HIV testing policy revisited

A few years ago, a colleague and I wrote a paper on some of the ethical issues surrounding proposed changes in HIV testing policy. Traditionally, HIV testing depended strongly on personal choice: if you felt you had been at risk of infection, you could (in theory) go to whatever available clinic offered HIV testing. The policy of voluntary testing and counseling (or VCT) was meant to do just that: support those who wanted to know their own HIV status. The policy change -- pursued by the World Health Organization and the Centers for Disease Control and Prevention -- involved putting greater pressure on individuals to get tested for HIV, given that (a) relatively few persons in high HIV-prevalent countries made use of VCT services and (b) antiretroviral treatment has become more available for those who test positive for HIV. 'Putting more pressure' took the form of an opt-out HIV testing policy, i.e. telling patients in clinics that they would be tested for HIV unless they choose not to be. While a more aggressive HIV testing policy could have some obvious benefits, my colleague and I were worried about possible negative repercussions that the policy might have. More precisely, the concern was less about the policy in the abstract, but what implementation of the policy might produce in settings marked by poverty, stigma, gender inequality and weak health care infrastructure.

This month's issue of the World Health Organization has a well-argued defense of 'opt-out' HIV testing policy. Michael April rests the argument on two philosophical foundations: consequentialism and what he calls 'libertarian paternalism.' On the consequentialist front, he basically argues that the positive consequences of having an opt-out testing policy outweigh the potential negative consequences. In regard to libertarian paternalism, April argues that there is nothing wrong with influencing persons to get tested for HIV by means of health policy as long as the influence does not constitute coercion and persons are thereby directed towards more health-promoting behavior than they might have otherwise.

Does the argument defuse the worries surrounding opt-out testing in poor countries in sub-Saharan Africa? Perhaps I should let the reader decide, but it is tempting to make a couple remarks. First, the consequentialist argument depends on the idea of 'weighing' potential positive consequences of opt-out testing against negative ones. Such weighing exercises in ethics are always slippery and elusive. On an individual level, it is not necessarily clear that getting tested for HIV has the best consequences, especially considering that health is not the only value at stake. (The astonishing book Three Letter Plague was centered around this theme.) If we go to a population level, and say that having opt-out testing will have overall better consequences than VCT, the consequences should (at least) be expressed in terms of lower HIV incidence. Maybe the policy will help to lower incidence, or rather, it may make a contribution as long as some other ducks are rowed up with it: presence of decent medical services (including HIV/AIDS care and availability of health care professionals), food and political security, opportunities for employment, and so on. As far libertarian paternalism goes, it seems plausible enough to say that people sometimes make decisions against their own interests, and that it can be justified sometimes to channel their behavior in more beneficial directions. But in an individual case, HIV testing conceivably might not be in a person's own interest, and hence libertarian paternalism would not be justified there. Though it sometimes makes appeals to individual self-interest, the whole argument works best at public health or population level: putting this policy in place, it is argued, will (likely) have positive overall consequences for many even if it might have negative consequences for some.

Perhaps so. On paper, the opt-out HIV testing policy has always looked promising. Our main concern was about such policies being implemented wisely and sensitively in the field, with a thorough knowledge of the cultures, communities and institutions involved, in order to avoid the best public health intentions going seriously astray.