Tony Bennett of
AIDSCAP-Bangkok has brought to our attention important
new developments in the clinical arena (message not
available). Specifically he cites experts who
suggest that new drugs may be able to reduce the level of HIV in blood
to such low levels that the body's immune system will be able to rid (or
at least control) the virus. His message also points to the need for more
extensive testing services, making HIV antibody tests widely available
to persons who might have contacted the virus. Finally, his message notes
that it is unlikely that developing countries will be able to afford both
HIV antibody testing and HIV treatment programs, at least not without the
assistance of international donor organizations.
There are now two reasons for periodic testing of self and sexual partner.
The first is to discover HIV so that infectious contact can be avoided
by susceptible partners. The earlier the better, since many people will
not use condoms when they have no sense that the virus is present.
The second reason is now emerging, namely treatment. We already have proof
that zidovudine therapy of pregnant infected women will reduce viral transmission
to their offsprings by two-thirds. The infected pregnant women need to
be identified by testing, however, before treatment will take place. In
the coming year we likely will hear more encouraging news about treatment
of HIV infected persons, to either cure or extend their life. Like with
pregnant women, treatment will not be applied unless people know they are
infected, using HIV antibody tests.
If existing counseling and testing centers continue to be the only source
of testing, the service will be too expensive for most developing countries.
Because people have no way to screen themselves before coming for counseling
and testing, such centers spend too much time and money attending to HIV
negative persons and too little on HIV case finding. Since early detection
is the goal, people engaged in high risk behavior will want to be tested
once or twice a year. Such extensive testing would result in too much volume
for existing counseling and testing centers to absorb. Thus we can either
give up on the idea of early detection and the associated benefits, or
develop new testing schemes that are inexpensive, widely available and
acceptable to people.
One idea is to sell simple, inexpensive screening devices in the private
sector, and encourage people to screen themselves at home before coming
to counseling and testing centers for confirmatory testing. Such HIV indicators
(i.e., simple tests that indicate the need to seek further medical care)
could be purchased by individuals at their local pharmacy or obtained for
home use at subsidized prices from government testing centers.
If HIV is detected early, there are potential prevention and treatment
benefits. If HIV is detected late or not at all (as occurs in many developing
countries), the virus has much time to move from one sexual partner to
another, thereby continuing the epidemic. At this point, there has been
little or no experimentation with the use of home HIV tests or HIV indicators.
Will people buy home tests? Will they interpret the findings correctly
and act to prevent or treat HIV infection? Will they discriminate against
those who harbor the virus, and cause further pain and misery? Too many
questions and too few answers. Yet without field studies or demonstration
projects, the questions will never be answered and early detection will
remain a distant dream.
If you plan to attend the coming AIDS meeting in Vancouver and want
to learn more about home testing, come to the debate between Dr. Doris Schopper (formerly of
GPA/WHO) and me on Monday, July 8 from 5:30 to 6:30 pm. Opening remarks will
be made by Dr. Helene Gayle, Director of the Division of HIV/AIDS Prevention,
CDC, Atlanta, closing remarks will be offered by Dr. Michael Merson, former
Director of GPA/WHO and now dean at Yale University School of Public Health.
Questions from the audience will be welcome.