Testing the HIV Testing Mantra

Early in my Johannesburg years, I used to have regular coffee chats with Dr. Francois Venter, president of the Southern African HIV Clinicians Society. Over cappuccinos (we both had serious caffeine addictions), we'd talk about how to save the world from AIDS. More often than not, we'd scheme about how to get everybody tested for HIV. It seemed like a natural triple-word-score of AIDS progress. If everybody knew who was infected, stigma would go down. The sick would seek treatment. And everybody would be more careful.

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Well, seems we were wrong, at least about that last part.

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Dr. Venter and I were hardly the only ones mulling those issues at the time. The picture above shows Randall Tobias, the former Bush Administration Global AIDS Czar (before his fall from grace) getting an AIDS test to publicize the importance of the issue. Former President Clinton has talked up testing endlessly. So has Richard Holbrooke, and many, many others.

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What we all missed was that while testing does indeed help people seek treatment, and likely eases stigma because the extent of HIV infection is clearer to all, there's little meaningful evidence that people who get tested act safer in the long run. In fact, the opposite may happen.

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Several studies, both in Africa and among the U.S. and U.K. gay communities, suggest that measures of safe behavior often deteriorate for those who test negative for HIV. Not knowing your status, it seems, inhibits certain kinds of reckless behavior, such as multiple partners, visits to prostitutes and sex without condoms. Knowing for sure that you are NOT infected, meanwhile, can do the opposite. It can validate past behavior, including risky behavior. It's like a smoker finding out they don't have lung cancer... yet.

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The good Dr. Venter gently broached this subject in a recent conference in South Africa, suggesting that the testing mantra is overdrawn. Kudos. The groupthink on this subject has gone on far too long. Kudos also to my co-author Daniel Halperin, who pointed out to me the limits of HIV testing a several years ago, allowing me to get off the bandwagon earlier than most. Here is his 2007 op-ed piece in the Washington Post about this.

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Nobody, of course, is suggesting that getting tested for HIV is a bad thing. It's a good thing. But let's not confuse something that is good for the individual (who may now seek treatment) with something that has the power to slow the spread of AIDS on a broad, society-wide level. The list of those things, sadly, is rather short.