iClinic - July 12, 2000
Marjolein Harvey
In a debate at the AIDS2000 conference in Durban on Wednesday, David Miller of the UNAIDS Department of Policy, Strategy and Rsearch, argued that voluntary counselling and testing (VCT) is an important point of access to services, aiding surveillance systems, prevention and education efforts even in resource-poor areas.
"None of the examples of VCT benefits in African countries had anything but the most basic forms of treatment - antiretrovirals were not an option," said Miller, adding that knowing one's HI status led to significant behaviour changes.
New UNAIDS studies in Africa show dramatic increases in demand for VCT when the services are made accessible, affordable and secure to those people who want to know their own HIV status.
"National household level and family planning surveys in Kenya, Tanzania and Zimbabwe have shown that around 60% of adults want to know their HIV status, while 15% or less have had access to VCT," according to a US Agency for International Development fact sheet.
Medical anthropologist with extensive experience in working with people living with HIV/AIDS (PLHAs) Joe Thomas, however opposed Miller in the debate by saying that in resource-poor settings HIV testing should not be promoted as a public health policy.
"I wish I could give you good news, but I have reviewed the literature, talked to healthcare providers and PLHAs and added my own experiences in delivering HIV programmes in resource-poor settings and the news is bad," said Thomas.
He argued that HIV test results do not provide yes or no answers, unlike other health diagnostic tests. "Yes may mean 'possibly' and results may depend on what tests are used [rapid HIV testing, Elisa or a combination]. Finally, the implications of HIV test results are so much bigger than medical," said Thomas.
Other problems with HIV testing in resource-poor settings according to Thomas are that there is little confidentiality of test results and already discrimination and rights violations of HIV-positive people is already especially prevalent at rural healthcare settings.
Thomas also seemed to align himself with the main finding of the Presidential AIDS panel that the Elisa test needs to be reassessed. "HIV tests are imperfect technology, research on tests takes place in different contexts from the reality of HIV and for which subtype are tests meant: HIV-1, HIV-2, A to O?" asks Thomas.
Another problem he pointed to is that a poor person generally has to make two trips: for the test and for the confirmatory test, losing two days of income.
Most people, both in resource-poor settings and in developed countries, never even come back for their test results, according to Thomas. "In the US, 25 million HIV tests are done every year [1995 CDC figures] - the testing industry is obviously a multi-billion dollar industry - and 25% of people who tested positive and 33% of people who tested negative did not return for their results. I am glad that the US can afford to do that," says Thomas.
He says that the intention to test is not always motivated by risk behaviour - marriage plans for example may be behind applying for a test - and testing is sometimes promoted as a prevention strategy in resource-poor settings because the healthcare worker only has a limited role in treatment.
The test provides a medical answer to a social problem and testing is often initiated by the healthcare worker just to satisfy a curiosity. He concedes that testing has some benefits: it may promote health-seeking behaviour, protect a partner, help assess the safety of having a baby or helps refer people to support services if they are available. But most tests need to be refrigerated, and this is often not available in resource-poor settings.
"Testing is not a prevention strategy - it is a diagnostic tool. There is limited scope for testing in resource-poor areas but VCT should be available on demand. VCT should be offered as a key component of a package of education and information, healthcare and support facilities and the creation of an enabling environment, in the context of human rights," says Thomas.
Following the debate, some members in the audience gave their input.
An NGO AIDS Free Africa representative: knowledge is key in the fight against AIDS - not knowing one's HIV status is playing with fire. Anyone claiming that HIV tests are inaccurate is talking nonsense. Governments and other groups working with HIV/AIDS cannot plan without testing, but tests are expensive - what about donor countries also focusing on tests? An African Midwife Research Network representative: pregnant women who come to antenatal clinics obviously did not have safe sex - not testing these women is denying her and her partner the right to life. To offer voluntary testing is more a western concept - in Africa, people come to healthcare workers and expect things to be done to them, to make decisions with healthcare workers is a foreign concept.
A healthworker from Malawi: rapid test kits can solve the problem of people not coming back for their results. The lack of confidentiality claim is an insult to healthcare workers in rural resource-poor settings.
A healthcare worker from Zimbabwe: VCT is promoted with almost religious zeal by NGOs and pharmaceuticals. But I see the suffering related to VCT: people who have had their test and have been counselled well are then left to their own devices and the stigma around HIV still exists. US public healthcare workers have vowed under oath not to do any harm, but nobody has ever assessed whether VCT may have potentially harmful outcomes.
A rural KwaZulu-Natal worker: I want people to get tested because it allows people to take responsibiliy for their own health.
An Indian paediatrician: Where I come from 150-160 mothers are seen by four doctors every day - pre-test counselling is an impossible workload.
A Zimbabwe healthcare worker: people have to pay $5 for the test and the transport to get there - with earnings of $25 per month this is an impossible financial burden. How can we get international donors to assist with antiretrovirals if we cannot even get funding for this little?
A South American healthcare worker: I support VCT but it is difficult in practice. So we assume that everyone is positive unless proven negative. We ask the world to forgive the debt burden. When antiretroviral treatment is made available by pharmaceuticals, donor countries and governments, only then will we aggressively promote people to get tested. Right now, the result of the test is merely a death sentence.
A US test manufacturer: tests are trustworthy and FDA-approved. AIDS is a silent killer - we can't deal with it without the knowledge provided by tests.
Dr Costa Gazi: we have a denialist president. Our main battle is to change attitudes and to change him. In SA, we do not do any HIV screening of pregnant women in antenatal clinics. I represent AID Babies Battling AIDS Trust and we urge that pregnant women get HIV tests to empower them through counselling, even if antiretrovirals are not available. We provide short course treatments in my hospital illegally and face imprisonment for that.
US Centre for Development Population Activities: neither speaker addressed gender issues. The impact of testing on men or women is very different and a negative test result does not say much about your status six months from now.
A young woman living with AIDS in Africa: I was tested HIV-positive in Zimbabwe in 1998, I weighed 34kg then and am proud to say I am up to 45kg now. Once I knew my status I had the opportunity to learn to live with it.
If I had not gone for that test, I would be dead now.
A Health Systems Trust representative: VCT is a diagnostic tool, not preventive. Confidentiality and discrimination in the rural context are real prblems and rural people are afraid to go for testing because of this.
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