Thursday, February 3, 2011

Increase Testing, Find Out What is Really Driving HIV Epidemic in South Africa

There is a debate in South Africa about whether schoolchildren from 13 up should be tested for HIV. Some are opposed to testing, apparently claiming that children "may not be psychologically prepared to deal with a positive result or the stigma likely to follow". But the point of pre- and post-test counselling is to psychologically prepare people for getting the test and finding out the result.

This may be more difficult in the case of younger children. But that doesn't make it any less necessary. The alternative is to wait until symptoms appear, by which time treatment will be more difficult and the risk of serious illness and even death are increased. If found to be HIV positive, people can be monitored and treated as and when treatment is required.

South African health services may not have the capacity to treat all those who are in need of treatment. But they need to test as many people as possible to assess what exactly their needs are. Even if they can't give everyone the level of treatment they require, those who are not tested won't get any treatment at all.

The fact that, as one teachers' union representative points out, even parents are afraid to be tested, is not a reason for not trying to increase the numbers of people being tested. People have been filled with notions about HIV in Africa being transmitted almost exclusively by promiscuous behavior, which means that HIV is still highly stigmatized, even after thirty years of research showing that it is not solely spread sexually and it is not primarily a matter of individual responsibility.

But teachers, teachers' unions and others should be aiming to reduce stigma, not accepting it as inevitable. They may be correct in claiming that the government is trying to make up the numbers for their exaggerated claims about how many people they were going to test in a short space of time. Certainly, testing large numbers of children, who may be seen as easy targets, is a very cynical way of achieving projected figures.

However, countries with high HIV prevalence need to test more people, especially younger people. There are three reasons, the first being that people have better health outcomes if the disease is caught early.

The second is that testing early should help to work out how people are being infected. For example, some will have been infected by their mother, some will be sexually active and some will not fall into either of these groups. People who are neither sexually active nor infected since birth will need to be investigated carefully to find out exactly how they are being infected.

Nosocomial infection is very likely to be responsible in many instances. Failing to identify such sources of new infection and failing to do anything about them will result in continuing high rates of HIV transmission in South Africa and other countries where similar failures occur.

The third reason for testing as many people as possible is that HIV prevalence among young people is a useful proxy for HIV incidence, the yearly rate of new infections. Incidence is very hard to measure but without such measurements, it is difficult to predict how the epidemic is going, whether it is increasing or reducing.

Being able to treat infected people is only one good reason to test as many as possible. Finding out what is driving the epidemic is, arguably, even more important. Far more people are at risk of becoming infected than are already infected. One of the aims of HIV policy in South Africa needs to be to prevent new HIV infections, not just to passively identify those already infected so they can be treated accordingly.

Young people, especially young girls, are those most at risk of being infected with HIV. That harsh reality is a lot better than the reality of being HIV positive. If people are still afraid to be tested then the South African Government needs to challenge global HIV policy, which denies that a significant amount of HIV transmission could be non-sexual. If South Africa, with the largest HIV positive population in the world, is not prepared to stand up to this erroneous claim, who will be?

Unfortunately, a lot of young people will be identified as HIV positive even though they have never had sex. And they will not all have been infected by their mother, who may not herself be infected. Not all HIV positive young South Africans are being infected sexually so it needs to be made clear how they are being infected. Only then can the South African epidemic be successfully tackled. The less involvement from UNAIDS and the HIV industry, the better.


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