2006 World AIDS Day

World AIDS Day 2006


  1. Addressing the “hidden HIV epidemic” – Do the new CDC (Atlanta) testing guidelines mean an end to AIDS exceptionalism?
  2. Making AIDS everybody’s business: new GTZ report describes how “AIDS mainstreaming” is key step towards achieving universal access



These articles have been produced by WHCA for the purposes of this briefing package, drawing on materials presented at the recent ECDC Workshop on HIV Prevention in Europe (Stockholm, 2-3 October) and materials prepared for the forthcoming Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH and UNAIDS international conference, AIDS Mainstreaming – Paving the Way towards Universal Access (29 November, Berlin), but do not claim to represent the views of the organisations concerned.

Whilst every effort is made to ensure their accuracy, please note that neither ECDC nor GTZ is responsible for their content and any inaccuracies are entirely the responsibility of WHCA.


1. Addressing the “hidden HIV epidemic” – Do the new CDC (Atlanta) testing guidelines mean an end to AIDS exceptionalism?

New USA’s Centers for Disease Prevention and Control (CDC, Atlanta) guidelines (see box below) now call for routine testing in health care settings for 13-64 year olds and change consent requirements to an “opt-out” approach.

Revised CDC Recommendations for HIV Testingin Health Care Settings, September 2006

  • Routine screening for HIV infection for all patients 13-64 years
  • Routine screening for HIV infection for all TB and STI patients, and pregnant women
  • Informed consent as "opt-out"
  • Annual testing for persons at risk
  • Results delivered as other diagnostic tests
  • Pre-test prevention counselling not required

Arguments for the new policy centre on the potential to reduce new cases of HIV by making more people aware of their status. Shifting people from the "unaware" to the "aware" group has been identified as one of the most effective HIV prevention measures. In the USA it is estimated that this could reduce HIV infection levels in MSM by as much as 30%.

Graph showing awareness of serostatus among people with HIV and estimates of transmission

Numerous studies have been carried out and there is now compelling evidence concerning the role of the “undiagnosed fraction” in new infections: those who are aware of their seropositive status cause 30-46% of new infections, while those who are unaware cause 56-70% of infections. Knowledge of one’s seropositive status often results in behaviour modification and is therefore one of the most effective prevention methods available, with a potential to reduce new infections by up to 30%

Proponents argue that this new CDC policy does not support coercive (mandatory) testing, nor does it underestimate the potential undesirable outcomes (such as discrimination or violence), but there is evidence from other countries that routine testing is acceptable and effective, and that “opt-out” is an acceptable method of “informed consent”. Some feel that by not offering routine testing where HIV infection is suggested, health care providers are letting patients down.

History of AIDS exceptionalism

When the first HIV test became available in 1985, the primary concern was to safeguard the blood supply. Attention was not focused on diagnosing HIV infection in individuals. Given significant stigma and discrimination issues, it was thought to be of paramount concern, especially by the most affected groups, to protect people’s human rights. Most of the affected individuals came from communities that were already the subject of a great deal of stigma and discrimination, e.g. MSM. This was compounded in the early days when the “shock” and fear factors of HIV/AIDS were still very high.

This “exceptional” situation became the norm, and to a large extent it is still so today – with little routine testing and much emphasis on the need to safeguard HIV infected persons’ human rights and anonymity. This is the case in spite of significant changes in treatment availability and survival rates and the paradigmal shift of AIDS, in most of the developed world, from “a death sentence” to “a chronic illness”.

“AIDS Exceptionalism” (Bayer, 1991)

The different way that HIV/AIDS has been addressed by public health compared with other infectious diseases:
  • HIV testing restricted, counselling emphasised
  • HIV case reporting by name limited
  • Emphasis on confidentiality and privacy
  • Partner notification and contact tracing limited

Systematic screening of blood donations has virtually eliminated the transmission of HIV through transfusion of blood or blood products,.

Following the first Mother to Child Transmission (MTCT) clinical trial in 1993, there came an avalanche of data showing that such transmission could be prevented with appropriate interventions, but it required an expansion of testing. Thus, pregnant mothers became the first group to be routinely tested in most countries, with the result that MTCT has been dramatically reduced – most countries in Europe now have reached, or are within reach of, the target that has been set by the Dublin Declaration, of less than 2%. The following graph shows the dramatic effect of routine testing on rates of MTCT in Europe:

However, routine testing is still not the norm for other groups, and the “undiagnosed fraction” of the HIV-infected population continues to give rise to the majority of new infections.

The “undiagnosed fraction”

The estimates of the “undiagnosed fraction” vary, but range from 30-80%. In the EU, the level of undiagnosed cases is estimated to be about 30%. However, in the Ukraine it is suggested that only 1 in 16 has been tested.

Concerns about changes in testing

The new CDC policy raises various ethical issues around human rights, privacy and autonomy.
Given continued high levels of fear, stigma and discrimination in many countries, the need to balance public health needs (to prevent and treat infections, and avert deaths) with the rights of the individual (autonomy, protection from violence and discrimination, privacy) is perhaps the biggest challenge to increasing uptake of testing.

