At present, testing for HIV can only be done at the client’s request and with his/her consent. Recently, the WHO issued guidelines enabling a shift from client-initiated testing to HIV testing recommended by healthcare providers if they find it necessary. Does this make sense in India, which does not have the resources to test millions, asks Ajithkumar K

Recently, the World Health Organisation (WHO) and UNAIDS released a document, Guidelines on Provider-Initiated HIV Testing and Counselling in Health Facilities. This document has provoked strong reactions on the feasibility and acceptability of shifting from client-initiated to provider-initiated testing.

When stigma and discrimination against HIV were the norm and no treatment was available, the knowledge that a person was HIV-positive meant ostracism, denial of healthcare, education and job opportunities, and even death. For this reason it has been internationally accepted that people should be tested for HIV only with their informed consent. They must be made aware of the consequences of the test. The request for the test should come from them, not from the provider.

However, this principle has not been practised uniformly. Client-initiated testing has not been the norm in many communities. Many healthcare professionals subject their clients to all those tests and procedures that they consider necessary, without their consent. One reason is that they fear the disease being transmitted from patient to provider, apparently unaware that standard infection control procedures prevent such infection. It is also a fact that healthcare institutions do not make provisions for uniform infection control precautions against all infections. Nor are providers assured post-exposure prophylaxis following needlestick injuries. The problem is compounded by the shortage of voluntary counselling and testing facilities, inadequate training and sensitisation of healthcare workers and the inertia of the system to adapt to emerging challenges.
 
Client-initiated testing strategies too are not completely free of problems. Surveys in 12 high-burden countries in sub-Saharan Africa showed that a median of only 12% of men and 10% of women in the general population had been tested for HIV and received the results. This indicates that client-initiated testing programmes have failed in detecting the vast majority of infected individuals, effectively denying them prevention and treatment services.

Global commitment and resources to combat the HIV pandemic have increased markedly in recent years. Thanks to the efforts of various international agencies, there has been a rapid scale-up of care and support mechanisms in the developing world in the last few years. With the advent of effective treatment which can suppress the virus effectively and give the infected person a prolonged and quality life, AIDS has become a chronic manageable disease, especially in affluent countries. It is therefore argued that we need to detect as many individuals as possible and early in the infection in order to treat them effectively.
 
What is provider-initiated testing?

This shift makes the healthcare provider responsible for initiating testing. The new guidelines suggest different approaches for scaling up and detecting HIV testing according to the local context:           

• Regardless of the type of epidemic in that community, the healthcare provider should recommend HIV testing to patients who show features suggestive of HIV infection, children of HIV-infected mothers, children with suboptimal growth, and men seeking circumcision.
• In a generalised epidemic (if resources are available), healthcare providers should suggest HIV testing to all clients who seek care, regardless of whether the patient shows signs and symptoms of underlying HIV infection, and regardless of the patient’s reason for approaching the health facility.
• In concentrated and low-level epidemics, healthcare providers should recommend testing for all clients with signs and symptoms suggestive of underlying HIV infection, including tuberculosis, and to children known to have been exposed perinatally to HIV.
• Such recommendations should be made with proper and detailed pre- and post-test counselling, with special components for special groups like adolescents and children. The test may be repeated every 6-12 months in high-risk groups.

The WHO guidelines state that the proposed changes are due to the success of patient- initiated testing in various countries in making use of this opportunity for systematic testing and care. This guideline also discusses the details of testing strategies, techniques and programmatic details and plans to scale up testing.

What does this change mean?

Many apprehensions have been raised about this shift in strategy:

We are able to provide standard testing to a limited number of people and are still expanding and standardising our voluntary counselling and testing centres. Do we have the facilities to test each of the millions of patients who attend healthcare facilities?

Do our resources allow us to test millions of people when the majority of these tests are going to be negative? Is it right to spend resources to test all inpatients when there are no basic facilities especially where the prevalence of the disease is not very high, as in sub-Saharan Africa.

The new guidelines are proposed in the context of a healthcare system in which universal testing (without consent) rather than universal precautions, is the norm. People who test positive, especially in private hospitals, face discrimination. We are yet to introduce comprehensive legislation on HIV and the mechanisms to implement existing guidelines effectively. The proposal for provider-initiated testing is already misinterpreted by many as a mandate for mandatory testing even though it clearly does not recommend mandatory testing.
 
It is estimated that the majority of the estimated 2.5 million people with HIV in India are unaware of their infection. We still need to make drugs available for all those who have tested positive and need treatment. If we increase the number of testing facilities without increasing access to treatment and mainstreaming care, what are we going to do for newly detected HIV-positive people? Should we not scale up care and support facilities before this shift in strategy?

In our overcrowded healthcare facilities, doctors get barely a few minutes per patient, too little even for basic care. Can we expect them to provide pre- and post-test counselling even if we train them?

There is an unequal power equation between care givers and the ill. Patients’ rights are not respected in the same way as they are in the West. How do we ensure that those who opt out of testing are not discriminated against, especially where HIV care facilities are not available?

If provider-initiated testing is started without adequate preparation and sensitisation of care providers it can inhibit groups with high-risk behaviour from approaching care facilities.

The HIV epidemic is an opportunity for us to recognise many things that we did not acknowledge before. This includes the right of patients to be part of decision-making regarding their own health, to fight for their own wellbeing, to be involved in policy decisions about their own health. This epidemic is unlikely to have a vaccine in the near future. HIV has actually brought patients’ rights to the fore. We are learning how to balance the community’s interest and individuals’ rights in the fight against this modern-day scourge. If we shift to provider-initiated testing without preparation, we may lose the opportunity to go forward and generalise the lessons we have learnt from HIV.

Of course, we must experiment in scaling up HIV testing, treatment and care. But we should be careful in each step forward. We do need to scale up testing and treatment facilities. We need to detect as many individuals as possible. It is imperative to have a national discussion on this issue and fine-tune the guidelines as suggested by the WHO and UNAIDS document itself before we start advocating them for the entire country.

Reference

http://www.who.int/hiv/who_pitc_guidelines.pdf

(Dr Ajithkumar K is a dermatologist with a special interest in HIV/AIDS-related problems, particularly mainstreaming care and support)

InfoChange News & Features, January 2008