Care and support for people living with HIV/AIDS

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Opening new doors with counselling and testingover the past decade. Thousands of HIV-positive and HIV-negative people tested atthe Centre have joined the Post Test Club, which not only offers its members healthcare and other services, but sends them into the community to spread informationabout HIV prevention. Between 1992 and 1998, Club members, trained during fourdaycourses to become peer educators, have reached 180 000 people and distributed1.2 million condoms. Individuals like these combat the invisibility of the epidemicby giving it a human face.Unfortunately, HIV testing facilities in the developing world are still far from adequate.In many places, especially in rural areas, it is simply not possible to get a test.In others, the quality of the counselling is poor. Often, clients have reason to fear thattheir results will not be kept confidential. People may be tested for HIV without theirknowledge or against their will, and employers or family members may be told of aperson’s HIV status – all flagrant violations of human rights. Testing without priorcounselling is especially common in medical facilities; doctors sometimes choosenot to inform infected patients that they have HIV for fear of depressing them.Perhaps surprisingly, the middle class and the wealthy may be especially poorlyserved. One thorough inventory of HIV counselling, testing, care and support servicesin the Kenyan capital of Nairobi found that slums and low-income areas wererelatively well provided with HIV support services. Almost all of these services aredonor-funded and are run by nongovernmental and community organizations. Nosuch services exist for the better-off.Even where testing and counselling services of reasonable quality are available, thestigma may be so strong that people choose not to know their infection status –which is their right. Improving the quality and availability of testing services musttherefore go hand in hand with efforts to diminish the fear and rejection of peoplewith AIDS, and with the establishment of policies and practices to ensure confidentialityof HIV test results and related information. Countries in the developed anddeveloping world have had some success in combating the stigma of AIDS throughpublic campaigns urging solidarity with HIV-affected persons and through publicstatements by respected leaders.The challenge of prevention for couplesVoluntary counselling and testing can help prevent HIV transmission in long-termrelationships when other prevention options – abstinence, fidelity and condom use– may be problematic.Few if any individuals in a stable partnership are willing to abstain permanently fromsexual intercourse. Not many will remain satisfied with a lifetime of sex that does notinvolve penetration. As for fidelity, people can be sure of their own behaviour butmany have doubts about whether their partner is always faithful. In any case, fidelity79
Report on the global HIV/AIDS epidemic – June 2000– even when mutual – is protective only when both partners have entered the relationshipwithout HIV infection.Condoms are commonly used in some areas for family planning purposes, but inmost populations, despite vigorous promotion campaigns, the use of condoms withspouses is very low. Low condom rates in marriage are common even when eitheror both partners also have unprotected sex outside marriage. In a large national surveyin Zambia, married men who reported extramarital partners were no more likelyto use condoms with their wives than men who said they were faithful. Since justone-third of men with extramarital partners had used a condom the last time theyhad casual sex, many married women are put at risk for HIV by their husbands’behaviour.In the light of these prevention challenges, it is hardly surprising that the scale of HIVtransmission within marriage and other stable relationships is considerable. Studiesconfirm that this is the case, especially in areas where infection rates are high.Just as voluntary HIV testing and counselling can be a first step in helping HIV-positivewomen reduce their chances of having an infected baby (see page 81), it canserve the same purpose for couples in which one partner might be infected and theother one vulnerable to sexual transmission of the virus. Studies of the preventiveeffectiveness of voluntary counselling and testing have yielded conflicting findings indifferent populations and places. Encouragingly, however, there is increasing evidencethat this measure can successfully prevent the onwards transmission of thevirus in heterosexual partnerships, especially when the two partners choose to comeas a couple for counselling and testing.While HIV testing can be useful for people who are already married and even oncea woman is pregnant, as described below, some argue that “premarital” counsellingand testing would be even more helpful, given the high risk in some placesof entering marriage when already infected and the general failure of condom promotioncampaigns to encourage open discussion and use of condoms for HIVprevention within stable relationships. In a number of countries, including twodeveloping countries with striking successes in prevention – Thailand andUganda – an increasing number of people are choosing to be tested for HIVbefore getting married. At Uganda’s AIDS Information Centre, the proportion ofthose getting tested because they are considering marriage or a new relationshiphas risen steadily over time, from 6% in 1992 to 33% in 1997. Two-thirds of thesemen and women came with their prospective partners, and the vast majoritytested negative. Indeed, people taking these “precautionary” tests were far lesslikely to be infected with HIV than people tested for other reasons. In 1997, just6% of premarital tests were positive, compared with a quarter of those tested forother reasons.Voluntary counselling and testing will never appeal to all individuals or couples,whether heterosexual or homosexual, and it will never successfully prevent onwardstransmission in all those who are tested. However, it is an important option to include80
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Care and support for people living with HIV/AIDS

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