While voluntary counselling and testing (VCT) is the mainstream HIV testing approach in HIV endemic countries, testing practices and policies are not standardised. The context of the health care environment, its resources and philosophy play a major role in determining HIV testing protocol. Some public health experts call for mandatory testing, especially in light of emerging research that points to treatment acting as a method of prevention.⁽²⁾ Rights-based approaches highlight the ethical dilemmas within mandatory testing approaches, given that HIV related stigma could translate into poor health outcomes as well as prejudice, violence and discrimination. Other rights-based models point to middle of the road approaches such as provider initiated testing. The latter has been proven to be successful in settings with high rates of vertical transmission.

This CAI paper briefly explores the issues and debates associated with HIV testing in high prevalence and incidence settings in Africa. Alternative approaches and calls for testing reform are explored in light of what this means for the future of HIV & AIDS programming.

Popular approaches to HIV testing

VCT has been defined as “a confidential dialogue between a person and a care provider aimed at enabling the person to cope with stress and make personal decisions related to HIV/AIDS…it includes an evaluation of personal risk of HIV transmission and facilitation of preventive behaviour.”⁽³⁾ The objectives of VCT include emotional support for those who consider HIV testing, prevention for those who are HIV negative and to provide support and facilitated decision-making following testing.⁽⁴⁾ HIV is a disease of intense stigma and an HIV positive diagnosis can possibly lead to negative outcomes for those who are not prepared to receive an HIV positive diagnosis. Due to the fact that stigma and denial may actively prevent people from accessing care, gaining support, and preventing onward transmission, UNAIDS and many other rights-based AIDS activists and NGOs have stipulated that “testing should be voluntary, and VCT should take place in collaboration with stigma-reducing activities”.⁽⁵⁾

According to UNAIDS, VCT has been touted as a cost-effective intervention in the prevention and treatment of HIV/AIDS. The VCT process creates a space for people to learn about and possibly accept their status in a confidential environment with referrals to both medical and psychological care.⁽⁶⁾ As with any intervention, there have been a number of challenges with implementation. Some of these include the reluctance of some to ‘opt-in’ for HIV testing due to stigma and discrimination. Other challenges include limited access and poor effectiveness of testing facilities. This is in part due to VCT not occupying a priority position in many low-resource, high endemic settings.⁽⁷⁾ Proponents of VCT argue that this effectiveness and uptake can be improved with HIV transmission information and education campaigns and by integrating VCT into other health and social services, beyond the clinic or hospital level.⁽⁸⁾

Alternatives: From mandatory to opt-out

There is growing criticism of the VCT process given the increasingly high incidence rates of HIV since the introduction of VCT in many sub-Saharan African countries. South Africa, for example, has experimented with other testing options such as mandatory testing, health provider initiated testing or opt-out testing. This array of alternatives provides a different approach to the HIV positive patient on an individual level, with a goal of curbing the problem at large.

Given the high prevalence rates of HIV in many low-resource settings in Africa, arguments for mandatory testing have surfaced. Mandatory testing can be defined in many ways but the most common seem to centre around laws limiting the rights of individuals to bodily integrity by requiring HIV testing. Failure to comply with this testing could then have legal implications. Those who argue for mandatory testing generally do so in the interests of the ‘public’s health’. Mandatory testing would promote the ‘public good’ by identifying new infections and beginning treatment, which has been proven to be a form of prevention in itself. Mass testing programmes have the potential to increase early detection and deter infection, thereby promoting safe sexual behaviour. Those who advocate for mandatory testing are generally of the mindset that it is a justifiable infringement of an individual’s right to bodily integrity and privacy (in certain circumstances) as the benefits to the society outweigh the individual cost.⁽⁹⁾

Opt-out or provider initiated testing is another potential HIV testing model and is currently the approach recommended by the WHO and UNAIDS.⁽¹⁰⁾ This is defined as health care providers offering a routine HIV test during any encounter with the health care services, with the option of ‘opting in’ or ‘opting out’. This usually occurs with ‘high risk’ groups such as pregnant women and men who have sex with men. Those who argue for this approach maintain that the overwhelming scale of the HIV epidemic and the vulnerability of certain groups to HIV infection requires traditional health measures to encapsulate those who are vulnerable – but yet do not see themselves as at risk.⁽¹¹⁾ Secondly, the high prevalence rates of HIV indicate that the virus is no longer an uncommon virus and see the benefits of ‘normalising’ HIV testing to the benefit of both the individual and of a greater HIV positive population at large. Opt-out or provider initiated testing is seen as an effective option due the unfortunate reality that, due to funding and roll-out constraints, ARV treatment cannot reach all who need it and reaching vulnerable populations is a major imperative.⁽¹²⁾

The complexity of consent

“Informed consent” is defined as an individual's right to make an informed, voluntary decision authorizing or refusing a medical intervention.⁽¹³⁾ As previously noted, it has played a major role in VCT by ensuring independence, agency and support during HIV testing as well as post-test results and decision-making. Advocates of opt-out HIV testing argue that the method of obtaining consent under the VCT process could be considered “ethnocentric Western rhetoric” which “exceptionalised” HIV and was a barrier to uptake.⁽¹⁴⁾ These advocates maintain that the opt-out / provider initiated method of obtaining consent is still protective of autonomy.⁽¹⁵⁾ On the other end of the consent spectrum, mandatory testing hinges on the idea that informed consent is waived in the interests of the population at large. Those who stand behind this method see HIV as a threat to the rights and autonomy of the uninfected and aims to protect them, by testing and treating the infected and mitigating the macro effects of the virus on the entire population.

