Zoë Warwick of the Chelsea and Westminster Hospital in London presented the Bangkok International AIDS Conference with an analysis of HIV testing at the clinic she has been working at in Tutume, a town of 15,000 people in the north-east of the country.
The number of HIV tests performed had increased fivefold over the last two years, she said. But four times as many women as men were testing, and men were still not coming forward till symptomatic.
Warwick said she wished to correct reports in publications like The Economist that only 18,000 Botswanans had come forward for testing, held back by fear of stigma.
In fact, she said, 70,000 tests had been performed up to May 2004. A presentation earlier in the week showed that testing had increased from 9,800 in 2001, 19,350 in 2002, and 23,600 in 2003. The large increase in the year 2003-4, she said, was due to phase II of the national antiretroviral (ARV) programme being rolled out, This had resulted in more asymptomatic people coming forward – but, so far, most of these were women.
Warwick looked at the pattern of HIV testing at the Tutume clinic and mobile satellite clinics in nearby villages during three two-month periods at the beginnings of 2002, 2003 and 2004.
During the first period ARVs were only available for the prevention of mother to baby transmission; by the end of 202 they were available at the phase I clinic in Francistown, a couple of hours’ drive from Tutume; and by October 2003 they were available in the Tutume clinic.
Tests increased fivefold from 159 during the two months at the start of 2002, to 310 in the same period of 2003 and 869 in 2004.
Although the proportion of men coming forward had increased slightly, women still outnumbered them by four to one during the latest period, said Warwick. In the last period 632 women came forward and 169 men.
While as many women tested positive as negative at Tutume, men were three times more likely to have HIV as not.
In the past, said Warwick, this was because routine ‘opt out’ testing was offered to only two classes of people: those with AIDS symptoms and pregnant women.
But it was also because men were still reluctant to come forward, she said. From 2002 to 2004 the reasons women were coming to be tested had changed. The proportion testing because pregnant had decreased from 55% to 26% of the total; the proportion testing because symptomatic remained the same, at about 20%; but the number presenting voluntarily while still asymptomatic had increased from 16% to 45% of the total.
In contrast, she said, the reasons for men testing had not changed in the two-year period, with the majority only coming forward when they were ill. As a result positive results outnumbered negative in men by nearly three to one (134 to 45).
HIV prevalence in those testing averaged 60% between 2002 and 2004, in contrast to national figures saying that prevalence had increased from 28% in 2001 to 41% in 2003; whether this was because Tutume has exceptionally high prevalence of is still only attracting the symptomatic is a matter of debate, she said.
Had the adoption of ‘opt out’ testing for clinic attendees meant that people were not so much coming to be tested as being pushed?
If people were testing reluctantly they were unlikely to come forward for results, she said. The recorded rate of return to get results at Tutume was 63%, she said, but this probably was an underestimate as people’s results were often recorded in private records separate from the testing logs.