Compulsory HIV Testing

No one can argue that HIV testing is a bad thing. Knowing one’s
status allows a person to access treatment earlier, change risky
behaviors, or rest assured that he/she is indeed HIV negative. With
that said, why not make HIV testing mandatory for everyone? Hello,
I am Katie Morris and this is The AIDS Pandemic, a podcast hosted
by Dr. Dave Wessner, associate professor of biology, and his
students at Davidson College.

Compulsory HIV testing—which requires that the entire population,
or at least certain high-risk groups, is tested for HIV—has gotten
a bad reputation in recent years from human rights activists who
argue for a person’s right to choose to know whether or not they
have HIV. However, studies have shown that usually, once a person
knows he/she is HIV positive he/she will change his/her risky
behaviors to avoid transmitting it to anyone else. Would compulsory
testing not at least hinder the spread of HIV among populations? I
fully support the freedom of choice, however I also support the
right to live and if compulsory testing can reduce the number of
people dying from AIDS it should at least be considered by policy
makers around the globe.

One of the largest barriers to HIV research and prevention programs
in the developing world is a lack of knowledge of the specific
epidemics in each country. By requiring people to be tested for
HIV, the public health community would gain valuable information on
how many people are infected and what groups are most at risk,
significantly aiding prevention programs. Bill Clinton, the former
President of the United States and founder of the Clinton
foundation, which funds a great number of HIV/AIDS programs around
the world, is an advocate for mandatory testing in developing
countries with high HIV prevalence rates. In a statement made to
Reuters, he said, "[W]e can save people's lives, and we can reduce
the stigma. There is no way we are going to reduce the spread of
this epidemic without more testing because 90% of the people who
are HIV-positive don't know it." Everyone who is sexually active,
injecting drugs, receiving blood transfusions, or breastfeeding is
at risk for contracting HIV, regardless of their age, skin color,
education, financial status, or sexuality. Therefore in order to
increase more individuals’ knowledge of their statuses so that they
do not unknowingly spread HIV, testing needs to go beyond voluntary
clinics.

In the aforementioned quote, President Clinton made a statement
about reducing the stigma around HIV by implementing mandatory
testing. This statement is contrary to what many human rights
groups argue. Their concern is primarily with confidentiality
breaches, especially in the developing world where the poor
infrastructure cannot guarantee secure record keeping and adequate
training for counselors. While a valid concern, so much of stigma
surrounding HIV in the developing world involves testing itself.
People are reluctant to be tested because they associate HIV
testing with people who are promiscuous, homosexual, or drug users.
By requiring everyone to be tested, the stigma associated with
those walking into an HIV testing clinic is eliminated. Also, in
places like sub-Saharan Africa where many countries have HIV
prevalence rates above 5%, mandatory testing has the possibility to
normalize being HIV positive. Of course this requires time and the
decision by people to be open about their status but there is
potential to show that everyone and anyone can contract HIV and
that good things—like treatment, support groups, and advocacy
opportunities—can result from knowing your status earlier.

Unfortunately, once you get into the implications of such a policy,
things do not remain so straightforward. In the developed world,
many argue that compulsory testing is simply a waste of money. That
same Reuters report found that in order for population-wide
mandatory testing to be cost-effective, the prevalence rate should
be above 5%. In the United States where HIV prevalence is believed
to be less than 0.004%, mandatory HIV testing may not be the most
financially wise decision even though the U.S. is one of the few
countries that can actually afford to successfully implement a
compulsory HIV testing program. It should be noted that there are
certain high-risk groups in specific regions of the U.S. with
prevalence rates above 5% that could benefit from mandatory
testing. However, requiring testing of one group and not another
can be considered discrimination and stigmatize or alienate certain
people.

In the developing world where, again, many countries, particularly
in sub-Saharan Africa, have HIV prevalence rates above 5% and could
seemingly benefit from population-wide HIV testing, new issues
arise. First and foremost, these countries lack the resources to be
able to test everyone. HIV tests are expensive and require sanitary
facilities, laboratories, and trained professionals to draw blood.
With this blood test, it can take up to three months to obtain
results, creating a large loss due to follow-up. Furthermore, what
happens next? HIV testing is only beneficial if it is accompanied
by proper education and counseling. These are additional costs and
require more trained professionals that are difficult to find in
the developing world. If a person tests positive, where do they go
from there? Will policies be enacted that require the person to
disclose their status to their friends, family, or sexual partners?
How will this be enforced? What if ART is not available or
affordable to the person who tests positive? Their positive test
results have just come as a death sentence, which can lead to a
fatalistic attitude and discourage behavior change. If a person
tests negative, there is a danger of developing a complacent
attitude—since he/she does not have the virus, he/she may feel no
responsibility to the HIV epidemic.

Although the benefits to compulsory HIV testing are clear, the
realities of implementing a population wide mandatory testing
campaign around the world make it not the best option at this point
in time. In the developed world where prevalence rates are low, the
cost of HIV tests outweigh the benefits of finding the few positive
people. This might not always be the case in the future with
treatment regimens improving and the early-detection of HIV
reducing the long-term opt-out costs of ART. In the developing
world, infrastructure, financial, and human resource barriers raise
concerns to human rights groups and make the implementation of such
a program a nightmare. Also, there remains the question of what to
do from a policy standpoint for the people who do test positive.
Compromises can be made to reap some of the benefits of compulsory
testing without requiring all of the necessary resources. First,
there are certain groups that should be required to have HIV
tests—pregnant mothers to prevent transmission of HIV to their
babies, health professionals to reduce the risk to patients, and
sex workers in areas like the Netherlands where their profession is
regulated. Second, opt-out HIV testing policies (administering an
HIV test to everyone except those who specifically ask not to be
tested) are a great way to encourage more HIV testing without
requiring it. This is more effective in the developed world where
people go for annual health check-ups but there are creative ways
to bring opt-out to the developing world through mobile clinics
strategically placed in markets, farms, churches, or schools.
Compulsory HIV testing is a messy topic but that doesn’t mean the
discussion should end there. We should continue to find ways to
have as many people as possible aware of their HIV status in hopes
of slowing the spread of the HIV epidemic.

Katie Morris, & David R. Wessner (2010). Compulsory HIV
Testing The AIDS Pandemic