Thursday, October 6, 2011

HIV Testing: Health Services Lack Integrity, Not Legislation

Making HIV testing mandatory in all health facilities is said to be under consideration by Kenya's National Aids Control Program (NASCOP). Mandatory testing is not currently permitted under Kenyan law. However, people seem confused about what is currently permitted, some people thinking they have to comply with whatever a health facility worker requests and others thinking a test is mandatory under certain circumstances, such as pregnancy.

Mandatory testing is being mooted because voluntary testing has not allowed the country to reach its stated target of 80% of people knowing their status by 2013. But it seems unlikely that requiring people to take a HIV test before receiving treatment for various conditions other than HIV in health facilities will increase the numbers of people testing. It may even result in fewer people seeking health services, including HIV testing and counselling.

It will be very hard now to claw back years of ground lost by insisting that 80-90% of HIV is transmitted through heterosexual sex in African countries. But this is what will have to be done to reduce the stigma that still surrounds the virus. It is this very insistance about African sexual behavior that gives rise to the stigma.

Health providers may worry that people will lose confidence in them, and indeed they may. But continuing to lie about sexual transmission and refusing to investigate the relative contribution of non-sexual transmission to HIV epidemics will not help to solve the problem. If health services are to be trusted, they have to find a way to reverse the years of dishonesty. Making HIV testing mandatory, and especially arguing for it on the basis of the same old lies, will be counterproductive and dangerous.

Many of the problems that arise for large scale health programs, including the extremely well funded HIV related ones, stem from a lack of sustainability. Several countries have run out of drugs at various times. Most lack the capacity to monitor for drug resistance, loss to follow up and various other problems. If more people are tested under current conditions, sustainability will be further reduced.

Similarly heavy handed attitudes have resulted in wiespread confusion about the benefits of condoms and the possible side effects of hormonal contraception. Health services often seem to be unable to follow up on initiatives they start, for example, providing adequate counselling, treatment, care and even food and transport to health facilities for HIV positive people. Another dubious health issue is that of concurrency, which has been widely discredited, although it never had much empirical support.

Male circumcision rollout in Zambia appears to be a perfect example of why people may mistrust large health programs, especially ones relating to HIV and sexual health: "A large minority of participants (30% of adults and 45% of boys) gave incorrect answers to one question; they believed that getting circumcised was risk-free and did not have side-effects."

The best way to reduce stigma and allow people to feel less apprehensive about being tested for HIV is to come clean about the relative contributions of sexually and non-sexually transmitted HIV; we don't yet know the relative contributions. Investigating possible outbreaks of healthcare transmitted HIV would go a long way towards reducing people's fears, which may be quite legitimate.

Health and social services also need to be able to guarantee that people found to be HIV positive will receive the treatment, care and support they need, which can include protection from stigma and discrimination. And health facilities have to be able to provide services that don't themselves carry a higher risk of transmitting HIV than various kinds of sexual behavior. There's a long way to go to regain people's trust, but now is the best time to start if we want more people to be willing to find out their HIV status.