Should more people have AIDS tests in China to prevent and control the disease? A health expert and a charity head differ in their opinions.

Li Dun

Better ways to control spread of virus

Voluntary counseling and testing for HIV/AIDS in China is done according to the Regulation of AIDS Prevention and Control, issued by the State Council, the country's Cabinet.

Although the regulation says an HIV test should be voluntary, in reality disease prevention and control departments at all levels make people undergo compulsory tests for the human immunodeficiency virus. Before surgeries and medical investigations such as gastroscopy and enteroscopy, some hospitals always demand that the patient undergo a HIV/AIDS test, without which they will refuse treatment.

Moreover, in many provinces authorities have introduced compulsory blood screening for HIV/AIDS among the so-called high-risk groups (drug addicts, sex workers, homosexuals and professional blood donors).

The authorities should stop subjecting people to compulsory an HIV/AIDS test because it not only violates the Regulation of AIDS Prevention and Control, but also because it is against basic medical ethics. Since informed consent is an essential medical ethic followed by all medical workers, compulsory HIV/AIDS test should be prohibited in a society governed by the rule of law.

Compulsory HIV/AIDS tests do not work as well as some people think. Given China's huge population and the high mobility of people, it is impossible to implement large-scale compulsory blood screening for HIV/AIDS. At best, the authorities can keep track of only some people, not all of them.

Some people say a compulsory HIV/AIDS test before surgery or medical investigations help protect medical workers' against HIV/AIDS infection. In fact, everyone associated with providing medical treatment should abide by the principle of universal prevention, because medical workers are required to assume that all patients have the potential to transmit diseases. So, they should protect themselves against the transmission of any disease, not just HIV/AIDS. And they can do that by following medical rules and regulations strictly.

On the other hand, even compulsory HIV/AIDS tests cannot determine whether a person is HIV positive or not, because the human immunodeficiency virus cannot be detected during the window period, that is, between infection and manifestation. Therefore, the most important thing to do is to follow strict protective measures during medical services.

The authorities' attitude toward HIV/AIDS tests reflects the entire society's orientation. Disease prevention and control departments have no choice but to adopt compulsory measures when it comes to category "A" infectious diseases such as cholera and plague to control their spread and safeguard the public. But other blood-transmitted diseases, especially HIV/AIDS, can hardly be transmitted through common interpersonal contacts.

Though sexual contacts have been confirmed to be one of the three main sources of HIV/AIDS transmission, the chances of infection through unprotected homosexual contacts is 1 percent. The chances of contracting the disease are even less, 0.1 percent, through heterosexual contacts. To guard against contracting preventable diseases, we should protect ourselves rather than blame others for spreading them.

Some people are worried that potentially HIV positive people may hide their illness if we practice voluntary tests.

But the root of this problem lies in the lack of privacy for and discrimination against HIV positive patients.

The existing practice is to report HIV positive people as soon they are diagnosed with the virus to the national disease control network. But the medical history of such people can be easily leaked because there's no institutional restriction on keeping it secret. And once that happens, HIV positive patients have to face severe social discrimination.

It is this harsh reality that forces to avoid taking an HIV/AIDS test, even though it is good for them.

Under such circumstances, protecting HIV-positive patients' privacy and eliminating institutional discrimination against them may be a more effective way of preventing and controlling the disease than a compulsory HIV/AIDS test.

The disease prevention and control authorities should introduce a system to prevent insiders who have access to HIV positive people's medical information from leaking them and punish those who do. The authorities should also introduce a policy to prevent discrimination against HIV positive people in medical treatment and employment to set a positive example on the issue.

The author is a scholar in health issues. This is an excerpt of his interview with China Daily's Wang Yiqing.

Ray Yip

Early diagnosis will help save lives

China has an estimated 750,000 HIV positive patients. Considering China's 1.3 billion population, the number of people living with HIV/AIDS in the country is relatively low, especially when compared with the United States, where the infection rate is about five times higher.

