By, The Sunday times, June 3, 2007The existing voluntary system protects no one, simply deferring individuals’ facing of the truth to when they are already ill and the effectiveness of treatment compromised, writes Francois Venter
The hospital antiretroviral clinic I work in is easy to access, has a very short waiting time and is free, yet the wards in the hospital are filled with people dying of Aids who discovered their HIV status only at admission
South Africa needs a new HIV testing policy. The current model — voluntary counselling and testing, which relies on initiation by the client — is well intentioned but deeply flawed.
It is failing and has failed throughout the world.
In an era where the government has committed itself to treating people with HIV/Aids through its ambitious new National Strategic Plan, we should not accept an HIV-testing policy that permits the majority of South Africans to continue their lives without recognising their risk of HIV infection.
HIV now accounts for half of all deaths in the country. Yet South Africans remain in hopeless denial of their individual risk. Aids denial by senior leaders has obscured the fact that they are joined by almost the entire population: only 2% of South Africans test for HIV each year.
Self-perception of risk is very poor. More than two- thirds of those who tested positive for HIV in a recent large survey by the Human Sciences Research Council (HSRC) reported before the test that they had no risk factors for the virus.
HIV is not a death sentence any more, nor does it attach only to small, already marginalised groups of society; it is an everyday disease of people who have sex. But somehow that message has failed to get through.
The voluntary counselling and testing model emphasises choice and free will. It allows people to delay the choice to test, often until that choice is pre- empted by severe illness, pregnancy or insurance sales people. This has proved fatal for the majority of people with Aids, and consumed massive state resources.
As a clinician, I see huge numbers of people tested when they are severely ill, and when the use of antiretroviral drugs is far more complex and less effective.
The hospital antiretroviral clinic I work in is easy to access, has a very short waiting time and is free, yet the wards in the hospital are filled with people dying of Aids who discovered their HIV status only at admission.
HIV is treatable — current drugs can provide more than 30 years of life or more if started in time. Testing early also allows for the development of support structures, understanding of the complexity of integrating treatment into everyday life, planning for the future and initiation of treatment before the person actually gets sick.
The emphasis on voluntary counselling and testing has allowed individual autonomy to trump public health, regardless of the consequences to broader society.
In the US, it is estimated that those who do not know their status (about 25% of the infected population) account for more than half of all transmissions of HIV. Ignorance fuelled by a denial of risk allows people to put their sexual partner(s) at risk. By contrast, those who know they are HIV-positive take more proactive steps to protect others.
A new universal policy in South Africa could insist on regular testing for healthy adults, either through incentive-linked systems (every well-resourced South African gets tax rebates if having tested that year, or a ‘bonus’ addition to a grant if depende nt on social security) or as an obligation (evidence of a recent HIV test would be required for engagement with any bureaucratic structures in South Africa).
Another possible solution is an “I know my HIV status” certificate issued by approved counsellors at regular intervals. The certificate would not record the HIV test result, simply that the person knows and understands that result, with a date.
The regularly updated certificate may be required for the issuing of all official documents (identity books, drivers’ licences, bank cards, tax submissions, social grant applications) and processes (membership of medical aids, applications for new jobs and university entrance, marriage, continuing to receive a social grant or pension).
The process would normalise testing across all economic levels and, while resource-intensive, would place the onus on the individual and away from healthcare personnel.
This approach respects confidentiality, would enable early diagnosis and intervention, and would allow infected people to plan their futures and their healthcare.
Supporters of the existing system of voluntary counselling and testing argue that the low take-up of HIV-testing is due to the fact that available testing services are dreadful, and that dramatically improving these services would automatically attract large numbers of testers.
The argument does not take into account the HSRC research that shows that most people have a poor perception of their own risk. Why would someone make their way to a testing centre if they did not think there was the possibility of their having HIV?
Opening a host of counselling and testing centres all over the country will not in itself increase testing, given that research shows that access to testing facilities does not seem to be a problem. The HSRC survey found that more than three-quarters of respondents knew of a testing site “nearby”.
Finally, more than 90% of those who had accessed voluntary testing graded their experiences as good to excellent; suggesting that client satisfaction with existing services is high.
Defenders of voluntary counselling and testing suggest that better education about HIV testing would increase the number of testers. But claims that HIV transmission is a disease of ignorance ignores the population’s everyday experience of other repercussions of sex, such as pregnancy and sexually transmitted diseases, as well as the fact that HIV is a common experience in South African life and in the media.
My patients seem to be well informed about Aids and testing, from sources as diverse as church to the TV drama Isidingo. Surveys, too, indicate high levels of knowledge and few pervasive myths about HIV in South Africa.
The most common reason given in the HSRC survey for not testing was the respondents’ belief that they could not possibly be infected. More education is unlikely to solve this.
A number of proponents of HIV-testing models other than voluntary testing have recommended that all people who enter the health system be informed that an HIV test will be conducted on them unless they expressly refuse it — so-called routine opt-out testing. Regrettably, this system will not reach healthy people but will instead focus on those who are already ill or pregnant.
Libertarians and human rights advocates emphasise that the state should not interfere with individuals’ decisions about their health, and that making testing universal would violate autonomy and choice — the “right not to know”.
Yet there are many instances where the state imposes benign legislation to assist with individual and public health. It legislates around a range of issues for the individual’s own good: seat belts are compulsory, smoking is restricted and there are moves afoot to force all South Africans to save for retirement and to contribute to medical aid schemes.
Legislating that you need to know your HIV status for your own good has a precedent.
Finally, everyone with HIV gets to know this eventually. By ensuring the right not to know we simply defer this discovery — and diagnosis — to the Aids stage, when someone is at their most vulnerable.
It should be acknowledged that HIV testing is a first step, not an end in itself. People with the virus still need to be able to enter the country’s system of care, a system that does not always function well.
The model of universal testing will compel the state to expand radically the HIV-testing facilities, possibly far beyond the narrow access in healthcare facilities, as well as dramatically scale up and improve HIV care services and human resources to accommodate the increased demand due to increased awareness.
It will be a very necessary allocation that will save our country the huge consequences and financial burden of a preventable and treatable disease.
We have had 20 years of a failed voluntary programme. We should transform it by urgently finding a way to make regular HIV-testing universal.
Dr Venter is clinical director at the Reproductive Health and HIV Research Unit and honorary lecturer at the Steve Biko Centre for Bioethics, both at the University of the Witwatersrand, and president of the Southern African HIV Clinicians Society. He writes in his personal capacity
Source: http://www.suntimes.co.za/PrintEdition/Article.aspx?id=481394
