Re:Are we ready yet for health care provider initiated testing?

[Guest guest]

An open letter to Dr. B.B Rewari, Sr. Physician, RML Hospital & National

Programme Officer (ART), National AIDS Control Organisation

New Delhi 110001. Re: Call for Consultation on HIV Counselling and Testing

Policy in India

/message/7160

Dear Dr. Rewari,

This is with reference to your posting - " Are we ready yet for health care

provider initiated testing? " on AIDS India e-forum on 19th April 2007

questioning existing policy on HIV testing (presumably of Voluntary Counseling

and Testing or VCT) and suggesting a shift towards provider initiated testing

and counseling (PITC). As civil society representatives aiming to secure a

rights based response to HIV in India, we acknowledge and share your concerns on

expanding access to anti-retroviral treatment (ART) for people living with HIV.

At the same time, we are apprehensive about the 'solution' that you propose and

seek wide ranging and effective consultation before introducing any change in

National HIV Testing Policy.

Your posting refers to UNAIDS/WHO support to routine HIV testing as a

justification for PITC in India. It is important to bear in mind that

UNAIDS/WHO move towards PITC has evoked debate and disapproval since its

inception. The UNAIDS/ WHO Policy Statement of 2004 advocating 'routine offer of

an HIV test met with stiff resistance from health and human rights quarters.

Activists cautioned against testing model(s) that override individual rights to

informed consent, confidentiality and counseling.

Last year, at the International AIDS Conference in Toronto, PITC remained the

most contested topic. Notably, many Botswanans (the country that has routinised

HIV testing in medical sites) acknowledged that PITC " hasn't exactly worked that

way " [1]. Although the number of pregnant women receiving HIV testing has

increased, the 'success' of routine testing is undermined by significantly

lesser number of women returning for their results.[2]

Further, without anti-discrimination remedies, people living with HIV

reported losing jobs after being 'routinely tested for HIV'. Some warned of

adverse consequences on disempowered persons including pregnant women, sex

workers and injecting drug users, who are unable to exercise rights in clinical

settings.

Evidently, international opinion on HIV Testing, particularly on PITC is

extensively divided. We, in India, cannot be impervious to such debates

especially since the above mentioned conditions are pervasive in our country.

Earlier this year, civil society groups voiced these concerns in an open letter

to WHO and UNAIDS. Criticising the WHO/UNAIDS Draft Guidance on PITC in Health

Facilities (November 2006) and the lack of consultation in developing them,

signatories called for its immediate withdrawal and an open, transparent

discussion on HIV Counselling and Testing. A response to the letter is still

awaited. According to WHO's public update, the above guidelines are still being

finalsed.

At a time when international norms are themselves unsettled, NACO's move towards

PITC in India is objectionable.

Notwithstanding the disagreement, we would like to point out that UNAIDS/WHO

recommend routine HIV testing in countries with generalised epidemics.

India, as you know, is epidemiologically characterised as having low HIV

prevalence overall. Thus, not only the urgency' but the 'need' for

introducing PITC in India is itself questionable. Furthermore, UNAIDS/WHO

advise that attempts to expand HIV testing must be accompanied by concrete

measures to enhance care and treatment and reduce stigma and discrimination.

As of now, lack of second line HIV treatment, persistent stigma and absence of

anti discrimination legislation lets down any claim for India's readiness for

PITC.

As you have yourself observed, health seeking in India is often unduly

influenced by fiduciary relationships between provider and patient; a fact

recognized by the human rights compliant VCT model. In this context, any policy

that may shift the balance of power further away from the patient to provider,

will unquestionably compromise free and informed consent for HIV testing raising

doubts about its legal and constitutional validity. This is especially true for

women, who rarely make health related decisions. We fear that PITC in ante-natal

care will further erode women's rights and autonomy.

