POSTING 46: ACCEPTANCE OF PERSONAL HIV SCREENING 


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

SEA-AIDS Network, June 25, 1998.

Posted in response to:

SEA-AIDS, June 24, 1998

From Rebecca Firestone, United States

One of the major questions surrounding personal screening for HIV is whether or not the person testing him/herself will know how to handle the results of the test. The rationale for clinic-based testing is that counseling and referral services can be provided for people who have just discovered that they are HIV-positive, and education can be provided to the "worried well."

Diagnosis with HIV-infection is a life-changing event, and as public health professionals, we have a responsibility to give the people we serve information and support, so they know how to interpret and respond to their test results, positive or negative. Clinics are vital for the education and counseling services they can provide, in addition to testing and treatment.

Because they act as an entry-point into the public health system, clinics are a place to ensure that people are receiving complete and accurate information about HIV. Testing on its own will not necessarily lead to behavior change, whether the testing happens at home or in a clinic. Education about HIV/AIDS and the skills to act on received information are necessary as well.

Several SEA-AIDS members have mentioned cultural context as a reason why personal screening would not work. I think this gets at the issue of HIV/AIDS education and access to information. A well-educated, middle-class population in the United States might be eligible for personal screening, because this group has had ample access to HIV/AIDS prevention messages, leading to an awareness of risk, a desire for confidentiality and the ability to act on the test results (I know I'm generalizing).

A remote Cambodian village (which I believe was one example given for cultural context) would probably be less eligible. HIV/AIDS prevention messages are less prevalent, which means less personal perception of risk and a lower demand for testing services. But if a Cambodian villager used a personal HIV test, and the results were positive, how can we ensure that this person knows what services are available to him/her or knows how to prevent further transmission? Even if the results are negative, this Cambodian villager is clearly concerned about HIV, so how can we ensure that he/she receives the right information to mitigate those concerns?

Dr. Frerichs is right that HIV testing resources could be more wide-spread and accessible, and we should be thinking about the logistics and costs involved. But I would like to know how Dr. Frerichs would ensure that the hypothetical user of a personal HIV test would get the information he/she needs to respond to the results of that test in a setting where information about HIV may be non-existent or inaccurate.

If we want to discuss testing, I suggest that we put greater emphasis on STD prevention and treatment. STDs are a co-factor for HIV-transmission, but we still don't have cheap, fast diagnostic tests for several major STDs, and syndromic management can be problematic, particularly for cases of vaginal discharge. We need effective behavioral risk assessments for asymptomatic cases as well.

Rebecca Firestone

Center for Health and Gender Equity

6930 Carroll Ave., Suite 430

Takoma Park, MD 20912


From Kenrad Nelson, Johns Hopkins University

I have been reading all of the sea-aids discussion on HIV testing. I think another good reason for testing using "rapid tests" in very high risk settings in the US and Europe is the 30% or so of people who come to an anonymous or other clinic for testing and then don't come back and can't be located to get their results. Obviously ,any potential benefit of early diagnosis -- counseling and therapy to prevent transmission and progression may be lost in this situation. Unfortunately at present there is only one licensed test available in the USA -- although several are available in Europe, Asia and elsewhere. I think physicians in the US may be reluctant to use a rapid test -- certainly for a definitive diagnosis -- because of the frequent problem of non-specific false positive results.

But it would certainly be important to find a better way than exists, or is being used ,now to be sure that everyone who DOES request an HIV test actually is informed of RELIABLE results quickly.. Unfortunately this isn't always happening now -- even (maybe especially) in the USA.

Kenrad Nelson, MD

Johns Hopkins University

R.R. Frerichs Posting

I am responding to the thoughtful comments of Rebecca Firestone and Dr. Kenrad Nelson. They both raise important issues of human behavior, influencing how we address the HIV/AIDS epidemic. Like Dr. Nelson and perhaps Ms. Firestone, I too foresee important uses for rapid tests in clinical settings where blood can be taken for testing, evaluated and the results are available for immediate discussion and counseling. Dr. Nelson is correct that clinicians would want to have at least two brands of rapid tests available so that one could be used as the screening test and the second (or possibly a third) as the confirmatory test. While there is much interest in the United States in rapid tests, we still only have one rapid test that is licensed by the FDA, hindering the implementation of this "quick diagnosis" plan.

My comments to SEA-AIDS on testing are intended mainly for countries in Southern Asia, although I recognize that the network extends well beyond the limits of this region. Dr. Nelson and his colleagues at Johns Hopkins University have considerable experience in Southeast Asia, providing ground-breaking work on the epidemiology of the disease in Thailand, and on intervention or prevention strategies. One such colleague is Dr. Chris Beyrer who has written a fascinating book about the region, "War in the Blood -- Sex, Politics and AIDS in Southeast Asia," Zed Books Ltd, New York, 1998. Perhaps Rebecca Firestone has also worked in the region, possibly in Cambodia with the villagers she refers to.

As all these individuals know, the situation in Southern Asia with respect to HIV/AIDS is complex, with no easy solutions in sight. This is why we desperately need more experimentation, trying different strategies to see what works and what does not. Mental barriers need to be reduced, however, before willingness will lead to actual experimentation. This willingness to experiment is especially important for those who control or influence funding sources. If their minds are closed to notions such as personal screening tests, resources for field investigations or demonstration projects will be hard to come by.

UNAIDS earlier this weeks released a comprehensive account of HIV/AIDS in the world ("Report on the global HIV/AIDS epidemic). It can be obtained at their website (www.unaids.org), along with an appendix and an accompanying spreadsheet that provides country-specific estimates of HIV prevalence in most countries. In Southern Asia, some countries based on infection percentages for 15-49 year old adults, could be view as high prevalence (Cambodia [2.40%], Thailand [2.23%] and Myanmar [1.79%]), others as medium prevalence (India [0.82%], Malaysia [0.62%], Vietnam [0.22%], Papua New Guinea [0.19%], Singapore [0.15%] and Australia [0.14%]), while other could be seen as low prevalence (New Zealand [0.07%), Sri Lanka [ 0.07%], Philippines [ 0.06%], China [0.06%], Indonesia [0.05%], Laos [0.04%] and Bangladesh [0.03%]). Of course these designations are arbitrary and do not present the variations within each country. No single testing policy should be employed in all of these countries. The need for testing will vary from one country to another, depending on the prevalence of the disease, and from one region within countries to another. Thus having personal screen tests widely available might be useful in some settings, but not in others.

In an excellent editorial in a recent issue of AIDS ("The demographic impact of the HIV epidemic in Thailand," AIDS 1998 (12)813-814), Dr. Kenrad Nelson summed up the situation in Thailand as follows: "In this area [the northern region], as elsewhere in Thailand, the major transmission risk has become sexual transmission among married couples and mother-to-infant transmission. Prevention of HIV transmission among married couples is a very difficult public health challenge. Regular condom use among married couples is unusual unless both partners are aware that one is infected with HIV. Diagnosis of HIV infection in married men or women prior to transmission to their regular partner is the public health challenge of the future of the control of the HIV/AIDS epidemic in Thailand." 

The challenge that Dr. Nelson writes of will not be met unless we are willing to experiment with new testing strategies that are effective at reaching the many people who could benefit from such knowledge, and are inexpensive and convenient to use. Clinic-based testing and counseling programs seem reasonable in some settings, but those who rely on this model alone, will not reach on a regular basis the general population in Southern Asia. Without such widespread coverage and the knowledge that ensues, it will be much more difficult to protect married women and children from becoming infected. This, after all, is what the testing discussion in SEA-AIDS is all about.

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