Informed consent is a very important issue in the medical field at large and deserves to be debated and discussed. This is especially relevant for HIV & AIDS in Africa where large numbers of patients may not be aware of their rights and the realities that come with an HIV positive diagnosis. While the VCT process is certainly protective of the human rights of HIV positive patients, it is worth debating alternatives given such high incidence and prevalence rates.

The implications: Public health and human rights

The implications of some of these alternative testing methods have been defined by conversations around protecting the human rights of persons infected and affected by HIV and promoting public health goals. The human rights of people who are coercively tested (as some argue may occur in the opt-out method) may be jeopardised as they may face violence, stigma and discrimination. This may result in low treatment uptake and negative, unforeseen consequences. Many who face these negative consequences of HIV related stigma are unlikely to access vital HIV related services which undermines the intent of the opt-out or mandatory testing practice. Human rights advocates argue that infringing on rights such as the rights to privacy, dignity and bodily integrity is not justifiable and mandatory testing results in increased vulnerability.⁽¹⁶⁾

From a public health perspective, there are specific drawbacks to mandatory testing in the African context. In sub-Saharan Africa, the social, economic and cultural contexts are unique from each other but also from other well-resourced settings. It is important that caution and a focus on context is exercised when prescribing policies that may have worked in other settings or conceptually ‘make sense’. For example, the World Health Organization argues for these reasons that routine or mandatory testing for HIV in sub-Saharan Africa may not be feasible in the short to medium term given lack of access to ARV therapy, inadequate health workforce, denialism and intense stigma and discrimination.⁽¹⁷⁾

Concluding remarks

The key issues surrounding HIV testing lie in the removal of the major barriers to testing / being tested. The major barriers to testing include, but are not limited to, a lack of awareness, stigma and resource constraints. This points to the need to tackle these barriers from socio-medical angles that focus on stigma, discrimination, funding and fear. Since HIV & AIDS is a “behaviour-induced epidemic”, prevention goals are rooted in behaviour change at the individual level.⁽¹⁸⁾ Given that behaviour change relies heavily on autonomy, education and consent, it is difficult to see how mandatory testing alone could be a feasible outcome. Opt-out testing may be a positive, middle of the road solution in response to poor VCT outcomes but coercion and consent need to be closely monitored. Those who determine public health goals and policies need to balance human rights, dignity and equity of outcomes with a desire to curb an epidemic. Without this respect, HIV testing practices risks infringing on the autonomy of all Africans, whether HIV positive or negative.

NOTES:

(1) Contact Katherine Austin-Evelyn through Consultancy Africa Intelligence’s HIV & AIDS unit ( hiv.aids@consultanyafrica.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) Nel, A., ‘Test and treat model: Feasibility for implementation in Africa’, Consultancy Africa Intelligence, April 2010, http://www.consultancyafrica.com.
(3) UNAIDS, “UNAIDS Technical update: voluntary counselling and testing (VCT)”, UNAIDS Best practice collection, May 2000, http://data.unaids.org.
(4) Ibid.
(5) Ibid.
(6) Ibid.
(7) Ibid.
(8) Ibid.
(9) Strode, A., et al., 2005. Scaling up HIV testing in resource-constrained settings: debates on the role of VCT and Routine ‘Opt-in or Opt-out’ HIV Testing. The Southern African Journal of HIV Medicine, September 2005, pp.45-49. http://www.ajol.info.
(10) WHO Website, http://www.who.int.
(11) Ibid.
(12) Ibid.
(13) Beauchamp, T.L. and Faden, R.R., 1995. Informed consent: II. History/meaning and elements. In W. Reich, ed. Encyclopedia of bioethics. New York: MacMillan Library.
(14) Groves, A.K., et al., 2010. The complexity of consent: women's experiences testing for HIV at an antenatal clinic in Durban, South Africa. AIDS Care, 22(5), pp.538–544. http://www.ncbi.nlm.nih.gov.
(15) De Cock, K.M., et al., 2002. Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. The Lancet, 360, pp.67-72. http://www.unhcr.org.
(16) Strode, A., et al., 2005. Scaling up HIV testing in resource-constrained settings: debates on the role of VCT and Routine ‘Opt-in or Opt-out’ HIV Testing. The Southern African Journal of HIV Medicine, September 2005, pp.45-49. http://www.ajol.info.
(17) Asante, A.D.Scaling up HIV prevention: why routine or mandatory testing is not feasible for sub-Saharan Africa. Bulletin of the World Health Organization, 85(8), pp.569-648.http://www.who.int.
(18) Strode, A., et al., 2005. Scaling up HIV testing in resource-constrained settings: debates on the role of VCT and Routine ‘Opt-in or Opt-out’ HIV Testing. The Southern African Journal of HIV Medicine, September 2005, pp.45-49. http://www.ajol.info.

Written by Katherine Austin-Evelyn ⁽¹⁾