You can have no test which is not fanciful

What should we be doing to encourage people to have an HIV test? According to even the most optimistic estimates, less than 10 percent of those living with HIV in Indonesia are aware that they are infected, and many are dying of AIDS undiagnosed. Does this matter?

Most would say yes. With treatment available now, we could save these deaths. Or could we? The health system is overwhelmed attempting to care for 20,000 or so people with HIV; how would they cope with 200,000? The drug supply chain is collapsing (regularly collapses) under the strain of supporting less than 10,000 on antiretroviral therapy; how would it cope with ten times that number? And of course, who would pay?

So when we again hear the experts telling us that voluntary testing must be replaced with a system whereby the doctor just refers any patient for an HIV test, I get a little worried. Apart from anything else, the Provider Initiated Testing and Counselling (PITC) system is still supposed to be voluntary: people are automatically referred to a Voluntary Counselling and Testing (VCT) service. The opponents of PITC reject it mainly because they fear that people will be coerced; telling us that the voluntary system must be replaced confirms their fears.

Actually, nobody seems to agree on what PITC means. My understanding was that it was supposed to mean that, if a patient has symptoms or behaviour patterns that could suggest possible HIV infection, the doctor should automatically refer the patient for VCT (some would suggest that this should be the case anyway). There is disagreement over whether the standard VCT would apply; some would replace individual pre-test counselling with mass provision of information.

But it is clear that the proponents do not stop there. They want to see HIV testing being done in the same way as tests for diabetes or dengue fever. Just send the patient to the lab with 'HIV' ticked on the list of tests (incidentally what was done with my partner back in 1991). They agree that there should be post-test counselling, but they gloss over how this should be done. They also ignore the fact that, despite what 'we' all say, post-test counselling is usually a waste of time. As soon as the counsellor utters the word 'positive', the client usually hears nothing else. Or if the word is 'negative', the same is true, if for different reasons.

Even worse is the fact that, no only is the medical profession unready to treat all these people, it is not even ready to accept them. We still hear almost daily reports of doctors who will not touch people they know are HIV-positive, who propose 'universal' precautions only for those known to be infected, and who discriminate against such patients. Many nurses are still scared to death of AIDS, perhaps reasonably given the attitude to universal precautions and infection control, and the frequent lack of any protocols on post-exposure prophylaxis.

We should definitely do a better job of promoting VCT. But we need to do a lot more than just case-finding.

Babé