Normalisation for whom?Testing for HIV infection remains the critical turning point for accessing appropriate and effective treatment. It has been undertaken for more than 20 years yet we still identify people too late for them to maximise the benefits of antiretroviral therapy. The UK National Guidelines for HIV Testing 2008  propose the normalisation of the test and extending the range of services which currently offer the test. Testing is this issue's main theme and is addressed by several contributors who consider the success and implications of such a change in policy.
In the UK maternity services, the move to a policy of a 'universal offer' in the late 1990s has been hugely successful as demonstrated by the increased numbers of women diagnosed antenatally and the significant reduction in mother-to-child transmission. Despite the shock of diagnosis, these women feel supported by the relationship they develop with their specialist midwife and doctor, which often continues long after delivery. This is an excellent example of how a service can provide both an effective and a supportive service. However, if the women could have been tested before getting pregnant, they might have been able to consider the situation for themselves without the added implications for their unborn children. However, the question is, would they have taken advantage of such an offer or was the pregnancy the stimulus?
The UK National Guidelines for HIV Testing 2008  propose extending the availability of testing to sexual health and point of care services (for example General Practice). For this to be successful, those involved need to be skilled communicators. There must also be a rapid and reliable referral system in place. Raising the issue of HIV testing during a consultation for a contraceptive seems appropriate; however, would that be so for other consultations? Too often guidance directed at primary care practitioners is focused on a single subject, which does not take account of 'real life'. For example, rarely does a GP see someone with high blood pressure without other health issues, yet some guidance on managing hypertension does not take into account other co-morbidities/health factors. What is the trigger (or incentive) to this offer and how are general practitioners and other healthcare workers prompted to make the offer?
Increasing the provision of testing is one part of the solution but a more difficult one is acceptability. From the patient/client's perspective, HIV has not become normalised but largely forgotten by the public and, when it is raised, frightening.
In a recent BBC news item  marking 25 years since US Health and Human Services Secretary, Margaret Heckler, made the historic announcement of the discovery of a virus thought to cause AIDS, one person who has lived with HIV since the early 1980s described living with it as 'a nightmare', due to its consequences and unpredictability, like living with a house guest who has outstayed their welcome. The stigma of HIV remains, and whereas in so many other conditions we test in order to treat and cure, in this instance we treat to contain. Testing is important in terms of accessing treatment and being able to live a near normal life, but for the individual it brings a possible lifelong burden of living with something that cannot easily be discussed openly.
Despite nearly 30 years of health promotion the legitimacy of safer sex messages is still questioned. While influential figures such as Pope Benedict XVI and many other religious leaders condemn condom distribution on the grounds of increasing promiscuity and worsening the HIV situation , people will be vulnerable to infection although reticent to talk openly about their sexual behaviour for fear of offending others. In welcoming these new developments in service provision, we must recognise that because normalisation may not currently be possible for every individual, the approach to testing in all services must be both informative and supportive.
[1.] BHIVA, BASHH, BIS. UK National Guidelines for HIV Testing 2008. BHIVA, London. Available at www.bhiva.org/cms1222621.asp (last accessed 15th May 2009).
[2.] BBC News. I can buy life. That's not fair. 23 April 2009. Available at http://news.bbc.co.uk/1/hi/health/8013896.stm (last accessed 11th May 2009).
[3.] BBC News. Pope rejects condom distribution. 18 March 2009. Available at http://news.bbc.co.uk/today/hi/today/newsid_7950000/7950045.stm (last accessed 11th May 2009).
Correspondence to: Carol Pellowe, Faculty of Health and Human Sciences, School of Community Health and Social Care, Thames Valley University, Boston Manor Road, Brentford, Middlesex TW8 9GA. (email: firstname.lastname@example.org)
Deputy Director, Faculty of Health and Human Sciences, School of Community Health and Social Care, Thames Valley University, London