Are we ready yet, for Health care provider initiated HIV testing?

[Guest guest]

Dear Forum,

Re: /message/7160

Provider-initiated testing violates human rights principles, especially so in a

country like India. The doctor is 'God' and whatever they say is swallowed whole

by most patients, whether literate or not, rich or poor alike. This basically

means that provider initiated testing can never allow the client/patient to make

an informed choice about whether or not to test. It amounts to coercion. As has

been argued time and again, any form of mandatory testing for HIV is against

human rights, in the face of rampant stigma

and discrimination associated with HIV & AIDS, whether it is pre-marital testing

or otherwise.

Imagine a situation where a woman goes for a gynaecological exam and the doctor

offers an HIV test to her. She will very likely agree without being completely

aware of the consequences of testing or those of being diagnosed HIV positive.

We all know that women are beaten, thrown out of the home, wrested away from

their children, blamed, etc. for being HIV positive. Provider initiated testing

will only lead to more such cases of violence against women.

If I go to a doctor for a health problem with, say my mother or husband, and

this service provider offers me an HIV test, what will be the reaction of my

mother or husband (considering patient confidentiality is anyway a joke in this

country)? They will want to know why it is being offered to me. What is it that

I have been 'up to' that the doctor wants me to get tested?

Whether or not I turn out to be HIV positive, I will have to face stigma and

suspicion by virtue of being a young woman.

Studies and testimonials across the country have shown the stigma and

discrimination prevalent among health service providers, let alone the 'common

person'. In such a situation, will service providers refuse to treat people who

turn out to be HIV positive after availing of provider initiated testing? And

who will the service providers offer HIV testing to? Everyone they see? Or will

they make judgements about who it should be offered to? What does this do to

'non-judgemental attitudes' towards health service seekers?

The email by Dr. Rewari mentions that service providers will offer HIV testing

to 'people who are likely to be at the risk of HIV infection'. Who exactly are

these 'people'? Sex workers? Men who have sex with men? Injecting drug users? Or

housewives? Who is it that we are talking about when we say 'likely to be at

risk of infection' and how is a health service provider qualified to make that

analysis?

Will they start asking clients / patients about their sexual histories?

Universal access does not mean that you start coercing all and sundry to test

and get onto ART if they require it. Universal access means that the Government

upholds its responsibility towards the citizens in making testing (with

appropriate pre- and post-test counselling) and ART freely available, affordable

and accessible. Dr. Rewari also writes that 'Even when Anti retroviral Treatment

is available, many do not access to such treatment'. We need to examine the

reasons for this and not make the simplistic assumption that many do not access

ART simply because they do not know.

There have been enough testimonials on this Forum about the many problems with

the ART delivery system, including shortage of medicines, high costs of CD4

tests, etc.

HIV is exceptional, which is why it has spawned such a large effort worldwide,

to tackle it. Because of this exceptionality, more than 20 years of work has

proven that a public health approach to HIV is not the appropriate one by

itself. A rights-based approach is imperative with relation to HIV. The sooner

we all understand that, the sooner we will be able to live in a world that does

not discriminate on the basis of HIV status (at the very least!), gender,

sexuality, sexual orientation, profession, caste or class.

WHO and UNAIDS only want their figures to look good, after abysmal failures like

the '3 by 5' initiative.

Let’s not allow them to coerce us into taking decisions that would be

counter-productive to the long campaign against HIV & AIDS.

“Women are not dying because of diseases we cannot treat...they are dying

because societies have yet to make the decision that their lives are worth

saving.” Dr Mahmoud Fathalla, Professor of Obstetrics and Gynaecology, Assiut

University, Egypt

Regards,

Arushi

Arushi Singh

E-mail <dawnlion@...>

[Guest guest]

Dear Forum,

This is in response to the posting 'Are we ready yet, for Health care

provider initiated HIV testing?'

First of all, seems to me there is an assumption that:

Because ART is available all PLHA will take it.

I am sure we have all come across many PLHA who have decided not to

take ART even if they fall under the 'eligible category', for various

reasons, some have decided to just postpone ART. Therefore, even if we

make HIV testing a routine we just cannot make ART a routine for all

PLHA. So, just knowing one's status for the sake of giving ART does

not seem to be a good reason why EVERYONE needs to be subjected to HIV

testing as a routine.

I agree that we must address the issue of encouraging more general

population to test for HIV. We could have TV/ Radio/ IEC messages that

encourages people to test or think of strategies that encourages more

and more people to test voluntarily. Many pregnant women are coming to

the ICTCs in Tamil Nadu with their spouses after hearing the TV/Radio

messages about HIV testing for pregnant couples. This testing for

everyone could be on a campaign mode.

The focus on the posting was on 'expanding' reach of the various

programmes rather than addressing the actual need of the community. If

we think, we must get more people to test, then we must develop

appropriate strategies which sensitively creates the need for more

people to test voluntarily.

With due respect to the UNAIDS/WHO policy, do we need to be

pressurised to work according to that policy? or could we develop a

policy that works for us?

