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Frerichs, R.R. Voices for HIV Testing and Normalization. 

SEA-AIDS Network, December 9, 1998.

R.R. Frerichs Posting

While much attention in the HIV/AIDS field has been focused on the important work of non-governmental agencies (NGO), the weight of most control programs continue to fall on the broader shoulders of government public health workers.

They have been asked to view HIV/AIDS as being different from other communicable diseases, and to rely on general intervention measures such as universal condom use for all sexually active persons or universal precaution for all medical care encounters as their main control strategies. In most developing countries efforts have not worked well, resulting in another 5,800,000 new HIV transmissions occurring world wide during the past year, including 1,200,000 new infections in South and South-East Asia (UNAIDS, 12/98). Two recent comments -- one by an activist physician in the United States and the other by an HIV infected woman in South Africa -- offer helpful suggestions to public health professionals who are seeking other ways to deal with the disease.

In a comment on a new urine test that is receiving considerable attention in the United States, Dr. R. Scott Hitt, chairman of the Presidential Advisory Council on HIV/AIDS, said "Increased prevention efforts for HIV infection must include more accurate means for determination of those in all risk categories who have been exposed to the virus." He further said, "and it should be the responsibility of public health officials to undertake every avenue to ensure that an individual at risk for HIV knows his or her status." (MSNBC, 12/4/98).

So who is at risk? Other than those who are engaged in sex work or exchanging blood with narcotics, perhaps the greatest risk is to long term sexual partners of HIV infected persons. For them, partner notification programs are especially important, along with continued assistance on ways to avoid infection in a marriage or intimate couple setting. Are public health officials in the developing world dealing with this issue, and if so, have they been successful? The second story starts out in a typical fashion, reminding us of the cruelty that all too often is associated with AIDS.

"DURBAN, South Africa -- Mercy Makhalemele found out she was HIV-positive when she was pregnant with her second child. She was 23, had been married for five years, and was faithful to her husband. She cried all the way home from the prenatal clinic, but was too afraid to tell anyone for nearly a year. When she finally did tell her husband, he beat her to the ground, knocking her against a lighted stove and badly burning her wrist, she said. Then he threw her out of the house, refusing to believe that he had given her the virus. The next day, he went to the shoe store she managed. With everyone watching, he shouted at her to collect all her things, he would have nothing to do with someone with HIV, the virus that causes AIDS." (New York Times, 12/4/98)

But the story did not end there, Instead, Mrs. Makhalemele decided to deal with the problem, and in her own unique way, became a foot soldier in the normalization process. The New York Times article continues...

"My story," she told a women's group gathered for a luncheon in Durban recently, "is not just my story. If you talk to other women, you will hear 90 percent the same. It will not be 50 different stories. Rejecting us is not going to solve the problem of this disease. It's just going to cause stress. So please, just accept us."

The story moved on to other persons, but eventually returned, first to the continued sadness that HIV brought to her life, and then to a showing of strength that should serve as an inspiration to others.

"When Mrs. Makhalemele gave birth to her daughter in 1994, none of the midwives would sew her up. Four hours went by before an aunt, also a nurse in the hospital, who came by to visit, read her chart and did the work. The aunt did not know, however, that Mrs. Makhalemele still had dressing inside of her and a massive infection followed. Mrs. Makhalemele told her husband she was HIV-positive largely because her baby daughter was so sick she felt she needed to be honest with him. After he threw her out, it was the child's pediatrician who took her in, giving her work as a maid. Though she was grateful, she was also humiliated." "A few months later, her husband got sick and a blood test showed he was HIV-positive. It was only then that he admitted that he had infected her and wanted her back." "Since then, both he and her daughter have died."

The evidence of her strength appeared thereafter, helped along by an NGO in South Africa...

"Mrs. Makhalemele is now employed by the National Association of People Living with HIV/AIDS to go around the country talking to people in a campaign to promote "disclosure and acceptance." But she is not advocating what she calls "reckless" disclosure. When she spoke to the women's group recently, she was accompanied by a shy young woman named Princess who is also HIV-positive and wants to volunteer with Ms. Makhalemele's campaign. But her boyfriend has threatened to kill her if she goes public. He already has a new girlfriend and does not want her to know about his HIV status. Ms. Makhalemele is counseling Princess to go slowly. She recently stopped more than a dozen young people from taking part in an AIDS awareness television show because she felt they did not truly understand the consequences of going public. "It is not for everyone," she said. "It is a very serious thing to do."

Slowly, with more opportunities for testing and more encouragement by public health officials and others, the normalization process will move forward, helped along by the Ms. Makhalemeles of the world. Yet such brave actions do not occurs by themselves. As part of a normalization strategy, they must be planned, nurtured, and widely brought about by coalitions that are committed to reducing HIV occurrence. To be successful, such coalitions should be lead by public health officials who understand the virus and the deadly nature of viral transmission, with strong support from NGOs who are closely tied to the human side of the epidemic. 

If you have had experiences with such efforts in a developing country (i.e., those where funds are limited and treatment is generally not available), please share them with SEA-AIDS so that others learn more about the testing and normalization process.