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R.R.
Frerichs Posting
While in Asia these past weeks, I gained fresh insights to the way HIV
is being addressed in the region. Partially this came while I was in Myanmar with a UN team to evaluate
their sentinel surveillance program and partially while in Thailand to
help conduct a policy workshop at Chulalongkorn University on HIV control.
As in prior years, we had workshop participants from throughout the region
(i.e., 32 from 11 countries) and had much thoughtful discussion.
In
trying in our policy workshop to address the reluctance to consider
testing options, we asked the participants to cite criteria they might
use to decide if HIV testing is warranted in one group or another, and
the forms of testing they might use. Criteria that surfaced included importance
or magnitude of the problem, cost, coverage, and benefits and consequences
of the decision.
We also asked them to consider what research might be done to address
their concerns, so that clearer advice could be given to policy makers.
We considered testing of blood donors, sentinel groups in surveillance
programs, couples intending to marry, couples intending to have children,
pregnant women, prisoners, STD patients and the general population. We
also suggested that if testing was to be done, their proposed strategies
might include testing that is unlinked anonymous, voluntary anonymous,
voluntary confidential, routine confidential, mandatory or compulsory.
It was an interesting exercise that SEA-AIDS members might also like
to contribute to, especially pertaining to countries in the region. Some
like areas of India, Myanmar, Thailand and Cambodia have high levels of
HIV infection, while others like China, Laos, Vietnam and Papua New Guinea
may be more regional in their epidemics, and still others such as the Philippines
and Indonesia seem to have lower levels of infection. Clearly testing strategies
for low prevalence areas will differ from those carried out in high prevalence
areas, since cost of detection would be formidable in the former, but more
reasonable in the latter.
While most Asian countries accept mandatory testing of donated blood,
they are less willing to mandate premarital or prenatal testing, feeling
that this decision should be left to the couple or the pregnant woman.
Yet as is now being debated by women's groups in Africa, in high prevalence
regions such voluntary testing seems more adverse to women than men, since
men are more likely to be initially infected and women to be susceptible,
and to infants rather than their mothers, since without testing many more
children would become infected. When testing is left voluntary, will women in Asia be able to encourage
their future husband to be tested and to share with them the results? Or
would they be better protected by a government mandate that all married
couples must be tested for HIV and syphilis and counseled as couples rather
than individuals?
If data for decision making are not available, would research investigators
be encouraged to evaluate the utility of mandatory testing in high prevalence
areas -- both premarital and prenatal -- or should such forms of testing
be left only to blood, no matter how common HIV is in the population?
Intriguing questions that need to be answered. I look forward to reading
if others in SEA-AIDS have criteria of their own (i.e., considerations
for decision making) that should be addressed when viewing testing strategies
in local Asian settings.
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