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LETTER |
Stephen Mills is with the Asia Regional Office of Family Health International, Bangkok, Thailand, and the Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, England.
Correspondence: Requests for reprints should be sent to Stephen Mills, MPH, Family Health International, 1339 Pracharat 1 Rd, 8th Floor, Bangsue, Bangkok 10800, Thailand (e-mail: smills{at}fhibkk.org ).
In writing about the Serostatus Approach to Fighting the HIV Epidemic (SAFE),1 Janssen and colleagues outline a noteworthy expansion to the US HIV prevention and care strategy for increasing the number of HIVinfected persons who know their serostatus and then providing enhanced quality care and prevention services. The authors have cited the important prevention and treatment benefits of this strategy. However, they make no mention of factors that may affect its implementation or actually make its use inadvisable.
There is substantial evidence documenting the consequences of knowing one's HIV serostatus, consequences that comprise not only the positive benefits outlined by the authors, but often a host of detrimental sequelae. Developing countries and even rural areas of the United States are hardly welcoming for people with new HIV or AIDS diagnoses. Stigma at the community level and violence at an individual level still mark the daily experiences of people living with HIV in most countries.2–8 Women in particular, though not exclusively, face abandonment, domestic violence, and, in extreme cases, murder by their partners or other members of a community unprepared to care for or tolerate those living with HIV. This occurs not just in developing countries, but also in developed ones with long-term experience with the HIV epidemic. A recent study using a US probability sample of HIV-positive patients in primary care found that 20.5% of women, 11.5% of men who have sex with men, and 7.5% of other men had experienced physical harm after their diagnosis.7
Furthermore, without emphasizing and ensuring that HIV testing is not coercive and that a community is ready to accept an increased number of people living with HIV, the SAFE strategy could easily go astray and be used by countries to support careless HIV testing practices—an unintended consequence with potentially harmful results. While the phrase "HIV voluntary counseling and testing" may be promoted in the pages of textbooks, the all too common result in clinics is only the last part: testing. In addition, the "surveillance" strategies of some countries still consist of testing large proportions of the population to determine their HIV status instead of establishing efficient sentinel surveillance systems.9
Unfortunately, we know little about how to reduce stigma and violence (let alone how to measure them), except that it takes the involvement and sacrifice of people with HIV to "mainstream" (to promote the recognition and acceptance of) the epidemic into a community's environment, and this takes time. While it is questionable whether we have achieved an acceptable level of mainstreaming anywhere on the planet, the situation is obviously better in some places than in others. Epicenters of HIV among men who have sex with men, such as San Francisco or Amsterdam, are areas where the SAFE strategy would be beneficial because of the presence of both experienced community-based care organizations and warning systems to monitor violence.
The expanded care and treatment services that the SAFE strategy will produce are desperately needed by the world's HIV-affected populations. But these people are just as desperate for a corresponding strategy of stigma reduction and violence prevention. A comprehensive package should include all of the above, together with funding to support its implementation.
References
1. Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock KM. The Serostatus Approach to Fighting the HIV Epidemic: prevention strategies for infected individuals. Am J Public Health.2001;91:1019–1024.[Abstract]
2. Garcia-Moreno C, Watts C. Violence against women: its importance for HIV/AIDS. AIDS.2000;14(suppl 3):S253–S265.
3. Gielen AC, Fogarty L, O'Campo P, Anderson J, Keller J, Faden R. Women living with HIV: disclosure, violence, and social support. J Urban Health.2000;77:480–491.[Medline]
4.
Rothenberg KH, Paskey SJ. The risk of domestic violence and women with HIV infection: implications for partner notification, public policy, and the law. Am J Public Health.1995;85:1569–1576.
5.
North RL, Rothenberg KH. Partner notification and the threat of domestic violence against women with HIV infection. N Engl J Med.1993;329(16):1194–6.
6. Zierler S, Witbeck B, Mayer K. Sexual violence against women living with or at risk for HIV infection. Am J Prev Med.1996;12(5):304–10.[Medline]
7.
Zierler S, Cunningham WE, Andersen R, Shapiro MF, Nakazono T, Morton S, et al. Violence victimization after HIV infection in a US probability sample of adult patients in primary care. Am J Public Health. 2000;90(2):208–15.
8. Hollander D. As if having HIV weren't enough. Fam Plann Perspect. 2001;33(1):3.[Medline]
9. Hansen H, Groce NE. From quarantine to condoms: shifting policies and problems of HIV control in Cuba. Med Anthropol.2001;19(3):259–92.[Medline]
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