Voluntary, opting-out or mandatory HIV/AIDS testing?

trueBy Dr. Sylvia Baluka

Everyone has a right to health. The human rights norms and principles include human dignity, attention to the needs and rights of vulnerable groups and an emphasis on ensuring that health systems are accessible to all.

Health for the majority of the world is considered a basic human right, manifested by making healthcare a public good.

Globally, HIV/AIDS raises a host of human rights issues including whether all adults in high prevalence HIV/AIDS countries (HPHCs) should be tested or people should be able to "opt-out" of testing or should be tested voluntarily for HIV/AIDS.

Voluntary testing does not; involve coercion, violate individual autonomy or confidentiality or involve discrimination or gender bias for instance women being tested more than men. However, voluntary testing ignores the human rights of unborn babies and the likely vertical transmission from mother to child in the absence of treatment.

Moreover people at the highest risk are the less likely to test voluntarily.

Although voluntary testing considers human rights it does not take into account the human rights tragedy that HIV/AIDS is. HPHCs suffer significantly from morbidity, mortality and lost productivity due to HIV/AIDS, and the human right to equitable development and the individual human rights of children to remain seronegative are negatively impacted.

"Opting out" of testing for HIV/AIDS means that every adult coming into contact with the healthcare system is asked to take the HIV test unless they ask not to be tested. This is unethical since it involves coercing and forcing people to test thus threatening their dignity and infringing on inherent human rights.

Opting-out testing offers a middle position and is considered ethical for patients with sexually transmitted infections, during pregnancy and in settings where HIV/AIDS prevalence is high and treatment is readily available. However, opting-out testing may become unethical if the patient is not given adequate and appropriate information.

Opting-out testing requires informed consent and confidentiality must ensured. Opting-out testing also suffers criticisms on the ground that patients may find it difficult to refuse what the healthcare service providers suggest or the latter may coerce some patients.

Opting-out testing may also encourage discrimination and gender bias for instance women may be tested more than men since they seek health services for different health conditions more than men.

Although mandatory HIV/AIDS testing may be justified in public health interest, it undermines the basic human rights. Testing all adults for HIV/AIDS in high HPHCs denies them the freedom of choice, humiliates them and undermines the quest for human rights for all.

Mandatory testing may also encourage; revealing of someone’s HIV status due to lack of confidentiality, discrimination and stigma associated with the knowledge of someone’s HIV status in the community may be problematic, and knowing everyone’s HIV status without providing access to appropriate treatment is ethically questionable.

Besides, testing everyone is very expensive and knowledge of HIV status does not guarantee that the person will seek treatment. Requiring all adults to consent to mandatory HIV testing may discourage some people from seeking healthcare services for fear of being tested, even when in need.

Women are likely to be tested more than men which will breed gender bias.

Spending scarce resources on mandatory or opting-out testing is not a wise investment especially for the HPHCs that are mainly resource constrained developing countries unless the root causes of the soaring HIV/AIDS prevalence are appropriately diagnosed and addressed.

Moreover, we are still faced with the difficulty of determining when to repeat mandatory testing. For instance if someone tested in January 2014 and is found seronegative but lives recklessly sexually thereafter, when should the mandatory testing be repeated given the resource constraints of developing countries like Uganda that account for the highest percentage of HPHCs.  

Encouraging people to test voluntarily for HIV/AIDS is still the best option but it should be embedded in a package including a strong component of education, counseling, public awareness and highlighting benefits of knowing ones status early and linkage to treatment.

Testing people who voluntarily come for the HIV/AIDS test respects their dignity provided the principles of confidentiality and privacy are respected.

Making HIV/AIDS testing and support services more accessible to all reduces cultural stigma, encourages testing and has potential to reduce the spread of the disease.