[Mb-civic] Sorry, but AIDS Testing Is Critical - Richard Holbrooke - Washington Post Op-Ed

[William Swiggard]

Sorry, but AIDS Testing Is Critical

By Richard Holbrooke
Wednesday, January 4, 2006; A17

A month ago, on World AIDS Day, I wrote that despite all the public 
rhetoric about progress, "we are not winning the war on AIDS" and that 
the "very best that can be said is that we are losing at a slightly 
lower rate" [op-ed, Nov. 29]. I thought this was fairly obvious, given 
the fact that on each World AIDS Day since the first one 18 years ago, 
the number of people who are HIV-positive has increased. I thought it 
was even more obvious from just one stunning fact: that of the 12,000 
people who will be infected in the next 24 hours around the world, over 
90 percent will not learn they are sick until roughly 2013, when they 
develop full-blown AIDS. Meanwhile, not knowing their status, they will 
unintentionally spread it to other people over the next eight years, and 
these people will spread it to still more, and so on.

Given this situation, I suggested that current strategies are clearly 
not working, especially on prevention. While continuing to support 
increased funding for treatment of those who already have AIDS, I argued 
that far more emphasis should be put on detection and testing so that 
people learn their status and then, with counseling, change their 
behavior if they are HIV-positive, thus reducing the spread of the HIV 
virus.

This may sound simple, even self-evident, to those not involved with the 
issue on a regular basis, but no column I have written for this 
newspaper provoked a greater reaction. To listen to some of the 
criticism you would think I had called for mandatory testing and 
quarantining of people with AIDS. "This man is out of control," wrote 
one prominent AIDS activist under the headline, "Someone stop this man." 
I was accused of "championing a conservative, traditionalist public 
health approach, which is simply looking to identify the infected and 
contain them."

Such criticism ignored my strong public advocacy over the past six years 
of much more funding for treatment. But far more distressing were the 
assertions of "progress" from world leaders and editorial pages. 
Originally designed to put pressure on public officials, World AIDS Day 
has turned into an empty rhetorical ritual in which world leaders issue 
high-minded statements, after which they let another year of living ever 
more dangerously pass.

Although there were plenty of calls for more funding for treatment, so 
far as I am aware no one suggested new prevention strategies or even 
admitted that today's approaches are not working. Current policies on 
prevention are simple enough: Conservatives emphasize promoting 
abstinence (which is why a minimum of 30 percent of the American 
contribution to the effort is earmarked for that purpose), while 
liberals stress the use of condoms and the need to avoid needle-sharing. 
Of course, any of these practices, if followed rigorously, will prevent 
the spread of AIDS, but none is ever going to be used by enough people 
to reverse the spread of the disease. It is a classic case of American 
"red state-blue state" politics and ideology trumping the brutal reality 
on the ground, or, more accurately, in a bedroom or alleyway.

I have been told repeatedly, for more than four years, that the case for 
testing is not proven. But isn't it obvious that AIDS will continue to 
spread more rapidly as long as 90 percent of those affected do not know 
their status? Wouldn't greater knowledge of one's status -- held in the 
strictest confidence (an essential part of any testing program) -- 
greatly modify behavior, both for those who are HIV-positive and for the 
large majority who, even in the worst-hit areas, are not infected? And 
wouldn't the greatest beneficiaries of widespread testing be women, who 
are all too often helpless victims but who do not know either their own 
status or that of any man in their life -- and who have no way of 
getting their men to be tested?

Yet the dedicated and committed professional community engaged in this 
desperate struggle, including UNAIDS and the World Health Organization, 
still refuses to make testing a top priority. (One commendable exception 
is Randall Tobias, the Bush administration's special envoy on AIDS, who 
makes it a practice to be publicly tested -- if possible with a local 
official -- in every country he visits; he well may be the most tested 
person on Earth.)

Why, in general, is the issue played down? I believe it is partly a case 
of a mind-set that was locked in 20 years ago, at the dawn of the AIDS 
crisis. Stigmatization was a huge problem then, even in the United 
States, and antiretroviral drugs were not yet available.

But times have changed, and so has the nature of the disease and the way 
it is spreading. (The greatest step forward in prevention would be the 
development of an effective microbicide that women could 
self-administer, but that goal is still eluding researchers.)

Recently there has been encouraging action in three small African 
nations -- Lesotho, Botswana and Malawi -- which have started making 
testing routine and officially encouraged (but not mandatory). Lesotho's 
new policy, creatively called KYS, or "Know Your Status," is especially 
worth watching because it is a formal, widespread national effort. If it 
works, perhaps the high priests of the worldwide effort on AIDS will 
stop listening to their own echoes and unexamined assumptions -- and 
take action. If ever there were a place where an ounce of prevention was 
worth a ton of cure, this is it.

The writer, a former U.S. ambassador to the United Nations, is president 
of the Global Business Coalition on HIV/AIDS, a nongovernmental 
organization, and writes a monthly column for The Post.

http://www.washingtonpost.com/wp-dyn/content/article/2006/01/03/AR2006010301273.html
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