Priorities for HIV testing in developing countries

The specificity and sensitivity of human immunodeficiency virus (HIV) antibody tests have increased and their use has expanded in developed and developing countries since 1985. Lately more expensive rapid (US $3-12/test) and cheaper HIV tests have been proposed. HIV testing by the inexpensive enzyme-linked immunosorbent assays (ELISAs) is often infeasible in developing countries because of the lack of equipment. In 1990 in Kinshasa Zaire only about 50% of blood donors were screened for HIV. Counseling before and after testing at centers sponsored by non-governmental organizations is limited in developing countries. HIV testing can lead to discrimination: people have been put in quarantine because they were found to be HIV positive. In regions of high prevalence high priority testing for blood transfusion is cost beneficial. A positive HIV test would justify the start of treatment for toxoplasmosis in a patient with a focal neurological deficit. In a region of high HIV prevalence a patient with chronic diarrhea would benefit more from an HIV test than from gastroenterological tests. The absence of facilities for CD4 cell counting makes it impossible to advise symptom-free HIV infected subjects. Prophylactic isoniazid may decrease the incidence of Mycobacterium tuberculosis infection among HIV-infected people but the potential for non-compliance with treatment and the risk that drug resistance will develop exist. Confidential HIV testing plus counseling and condom promotion decreased the incidence of HIV infection and gonorrhea among women living in Kigali Rwanda. There has been successful counseling of discordant couples with HIV infection in Kigali Rwanda and Kinshasa Zaire. HIV testing in the most cost-beneficial way should be done for both members of a steady couple at the same time. HIV tests should be more available in developing countries and national guidelines for HIV testing should be set.