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The widely held assumption that people would volunteer for AIDS-tests in droves once treatment became available was wrong. And the reason for that appears to be that the government has not managed to reduce the stigma associated with AIDS, and thus with seeking out a test for it if you suspect you might be infected.
To combat this, the whole basis of AIDS testing in Botswana has just been changed. The idea is to “downgrade,” the process into something low-key, routine and stigma-free. Until now, a potential test subject had to opt in, by asking for a test. Having asked, he was given 40 minutes of counseling to make sure he really knew what he was doing before any test was carried out. The new policy is to people routinely when they visit the doctor. That way, having a test cannot be seen as an indication that an individual believes he may be infected. The test is not compulsory, but objectors must actively opt out. Silence is assumed to be consent, and no counseling is offered-just as would be the case for any other infectious disease.
This policy shift is probably just the first of many that will take place in Botswana, South Africa and other African countries that are planning the mass provision of anti-AlDS drugs in public hospitals. Dwain Ndwapi, a doctor at Botswana’s largest AIDS clinic thinks that there are circumstances in which testing should be compulsory. In particular he believes that the currently high rate of transmission from mothers to new-born children could be reduced to zero if expectant mothers were always tested—and if those who proved positive were treated with an appropriate anti-retroviral before they gave birth. Another controversial change in the air is to reduce the frequency of two costly tests of patients’ blood. Viral-load tests and CD4-cell counts both measure how acute an individual’s infection has become. That helps a patient’s doctor to decide when to prescribe anti-retrovirals. But laboratory capacity in Africa is inadequate for regular testing of the millions of people that need such drugs-at least if the tests are carried out as frequently as they would be in a rich country. Less frequent testing of each individual would allow more individuals to be given at least some tests.
But that must be balanced against the need to treat more people faster. Doctors in Botswana are staggered at how desperately sick many patients are when they first arrive. They had expected people to walk into clinics for AIDS tests. Instead, many come in on stretchers on the verge of death. Treating the very ill takes much more lime and money than giving anti-AIDS pills to relatively healthy people, and it means that these people may have been inadvertently infecting others for longer. If routine tests persuade more patients to gel help before they slump on a stretcher, all the better.