Re: Are we heading towards mandatory HIV testing?

April 8, 2008

Dear all,

We were discussing this issue few months back.

I have a feeling that the HIV politics is changing over the last few years.It

was a disease of the oppressed ,marginalised and a disease with no treatment.

It had many unique features to it . It was a modal for those who were fighting

for the existence.

we thought it will be a reason for our health care system to change, a reason

and modal to fight against the existing economic and political scenario in the

health.

But universal free ART ( just like any other empowerment ) removed all those

unique features from HIV and it is just another chronic illness now.

Hence we may not be successfull in using this epidemic as a tool for a change in

the right direction. The policy makers and the funding agencies are very clear

about the directions in which they should go.

what ever we discussed in the earlier discussions were already discussed in

various fora much before that discussions and it didn't make any defence in

accepting PITC as the strategy.

I think in the coming days, HIV will be seen as another disease --probably

little better in that status because of better funding and better salary till it

looses its charm.

Dr Ajithkumar.K

Trichur

--

Dr Ajithkumar.K

Asst Professor In Dermatology and Veneriology

Medical collge Chest Hospital

MG Kav,Trichur, Kerala, India

Ph 04872333322 (res)

9447226012

E-MAIL: <ajisudha@...>

April 9, 2008

Dear FORUM,

Are we heading towards mandatory HIV testing? This is in response to Dr Rajesh

Gopal's comments on this forum

Re: /message/8667

Being a professional counsellor and a counselling supervisor and after working

in the HIV/AIDS setting for a number of years, I find in the HIV setting - the

word counselling has a different meaning it is 'telling people to test because

it is good for them' and the counsellor is 'someone who tells people what to do'

a sad reality in most of the ICTC settings. The counsellor seems to be employed

because it is politically right.

I conduct several trainings, workshops etc and I find that counsellors very

often repeats the advice that a doctor or someone in authority asks them to and

because it is coming from the counsellor it is " counselling " .

Recently in a meeting with out reach workers they tell me that they tell

positive people what to do just like the counsellor does. But when it comes from

the counsellor " it is counselling " and there was so much resentment because the

counsellor gets paid more than them and does the same job except from a room!

This being the scene in most settings, there are some policy makers who argue –

Why do " pre test counselling " why not just do a great " post test counselling "

for those who are positive. Provider initiated testing therefore seems to be a

logical step in the current scenario.

As a country we do not do mandatory testing; provider initiated testing has no

place in my opinion. Unfortunately we seem to be allowing funders to decide

policies to be practiced in this country.

Funding always comes with strings attached so for those who are in the policy

making position it is a difficult decision to make – to be lead into believing

what funders say (which in the current situation seems true) or take a stand for

what is difficult but is right. which is Strengthen our counselling services.

Advocate for quality counselling

A trained counsellor would tell you that post test counselling begins before

testing is done. It is next to impossible to do a great post test counselling

without pre test counselling. What we currently do in post test counselling for

positive people is mainly damage control and the counsellor has to try and

assess

Is the client is contemplating suicide, Is he or she prepared to tell his or her

partner orspouse. How is he or she going to handle stigma or discrimination. Is

he or she in denial about being positive. Check for mental illness What being

'positive' means to this individual and so much more. in a few minutes

If a good pre test counselling is done, then most of the above issues are

addressed and if and when the client turns positive, what he or she needs to do

becomes logical steps. In other words doing 2 or 3 sessions as pre test

counselling is better than doing one poor but politically correct post test

counselling session.

The same could be said for Adherence counselling – Doing 3 to 4 sessions before

patient starts ART is much better than damage control counselling and rushing

them to 2 nd line drugs and after that what is?

Many issues need to be addressed before starting on ART

Financial status, family status, job, understanding what is ART Is his/ her job

going to interfere with timely ART? Does he/ she understand 1st line 2nd line

drugs? Drug resistance? Who do they contact and what should one do if they

forget to take the medicine What is the family situation? Is spouse/ partner

Positive? Is he or she on ART Are children positive? Are they on ART?

Very importantly are they having an alcohol addiction problem

Unfortunately, even today none of these issues are addressed. The only criteria

for ART seem to be - the CD4 count.

And every counsellor in the ART center will tell that a number of patients on

ART are still having a serious alcohol problem and have a poor understanding of

what is means to be on ART. Starting ART just like the PIT is initiated by the

doctor and not by the patient.

There is some information on ART and its side effects but making the decision

if the person wishes to take ART is not done. We seem to be in a rush to start

people on ART because we have the ART and now the 2nd line drugs.

If something goes wrong in other words if the person refuses ART or if the

person does not want to test it is looked as bad counselling. Counsellor is not

efficient. We are quick to blame the counsellor.

Provider initiated Testing and Provider initiated ART is against the principle

of counselling (unless the counsellors are trained in crisis counselling or

brief therapy) where we believe in the ability of each individual to make

decisions regarding their own lives.

