provides a glimpse of how scientists and public health workers in modern times address personal differences in the formulation of public health policies.