A discussion/ debate with different people especially with those working as care

providers in HIV care for the last 10 - 15 years in India could share their

experiences and expertise.

Care providers such as those working in the grassroot level like

CBOs, NGOs, counsellors, outreach workers etc, are the key.

NACO must develop a policy only after this discussion.

Magdalene Jeyarathnam

Director

Center For Counselling

Chennai

Tel: 9884700174/ 9884100135

e-mail: centerforcounselling@...

<magdalene.jeyarathnam@...>

[Guest guest]

Dear Forum

Re: /message/7160

This is in response to the several posers Dr B.B.Rewari MD,FICP,FIACM,FIMSA,

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

Control Organistion had posted in the forum. Our responses are posted here:

Q 1. Is the concept of Provider initiated testing relevant for India?

It is relevant to the extent that it is already being practiced on a large scale

for all ailments requiring invasive procedures. But we are sure HIV cannot be

put in the same bucket as the rest and needs different process owing to the

continued prevalence and practice of stigma and discrimination. Many people have

innocently shown us the tests the doctor had asked them to undergo before

surgery and HIV is invariably one of them. It is irrelevant in as much as we

cannot guarantee 100% ARV coverage.

Q 2 Are we ready for it now?

In the context of continued insensitivity of the healthcare providers and their

obduracy to follow procedures of informed consent, confidentiality etc., we feel

efforts must first be initiated to bring the topic under larger public debate

and deliberations which may create an environment of preparedness, and then

there is no need to answer this question at all. Till then the answer is a very

emphatic no. Who are " we " ; the community or the data consumers?

Q 3 Are we not already doing it in practice because in our country whatever

doctor says is followed by patient. So in a way it is already provider initiated

or provider suspected, though it has

element of pre test counseling in it?

This question needs to be divided into two parts and answered. First if doctors

are already " doing it " they are not acting ethically, and need to be sensitized.

Professionals should not resort to questionable means of satisfying data hunger.

If we believe this practice is ethical, then we need to look no further.

Second, it is not just a matter or pre test counseling that is an element here.

There are human rights issues involved. What about informed consent, and

confidentiality? Finally, would the healthcare provider produce report of

*his/her* HIV status to the patient?

Q 4 Is this going to decrease the stigma as the testing will be in a way

normalized to some extent?

If all ethically questionable practices are tolerated merely on the grounds of

that it has always been practiced, it leads to uncomfortable questions.

In any case the argument that an ethically questionable practice can be

tolerated because it might reduce stigma is unsound.

Q 5 will it increase the number of positives detected and increase the

coverage by ART as presently patients do not even know that they are

infected and may need ART?

Sure it will. Mere detection of PLHAs is not an answer in itself. Out of the 5.2

lakh (10% of total estimated PLHAs) PLHAs in the country requiring ART, we are

able to provide it only to 47,000 PLHAs. Out of this lot, there is apparently a

dropout rate of approx 20%. So what is the big deal in identifying more people

requiring ART without being able to dispense it?

It will show a definite rise in the number of people living with HIV. Is it what

we want? Then, we can make it mandatory for all Indian citizens to take a HIV

test. Why wait till they get into the healthcare setting? That will increase the

number 100 fold.

I feel the idea of healthcare initiated testing is a violation of human rights

and if permitted would simply legitimize the violations already happening and

increase data consumption.

Regards

R. Meera, S.V. Sreeram

Women's Initiatives (WINS)

Tirupati

Meera Raghavendra

e-mail: <rmeera102@...>

[Guest guest]

Re: /message/7160

Dear FORUM,

Let me try to compile my views on Provider initiated testing:

As I have warned about this in an earlier mail few months back I was expecting

this when United States changed their testing strategy. If we were to change to

PIT it would have happened long back in early 1990s and this have not yet

changed much as far as a common average Indian is concerned.

Q 1. Is the concept of Provider initiated testing relevant for India? Q 2 Are we

ready for it now?

Provider initiated test is relevant for India but providers are not yet ready

for that. When ever our providers are ready to defferenciate provider initiated

testing and provider forced testing we will be ready to take it up as a

strategy.

Q 3 Are we not already doing it in practice because in our country whatever

doctor says is followed by patient. So in a way it is already provider initiated

or provider suspected, though it has element of pre test counseling in it?

HIV is an opportunity to change what all un acceptable practices we were doing

in the areas of resource allocation, universal precaution, planning, training of

health care professionals, human rights,

If we miss this opportunity we will never improve. The only reason why we spend

out resources and emotions on HIV is hat it is a historic opportunity to

improve.

Q 4 Is this going to decrease the stigma as the testing will be in a way

normalized to some extent?

Universal availability of test and treatment will but not PTC

Q 5 will it increase the number of positives detected and increase the coverage

by ART as presently patients do not even know that they are Infected and may

need ART.

To early to think in that line as we couldn’t cover those who are known to be

positive? A sudden increase in number may affect the efficiency of program.

Dr Ajithkumar.K

e-mail: <ajisudha@...>