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Exceptionalism in HIVChallenge for Africa tooPast experience has been ignored

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7147.1826 (Published 13 June 1998) Cite this as: BMJ 1998;316:1826

Challenge for Africa too

  1. Peter Godfrey-Faussett, Senior lecturer,
  2. Rachel Baggaley, Consultant (baggaleyr{at}who.ch)
  1. London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. Unit of AIDS and Sexually Transmitted Diseases, World Health Organisation, Geneva, Switzerland
  3. Dunure, Wigtown, Wigtownshire, DG8 9DZ

    EDITOR—The 24 January issue on antenatal HIV testing emphasised the need to promote routine voluntary HIV counselling and testing to maximise the opportunity for interventions in those found to be infected. More than 20 million of the 30 million people estimated to be infected with HIV at the end of 1997 live in sub-Saharan Africa, where some spend less than $15 (£9) per capita on health each year and over 90% of those infected are unaware of their infection. The opportunities for the medical interventions discussed are therefore limited.

    Nevertheless, although individual benefits may be small, the potential benefits for society are huge. HIV/AIDS “exceptionalism” in parts of Africa has led to an environment of stigma and denial, with the tacit support of policy makers and healthcare staff. HIV is rarely entered in African death certificates, yet treatment decisions are made on the assumption that a patient is infected. Half of those counselling others to consider HIV testing choose not to be tested themselves.1 Fewer than half those tested feel able to tell their sexual partner that they have been tested, whatever the result.2 Many people assume that they are infected and that testing would merely increase despondency. Only 7% of couples invited for counselling and testing in Lusaka decided to have a test.3

    Normalisation, as defined by De Cock and Johnson, would be an important step in improving the environment for preventing HIV transmission.4 However, to maximise the impact of HIV testing on prevention it needs to be promoted earlier. Women attending antenatal clinics provide an opportunity for screening. However, if anti-retroviral drugs are not available and if strong financial, cultural, and public health considerations make avoiding breast feeding difficult, the distress and anxiety caused by discovery of a women's HIV seropositivity when she is already pregnant may outweigh the benefits. Promotion of voluntary HIV testing for young people before they are pregnant or sick would offer greater chances of preventing transmission.

    Among clients of TASO, the largest AIDS support organisation in Africa, the most commonly cited advantage of being tested was access to the centre's basic medical service.5 In Lusaka, the most common reason for declining a test was that no medical intervention was available.3 Prophylaxis against tuberculosis is beneficial to HIV positive people even in areas of high tuberculosis transmission. Thus, relatively small and low cost improvements to the care and support offered to HIV positive people could enhance demand for testing and help to bring HIV back to normality in Africa too.

    References

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    Past experience has been ignored

    1. M F Brewster, Retired general practitioner
    1. London School of Hygiene and Tropical Medicine, London WC1E 7HT
    2. Unit of AIDS and Sexually Transmitted Diseases, World Health Organisation, Geneva, Switzerland
    3. Dunure, Wigtown, Wigtownshire, DG8 9DZ

      EDITOR—De Cock and Johnson propose the “normalisation” of current HIV testing practice, which they describe as “exceptionalism.”1 This description of the past flagrant disregard of epidemiological and ethical principle sounds impressive, and the authors go on to state that this policy of exceptionalism had the support of, among other groups named, “physicians.”

      The fact is that many doctors disagreed with BMA resolutions on HIV testing policies, which defied common logic and morality. Clear issues of disease management were obfuscated by unethical and irrelevant arguments about citizens' legal, civil, and personal rights. Rational thinking fell prey to vocal lay pressure groups. Emotive expressions such as horrible disease, fatal illness, social stigma, employment threat, insurance risk, informed consent, and other newly coined phrases became grounds for advising patients not to have HIV tests in case the result was positive. Legal “experts” pronounced on hypothetical situations never contested in court. Doctors seemed frightened into forgetting that less than half a century ago syphilis, gonorrhoea, tuberculosis, and smallpox were horrible, unpleasant, and (except gonorrhoea) commonly fatal diseases without known effective drug treatment.

      The tried principles of our predecessors were ignored, and the authors rightly mention that the legal matter of responsibility for all this may now become a matter of negligence. This country has untraceable women citizens who have tested HIV positive. There are counselled people who have refused tests and may be HIV positive. Spouses, partners, and others are at risk, and babies, lacking effective drug protection, will be born HIV positive. The public will soon perceive the immorality of using anonymous antenatal blood samples for obtaining central government HIV statistics. Changes must be immediate.

      HIV testing should become routine for antenatal clinics. Counselling should be reserved for HIV positive patients. Similar testing should become routine at all sexually transmitted disease clinics.

      This country is fortunate that HIV has proved less infectious than at first was feared. Britain could have had a major public health problem. Before marrying in America many years ago, I required a certificate of negative syphilis serology. My wife, during pregnancies, was neither asked nor counselled before she was tested for syphilis in Britain. Ian Grant's prophetic letter in 19882 should be reprinted.

      References

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