Kevin De Cock and colleagues propose that an individual's knowledge of his/her HIV status is crucial if effective treatment programmes are to be implemented in less-developed settings such as sub-Saharan Africa.
Professor De Cock comments: "Prevention and care in Africa need a serostatus-based approach aimed at universal voluntary knowledge of serostatus, simplified clinical testing, and prevention of discrimination. Defining different categories of testing, consent, and counselling is necessary. International agencies should reassess their HIV testing policies on the basis of public health needs and targets, and the declared global emergency relating to treatment. Of three possible positions, staying silent will abdicate leadership, and endorsing traditional practice will reinforce barriers to prevention and care; only strong guidance to promote and facilitate HIV testing will allow urgently-needed expansion of treatment and prevention services."
In a second viewpoint (p 1850), Jeff Stringer and colleagues from the Centre for Infectious Disease Research in Zambia (CIDRZ) outline a different perspective. They propose that in the specific circumstances of preventing mother-to-child HIV transmission (MTCT), it is not necessary to test women for HIV before offering prophylaxis with single-dose nevirapine. The authors propose several circumstances where perinatal nevirapine should be offered to women of unknown HIV serostatus.
Dr Stringer concludes: "The primary purpose of MTCT-prevention services is the prevention of AIDS in children. Therefore, to have an effect commensurate with the scope of the epidemic, we must broaden the indication for nevirapine to include not just women with confirmed HIV-1 infection, but those living in high-prevalence areas who are unable or unwilling to access testing. Such an approach should not undermine the rapid expansion of VCT [voluntary counselling and testing]; the two can and should occur simultaneously, and indeed complement each other. But, since administration of single-dose nevirapine without HIV-1 testing is feasible, cost effective, and safe, implementation of nevirapine should not be held hostage to the inherent complexity of establishing testing services."
* This week's Lancet editorial (p 1773) comments on initiatives to promote palliative care within the HIV/AIDS context. The editorial concludes: 'Palliative care with effective pain relief, and the funding it is starting to attract, presents not a threat but an advantage to more mainstream anti-AIDS activities. We urge all those involved in tackling the HIV/AIDS pandemic to seize this opportunity.'