Graeme Storer in his thoughtful posting
felt that I had "side-stepped
an important question raised by Ms Sacks in her posting ((#67) namely,
where would resources (in her words, "the few development dollars that
still float around Asia") be best placed?" Perhaps he is right, but more
out of oversight because of the unique personal nature of Sack's posting
rather than neglect. Storer writes:
STORER ASSUMPTION ONE
I would like to question two assumptions that underpin testing: first,
that testing is advisable because those who test positive are in a better
position to manage their health. This is an assumption that holds true
in 'developed' countries where treatments are affordable, and often subsidised.
first assumption seems to be made from a medical point of view.
The implication is that if treatment is not available, then there is no
reason to diagnose a condition. While the logic of this statement might be
acceptable for various forms of cancer, cardiovascular disease or other
non-infectious disorders, the logic seems more assailable when considering
a communicable disease such as HIV.
There are two intentions for testing:
to make the infected person aware of his or her infection, and
to make the sexual or blood partners of the infected person aware of the
risk they face with intimate contact.
Those concerned mainly with medical
care tend to focus on 1) while public health professionals such as me consider
more closely the benefits of 2). I also feel that in the absence of treatment,
1) remains important for the infected persons. They know to try to avoid
opportunistic infections, to avoid passing the virus to intimate loved
ones, and if pregnant, to consider alternatives to breast feeding.
STORER ASSUMPTION TWO
Second, that people will be both willing to test and willing to pick
up their results. I'm not sure that this assumption is valid when testing
is no longer anonymous, but linked to notification, which in my opinion,
would lead to an increase in discrimination (either felt or enacted).
I agree that many people are not willing to be tested, or if tested,
would not return for their results. This has occurred in many countries,
both developed and less developed. Where I differ with others is accepting
this situation. I feel that it is important that people know they are infected
and that their long-term sexual partners know as well. I also feel that
public health professionals should help infected persons and their partners
address the disease, helping them to avoid further transmission.
testing, it seems unlikely that a substantial proportion of married couples
would use condoms on a regular basis. Thus without testing, the other partner
will probably become infected. Such transmission would no doubt occur with
testing, but hopefully if public health and medical professionals provide
good advice, would occur at a lower rate.
Finally, I agree that discrimination
is a major problem for HIV infected persons. To address this issue, I have
long favored strategies to normalize HIV, and in the past four years have
included specific details for health professionals throughout the region
in the HIV/AIDS policy workshop my colleagues and I conducted at Chulalongkorn
University. Normalization is not just a good thing to do because it helps
HIV infected persons. It also is a good thing to do because it opens the
door to more extensive testing, which should create epidemiological benefits
for the society.