POSTING 68: HIV TESTING REALITIES


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Frerichs, R.R. HIV Testing Realities.

SEA-AIDS Network, January 23, 1999.

Posted in response to:

SEA-AIDS, January 22, 1999

From Nicholas Bates, Australia 

Rachel Sacks (#67) has hit the nail on the head, and certainly expressed many of the feelings I have had in response to Ralph Frerichs' many contributions to this discussion list over the last few years.

I noted that in his response to Sack's "tirade" (her word) that Frerichs mentioned that he has most recently been working in Mongolia - a country where I have also done some work and where widespread HIV testing has been carried out with little or no thought as to the consequences of finding large numbers of infected people.

When people are diagnosed as HIV positive (very few at this stage) there is a huge outcry in the media and widespread panic meaning that once again everybody (i.e., the media and the government) talks about testing (test, test, test!) and not about prevention or even care and support. Arguments are put forward by health officials as to why testing facilities for HIV need to be improved while there is virtually no reliable facility for diagnosing many of the STDs which pose a far greater threat to public health. Meanwhile the general public are desperate for information on prevention for both HIV and STDs and access to cheap and good quality condoms.

Actually for about $50 US (probably less if you are a local) you can get a certificate in Mongolia from a doctor showing that you have been tested for HIV antibodies and are HIV negative - without ever having to have your blood tested!  Saves wasting money on pathology and helps poorly paid doctors, especially in the public system, to make a little extra money.

Nicholas Bates

R.R. Frerichs Posting

In his recent posting Nicholas Bates comments about his feelings (i.e., "Rachel Sacks has hit the nail on the head") and Mongolia. Regarding feelings, when dealing with social issues there are always going to be differences of opinion. Yet for the SEA-AIDS forum to function, reasonable people must be able to put their ideas in a clear form (as Nicholas Bates has tried to do), so that we can address specific points of agree or disagreement. Such clarity is often missing when heat captures the moment. Heat of an insulting nature has the further effect of limiting dialogue, so that only safe messages of enquiry appear and not unsafe messages on controversial topics.

With that said, I would like to address Nicholas Bates' second point, namely my recent consultancy in Mongolia. It is an interesting country that has received some attention in SEA-AIDS during the past few days, but perhaps more discussion is needed. I was there in December as a United Nations consultant, helping them establish cost-effective strategies for HIV/AIDS control. Several months earlier I had visited Mongolia with the Albert Schweitzer Institute for the Humanities, joining colleagues with varied views and backgrounds (I like working with strong people of diverse views) to discuss the HIV/AIDS with local health professionals. 

Given my many posting in SEA-AIDS on the need for HIV testing in high prevalence countries, Nicholas Bates and others may be surprised that I do not advocate widespread HIV testing in low prevalence countries such as Mongolia. Here is what I wrote about testing in my report that was sent out earlier this month.


Because Mongolia is not yet experiencing an HIV epidemic, it is important that an inexpensive information system be established that provides early warning of a coming epidemic. Such a warning system which monitors a sample of persons is far less costly than universal border or visitor testing programs that monitor all people who enter the country for other than a brief stay. Testing programs during the early stages of the epidemic are very costly for detecting cases, drawing vital public funds from such important endeavors as sentinel surveillance and broadly based health education programs. 

At best, routine testing programs in the early stages of an epidemic are viewed by many as an inconvenience, while at worse may be seen as a violation of human rights. Contrary to some international consultants, I do not view routine HIV testing as a violation of the rights of either HIV infected or susceptible persons. Instead, when the prevalence of HIV infection is sufficiently high, I see widespread testing as an important means for public health officials to protect susceptible persons from harm. My objection to testing in the early stages of the HIV epidemic is not related to the issue of human rights violations per se, but rather with the inefficiency of such testing when only a few HIV infected cases exist. An effective sentinel surveillance program avoids unnecessary widespread testing when not needed, and guides the implementation of voluntary and then routine testing programs when testing is needed.


Other issues are discussed in the report, but this was the section most appropriate to the Bates posting. I am not sure about the accuracy of Nicholas Bates' claim when he wrote: 

"Actually for about $50 US (probably less if you are a local) you can get a certificate in Mongolia from a doctor showing that you have been tested for HIV antibodies and are HIV negative - without ever having to have your blood tested! Saves wasting money on pathology and helps poorly paid doctors, especially in the public system, to make a little extra money." 

Nevertheless, I do agree with some of his general concerns about excess testing in a low prevalence country. Finally, I hope that Nicholas Bates and others will continue to help Mongolian health professionals address the potential for HIV/AIDS in their country, and think of ways to enhance their laboratories and expand both education and the availability of condoms. While problem recognition is important, deriving inexpensive solutions that are tailored towards the local economy requires much thought and assistance.

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