8 With the availability of treatment, however, such exceptionalism came to be less defensible, and scaled-up testing is increasingly advocated both as a gateway to treatment and prevention and as a way to “normalize” and destigmatize HIV. Fears of the social and political consequences of mandatory reporting of HIV-positive status, and concerns that such measures could lead to discrimination and “drive the epidemic underground,” prevailed over traditional public health approaches, and only confidential and anonymous testing was considered acceptable. In the mid-1980s, when tests became available, public health measures that were commonly accepted for other diseases (such as compulsory testing, contact tracing, and quarantine) were called into question. The history of HIV testing shows that the issue has always stirred much controversy. The latter is conducted at health facilities as part of clinical care to diagnose patients who present with signs and symptoms suggestive of HIV or to aid in providing care to nonsymptomatic patients in areas of high prevalence or at clinics used by populations that may be at special risk of HIV. In an effort to avoid the potential confusion of earlier terminology, the World Health Organization (WHO) has recently proposed a formulation that distinguishes between 2 types of HIV testing, both voluntary: client-initiated testing, corresponding to what is usually referred to as voluntary counseling and testing, and provider-initiated testing. The terminology reflects ongoing debates about consent, as well as the tension between safeguarding individual rights and protecting public health: should testing be universal, routinely practiced, routinely offered, or only performed at an individual’s request and where indicated for individual cases? Is voluntary counseling and testing the only way to ensure consent? 4 – 6 This is different from “routinely” conducting tests in medical settings without informing patients or seeking their consent. Routine testing in clinical settings, whereby patients are asked if they would like to be tested (“opt-in testing”) or are informed that they will be tested as part of routine procedures unless they refuse (“opt-out testing”), is increasingly advocated. Voluntary counseling and testing emphasizes the need for voluntary, informed consent prior to testing as well as pre- and posttest counseling. Diagnostic testing refers to HIV testing that occurs within a clinical care setting to aid in patient care management. HIV testing is often used as an umbrella term to refer to both testing and counseling services. Concerns over the gap between needs and reality have led to urgent calls for dealing with this important “unfinished business” and expanding testing in developing countries. 2 This means that most people living with HIV get testing and counseling only when they already have advanced clinical disease. 1 Even in more developed countries, about 20% to 30% of seropositive individuals are unaware that they are HIV positive. Recent estimates based on surveys in 12 high-burden countries in sub-Saharan Africa indicate that a median of just 12% of men and 10% of women in the general population have been tested for HIV and received the results. The use of testing globally, however, is very low. To scale up treatment and prevention, rapid increases in both the volume of testing and the ability to counsel those who are tested are needed. Testing for HIV is the gateway to treatment, care, and prevention.
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