Lesotho introduces door-to-door HIV test

They will approach people at the small stone houses where they live in the mountains, in the industrial zone factories where they stitch Gap sweaters, the churches where they go to mass and the mess halls where soldiers eat. Lesotho is calling it ‘Know Your Status,’ an initiative of the government and the World Health Organisation. Modelled on mass immunisation campaigns such as those for polio, the HIV testing effort will cost $12.5-million (U.S.), most of which has yet to be raised from international donors, and run until the end of next year. Organisers hope it will resolve one of the stickiest problems of responding to AIDS in Africa: the stigma and fear of the disease, which is still so great that many people don’t get tested. Parents won’t take sick children for HIV tests, and even doctors and nurses fail to suggest testing for the most obvious AIDS patient, out of a desire to protect “confidentiality” or to avoid the implied shame. It is estimated that 265,000 people, or one in three adults in Lesotho, are living with HIV-AIDS and 50,000 are already so sick they need antiretroviral treatment. But only 72,000 people have ever been tested for HIV, even though the government has been committed, since 2004, to providing free ARV drugs to those who need them. The Ministry of Health says that just 12 per cent of women and 9 per cent of men know their HIV status. The Lesotho campaign will rely on HIV tests that produce results in minutes. These are cheap, about $2 a test, and use a finger-prick of blood rather than a syringe, so are more easily administered by lay people. Studies show that a third to half of people don’t come back if they must collect their test results days or weeks later. Community members will be asked to decide themselves how they wish to be tested ‘ whether, for instance, they want to be tested by residents of the village or by outsiders to preserve confidentiality. Key to the plan is the idea that no one will be offered testing without a full range of counselling, support, prevention and care options being available, whatever each person’s diagnosis. “The brilliance of Know Your Status is what’s embedded is that you cannot be more aggressive or proactive about asking people to get tested unless both treatment and prevention are in place,” said Jim Yong Kim, the former head of the AIDS directorate at the WHO, now a director for the medical aid agency Partners in Health, who helped pilot the plan. Lesotho’s plan recently won the praise of former U.S. president Bill Clinton, whose charitable foundation is a major player in the world of AIDS care. “I think there needs to be a total rethinking of this testing position in the AIDS community and a real push for this,” Mr. Clinton said. He noted that 90 per cent of those believed to be HIV-positive in the developing world do not know their HIV status. In Africa, where HIV is primarily a disease of heterosexual, married people, and in particular in countries where the prevalence rate is more than 15 per cent of the population, an increasing number of people argue the “human-rights-based approach” to testing is ill-fitting. They say it needs to be replaced with a public-health model in which HIV is treated more like diabetes, just one more disease for which a sick person is routinely screened. Lesotho’s campaign has a public-health ethos, treating HIV like a communicable disease to be tracked down and controlled, but it still makes an exception of HIV by putting heavy emphasis on confidentiality and counselling, because there is such great stigma attached to the illness here. Lesotho’s bold plan is not without its critics, who say it looks great on paper, but that it is unrealistic to think that a few months of community education will be enough to erode that pervasive shame. “You will agree to test and they will tell you the result and they will leave you with no psycho-social support, they will just leave you,” predicted Makokoli Nthinya, program officer for an AIDS support organisation called Positive Action. “People don’t disclose even to the closest, closest person taking care of them because they say, ‘When I tell, I will get no support.’ The support systems are not adequate.” The government says its plan to hire 3,500 new community-health workers, and train thousands of volunteers, will counter this problem. But “then you have people in the mountains with no access to ARVs; they are hours from a clinic or they have no money for transport,” Ms. Nthinya worried. In theory, treatment will be available everywhere before people are tested. But the glacially slow pace of treatment rollout ‘ just 6,000 people were put on the drugs in the past 18 months ‘ raises serious questions about how well a decentralised treatment program will run, and suggests that testing will either proceed equally slowly or that HIV-positive people won’t have easy access to the drugs. Conversations with people ostensibly already trained to be “peer educators” in communities outside the capital reveal a vast level of ignorance of HIV transmission, and such pervasive fear that even those who have been tapped to “mobilise” people for testing say they would not themselves take the test. ‘ Globe and Mail.

May 2006
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