Testing and Counselling

  • Public vs. individual interest and benefit (including cost and health benefits)
  • Ethical issues:
    • Individual’s privacy, autonomy and integrity
    • Individual and public responsibility
    • Human and civil rights, incl. sexual and reproductive rights of HIV+ and HIV-
    • Criminal liability
    • Public and private morality

Stigma and discrimination are made worse by the fact that many of the groups involved are already beyond the law and norms of “acceptable” behaviour. Where the social "penalties" of being HIV+ are high, or where an individual attending for testing risks imprisonment (for example, for illegal drug use), that is a powerful disincentive to be tested. "Criminalisation" is strong disincentive to testing. Other obstacles include inequality of access to testing for some groups and the implications of testing where treatment cannot be provided.

Increasing voluntary testing

Making sure facilities are provided at the right scale and widely available is important. Making sure that testing facilities are available to isolated and hard-to-reach populations is critical. Involvement of sectors other than the Health Sector – for example Legal, Employment, Housing, Education – in addressing some of the social and legal issues and the safeguarding of the rights of the individual (both human and civil) can help uptake of testing.

Several effective approaches to “lowering the bar”, to make it easier for people to attend for testing and for clinicians to prescribe testing, have been developed. For Intravenous Drug Users (IDUs), the inclusion of free and anonymous testing in low-threshold centres is very effective, and also the provision of settings at "street level", which are accessible and can reach hard-core drug users (some countries have mobile settings, such as a bus – this is also effective in reaching Commercial Sex Workers (CSW) on the street). In some countries it is possible to undergo testing in different settings, including the possibility of ordering tests online over the Internet. Another effective strategy identified is the "social network" strategy, where people are asked to refer people in their social network for testing.

Finally, training health professionals, and supporting them in overcoming their discriminatory behaviours and in dealing with issues of anonymity and confidentiality, can improve their confidence and performance in helping people deal with issues of diagnosis, testing and counselling.

Internet resources

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm : Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings

http://www.who.int/3by5/publications/briefs/hiv_testing_counselling/en/ : HIV testing and counselling: the gateway to treatment, care and support

http://www.who.int/bulletin/volumes/84/10/interview1006/en/ : Interview on HIV/AIDS with Dr Kevin de Cock, Director, Dept of HIV and AIDS, WHO, Geneva

: WHO and UNAIDS Secretariat Statement on HIV Testing and Counselling, August 14 2006

: HIV Testing and Counselling topics, with links to various documents and other resources

http://www.ecdc.eu.int/Press/pdf/press_release.061004.pdf : ECDC Press release following recent HIV/AIDS meeting

http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm : CDC’s HIV Testing page

: Q&A for members of the general public on the revised guidelines

http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm : Q&A for professionals on the revised guidelines

2. Making AIDS everybody’s business: new GTZ report describes how “AIDS mainstreaming” is key step towards achieving universal access

Development and funding agencies gather in Berlin, 29 November 2006, to identify best ways to help countries scale up action to reach the goal of universal access to HIV prevention, AIDS treatment and care by 2010 (set by the G8 and the UN General Assembly in 2005). The conference “AIDS mainstreaming – paving the way towards universal access”, jointly organized by GTZ and UNAIDS, will look at progress to date, current plans, key obstacles to their implementation and ways to overcome them.

Practical lessons learned from five years of German AIDS Mainstreaming experience, which has integrated AIDS work as a necessary and central action area into all its development policies, programmes and workplace practices, will inform conference discussions.

In Sub-Saharan Africa, for example, GTZ works in 31 countries, including most of the 17 Sub-Saharan African countries where the HIV prevalence rate among adults (15-49) is the highest in the world, ranging from 5% to 34%. In early 2003, GTZ launched a Workplace Programme on HIV and AIDS that applies to all GTZ workplaces. Participation in this programme is mandatory and provides employees and their families with location-specific information and education as well as HIV counselling and testing. Where necessary, treatment and social support are provided for affected staff members and their families.  
In the course of developing, monitoring and refining its own workplace programme, GTZ has learned lessons which they have been able to apply to a wide range of development activities. Informed and trained employees, for example, have become effective peer educators, advocates and activists in their respective areas of work, be it education, local government or water and sanitation.

According to a new GTZ report to be launched at the conference, AIDS mainstreaming activities in rural communities in Lesotho, Cameroon and Swaziland, for example, have shown that trained paraprofessionals and volunteers, with a little support from professionals, can provide many of the health and social services that professionals might otherwise have to provide. They have also found that they can often make do with existing infrastructures, using a school for counselling and testing and a house for care of the seriously ill. The report concludes that “mainstreaming AIDS may be the single best, most affordable and sustainable way that GTZ and many other organizations can contribute to the goal of universal access.”

For more information on Mainstreaming see: www.gtz.de/aids
For more information on universal access see: http://data.unaids.org/pub/Periodical/2006/20060223_Universal_Access_bulletin_7_1_en.pdf, and http://data.unaids.org/Topics/UniversalAccess/UniversalAccess_Bulletin_23Jan2006_en.

For information on the Conference contact : Carmen Perez Samaniego (Carmen.Perez-Samaniego@gtz.de)