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Q. Can mandatory
HIV testing stop the AIDS epidemic?
Forcing someone to undergo medical testing of any kind is
an invasion of privacy and a violation of human rights. This is a fundamental
reason why WHO and its member countries have taken a strong position against
forced testing for HIV. But what about protecting the health of the
public? The following Questions & Answers explain why compulsory
HIV testing, far from protecting the public health, can actually
endanger it. They have been contributed as the first of an occasional
series by Suzanne Cherney, GPA's communications scientist. 
Q. Some people
say that the reason AIDS continues to spread is that we aren't
aggressive enough about finding out who is infected with the human
immunodeficiency virus (HIV). Shouldn't we be testing everyone for HIV
- if necessary, against their will?
A.
If a person tests positive for HIV, it means that he or she has HIV infection
and, scientists believe, will ultimately develop AIDS - a fatal disease
for which there is at present no cure. But this can take 10 or even 15 years,
and some people would prefer to live those healthy years without
knowing their diagnosis. In addition, people with HIV infection or AIDS can
suffer exclusion, discrimination and even persecution. So testing for
HIV is a vefy serious matter. People who are counselled about the personal
and social implications of taking an HIV test can of course decide to
be tested voluntarily. But forcing someone to undergo HIV testing is a
highly coercive, intrusive measure.
Q. But why worry
only about the infected people? Surely compulsory testing is justified in the
case of a fatal epidemic disease?
A.
There are a number of reasons why compulsory testing for HIV makes no sense.
To begin with, testing someone for HlVjust gives you a diagnosis, and a
diagnosis alone never stopped an epidemic. Testing only helps if there
are ways of breaking the chain of transmission. For example, when you test
donated blood prior to transfusion and discard the infected
blood, you are helping to prevent the spread of the virus. The
testing of blood for transfusion, and of tissues or organs for
transplantation, is the only area where testing needs to be compulsory.
Q. Testing has
helped contain other infections diseases. Why not AIDS?
A.
Because HIV is different. There is no drug available that can cure the
infection or make the person uninfectious - that is, incapable of
transmitting the virus to another person. And once a person is infected
with HIV, it's for life. A person who tests
positive for syphilis can be cured with a short course of antibiotics.
A person diagnosed with tuberculosis can be made uninfectious
with antibiotics. When someone tests positive for meningitis,
the individuals in close contact with him or her can be treated
and/or vaccinated. With HIV, there is no medical way to test and
treat" or "test and vaccinate, so as to break the chain of
transmission.
Q. Yes, but
people with HIV are nevertheless a danger to others. They could be
isolated.
A.
They don't need to be, because HIV infection is not "contagious, in the
usual sense. Unlike tuberculosis, it doesn't spread through coughing.
Unlike typhoid, it can't be transmitted through food or water. You can't
catch HIV from swimming with an infected person, or sharing an
office or home, or drinking from the same cup. So locking up infected people
is not justified or practical. It's not even necessary isolate
HIV-infected people when they're hospitalized. We all have a responsibility
to look after ourselves. And the fact that HIV spreads mainly through
sexual intercourse means that uninfected people are not defenseless
against the virus. They have ways of protecting themselves from HIV
without locking up the infected individuals. They can abstain from sex,
stay faithful to an uninfected partner, engage in sex without penetration,
or else use a condom every time for sexual intercourse.
Q Still, if we
could screen the whole population through compulsory testing and then isolate
the infected people for life, it might stop the epidemic.
A.
Mass HIV testing sounds straightforward. In practice, it's extremely costly,
logistically unwieldy, incapable of identifying everyone who is
infected, and fraught with problems that could be avoided by offering
voluntary tests and guaranteeing the confidentiality of the test
results.
Logistically, it's impossible to take blood samples
from everyone, test them, and give everyone their results on the same
day. So, even if the authorities managed to trace all infected people
(clearly, many won't turn up voluntarily to find out their test
results) and isolate them, this wouldn't prevent sexual contact between
the uninfected and those who have yet to be tested.
