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
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Contact: Richard Lane
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Lancet
27-Nov-2003