June 12, 1998
Martin Foreman, London
a wonderfully ordered world Prof Frerichs lives in! I imagine he and those who
argue so persuasively at HIV InSite wake up every morning in a tidy and
dust-free house, eat a carefully balanced meal, drive in a comfortable,
air-conditioned car to a pleasant office with polite and friendly colleagues,
and work with calm efficiency. At the end of the day they arrive home well
satisfied with the day behind them and each night they have seven or eight hours
restful sleep. If they should search for sexual adventure, they balance intrigue
with caution, use condoms consistently and welcome "instant HIV tests"
as a further tool to manage their carefully constructed lives.
however, that is not the world in which most people live, and it is probably not
the world in which most cases of HIV transmission occur. Indeed, for most people
sex and drug-taking is not an ordered activity and the circumstances in which
the instant test would be most useful are the circumstances in which it almost
certainly won’t be used.
the following examples. You are in the near darkness of a sex club in London,
with a condom stuffed in your shoe. Usually you remember to reach down for it
and put it on, but with an erection in hand, neither you nor your partner(s)
have the time, the light or the inclination to first pull out and use an instant
are being held in a police cell in Recife, Brazil. For five dollars you and
fellow inmates can have ten minutes each with the local prostitute in a corner
of the cell covered by a blanket as other inmates look on. If you are lucky, you
have a condom, but an instant HIV test? Is the police guard, who had to be
bribed to provide the young woman, going to provide that as well? And are the
other prisoners going to allow you the time to try it and wait for the results?
You and three other young men are huddled round a spoon in an empty apartment in
Kaliningrad, Russia. One of the three says, "hey, before we share this
needle to get high, let’s take time out to see if any of us have HIV."
The mildest response from the others would be the Russian equivalent of a
are a truckdriver in Bangladesh or Benin, having sex in the cab with your young
male assistant or in a 3’ by 6’ room with a young woman who has already had
six other customers that day. You are barely literate and luxury for you is a
shower and a long night’s sleep. You think condoms are a waste of time, but
you sometimes use them. This test? Forget it.
HIV tests are a great marketing gimmick, profitable for the manufacturers and
useful, I am sure, for careful people with middle-class lives in whichever
country they live - people who almost certainly think carefully about their sex
lives and are already protected by condoms. But for the majority of the world’s
population an Instant HIV test is about as useful as Instant Messaging on the
I am responding to the June 12 posting by Mr. Martin Foreman, Director,
AIDS Programme, Panos, London. In colorful, but realistic terms, he describes
circumstances which place people at high risk of becoming HIV infected.
He correctly observes that such individuals would likely not be helped
by personal HIV screening tests. By implication, Mr. Foreman seems to suggest
that most persons who become infected do so because of uncontrolled lust
or desire for a drug high.
As an epidemiologist I would certainly agree that the frequency of being
caught in uncontrolled situations may be substantial. But likely, the frequency
is not high enough to account for the rapid spread of HIV in many developing
countries. Instead, in such settings most people lead more controlled lives,
but happen by circumstance to encounter a virus that spreads via sexual
intercourse, blood, or from mother to child. For these more controlled
individuals, personal HIV screening tests become but another option for
Would Mr. Forman want to deny the vast majority of people this
option, just because the detection method may not work with a minority
who are engaged in high risk behavior? Would his lack of support mean that
such personal screening tests would not be funded or tried by NGOs working
in developing countries? Would his thoughts prevent couples in poorer settings
who plan to be married or women who plan to have children do testing in
the privacy of the home to determine the presence of HIV?
Opinions of persons
in London and other wealthier settings guide purse strings, which then
guide prevention or intervention programs in developing countries. Are
the opinions valid? It would be good to hear from health professionals
in high-prevalence developing countries who face on a daily basis the reality
of the epidemic. Their opinions are certainly the most important when it
comes to their home countries, although they too must confront the reality
that external funds do not always flow to those who go against the tide
of Western opinions.
Or equally important, perhaps colleagues in wealthier countries who
fund HIV/AIDS programs would consider remaining neutral on this issue,
thereby opening the door to further experimentation by public health officials
in the developing world.