And even if these logistic obstacles could somehow be eliminated, no
mandatory testing programme can expect to identify all HIV-infected
people. Individuals who think they might be infected can go to extremes to
avoid testing and follow-up, given the serious consequences of a
positive HIV test - especially when there is a threat of isolation. Not all
HIV-infected people will be identified even if they are tested. Most
commercially available HIV tests work by detecting not the virus itself
but antibodies to the virus which the person's immune system produces
following infection with HIV. But it takes up to 12 weeks, or sometimes more,
for those HIV antibodies to be produced and become detectable in a blood
sample. This is the "window period" during which the infected
person continues to test negative.
At best, an HIV test result is a "snapshot" of
someone's infection status today. It's no guarantee that he or she won't
become infected tomorrow, or next week or month - and how often can people be
tested?
In any case, periodic testing of the entire population is
prohibitively expensive in terms of staff time, transport of blood samples,
and so on. (The actual HIV test kits account for only a fraction of the total
costs). In many developing countries, testing the whole population just
once would cost more than the government is able to spend on all health
care in a year.
Q. Surely some
countries have attempted to test everyone?
A.
No. The financial and logistic impossibility of testing the whole
population periodically has been recognized even by the few countries
that have devoted most of their AIDS budget to testing. And most of
these now realize that instead of mandatory testing - which failed to stop
the epidemic - they should use their resources for preventive measures
of proven effectiveness, such as informing the general public about HIV
transmission, making condoms cheap and accessible, providing
school-based
education for young people, and ensuring blood safety.
Q. Even if you
can't identify and trace all infected people, you could at least
isolate the ones you find.
A.
Apart from being a serious violation of human rights, lifetime
isolation would be an unnecessary economic burden on the individuals'
families and on society. In many places in Africa, and
increasingly in Asia, 10% or more of all young adults
are infected. Isolation means forfeiting their economic productivity during
the decade or so of good health that these young adults can expect, It means
depriving their families of breadwinners and care-givers. And it means
keeping thousands or even millions of fit individuals fed, ciothed and
looked after for years on end - at government
expense.
Q. I am still
concerned about all the healthy people walking around with HIV who don't even
know they have the virus. Granted that isolation makes no sense and that
there is no medical way of curing them or making them uninfectious.
Compulsory testing would at least force them to find out their
diagnosis and take precautions against transmitting the virus to
others.
A.
In other words, won't people who learn they are HIV-infected through
compulsory testing simply avoid unsafe sex from then on? To begin with, not
even voluntary .counselling and testing achieves a uniformity
"preventive" effect. When testing is purely voluntary, and people
are presumably well motivated to protect themselves and their loved ones, the
evidence shows that some infected people manage to change their sexual behaviour,
others do not.
* (For example,
helpful behaviour change (increased condom use) has been seen in
couples who seek voluntary testing together and find out that just one
of them is HIV-infected).
Is compulsory testing likely to be more effective than
this in achieving behaviour change? On the contrary. First of all, someone
who is forced to find out he or she is infected may have less interest
in protecting others - or even in self-protection (safer sex protects
both partners). But the main point is that a permanent, lifelong change in
sexual behaviour isn't achieved automatically or quickly. The
consistent use of condoms, for example, takes continuing motivation, will
power, personal commitment. It takes the availability of inexpensive and
readily accessible condoms. And for someone in a long-term relationship, it
takes the full cooperation of the other partner. The bottom line
is that HIV prevention rests on the individual's willingness to avoid
unsafe behaviour Will power and motivation can't be coerced. You don't
gain people's voluntary cooperation by forcing them to be tested.
Q. True, but
even if the infected person doesn't voluntarily adopt safer behaviour, at
least other people can bewarned...
A.
Who? Medical test results are supposed to remain confidential. Imagine how
suspicious we would be of doctors if they turned into law enforcement
officers ! We'd stop seeking medical help for a whole range of
problems if we thought our diagnoses would be handed out, This doesn't mean
that voluntary contact tracing is useless, though with HIV it's far
less useful than for syphilis or gonorrhoea, where the sexual
contact can be tested, treated and cured. But it's obvious that people
infected with HIV will be less likely to volunteer information about their
sex partners if they suspect that those individuals in turn may
be forced into testing. Once again, making the test mandatory instead of
voluntary makes it less rather than more effective.