A relatively low rate of infection, by implication, offers a better chance of implementing effective measures to prevent the spread of a disease, HIV/AIDS is no exception. But there is a major difference between China and the US. About 80 percent of the people living with HIV/AIDS in the US know they are infected, whereas only 25 percent of such people in China are aware of their medical condition.

Why does knowing about one's HIV condition matter? An HIV positive person who knows about his/her infection is more likely to make efforts not to spread the disease than those who remain unaware. A number of international studies show the chance of an HIV positive person spreading the disease is reduced two-thirds if he/she is aware of his/her medical condition.

Nowadays, with the availability of highly effective antiretroviral (ARV) drugs, not only can a patients' life be extended, but also ARVs suppress the human immunodeficiency virus to levels low enough to make patients on therapy nearly "non-infectious".

The truth is that HIV positive people who do not know their medical condition not only cannot benefit from the potentially life-saving effect, but also make them disease-transmission agents. In essence, HIV tests for early detection, like in most other communicable diseases, can prevent the disease from spreading.

Why this emphasis on HIV positive patients in China knowing about their medical condition? The emphasis is not because the current policy, known as "prevention with positives", is too weak. On the contrary, China has a very strong policy for this effort, as the "four frees and one care" policy implemented in 2004 shows. Among the "four frees" are free HIV testing and antiretroviral drug treatment. The third is the free routine HIV test offered to pregnant women and ARVs provided to mothers who have tested HIV-positive to prevent mother-to-child transmission. This is a perfect example of "prevention with positives".

Despite such a clearly focused policy, why does China lag behind in "prevention with positives"? Given the funds allotted for HIV/AIDS prevention and control in China, it would be fair to say that it has nothing to do with resource constraints. The main reason why the country lags behind in efforts to prevent the spread of and control the disease can be traced to technical and managerial obstacles. Access to HIV tests is limited and inconvenient, and many aspects of the test discourage people from taking it.

Liberalizing the testing policies and procedures and allowing community health clinics to be part of the group of medical facilities offering free HIV tests will be a giant leap forward in improving accessibility. The more widespread use of a rapid test instead of the traditional testing procedure would shorten the time of getting the result from 1-2 weeks to 30 minutes and make testing more attractive. The key is to make it easier and more routine to get HIV testing.

There is a historical reason why HIV tests have been treated carefully to the point where existing procedures impede efforts of effective prevention. Since AIDS was diagnosed as a disease, a stigma has been associated with it. That stigma is still prevalent in China. An HIV positive patient in China still faces severe discrimination, especially when it comes to getting a job, or buying or renting a house.

Before the availability of ARV drugs, many people gained little or nothing by knowing that they were HIV-positive apart from being cautious enough not to transmit the disease to their loved ones. That's why HIV tests should be carried out extremely carefully, at least to prevent causing harm to HIV positive patients.

But one has to realize that the widespread availability of ARV drugs has changed the game entirely. Not only does early diagnosis prevent the spread of HIV/AIDS, but also it saves lives. Contracting HIV/AIDS is no longer tantamount to be given a death sentence. Rather it opens up the possibility of getting lifelong, routine treatment.

The realization of the importance of early diagnosis through an HIV/AIDS test has gradually changed the attitude of people in the US and other Western countries. What began as a highly restrictive approach in the 1990s has become a more liberal and routine process, especially over the past decade. China can catch up with the Western world fast if its people realize the importance of effective "prevention with positives", especially because the country has little or no constraints in terms of commitment and resources. The key is to adopt a more up-to-date approach that will substantially improve the efficiency and effectiveness of HIV tests.

For the question, "will China be able to control AIDS soon", the answer is "yes" if more than 60 percent of HIV positive people in China know their medical condition. The answer is based on an international model on the effectiveness of various HIV-related intervention measures.

If health centers across China can be authorized and supported to conduct HIV tests, I am pretty optimistic China can raise the current level of only 25 percent HIV infected people knew their medical condition to 60 percent within a few years. When that happens HIV epidemic would be under control.

The author is China country director of Bill & Melinda Gates Foundation.

(China Daily 12/06/2010 page9)