While appreciating your call for a debate on HIV Testing policy, we urge you to:

* Make public the draft 'new' policy on HIV Testing that you have

referred to in your posting, and;

* Hold wide ranging consultations to discuss efforts to expand rights

based HIV Counselling and Testing among other interventions for prevention, care

and treatment with people living with HIV, community based organisations of sex

workers, men having sex with men and injecting drug users, medical workers,

lawyers and others that contribute to the HIV response.

We look forward to your response on this critical matter.

Lawyers Collective HIV/AIDS Unit

_____

[1] Adam Graham-Silverman, " IAC: Botswana, Don't You Wanna Get Tested? "

Available at http://www.poz.com/articles/401_10068.shtml . The article quotes

comments from Botswanans on PITC in practice.

[2] Stuart Rennie & Frieda Behets, " Desperately seeking targets: the ethics of

routine HIV testing in low income countries " , Bulletin of the World Health

Organisation, January 2006, 84 (1). Available at

http://www.scielosp.org/scielo.php?pid=S0042-96862006000100014

<http://www.scielosp.org/scielo.php?pid=S0042-96862006000100014 & script=sci_a

rttext> & script=sci_arttext

Tripti Tandon

Lawyers Collective HIV/AIDS Unit

63/2, 1st Floor, Masjid Road,

Jangpura, New Delhi - 110014

Phone - 011-24377101, 24377102, 24372237

Fax - 011-24372236

E-mail - <mailto:aidslaw1@...>

[Guest guest]

Dear FORUM,

I think it is a little premature to initiate a debate on Provider Initiated

Testing and Counseling (PITC) guidelines, when WHO and UNAIDS are in the process

of finalising the guidelines for issue some time after the World Health Assembly

session in May 07.

In the Asia Pacific Region, WHO UNAIDS and UNICEF have taken the initiative to

organise a regional consultation on counselling and testing which also includes

PITC. This Consultation will be organised in Phnom Penh ,Cambodia from 4 to 6

June,07 with participation of Govenments and civil society partners from the

region. This should provide an appropriate forum for frank exchange of views on

some of these misgivings on PITC and their relevance and applicability to low

and concentrated epidemic countries.

I suggest we should wait for an organised consultation like the Phnom Penh

one,and the issue of finalised guidelines by WHO and UNAIDS, before launching

another debate on this important and sensitive issue.

Prasada Rao,

Director RST UNAIDS,

Asia Pacific Region,

Bangkok

e-mail: raojvrp@...

[Guest guest]

[Moderators note: Moderator would like to comment on Dr B B Rewari's

willingness to engage in a policy dialogue with the wider stake

holders through AIDS INDIA e FORUM. A mechanism and willingness to

listen to a regular policy feed back is an essential element of an

effective HIV response. Many of the Indian bureaucrats are notorious

in their disregard to the policy feedback from wider public. in this

context Dr B B Rewari's approach is a refreshing change. He

responded many of the policy and program concerns of access to ART

services in many parts of the country, articulated through this

FORUM. This is particularly, commendable, when some of the agencies

are trying to stifle the voice of ordinary stake holders, who are

willing to voice their concern through this FORUM. On behalf of about

5,000 subscribers of this FOURM, I would like to say, THANK you

Dr .Rewari. We need people like you at the helm of HIV response in

India.]

_________________________

Dear All,

Ref: /message/7160

I have only started a discussion to get the views of people with

different background but involved in HIV care. This is not an

official discussion from NACO. The concerned unit at NACO may decide

at an appropriate time to have an official national consultation or

may not have any change in policy. The purpose of this discussion is

to share my experience and some thoughts and queries on the issue as

a care provider for PLHAs. It is always helpful to get to know about

views of others. It gives some food for thought and enlarging ones

own vision on such issues on which differences are bound to be there

between planners, care providers, human right bodies and PLHAs etc

Dr B.B.Rewari MD,FICP,FIACM,FIMSA

Sr.Physician,Dr RML Hospital & National Programme Officer (ART)

National AIDS Control Organisation

New Delhi

e-mail: <drbbrewari@...>