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Frerichs, R.R. Response to Acceptance of HIV Personal Screening.

SEA-AIDS Network, June 15, 1998.

Posted in response to:

SEA-AIDS, June 12, 1998

From Martin Foreman, London

What 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.

Unfortunately, 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.

Consider 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 HIV test. 

You 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 four-letter-word.

You 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.

Instant 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 Internet.

Martin Foreman

Director, AIDS Programme

Panos, London

R.R. Frerichs Posting

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 protection. 

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.