This article appeared in the Georgia Straight on March 9, 2000.
by Janet Smith
(Artwork by Mark "Atomos"
Pilon. Reprinted with permission.)
If you've ever had to have an HIV test, you probably know it can make for the most agonizing two weeks in a person's life. Maybe you had too many martinis and did something rash with someone you'd just met; maybe you're a health-care worker and accidentally stuck yourself with an infected needle. It doesn't matter why you need one. Every test takes the same amount of time. Someone at a clinic takes a sample of your blood and it's sent to a laboratory, where it goes through batches of so-called ELISA tests. If they repeatedly show positive, your blood undergoes a confirmatory test called a Western blot. About 14 days later, you visit your clinic to get the news.
But soon Health Canada is expected to approve two tests that can be completed in about 15 minutes without sending the samples to the lab. (It has already approved one such test for lab use in Nova Scotia.) Unlike the current procedures, so-called rapid HIV-screening tests can be done on samples taken from a simple finger prick. They're as accurate as the old ELISA tests, which means if your test is negative, you can immediately go home - bearing in mind you could still be in the three-to-six month window before the virus shows. But if your test is positive, it could be false, and for now, positive results will still need to be confirmed at a lab with a Western blot.
You'd think that news of the rapid tests would receive a warm welcome, and in some ways it is. But making the test for HIV quicker and easier is also causing a small storm of debate about who will have access to rapid-test kits and how they'll use them.
Steve Martindale, a local AIDS researcher whose Vanguard Project - a research cohort of gay and bisexual men - helped carry out local trials of the rapid-test kits, explains it this way: "If you had an instant cancer test or an instant test for juvenile diabetes, there probably wouldn't be a debate. But because of the stigma and potential for discrimination with HIV, the whole discussion is taking place in a different context."
Lawyer Richard Elliot, director of policy research for the Canadian HIV/AIDS Legal Network, has been immersed in that discussion as part of the research for his soon-to-be-published paper "Rapid HIV Screening at the Point of Care: Legal and Ethical Questions". One of his concerns is that patients receiving the rapid tests won't be given enough counselling about what the results mean. With the rapid results, Elliot says, counselling is even more important because patients will learn results, positive or negative, on the spot; under the current system, they're not told about false positives.
"You're compressing the process at a time when we already know that counselling is inadequate," he told the Straight from his office in Toronto. "Patients need to understand questions like, What does this test mean? What is a false positive?"
Another pressing issue is who will be allowed to administer the tests. Health Canada is expected to approve the rapid-test kits with labels that say For Professional Use Only. But Elliot said only health-care workers who have counselling experience and professional codes should have access to the kits. "What is a 'professional'? Does this mean a dentist or a massage therapist will be able to purchase this kit and give you an HIV test in their office?" he asked.
In his report, Elliot says, he stresses that health professionals should never be allowed to test clients before agreeing to treat them.
He also envisions several scenarios in which a patient's consent could be compromised with new rapid tests. Perhaps the most daunting debate surrounds that in which a pregnant woman who has received little or no prenatal care shows up at the hospital emergency room in labour. Studies have proven that giving antiretroviral drugs to an HIV infected woman before delivery can greatly reduce the child's chances of contracting the virus. With the new rapid tests, doctors could immediately gauge whether or not the woman had the virus. But does this give them the right to make the test mandatory? Elliot says that while it would be unethical not to offer the woman a rapid test, factors such as side effects from the drugs and the chances of a false positive make the question a complicated one for the patient. He's recommending Health Canada study the issue more after the release of the rapid tests.
Of even greater concern to Elliot and others is the chance that rapid tests, which are almost as easy to administer as home pregnancy tests, will become available to the public. As yet, no one has applied to Health Canada to sell kits at the retail level, but home use is not unthinkable.
In his 100-plus-page paper (available mid-April from the Canadian AIDS/HIV Clearinghouse [613-725-3434] and via www.aidslaw.ca/), Elliot recommends Health Canada set up a committee of medical professionals and others to make sure rapid tests are given by the appropriate health-care workers and with the proper amount of counselling and consent.
Rapid tests are receiving some strong positive feedback. Researcher Darryl Cooke, who helped run trials of the kits for the BC Centre for Disease Control, found the tests to be highly accurate. He says they'll be of great use to this city's street clinics, where it is sometimes difficult to get transient patients to return after two weeks for results.
For his part, Martindale did an informal survey of the Vanguard Project men who took part in the rapid test trials. Of the 66 who responded, 82 percent thought the tests were a good idea.
Still, a minority of the Vanguard people felt strangely attached to the two-week waiting period. As one anonymous participant wrote on a questionnaire: "Having to wait the two weeks for the result was a good thing, because it gave the person being tested a period to contemplate the possible results of their actions."
But far more common were responses like this: "As long as these kits administered by trained professionals, I think they are a good idea. I am sure I am not the only one who, after waiting two weeks for a test result, has managed to convince himself that the test is positive." In the end, getting rid of that anguish will, for many, make the ethical struggles worthwhile.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044