Suppose an infected man refuses to use condoms or tell his wife about
the infection. What will happen if the health care provider doesn't
keep the diagnosis confidential but goes ahead and informs her? The wife
might decide to leave the relationship, assuming she is economically
able to do so, But white that might help her (if she is still
uninfected), there are two reasons why it might endanger the
public health. First, her rejected husband may well find new sex partners
- and the epidemic will continue to spread. Or, if she is infected but
doesn't know it, she might infect her new partners. Secondly, there is
ample evidence that in places where test results aren't kept strictly
confidential, people simply avoid HIV testing and continue to behave as
though they were not infected. Helpful behaviour change that might have
occurred as a result of voluntary counselling and testing is thus
forfeited.
Q. In some
places, couples have to get tested for syphilis before marrying. Why not for
HIV?
A.
Even with syphilis, a curable disease, experience from around the world shows
that mandatory premarital screening has little or no impact on the
public health. For HIV, mandatory testing makes even less sense. First,
fear of a compulsory test will dissuade many couples from marrying
where such a requirement exists - a disadvantage that voluntary test doesn't
entail. Second, why pick the time of marriage? People often begin their
sexual experimentation well before that. (Indeed, if premarital sex
were rate, testing before marriage would turn up virtually no positive
HIV results!). And, most important, sex with other partners can and
does take place after marriage. For the many people whose main risk of
HIV is their partner's extramarital activity, a negative premarital 'test
offers no protection - just an illusion of safety.
Q. But HIV can
be transmitted from an infected woman to her fetus or newborn. Wouldn't it be
helpful at least to insist on testing all pregnant women?
A.
Once a woman is pregnant the fetus may well be infected aiready, although
there is no way to know this. At this stage the only possibilities for
prevention are abortion, a decision not to breast-feed (although in
many settings bottle-feeding May be more risky for the baby), or
treatment with an antiviral drug around the time of delivery (this is
expensive). All these are major decision which cannot be forced on any woman
but which she must take, if at all, voluntarily. Therefore, voluntary
counselling and testing is what should be offered. Forced testing may also
dissuade pregnant women from seeking medical care. In any case, the best time
for prevention is prior to pregnancy. Married or unmarried, people need
to be aware of all the implications of HIV infection before they
decide whether to have children.
Q. Some
employers test job applicants before hiring them. Does that make sense?
A.
No. It won't protect the general public. And it won't protect the firm's
employees because HIV infection is not contagiouss and doesn't spread at the
workplace. The emphasis in any form should be on preventing infections
among the existing workforce, which is always far larger than the number of
new staff recruited each year. Some employers provide their workers
with AIDS education, encouragement for condom use, and care for sexually
transmitted diseases (STDs) such as syphilis and chancroid, which if
left untreated greatly increase a person's susceptibility to HIV
infection. They report a decrease in STD rates among their employees, which
is good news on two counts. It means employees are less likely to get
HIV and, for companies that offer or reimburse STD care, it means a
decrease in company expenditure.
Q. I can see why
forcing ordinary people to be tested is useless. What about restricting
compulsory testing to high-risk groups?
A. At first sight this seems more practical than
compulsory testing of the general population testing of the general
population, but in fact it's got even more problems. To begin with,
many such groups are hard to define, and even harder to locate. For
example, men who have unprotected sex with prostitutes are clearly at
high risk - but how do you identify them? And where do you draw the line?
At those who seek out a sex worker twice a year? Or those who do so
every payday? And what about
their wives - are they a high-risk group to be tested? In many places,
after all, most women with HIV have been infected by their one partner -
their husband.
Q. One
well-defined group, at least, is drug users who inject their drugs. Isn't it
true that they are at high risk of acquiring HIV?
A.
Yes. If they don't use new or freshly sterilized equipment every time they
inject, they can easily become infected - and pass the virus on to
their sex partners. So the most urgent need is to reach them to clean their
equipment carefully each time, never share it with anyone, or
exchange their used syringes for sterile ones - and to encourage them to use
condoms for sex. (Over the longer term, they need encouragement to switch
from drug injecting to safer forms of drug use, or no drug use at all).
These so-called "harm reduction" measures are clearly
vital for the public health as well as for the users themselves.
