HIV testing

[Guest guest]

Wilton.

Nice set of comments and good discussion. I was not a part of the initial

comments that led to your inclusion in this discussion. Many of us are

familiar with papers and conference presentations on HIV generated from

your work in the east.

1) Chronic problem with low prevalence. Do we really know that the

prevalence has remained as low as it was when HIV education programs for

farmworkers first were initiated? Have there been additional factors that

enter the picture that once were not present. For example, (A) an increase

in internal migration within this country and shorter periods of continual

return to the same area, hence greater likelihood of exposure and variation

in levels of risk to farmworkers from locale to locale; ( migrants who

return to high prevalence areas in home countries and then, (a) turn around

and come back, or ( pass along what they have acquired in this country to

someone else who at some point in the chain of transmission comes back, or

© pass along to someone who migrates for the first time; © diffusion

and increase in HIV prevalence in rural areas (according to Lam and Liu

1994) among those whom farmworkers have contact. Has prevalence been

increasing or fluctuating at a level of minimal increase that is maintained

at the new level, hence an increase all the same? How can we assume how

many " very small pockets " there are without testing? The oft-cited Belle

Glade study was a seroprevalence study of those at risk in an agricultural

town; if one reviews the report, " farmworker " is unspecified. Other

studies have been more precise in designating farmworkers...

2) Matching results with correct person. We've employed the approach of

permitting someone to use whatever name they feel comfortable with, but

indicating in a way that they'll remember that this was the name they used

with us. " We are not concerned with the name you use, but please remember

to use that same name with us again. " Placing the practice in the open,

I've found greater willingness to use a correct name...

3) Care and treatment of those who are seropositive is a more serious and

worrisome problem. Some may choose not to provide HIV testing services,

knowing that services in rural areas for those who " migrate " or " lack

papers " is non-existent. Nonetheless, there are a number of clinics I've

encountered in various states that include training in either triage to

appropriate sources or ascertain who of staff might provide that service.

The catch is placement in that community to qualify for the services. Or

the perennial problem of how to provide contact services at those places

where workers travel... Some places in " the big city, " I might add, may be

willing to include rural areas, given their need to continually keep their

numbers up...

4) Negative impact if a community is singled out, that they " have and

spread disease. " My view is that this is less a concern at the present

time, than it was when HIV programs for minorities first began. By

excluding farmworkers from what others are entitled to and have access, is

there a message that this is a problem that farmworkers cannot handle,

therefore they can be excused. Here it is that we can benefit from a

paradigm shift that pays greater attention to both sides of a risk

scenario. One makes choices, as best one can; one should make informed

choices, but one always cannot; one's choices may not always be predictable.

(5) Selective screening and education. I believe there is a distinction

between those programs that incorporate both education and selective

screening as a service, as you've identified, and those that use Orasure

(or another means of testing) as part of a research-education project.

Yes, education continues to be an area of concentration...

There is, and continues to be, great variability in approaches to HIV in

relation to farmworkers in distinct parts of the country. The issues that

you raise may be more specific to some areas than others.

V. Bletzer. Dep. of Anthropology, Arizona State University.