HIV treatment as prevention – a short postscriptPosted on March 27th, 2009 1 comment
My last post was published about 30 minutes ago. Within minutes I received my copy of the Lancet. There were about eight letters in response to the article I had referred to which presented the mathematical model of the outcome of an initiative to test and treat every infected individual as a means of ending the epidemic. It is reassuring that most expressed reservations regarding the assumptions on which the model was based, and in general about its feasibility. The Lancet issue containing these letters is: The Lancet Vol 373, March 28, 2009.
Only one letter emphasized the ethical problem concerned with treating people who do not need to be treated themselves, for the good of the public.
This was the point I concentrated on in my recent post, and in my own letter in response to the article. The potential hazards of treating individuals with higher CD4 cell numbers, where there were no proven benefits to be had were referred to by others.
Despite these welcome responses, I believe it is likely that attempts to advance this idea of universal testing and treatment of all infected persons will proceed.
As a project it will get nowhere. But there is another consideration that is propelling it. There is a political constituency that has been advocating mandatory universal HIV testing almost since the test became possible.
We should be doing all we can to encourage individuals to be tested. But absolutely not to the extent of enforcing tests. The views of the AIDS pioneers referred to in the previous post unfortunately can provide some spurious ammunition to those who would like to see mandatory HIV testing in place.
Our efforts should be concentrated on finding ways to encourage individuals to be tested. What obstacles are there in different communities that discourage testing? How can we remove them? Some are quite obvious and probably apply to all communities, such as stigmatization and problems with access to care.
The following may seem counter intuitive, but the removal of written informed consent which ostensibly should facilitate testing, may actually be less effective in this respect than encouraging testing with written informed consent. Removing written informed consent can be seen as implying that HIV disease is not serious, a view that might well make anyone suspicious of an authority that presents this opinion, no matter how indirectly.
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