The Bronx, a borough of New York that is home to 1.3 million people, has decided that it is going to try to test all adults for HIV over the next three years, according to The New York Times.
The NYT story elicited this comment from a friend of mine, a journalist who is much more informed about HIV than most. “The trouble with this story is it doesn’t say WHY they want to do testing nor indeed WHO has HIV! So are they testing people needlessly ? Is it good surveillance or bad public health? For us lay people, v confusing!”
It’s pretty confusing for a lot of non-lay people, too. I can safely say that is it NOT good surveillance. Surveillance aims to track trends in infection, to guide prevention and care programmes. This is case-finding, which is quite different. The Bronx is trying to identify individuals infected with HIV, so that it can get them onto treatment if need be. It OUGHT to be trying to identify people in need of prevention services, too, but that doesn’t seem to be on the agenda.
So is this mass testing good public health? Not if we ignore prevention needs, certainly. But even if we don’t, I’m dubious. To me, good public health implies protecting the greatest number of people at the lowest possible cost. Mass testing doesn’t do that. In the United States, as in virtually every country outside of sub-Saharan Africa, new HIV infections are concentrated very largely among people who have pretty well-defined risks: they inject drugs or they’re active on the gay scene. People who sell sex or buy it will be at higher than usual risk, too. As is anyone who has recently immigrated from one of the handful of countries in sub-Saharan Africa where HIV prevalence is very high. The Bronx could scoop up a very significant proportion of infections by targeting its testing at those groups.
The problem is, of course, that targeted testing is perceived as “stigmatising”. The United States in general, and the Bronx in particular, has decided that it is better to test everyone than to risk making someone feel uncomfortable by pointing out that their behaviour puts them at higher than average risk for HIV infection. Fair enough, if you’ve got unlimited budgets. But this will mean spending US$ 12 a pop testing several hundred thousand people who are highly unlikely to be infected, to spare the feelings of those who might. I’d be interested to know whether residents of the Bronx who have difficulty accessing other basic health services think it’s a good investment.
While we’re on the subject, MTV is airing rap artist Common performing lyrics written by 18 year-old Jose Rivera from Ewing, Nebraska. They’re hoping to encourage young people to get tested across the country on June 27th, National HIV testing day. Watch Common bring them in for testing right here. Think of me rolling my eyes in time to the music.