Rapporteur report
Track C: Biomedical Prevention report by Nick Walsh
The session focused on the benefits and risks of scaling up provider and client initiated HIV testing.
The World Health Organisation WHO/UNAIDS Guidance on Provider-Initiated HIV Testing and Counseling in Health Care Settings were outlined by Kevin de Cock. In general HIV diagnosis occurs later than is necessary in both the South and North. Testing strategies must take into account the dynamics of the local HIV epidemic.There should be an expansion of client initiated HIV testing (VCT) and a scale-up of provider initiated testing and counselling. WHO/UNAIDS does not support mandatory HIV testing apart from in organ and human tissue donation.
The US Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings (2006) were presented by Bernard Branson and lessons learned discussed. Importantly routine, voluntary HIV screening for all persons aged 13-64 is now recommended in US health care settings, not based on risk and that separate signed informed consent should not be required. A number of examples were given. The latter issue (informed consent) is believed to have increased rates of testing in San Francisco. Rapid testing in emergency departments improved the rate of results provided and allowed those positive to access an HIV treatment service within a median of 18 days. In a Chicago hospital it was noted that clients having provider initiated testing were ‘sicker’ than those seeking testing themselves (client initiated). High rates of voluntary uptake after counseling were observed. Opt out screening in an emergency department in Washington DC was seen as acceptable by clients. In effect, streamlined and rapid testing programs appear to have increased HIV testing uptake and are acceptable.
Stigma continues to impede our ability to tackle HIV across the world. Justice Michael Kirby from Australia argued the necessity of reducing the ignorance, xenophobia and legal barriers that continue to affect PLHA. Although we need to increase HIV testing, we need to keep in mind the human rights of those who are being tested. Stepping up testing has to occur in the context of scaling up supporting measures to combat stigma. Justice Kirby emphasized the importance of adhering to the fundamental principles of international law and reminded the audience of the mandate of the United Nations to uphold the human rights of people across the world.
Any HIV testing program or policy must take into account the needs and rights of patients. Promise Mthembu from South Africa, spoke from the perspective of PLHA. Does provider initiated testing compromise the rights of individuals and contribute to stigma? Whose agenda are we actually serving? What about the fact we cannot meet treatment demande for those that test positive? What about the psychological harms of testing, particularly when those who are already marginalised test positive? Will this further marginalise people? Promise Mthembu finished by calling for advocates of testing to advocate for women’s rights; for WHO to advocate for testing to live up to the principles of human rights in health; for WHO to document rights lost as a consequence of testing into order to combat stigma and discrimination; and for WHO to approach testing through the lens of human rights.
Much of the session was high level and so it was fitting the session ended with Sheri Weiser’s presentation reviewing provider initiated HIV testing in Botswana - an example of a high prevalence country which recently increased testing substantially. In a 2004 cross sectional survey of almost 1300 clients of HIV testing programs, some of the barriers to HIV testing were being afraid to know HIV status, that clients had no reason to believe they were infected and that a positive test would mean they would need to change their sexual partner. Correlates of testing were higher level of education, more frequent visits to medical practitioners, and being female. In general routine testing was viewed as acceptable though the most common negative experience was feeling that one could not refuse a test. Routine testing has resulted in a higher rate of testing at the population level and earlier HIV diagnoses. Despite this, men are less likely to be tested, and 10% of those surveyed were concerned about confidentiality.
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