The biggest hurdle for harm-reduction programmes is
that drug users live on the margins of society. Almost everywhere, drug
use is secretive or frankly illegal, and users are mistrustful of
authorities. In many places, health workers have to persuade the
local police not to arrest drug users who come in for education, new
syringes, bleach or condoms. Any threat of mandatory HIV testing would scare
them away even more, doom the harm-reduction programmes to failure,
and endanger the public health
Q. Shouldn't we
at least insist that sex workers be HIV-negative?
A.
This is yet another idea that sounds fine in theory but works poorly in
practice. Compulsory testing is as counterproductive for prostitutes as
it is for drug users. Authorities need to work with prostitutes, not against
them. They need to strengthen their ability to demand condom use by clients.
(This is the standard harm-reduction measure for commercial sex work). If
prostitutes are harassed an driven away by the threat of mandatory testing,
they will be out of reach of effective harm-reduction programmes.
Prostitutes who can't escape testing and turn out to be HIV-positive
may be fired (it they work in a brothel) or lose their registration.
But this doesn't protect the public health. Infected individuals will
simply move on to another place. Where there is a system of
registration, the infected sex workers will join the ranks of
unofficial prostitutes, who generally have even less power to negotiate
safer sex. Testing doesn't even protect the local clients. No matter
how many 'condom only, signs are posted, any brothel owner (or
government official) who insists on testing sex workers -and lets the clients
know that they are HIV-negative - is sending a clear message that
if a client doesn't want to use a condom, he'll still be safe. Of
course, the client may well be infected himself and infect the prostitute,
who will then infect others who decide not to use a condom, and so on.
Testing sex workers even as often as every 3 months still means that,
because of the "window period" they can have HIV for nearly half a
year - and infect many clients - before their infection is diagnosed.
Q. You may well
ask, why test the prostitutes and not their clients?
A. From the standpoint of common decency, it's just as
important to safeguard sex workers as sex work clients. From the
standpoint of public health, protecting the prostitutes is even more
important. Besides, there's something illogical about
putting the responsibility for HIV prevention and safe sex on the
sex worker. After all, in almost all cases, whether the
prostitute is male or female, it's the client who has to wear the
condom!
If condom use by men is the key, why not try to test
STI patients systematically for HIV? After all, they're mostly men. And
by coming down with a disease like syphilis or chancroid, they have
proven that they are engaging in unsafe sex and are at risk of HIV.
There's no doubt that men (and women) with an STI are a very important
"audience" indeed when it comes to HIV prevention. Attendance
at a clinic or doctor's office provides the ideal opportunity for educating
them about AIDS and condom promotion - just at the time they are
confronted with evidence of their vulnerability to all STIs. But people with
an STD need encouragement to seek care at the earliest possible sign of
disease. Any threat of mandatory testing would frighten them
away.
Q. So compulsory
testing can't even help with people who engage in high-risk behaviour?
A.
No. When it comes to drug injectors, sex workers and STI patients, mandatory
HIV testing has nothing to recommend it - and mulfiple disadvantages as
compared with voluntary testing. First, people are hard to track down
for compulsory testing, and expensive to trace for follow-up. Then, what do
you achieve? When you find infected individuals, you can't isolate them
for life or enforce behaviour change. Indeed, voluntary testing is
more likely to result in the adoption of safe behaviour.
Not only are the benefits" of compulsory testing
illusory, but the side effects are a positive danger to the public health.
The main ones are driving vulnerable people away from harm-reduction
and other prevention programmes, and encouraging a false sense of
HIV-free security in the general population. Voluntary testing hasn't
got these disadvantages. Hence, there's nothing to be gained for the
public health, and much to be lost, by making HIV tests
compulsory instead of voluntary and
confidential.
Q. Aren't
coercive measures ever necessary?
A.
Yes. It is occasionally necessary to override people's individual rights in
the interests of public health. For example, WHO recommended obligatory
vaccination against smallpox until it was eradicated, and still
endorses the need for mandatory vaccination against yellow fever for
people travelling from zones where this disease is endemic. If one day
a medicine is found that can make HIV-infected people non- infectious to
others, WHO will re-examine its policy on HIV testing. For the moment,
AIDS happens to be a disease for which coercive testing is not only
pointless but harmful to the public health.
I:n the AIDS era, there is no way to sideline the infected people so that
everyone else can go on living as before. Today, everyone has a
responsibility to avoid unsafe behaviour.
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