Testing key to curbing AIDS pandemic - Holbrooke

(18 March 2005)

BEIJING - Better testing is the key to fighting the global AIDS pandemic, Richard Holbrooke said on Friday in Beijing, where he was in town to encourage Chinese businesses to play a role in stopping the spread of the disease.

The former ambassador to the United Nations who now heads the Global Business Coalition on HIV/AIDS also had harsh words for the World Health Organisation, saying its emphasis on providing anti-retrovirals was misplaced when most of those with the disease did not know they were infected.

"The failure to test is the weakest link in the policy. If testing is not encouraged, AIDS will become, worldwide, the ultimate weapon of mass destruction," he told a news conference.

Holbrooke praised China's efforts to fight AIDS, saying the SARS outbreak in 2003 had been critical to changing central government's attitudes toward the disease by highlighting the economic consequences of allowing its spread.

He had harsher words for the WHO's "3 by 5" initiative to provide anti-retroviral therapy to 3 million people with HIV/AIDS by 2005, saying it was an advertising slogan that could not be fulfilled and that just 800,000 had been reached to date.

"Even if they did get to 3 by 5, they wouldn't catch up with the spread. The only way to get there is with testing," he said.

POLITICAL SENSITIVITY

WHO officials in Beijing were not immediately available for comment.

But Holbrooke's emphasis on testing highlights the problems remaining in China, where, despite high-level shows of support, prevention is still hampered by social stigma and political sensitivity.

Holbrooke said testing should be carried out routinely for patients undergoing operations, couples getting married and for pregnant women, but he acknowledged compliance with such a policy would be difficult without guarantees of confidentiality.

That presents a challenge for China, where the government was slow to acknowledge the epidemic and says it has fewer than 1 million cases -- a figure many AIDS organisations say is a gross underestimate.

At the highest levels, the government's attitude has changed.

"The government will further enhance legislation on prevention and treatment and invest additional resources in this work," Health Minister and Vice-Premier Wu Yi said.

"I hope Chinese businesses will take advantage of the growth of their companies to ... take steps to harness and develop workers' enthusiasm for this cause," she told Friday's forum, aimed at harnessing business resources and skills to fight AIDS.

Her comments followed the lead of President Hu Jintao and Premier Wen Jiabao, who have both visited hospitals to shake hands and chat with AIDS patients.

But China has also been criticised for not holding any local officials accountable for a blood-selling scandal involving state-run health clinics, and journalists who travel to the countryside to report on the disease are routinely detained.

"China is at a crossroads in the fight against AIDS," Holbrooke said. "They're either going to stop it and strangle it, or it's going to spread."

By Lindsay Beck (Reuters)

Source

From VCT to ‘routine testing’?

Why we should oppose a return by stealth to the days of mandatory HIV testing

It is time to raise the alarm about HIV testing. In addition to fighting HIV and AIDS, we now must return to an issue that many of us thought had been settled years ago: voluntary versus mandatory testing.

No-one who believes in enhancing treatment access can question the need to scale up HIV testing. The expression “routine testing” has been often used at the XV International AIDS Conference to describe this. On the surface, it may seem perfectly reasonable to choose the word “routine” to describe a procedure that is to be done systematically in a health setting.

However, given the past history of the responses to HIV/AIDS, there is an ominous subtext taking form. Early in the AIDS epidemic, members of affected communities and human rights activists argued that the HIV test must be voluntarily, because consent was central to encouraging testing and creating a climate of confidence and mutual trust between the person tested and service providers. Most public health professionals eventually recognized this.

The mounting pressure towards making HIV testing mandatory was curbed at that time. HIV testing with pre- and post-test counselling, often referred to as VCT (voluntary testing and counselling), became a central part of the global response to HIV/AIDS.

The experience of the last 20 years has clearly established that VCT remains the approach of choice to enhancing HIV/AIDS prevention, care and treatment, and today no one would dare claim mandatory testing in the health-care setting is an acceptable option. But with increasing frequency in recent months other terms have begun to creep into the dialogue gradually overshadowing VCT – most notably “routine testing.”

Why does this matter? Because the vagueness of this term hides the underlying intent and a range of practices, some of which with greatly damaging potential.

Much of the momentum behind the shift in terminology can be attributed to the urgency of scaling up access to antiretroviral (ARV) treatment throughout the world in particular where coverage of VCT remains low. Since many of the people who could benefit from ARVs do not currently know their HIV status, an enormous testing campaign must accompany any scale-up efforts. However, the rhetoric of “routine testing,” obscures a central issue – whether HIV tests are being routinely offered or routinely imposed, and whether in either case the individual has a true informed choice to opt in or opt out of being tested.

“Opt in” testing commonly refers to a situation in which patients are offered an HIV test by the service provider and make an informed decision to be tested. “Opt out” testing refers to a situation in which patients are systematically given an HIV test unless they take the initiative to decline.

If the world of HIV is to move forward we cannot afford vagueness in such critical concepts surrounding the key entry point to ART scaling-up. While every effort should be made to increase the practicality of VCT, the principle of voluntariness remains central to sound public health practice.

HDN Key Correspondent
Email: correspondents@hdnet.org

(July 2004)