August / September 1994
Face-Off: Access Should Be Our Primary Concern
by Martin Delaney
People are not using current testing options
The discussion of home HIV antibody testing is not a debate about whether testing should be accompanied by counseling. Of course it should, and the home testing process being proposed includes a mandatory, competent and highly consistent counseling mechanism. Nor is it a debate about the quality of testing currently being made available to people in a variety of settings. Most such testing services already do a fine job. There are two principal questions here: (1) whether most people are actually using the existing text counseling services, and (2) whether there is anything wrong with people having an additional personal option about how to access testing and counseling.
The CDC reports that the majority of Americans being tested (56 percent) received no pretest counseling, while 68 percent reported no posttest counseling. This is a disaster. Moreover, 17 percent report that they are already receiving their test results by phone, while 14 percent are receiving them by mail -- ostensibly with little or no counseling. There is a great deal of room for improvement. There is no question that many community service organizations provide excellent testing and counseling services, and they will continue to do so, unhindered by access to any new options. But for most people this is simply not the vehicle of choice for getting tested. For whatever reasons, a great percentage of the population is simply getting blood drawn by physicians, which guarantees nothing in the way of counseling or follow-up services. The hope of a well-designed home-testing service is to provide an option of simplified, confidential testing which incorporates a professional and consistent counseling process, as well as a referral to additional resources and support services.
For some people having a face-to-face encounter with a stranger is simply not an attractive option for talking about HIV testing and counseling. There are many people who are far more comfortable discussing sensitive matters by phone. Examples of this phenomenon include the popularity of radio talk shows, AIDS hotlines, phone sex and crisis counseling -- all of which have been found to be very attractive for many people. Many AIDS hotlines not designed for test counseling are already supporting a great number of recently tested people, simply because callers find it easier to talk about the issues by phone. People are just different, and we should respect their diversity. For some, a well-designed home testing and phone counseling program will be a welcome option which will make it easier to get tested and easier to talk about it.
It's true that home testing cannot solve all problems. There are conceivavle, if remote, ways to abuse such a program, but this is a problem which can be solved, not an insurmountable obstacle. Also home testing and phone counseling cannot guarantee that high risk people will get ongoing risk reduction messages. But there is no such guarantee with face-to-face counseling either. And, as the CDC data shows, most people are already opting out of the loop of on-going counseling.
We should not be in the business of trying to tell people how to get tested. We should be creating options and alternatives which are sufficiently attractive and which meet personal preferences in order to increase the opportunity for testing. Rather than attack a new approach such as home testing, we should put our energies into making sure that the programs that are approved are the best programs of their type, offering the most professional and consistent counseling messages possible. Beyond that, this becomes a matter of personal choice. Not everyone wants or needs government to tell them how to run their lives, whether the question is sexual behavior or HIV antibody testing.
Click here to read the companion article, "Face-Off: Easy Access to Testing is Not Enough".
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