Moses R Kamya1; Rhoda Wanyenze; Alice S Namale
Makerere University Faculty of Medicine and Mulago-Mbarara Teaching Hospitals Joint AIDS Program, Kampala, Uganda
In their article "Desperately seeking targets: the ethics of routine HIV testing in low-income countries" published in the Bulletin in January 2006, Stuart Rennie & Frieda Behets explore some of the ethical challenges of routine ("opt-out") HIV testing in low-income countries.1 They argue that such testing policies violate human rights since patients do not have sufficient liberty to say "no". In response, we would like to draw attention to the high unmet demand for HIV testing, share our experiences in providing routine HIV testing and counselling (RTC) and discuss the ethical balance between the right not to know ones serostatus and the rights to care and prevention.
HIV counselling and testing are vital: they provide an opportunity to reduce the risk of individuals becoming infected; while those who are already infected can receive care and be supported to avoid transmitting the virus. After two decades of voluntary counselling and testing, over 90% of the HIV infected individuals worldwide are unaware of their serostatus. Only 15% of Ugandas population has accessed HIV counselling and testing, although 70% desire to be tested. We must change our approach to challenge this situation.
RTC is not a departure from "voluntariness", because patients can opt-out. In Mulago and Mbarara hospitals in Uganda, we have been providing RTC since 2004. Health-care providers routinely offer HIV testing to patients but emphasize their right to opt-out. Care for HIV-positive patients is initiated at the time of diagnosis. The majority of individuals offered testing (over 95%) accept and receive their results,2 with over 90% reporting that they feel relieved after being tested.
Patients rights are emphasized throughout Rennie & Behetss article but only in relation to opting-out of HIV testing. While all rights are important, the ethical balance between the right not to be tested and the rights to care and prevention is weighted towards the latter. Many people in low-income countries desire to be tested and would do so voluntarily if an HIV test were offered to them.3,4
Gender-related violence is common in low-income countries. However, HIV counselling and testing programmes are not the root cause of such violence. For example, in Uganda one such programme that implemented testing of couples was not associated with any increases in domestic violence.5
Rennie & Behet stress antiretroviral therapy but do not highlight prevention and other forms of care. For HIV-infected people, knowledge of their serostatus can reduce risky sexual behaviour by 65%.6 Provision of co-trimoxazole (trimethoprimsulfamethoxazole) prophylaxis reduces HIV-related mortality by 50% at minimal cost.
Rather than discouraging use of routine HIV testing and counselling, we should find ways of addressing the issues that Rennie & Behets raise; otherwise, we will miss an opportunity to diagnose, treat and stop the spread of HIV infection.
1. Rennie S, Behets F. Desperately seeking targets: the ethics of routine HIV testing in low-income countries. Bull World Health Organ 2006; 84(1):52-7.
2. Wanyenze R, Kamya M, Mayanja-Kizza H, Nawavvu C, Mayanja B, Walusimbi M et al. Routine HIV counseling and testing at Mulago and Mbarara University Teaching Hospitals: feasibility, acceptability and lessons learned. Third International AIDS Society Conference on HIV pathogenesis and treatment, Rio de Janeiro, Brazil, July 2005. Available at: www.ias-2005.org/planner/Presentations/ppt/3468.ppt
3. De Cock KM, Bunnell R, Mermin J. Unfinished business expanding HIV testing in developing countries. N Engl J Med 2006; 354:440-2.
4. Wanyenze R, Kamya M, Liechty CA, Ronald A, Guzman DJ, Wabwire-Mangen F et al. HIV counseling and testing practices at an urban hospital in Kampala, Uganda. AIDS Behav 2006;10:361-7.
5. Apondi R, Bunnell R, Awor A, Wamai N, Bikaako-Kajura W, Solberg P et al. Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda. Fourth Uganda AIDS Conference, April 2005.
6. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. JAMA 2004;292:224-36.