Testing times

With the success of antiretrovirals, experts are asking whether screening for HIV should be made compulsory, reports Toby Reynolds

Until recently testing for HIV was centered on the rights of individuals-with consent and counselling needed before the test can be done. Now, HIV testing is becoming the norm in many countries, and a global drive to broaden the uptake of treatment for HIV is gaining momentum.

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Closing in on HIV

In the 1980s and '90s HIV/AIDS prevention strategies strove to protect the rights of individuals. Medical ethics gave special status to HIV testing because of the stigma surrounding a positive result and the lack of medical treatment available. This "HIV exceptionalism" meant a test required specific consent, often in written form, and special counselling sessions.

New treatments have improved the prognosis for people living with HIV, particularly in developed countries. Management of HIV/AIDS now advocates mass treatment in addition to prevention. For example, the "3 by 5" initiative of the World Health Organization and UNAIDS tried, albeit unsuccessfully, to get antiretroviral drugs to three million HIV positive people in poor and middle income countries by the end of 2005.

Treatment that is increasingly effective, and more available, gives people an incentive to know their HIV status. However, some argue that voluntary counselling initiated by the patient and HIV testing is not reaching enough people.

Why the exception?

UNAIDS and WHO say that surveys done in several countries with a high burden of disease consistently found less than 10% of people living with HIV were aware of their infection. Both organisations recommend more diverse approaches to testing, including routine screening initiated by the provider, where treatment is available.

The US Centers for Disease Control and Prevention (CDC) used a similar argument in September when it recommended HIV testing should become a routine part of medical care for patients aged 13-64. It estimated that about a quarter of a million US citizens who were infected with the virus were unaware of their status.

"Our goal is to ensure that everyone who receives medical care also has the opportunity to learn if they are infected with HIV," Kevin Fenton, head of the CDC's National Center for HIV, Sexually Transmitted Disease, and Tuberculosis Prevention, said when the recommendations were published. "Making the HIV test a normal part of care for all Americans is also an important step towards removing the stigma still associated with testing."

The CDC recommended dropping requirements for counselling before HIV testing and separate written consent. It said doctors had found these factors impractical in busy medical centres. Testing could not be done without a patient's knowledge and would still be voluntary, but on an opt out rather than an opt in basis.

Some of the countries that are most affected by HIV/AIDS are among the keenest to widen their screening programmes. Botswana began routine HIV testing in 2004, and Lesotho announced a universal testing plan in 2005. Malawi has also expressed interest.

In South Africa, supreme court judge and HIV positive AIDS activist Edwin Cameron called in May for the normalisation of HIV testing and said that the "exceptionalisation" of HIV infection in the healthcare environment might be doing more harm than good.

Need for debate

Not everyone is so enthusiastic for a change. Opt out routine HIV screening raises the question of whether non-refusal of a test is equivalent to informed consent. Detractors say it may not be, especially if people are unfamiliar with biomedical science or may be pressured into acceptance.

"Unless people realise they can say no to an HIV test and have the confidence and power to make that choice, this strategy will take away their control," the International Community of Women Living with HIV/AIDS said in a statement.

Since 2004, some provinces in China have invited people from high risk groups to be tested. As a result many more HIV positive people know their status than would have done otherwise. The proportion of people declining the invitation has been very low, and critics say that public health leaders should be wary of condoning routine testing until they know it is truly voluntary.

For others, opt out testing may not go far enough. Some academics have already said that the benefits of testing-for example, in reducing the transmission of HIV from mother to child HIV-may outweigh the importance of individual autonomy, and have argued for compulsory testing in some settings.

Former US president Bill Clinton, who has helped negotiate wider access to antiretroviral drugs, has voiced support for the idea of mandatory testing in countries with a high prevalence of HIV, where treatment is available, and where measures to prevent discrimination are in place.

"There is no way we are going to reduce the spread of this epidemic without more testing because 90% of the people who are HIV positive don't know it," he said in March.

"The whole idea is to treat this as a public health problem, not as some source of shame or disgrace, and to keep as many people alive as possible."

Leading South African HIV/AIDS clinician Francois Venter of the University of the Witwatersrand, Johannesburg, called in October for universal HIV testing in his country, arguing that opt out programmes being considered for sexually transmitted diseases, tuberculosis, and antenatal settings would identify people infected with the virus too late.

"What I was trying to provoke was a broader debate about testing and I think that worked. For the first time we have started to talk about where we are going to take this thing next. Into schools? Into churches? Are we going to start doing targets at the workplace to encourage testing?" he said.

"At no point did I ever say that counselling should be removed or that confidentiality should be violated ... But the previous argument that 'I don't need to know because there is nothing you can do for me' doesn't hold any more.

"I think that from a public health level you can also argue that people have a responsibility to know their status. If you are positive and elect not to test it is not just about you. It is about your sexual partner, and it is about the fact that if you get sick the society has to pick up the pieces."