Intended for healthcare professionals

Education And Debate

From exceptionalism to normalisation: a reappraisal of attitudes and practice around HIV testing

BMJ 1998; 316 doi: (Published 24 January 1998) Cite this as: BMJ 1998;316:290
  1. Kevin M De Cock, visiting professor of medicine and international healtha,
  2. Anne M Johnson, professor of epidemiology (
  1. a London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. b Department of Sexually Transmitted Diseases, University College London Medical School, London WC1E 6AU
  1. Correspondence to:Professor Johnson
  • Accepted 27 November 1997


Since recognition of the first cases in 1981, AIDS has been handled differently from other infectious diseases. Recently, therapeutic interventions that influence the clinical course and perinatal transmission of human immunodeficiency virus have become available.1 2 3 In this paper we argue that earlier and more widespread diagnosis of HIV infection will be required for these interventions to fulfil their potential.

Origins and nature of HIV/AIDS exceptionalism

At the start of the epidemics in the United States and the United Kingdom, men who have sex with men argued when HIV/AIDS was first recognised—with the support of civil liberties groups, physicians, public health officials and others—for policies that differed from a traditional infectious disease control approach.3 4 5 6 This strategy has previously been termed “HIV/AIDS exceptionalism.”3 Clinical confidentiality and anonymised surveillance systems were emphasised, and informed consent was strengthened. The use of HIV antibody tests, when they became available, was restricted in a way not seen previously for other diagnostic investigations. This initial response, based on concerns about abuses of civil rights, was influenced by the vocal involvement of members of affected communities in the science and politics of HIV/AIDS (AIDS activism).

Exceptionalism initially had a limited effect on clinical care because treatment had only a modest influence on prognosis. The issue of generalised antenatal testing in women retained a low profile because women accounted for a minority of people in industrialised countries infected with HIV. Concerns about discrimination and compulsory testing dominated debate at a time when the only measures to prevent transmission to infants were termination of pregnancy or avoidance of breast feeding.

Normalisation then refers to treating HIV/AIDS more like other infectious diseases for which early diagnosis is essential for appropriate therapeutic and preventive measures, within the requirements of informed consent and respect for confidentiality.

Recent advances in HIV/AIDS

A number of recent scientific …

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