August / September 1994
Face-Off: Easy Access to Testing is Not Enough
by Jim Graham
Effective counseling and follow-up care are essential
Even as we struggle as a nation to find ways to improve health-care, advocates for home HIV testing tell us that we really can settle for something less: Telephone diagnosis of this potentially life-threatening disease will be just fine.
Stripped to essentials, frequently heard arguments for telephone HIV diagnosis go something like this: Current test counseling isn't all that great -- with the exception of a few testing sites -- so this can't make it that much worse. Then you'll hear them say, this is going to happen anyway, so le's make the inevitable as good as possible. As any debater knows, this latter argument is particularly skillful, because it gets you thinking that something is going to happen, like it or not. The first argument assumes that we've already lost the battle for quality, so what the hell.
Nonsense. A bad idea doesn't become good simply because it may be inevitable. And we can make things better by improving the quality of HIV diagnosis counseling.
Without the benefit of one-on-one counseling by trained professionals, the increased risk of severe psychological trauma and suicide for individuals who discover their positive HIV status is very real.
Competent pretest and posttest counseling reduces the level of misinformation, myths and fear surrounding HIV, resulting in minimal psychological trauma. Even a negative HIV test result requires careful delivery. Printer matter in a test kit is not a substitute for pretest counseling. Those who test negative, but do not receive adequate pretest counseling, particularly regarding the "window" issue (the six week to six month period following exposure to HIV when antibodies may not be detected in the blood), could be placed at greater risk.
There is another argument: That telephone HIV diagnosis will be good for disadvantaged populations, since they'll have access they don't have now. This may be just another bill of goods for poor people.
Let me illustrate. In the District of Columbia, over a recent three year period, the National Institute of Drug Abuse funded a research project in one of the most disadvantaged areas of our city, a place called Anacostia. For 36 months, an almost exclusively African-American population was tested, ostensibly to find out whether knowledge of antibody status would positively impact risk reduction behaviors. That thesis was neither proved nor disproved. What did happen was that more than 130 people were diagnosed as being HIV positive. Thereafter federal dollars and the research project pulled out, leaving these individuals with their test results.
Was access to early medical intervention improved? Sadly, no. And the same is likely to happen with many of these home tests.
What about youth and other vulnerable individuals? Will the overbearing parent or spouse or employer be able to pressure an individual into being tested against their will? When we asked that question of one drug company representative, he said he hadn't thought of that.
I'm not saying the advocates aren't well intended. But, with disturbing frequency, if you scratch the surface of this support you find not only principles but also drug company dollars. Money for this nonprofit or that magazine or one well-placed agency or another seems to have helped grease the path.
But, if you've got reservations about home testing, then expect the backside of the corporate hand: Yanked donations and advisory committee appointments and harsh personal attacks.
There are no quick fixes to the real obstacles preventing access to effective HIV counseling and testing and adequate follow-up care. HIV home testing will not begin to solve the problems of the lack of culturally competent testers, well-equipped test sites and adequate follow-up care.
Click here to read the companion article, "Face-Off: Access Should Be Our Primary Concern".
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