about Epidemiology & the department

Epidemiology academic information

Epidemiology faculty

Epidemilogy resources

sites of interest to Epidemiology professionals

Frerichs, R.R. Frerichs response to routine HIV testing issues

SEA-AIDS Network, December 17, 1997.

Posted in response to:

SEA-AIDS, December 6, 1997

From Chris Green, Jakarta, Indonesia

Once again we must thank Prof. Frerichs for raising an important concern. We have long identified perceived risk to medical staff as a significant potential cause of discrimination towards PWAs. In Indonesia at least, medical staff including doctors are poorly informed about the risks of infection by AIDS and the easy way out is to avoid treating people infected by HIV. Nurses and hospital administrative staff often demonstrate their fear to the dismay of patients and families.

But as Sally Smith from Nepal has pointed out, we gain little by testing. What is primarily needed, as is so often the case when irrational fear must be addressed, is education. In one hospital here in Jakarta, I discussed this point with the nursing manager. She recalled that when the first case of AIDS was admitted in the early '90s, many of the staff were unwilling to approach the patient. She then started a program of education, not only of the nurses but also the administrative, cleaning and catering staff, to ensure that they were aware of the methods by which HIV is (and is not) transmitted, and the relatively simple rules of Universal Precautions which will prevent that transmission (and that of other equally dangerous and much more easily transmitted infections) in a hospital setting. She also prepared a clear procedure to be followed in case of needlestick or other potential injuries. The result is that this hospital is still the most welcoming for AIDS patients. Further, to my knowledge no potentially infecting injuries have occurred there.

However, as far as I am aware, few hospitals in Indonesia have emulated them. General knowledge of Universal Precautions is limited.

I know of no publication in Indonesian language (or perhaps more importantly, in cartoon form, as has been prepared in Australia), which describes Universal Precautions and their relevance to AIDS and other infectious diseases. Similarly provision for disposal of 'sharps' appears to be haphazard at best. And I doubt more than a handful of hospitals (if that) have a procedure for needlestick injuries.

It is to these requirements that attention must be given, rather than the illusive solution of universal testing, which besides being impractical and causing a false sense of security, will almost certainly be administered with little concern for the rights of the patient. I would be interested to hear how these challenges have been addressed in countries where the epidemic is more mature.

Chris W. Green 

Jakarta, Indonesia

SEA-AIDS, December 6, 1997

From Lalit M. Nath, India

I note that the same arguments in favour of testing are still being put forward, regardless of the fact that no one is against appropriate testing!! Incidentally, India does have an official policy on testing, the document is available from NACO. 

Was there not a report of someone who was tested, diagnosed and counseled in New York or New Jersey -- and went on to willfully infect several girls.

Lalit M. Nath

SEA-AIDS, December 9, 1997

From Karla Meursing, Australia

The benefits of early detection of HIV infection depend on the context testing is done in. Indiscriminate calls for early testing can cause damage.

I agree it would be worthwhile to make sure that voluntary testing is available, provided it is accompanied by counselling and long-term support options. However, in many context the "voluntary" character of testing can become clouded with direct and indirect pressure on a person to 'choose' for the HIV test. For example, in hospital patients are often eager to please their doctor and this may be their main reason to agree to an HIV test, rather than the desire to know their HIV status.

In addition, the effect of testing (voluntary or otherwise) depends on what action the infected person takes after the test result is known. Positive action - such as using condoms, informing one's partner, and planning for the future - presupposes the infected person actually has the power, the resources, and the information to translate knowledge into action. 

If we have learnt anything from years and years of HIV education, it is that "telling people (of the risks of HIV, or of their HIV status) is NOT enough to effect behavior change." Thus, simply being told one's HIV status is not enough to effect protection of others, nor to achieve improvement in the predicament of the seropositive person him/herself. 

In order to achieve these ends, the person with HIV should have access to adequate treatment and to family planning and condoms. He/she should also actually have the social power to use family planning and condoms; have access to information, and social and material support; and to legal and other effective protection, should his/her environment react with discrimination and rejection.

In many countries in the world, these conditions are not met. Thus, issues of prevention (by early detection for instance) and of support and care are intimately linked, and the issue of testing should be always be considered in conjunction with the issue of support and protection available to those infected. If there is very little, or no help available for people with HIV, public interest in voluntary testing is likely to be low, and people who find out they have HIV may well feel so helpless they decide to hide their HIV status and continue to live as others do - which may include unprotected sexual intercourse.

For an in-depth discussion and many illustrations of what it means to be HIV positive in a society where fear of HIV has resulted in severe stigma, and where poverty limits the options of people with HIV to cope with their diagnosis, I refer to my book: A World of Silence - Living with HIV in Matabeleland, Zimbabwe (1997 Royal Tropical institute Amsterdam). 

Dr. Karla Meursing

International Health Unit

Macfarlane Burnet Centre for Medical Research

PO Box 254

Fairfield, Vic 3078, AUSTRALIA

R.R. Frerichs Posting

Several people responded to my posting on routine testing in a hospital setting. Unfortunately, all too few of the postings were from those Asian countries where HIV is common, and the need to protect health workers from HIV is a day to day reality. Perhaps with respect to testing it would helpful if I make my views clearer. When HIV is uncommon, as it is in Indonesia, the Philippines and the Central and Northern region of China, I recommend testing in sentinel surveillance settings, and testing of blood for transfusions.

The blood testing should be done with pooling to save cost, using pools of five or ten depending on the setting. When HIV is common, as it is in areas of India, much of Myanmar, Thailand, and Cambodia, and areas of Southern China and parts of Vietnam, I still recommend an active sentinel surveillance program and blood testing, the same as for low-prevalence countries.

Yet in these higher prevalence countries, I also recommend testing of couples planning to be married, pregnant women, and routine testing in hospital settings. In each instance, there is something to be done to prevent further viral transmission.

Finally in such higher-prevalence settings, I recommend that home tests be made widely available for distribution and sale in the private sector, thereby allowing people who value testing to more easily know their HIV status. I do not favor limiting testing to clinic settings, where scheduling problems, delays in notification, and few urban settings prevent many people from knowing their test results.

In the broader scene, I foresee that international funding for HIV programs will continue to decline, as more and more pressure is being placed in the United States and Europe to have governments offer costly treatment to asymptomatic HIV infected persons. I also see that other groups in the developed world -- notably those interested in various forms of cancer -- are wanting more public money for their efforts, again placing downward pressure on international HIV assistance programs.

Finally, I foresee that government assistance programs will decline, as financial pressures being felt throughout Asia result in painful cost-savings measures. Thus if people in the developing countries of Asia are to be informed of their HIV status, new financial mechanisms and delivery systems will need to be established that do not rely entirely on international or government funds. The private sector is but one area that should be tried, but we need to move soon if further lives are to be saved. In moving into a more experimental mode, local investigators need first to do a situational analysis to determine what now exists with respect to testing and AZT treatment. They then need to keep a goal in mind (i.e., all HIV infected persons should know their status) and do a series of operations research (OR) studies to determine the most cost-effective means to reach this goal.

Such OR studies of testing are not yet needed in countries like Indonesia and the Philippines, but are essential in the higher-prevalence countries of South and Southeast Asia. 

UNAIDS now estimates that there are 30,600,000 persons infected with HIV in the world. They further estimate that only 10% know of their infection. The other 90% continue to unknowingly spread the virus, keeping the epidemic alive in many developing countries. With widespread testing, we hope to change these dismal statistics, but can only do so if there is enthusiasm and support for this approach, and experimentation with new test delivery systems.