Should everyone be tested for HIV? Really?

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.

This post was published on 27/06/08 in Ideology and HIV, Science.

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  1. Comment by Petal, 01/07/08, 04:11:

    I take the argument you make, but on the other hand, by testing everyone the stigma of getting tested is also removed. I went for a full STI screen in the US after a condom broke and was shocked that the doctor tried to discourage me from taking it – surely if I’ve put myself at risk for one STD, I’ve put myself at risk from them all??

  2. Comment by Kevin Carmichael, 01/07/08, 05:31:

    What I struggle with is how we get persons who have risk factors to admit them to themselves and then take the next step and get tested.

    I get tired of having patients with “no risk factors” admitted to the hospital with PCP or another OI.

    So, when I get the chance I encourage everyone who has ever had sex (I tell them they don’t need to raise their hands) to get tested with the goal of finding that they are negative and then using that “teachable moment” to make the changes needed to stay negative.

  3. Comment by Amanda, 01/07/08, 06:39:

    That’s not the only issue. I’ve just finished the chapter on IV drug users. Obviously, mass testing without the proper questions (and reliability issues of questioner and interviewee) won’t yield useful data anyway.


  4. Comment by Anna, 12/11/08, 08:36:

    Very scary, especially since the HIV test is horrendously inaccurate. Yes, we have to practice safe sex but the there are 70 conditions other than HIV that can produce a false-positive result. Why are no other communicable diseases treated this way? AIDS drugs are ultra-toxic, they can actually cause immune dysfunction that is similar to AIDS. In other words they can kill. We owe it to ourselves to educate ourselves about HIV, not just accept the status quo. To me accepting what the establishment is telling me is accepting that the earth is flat. Well, folks, it is round and the HIV test is not accurate. Check out:


    It’s a New World Order if we have forced testing for a disease that may not exist as we know it.

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