I am responding to Dr. Thomas Chung from Hong Kong
(message not available) who asked for a discussion
on whether HIV testing should be promoted at the community level. To address
the issue, we need to consider the prevalence of HIV in the population,
the cost of periodic testing, the public health and individual benefits
of testing, and the medical, psychological consequences of testing. If
HIV is rare or non-existent, then HIV testing should likely be limited
to blood screening and sentinel surveillance, focusing on high risk groups.
If HIV becomes evident in such high risk groups, however, then screening
and diagnostic testing should be promoted in the general community.
Because of cost and privacy issues, people should be encouraged to screen
themselves with self-purchased home-based HIV indicators (i.e., tests that
indicate the need for further testing) at periodic intervals (i.e., once
or twice a year). The government should license the HIV indicators, and
charge the manufacturers a small fee to monitor the quality of their products.
When using HIV indicators, if positive, the instructions should warn
of the high number of false positives associated with any screening test,
and refer the user to a medical care provider for diagnostic testing and
counseling. It is too expensive and inefficient for most countries to offer
clinic-based diagnostic testing to people who have not been previously
screened with HIV indicators. In such non-screened situations, 95-99% of
those coming to diagnostic clinics for costly pretest counseling, blood
drawing, and posttest counseling are HIV negative. With the prior self
use of HIV indicators, likely 50% or more of those coming for diagnostic
testing would truly be HIV positive. The savings from not testing and counseling
endless numbers of HIV negative persons would be spent on better serving
those who are infected, including long-term follow-up, education and support.
The health of the public is best served when people are aware of their
sexual partners' HIV status. When HIV is common in the society, all sexually
active couples should be encouraged to periodically screen one another,
and diagnostic testing should be routinely offered in medical care settings
before marriage, before becoming pregnant, and during pregnancy. Because
of the stigma associated with HIV, aggressive testing policies should be
accompanied by programs that normalize the view of HIV in the general society,
so that infected people are more willing to share their status with others.
Included in such normalization efforts are enforced anti-discrimination
laws, and media presentations featuring HIV infected and non-infected persons
having personal, but not sexual contact. The media messages should focus
on both the responsibility of HIV infected persons to inform others of
their status, and the responsibility of the society to be accepting and
caring, similar to the way they address other life-shortening diseases
such as cancer, diabetes or heart disease.
Finally, the medical community, patients and society need to hear more
about how knowledge of HIV infection can help the infected patient, both
in regard to personal care and in avoiding further transmission to others.
Messages of fear or rejection, now evident on posters and billboards
in many countries, should be discouraged. Above all, there should be no
support of problem avoidance. Hiding HIV from view only benefits the virus,
and does little to help the infected individual or safeguard the society.