The ethics of urgency

According the latest figures of the WHO, in sub-Saharan Africa, 3.2 million people became HIV infected in 2005. Even more shocking is the fact that roughly 90% of HIV positive persons in the region do not even know they are infected. This can easily be interpreted as a failure of traditional HIV testing policy of voluntary counseling and testing (VCT). As the name suggests, VCT involves people coming of their own free will to clinics to be tested, and being counseled about the implications of a positive (or negative) test result. For decades, VCT has been the standard HIV testing strategy for decades in sub-Saharan Africa. It has obviously not proven a rousing success.

In the light of this, the WHO has recently embraced routine HIV testing in areas of high prevalence where AIDS treatment is available. Routine testing basically means informing persons presenting at clinics that they will be tested for HIV, unless they choose not to. Opt-out policies can increase the numbers tested, but also diminishes the ‘voluntary’ component in HIV testing. The WHO believes that since routine testing involves possibility of refusal, the policy balances public health and ethical concerns.

Some commentators, however, worry about the implementation of routine testing policies in low-income countries. What will routine testing for this still-stigmatized disease really involve for individuals, particularly for women? There is also a ‘slippery slope’ concern: if routine testing does not increase the numbers of tested individuals, what more aggressive HIV testing policies will be proposed next? Frankly, I am one of those commentators.

In the most recent issue of Developing World Bioethics, Peter Clark argues that the time for more aggressive HIV testing policies within sub-Saharan Africa has already arrived. Clark argues that mandatory HIV testing of all pregnant women in Botswana – i.e. testing them for HIV whether they consent or not -- is economically, scientifically and ethically justified. Actually, he goes even further: since those who get tested do not sometimes adhere to treatment regimes, Clark is also ready to defend mandatory treatment of pregnant Botswanans and their children – though he thankfully spares us the gory details of how to implement forced medication. Restricting the privacy and autonomy of individuals, he writes, is a lesser evil than the death and social destruction caused by HIV/AIDS.

As far as awareness of the horrors of the epidemic is concerned, Clark’s heart is in the right place. But it is unclear that he put all the potential costs of the policy into his utilitarian calculus. Privacy and autonomy are not the only concerns. There is also stigmatization (and possible harm) of being found HIV positive. There is also the fact that this mandatory testing policy targets pregnant women, not the men they likely received the infection from. How are local communities likely to react to mandatory testing (or treatment)? And what, if this policy did not work, would come next?