Counselling empowers people to make choices. Counselling has to be pro active

not damage control. PIT may work in countries where people are assertive, know

and exert their rights. Where there is a support system or not looked down upon

by the community and families. We are still gappling with helping people be

assertive to make decisions regarding their own health and their own lives.

Especially for women - Decisions are made by the husband, in law, extended

families, their employer and in this case the doctor.

I maybe wrong - I think we have 26 million women giving birth every year so PIT

means taking away the rights of all those women to make a choice about testing

and what is going to happen to their lives if they test positive. Do we have a

system where we could support all these women if and when they get thrown out of

their homes?

To go back to Quality Counselling:

1. Consistent training for counsellors – not just a 12 day training and forget

about them. But, every 2 or 3 months a 2 day refresher training which will

address some skills and some issues coming up during their counselling We have

counsellors who got recruited in 1999/2000 who have only received a 12 day

training in their entire career in the ICTC.

2. Support by providing 'Counselling Supervisors' – Supervision of counsellors

not by doctors/ engineers or others who are highly trained and are efficient in

their own professions but by counselling supervisors who are skilled in

counselling.

PIT will work only where is some sort of gender equality, people are treated and

respected as individuals rather than in our setting where everyone is part of a

large family or community. We to wok on something that works for us. Discussions

with women's groups, PLHA groups, MSM groups, TG groups will help.

Sorry this mail is very long. Please feel free to write your comments/ views on

any of the issues I have raised.

On a lighter vein I feel 'counselling' and 'counsellor' has to be rescued and we

need advocacy for 'counselling' in the same intensity as people who are

stigmatised because of HIV.

Magdalene Jeyarathnam

Founder/ Director - Center For Counselling

18 Radhakrishnan Salai, 9th Street,

3rd Floor, Mylapore, Chennai 600 004

www.centerforcounselling.org centerforcounselling.blogspot.com

email- magdalene@...

telephone - 044- 42080810, mobile - 9884100135

April 9, 2008

Dear forum,

Re: /message/8667

Yes , slowly we are heading towards a slippery slope of mandatoriness which

could compartmentalise communities into two categories-- HIV- positives and

right- now- taken -for -granted HIV- negatives.

I think what Dr. Rajesh gopal means by " primodial " prevention of HIV is

really primodial prevention of poverty. But that is not a priority of clinicians

to embark upon.

They have to work for early detection ,early treatment and secondary prevention

efforts.VCTC and ICTC datas prove that 99 percent HIV POSITIVES were diagnosed

by physician initiated testings through their routine recommendations. Voluntary

direct walk -in utilisers of VCTC could be less than 1 percent. Voluntary

clients could be improved by removal of stigma for which all these bandwagon of

NGO'S were working for all these 25 years.

Physicians initiated testing of their patients not for their protection alone

but for the protection the patient, and his significant others and so called

presumptively hopeful HIV negatives or never tested timids and moralisers.

DOCTORS presribe a test upon clinical evidence base and mandatory tests are

done only at blood banks and in ICTC , a mandatory testing is done only for

antenatal mothers and that too could be considered scientifically rational.

Routine presurgical testing presriptions are common which are not however

entertained in ICTC set up. However such testing has detected many positives and

they were surgically treated too in most instances .

While other situations like employment screening which is mandatory has no

clinical rationale but only political irrrationality.

When will we able to consider HIV disease as a normal communicable disease,

where early diagnosis and early treatment is the motto like any other

communicable disease and HIV testing is done only with clinical evidence and

physician initiation ?

Dr.Umesh

District Hospital, Pathanamthitta, Kerala

E-mail: <ummusen1957@...>

April 13, 2008

Dear FORUM,

NACO had started a campaign inviting people who have no problems to come forward

and get their HIV status tested at VCTC, through advertisements in daily papers.

I had written about such unscientific method earlier as well.

I do not know whether due to that or otherwise the ads stopped. But during a

recent visit to Guwahati I found the posters were received from NACO at the

local centre advising expectant mothers to get their HIV status tested. This

again is uncalled for, and is unethical.

I wonder whether ICMR has been consulted, and ethical clearance obtained.

I think mass testing of HIV should be put to a stop to safeguard agianst spread

of blood and body fluid transmissible diseases, including HIV, as disinfection

and proper disposal of injection waste cannot be ensured.

This method to increase requirement of testing kits benefiting the MNCs is a

dangerous trend for our society, and should not be allowed.

I shall be writing to the DG Naco, separately.

Thanks,

Air Mshl Lalji K Verma, AVSM (Retd)

MBBS, M Sc (E & E), psc, FRSA

President, ISHWM

253, AFNO Enclave, Plot-11, Sector-7, DWARKA, New Delhi 110075.