Edgar Lungu’s mandatory HIV testing, counseling and treatment is in conflict with the voluntary approach of the World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS).
Edgar says the human rights argument against mandatory HIV testing should not arise and that there will be no debate about it. He believes that protecting the lives of the affected and those they can affect overrides the human rights argument against mandatory testing.
Although WHO and UNAIDS see HIV testing and counselling (HTC) as a critical and essential gateway to HIV prevention, treatment, care, and support services, they are opposed to that being mandatory. No one can deny the fact that early knowledge of one’s positive HIV status maximizes opportunities for the people living with HIV (PLHIV) to access treatment, thereby greatly reducing HIV-related morbidity and mortality, and/or preventing mother-to-child transmission of HIV.
Being on effective HIV treatment reduces, by up to 96 per cent, the likelihood that someone living with HIV will transmit HIV to his/her sexual partner.
Those who are HIV negative can continue to make efforts to protect themselves from acquiring HIV through evidence-based prevention methods: safer sex, use of condoms, voluntary medical male circumcision, safe injecting equipment, reduced number of sexual partners. WHO, UNAIDS, and many other organisations have endorsed the concept of “universal access” to knowledge of HIV status. They have also endorsed the concepts of universal access to HIV prevention, treatment, care and support, as well as protection from discrimination based on HIV-positive status.
WHO has defined five key components – the “5 Cs” – that must be respected and adhered to by all HTC services. These components are: consent, confidentiality,
counselling, correct test results and connection/linkage to prevention, care and treatment.
WHO insists that people being tested for HIV must give informed consent to be tested; they must be informed of the process for HTC, the services that will be available depending on the results, and their right to refuse testing. According to WHO, mandatory or compulsory (coerced) testing is never appropriate, regardless of where that coercion comes from: healthcare providers, partners, family members, employers, or others. WHO recommends that voluntary HTC be available through a wide range of service delivery models and approaches. These include provider-initiated testing and counselling (PITC), which involves the routine offer of testing to all people receiving medical care in high-prevalence settings and in clinical sites, such as sexual health and tuberculosis (TB) and drug treatment clinics, antenatal, childbirth, postpartum services and sites offering services to key at risk and vulnerable population, in all epidemic settings. They also include a range of other testing and counselling services, including the offer of testing in non-medical settings by non-medical personnel, such as in community outreach, couples testing, door-to-door offer of testing, home-based testing and others.
WHO and UNAIDS do not support mandatory or compulsory testing of individuals on public health grounds. Clearly, no one can argue that HIV testing is a bad thing. Knowing one’s status allows a person to access treatment earlier, change risky behaviours, or rest assured that he/she is indeed HIV negative. With that said, what is wrong with making HIV testing mandatory for everyone?
Compulsory HIV testing – which requires that the entire population, or at least certain high-risk groups, is tested for HIV – has gotten a bad reputation in recent years from human rights activists who argue for a person’s right to choose to know whether or not they have HIV. However, studies have shown that usually, once a person knows he/she is HIV positive, he/she will change his/her risky behaviours to avoid transmitting it to anyone else. Would compulsory testing not at least hinder the spread of HIV among population?
We fully support the freedom of choice. However, we also support the right to live and if compulsory testing can reduce the number of people dying from AIDS, it should at least be considered by policy makers. One of the largest barriers to HIV research and prevention programmes is a lack of knowledge of the specific epidemics in each country. By requiring people to be tested for HIV, the public health community would gain valuable information on how many people are infected and what groups are most at risk, significantly aiding prevention programmes.
We can save people’s lives, and we can reduce the stigma by mandatory HIV testing. There is no way we are going to reduce the spread of this epidemic without more testing because 90 per cent of the people who are HIV positive don’t know it. Everyone who is sexually active, receiving blood transfusions, or breastfeeding is at risk for contracting HIV, regardless of their age, education, financial status, or sexuality. Therefore, in order to increase more individuals’ knowledge of their statuses so that they do not unknowingly spread HIV, testing needs to go beyond voluntary clinics.
Mandatory HIV testing is contrary to what many human rights groups argue. Their concern is primarily with confidentiality breaches, especially where the poor infrastructure cannot guarantee secure record keeping and adequate training for counselors. While a valid concern, so much of stigma surrounding HIV involves testing itself. People are reluctant to be tested because they associate HIV testing with people who are promiscuous, homosexual, or drug users. By requiring everyone to be tested, the stigma associated with those walking into an HIV testing clinic is eliminated or reduced. Also, with our very high HIV prevalence rates, mandatory testing has the possibility to normalise being HIV positive. Of course, this requires time and the decision by people to be open about their status but there is potential to show that everyone and anyone can contract HIV and that good things – like treatment, support groups, and advocacy opportunities – can result from knowing your status earlier. Unfortunately, once you get into the implications of such a policy, things do not remain so straightforward. Many argue that compulsory testing is simply a waste of money and that in order for population-wide mandatory testing to be cost-effective, the prevalence rate should be high. How high?
There are also issues of lack of resources to be able to test everyone. HIV tests are expensive and require sanitary facilities, laboratories, and trained professionals to draw blood. Currently, our HIV programmes are funded by the donors. What is going to be their reaction to our mandatory HIV testing which we say is not for discussion?
Furthermore, HIV testing is only beneficial if it is accompanied by proper education and counseling. These are additional costs and require more trained professionals that are difficult to find in our poor world. If a person tests positive, where do they go from there? Will policies be enacted that require the person to disclose their status to their friends, family, or sexual partners? How will this be enforced? What if ART is not available or affordable to the person who tests positive? Their positive test results have just come as a death sentence, which can lead to a fatalistic attitude and discourage behaviour change. If a person tests negative, there is a danger of developing a complacent attitude – since he/she does not have the virus, he/she may feel no responsibility to the HIV epidemic.
Although the benefits to compulsory HIV testing are clear, the realities of implementing a population wide mandatory testing campaign make it not the best option at this point in time. Infrastructure, financial, and human resource barriers raise concerns to human rights groups and make the implementation of such a programme a nightmare. Also, there remains the question of what to do from a policy standpoint for the people who do test positive. Do you arrest, prosecute and jail them?
Compromises can be made to reap some of the benefits of compulsory testing without requiring all of the necessary resources. First, there are certain groups that should be required to have HIV tests – pregnant mothers to prevent transmission of HIV to their babies, health professionals to reduce the risk to patients and sex workers. Second, opt-out HIV testing policies (administering an HIV test to everyone except those who specifically ask not to be tested) are a great way to encourage more HIV testing without requiring it.
Creative ways to bring opt-out should be found. This can be done through mobile clinics strategically placed in markets, farms, churches, or schools. Compulsory HIV testing is a messy topic but that doesn’t mean the discussion should end there. There’s need for continuous discourse. It doesn’t make sense to declare that Edgar’s mandatory HIV testing policy is beyond discussion. We should continue to find ways to have as many people as possible aware of their HIV status in hopes of slowing the spread of the HIV epidemic. An authoritarian or autocratic approach to this issue is dangerous. There are still many things we need to learn and we cannot close off discourse in this way.
For instance, one of the “benefits” of HIV testing is the ability to prevent HIV-positive patients from using scarce hospital services, presumably because such services would be wasted on these individuals. Also, it is well established that HIV testing that is done without patient consent not only is unethical but also can be actively harmful to the patient and counterproductive with respect to prevention efforts.
Thus, mandatory HIV testing is inadequate and unethical, and by no means should it be considered a “simple” shortcut to getting HIV-positive patients to help prevent the spread of HIV to others. HIV testing needs to be part of a “package” of support and care services. These need to begin in the hospital and extend into the community.