The Serostatus Approach to Fighting the HIV Epidemic (SAFE), described by Janssen et al. in the July 2001 issue of the Journal,1 marks a long overdue attempt by the Centers for Disease Control and Prevention to retool the HIV prevention effort that has been losing steam. The results of the current HIV prevention efforts are quite disappointing: the majority of adults in the United States (about 56%) have never been tested for HIV,2 the incidence of HIV is increasing in minority communities, and HIV infection is making a comeback in communities that successfully fought its spread few years ago.3
A careful analysis of SAFE raises some concerns. First, basing prevention interventions solely on “high-risk individuals” dangerously delimits the target population. Second, routine appraisal of individuals' risk for HIV has been shown to be inaccurate.4 HIV prevention should be based on “individuals at risk” for HIV infection instead. Such a criterion would better portray SAFE's commitment to protecting the entire community.
In summarizing Janssen's commentary, Levi states that “one of the impediments to people's learning their HIV status … is the stigma and discrimination that people with HIV often face in the community” 3 The review of the literature does not support this statement. In a cohort of 396 women who had never been tested for HIV, only 1.8% cited fear of discrimination as the main reason for not being tested.5 Healton et al.6 reported similar findings in New York. However, one must be careful to avoid creating stigma during SAFE's implementation. Using term such as “high-risk individuals,” limiting activities to specific high-prevalence geographically circumscribed areas, or offering voluntary HIV testing in medical settings where large numbers of HIV-infected people may seek care for non–HIV-related illnesses may create more prejudice in the long run.
To increase the number of people being tested for HIV and reduce stigma at the same time, voluntary HIV testing should be integrated into routine primary care. Integration into routine care will not only increase the number of people being tested and being counseled for HIV but will also reduce the stigma attached to HIV testing. Studies have shown that patients are more likely to get tested when their physicians suggest the test.5 Concerns that such a move may prevent people from seeking needed health services are not justified. The use of routine HIV testing during pregnancy has not prevented women from seeking health care services.7
Integrating voluntary HIV testing into routine primary care will strengthen SAFE, a badly needed initiative.
References
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